The periodontium and pulp are two most important entities of the tooth, infection from one can travel towards other by different pathways. Neglect of either one can lead to failure. This presentation will help you learn clear steps towards diagnosis and treatment planning of such lesions

1. THE PERIO ENDO
INTER-RELATIONSHIP
Dr. Almas Muhammad Arshad

2. PERIODONTIUMPULP

3. CONTENTS:
• Introduction
• Pathways of Communication
• Classification
• Symptoms
• Investigation
• Decision Tree
• Case Reports

4. o Pulp and the periodontium have
embryonic, functional and anatomical
relationship.
o Caused by mixed anaerobic bacteria
(J Clin Periodontol 2002: 29: 663–671)
o Combined Endo-perio lesions are
estimated to cause 50% of tooth
mortality J Conserv Dent. 2008 Apr-Jun; 11(2): 54–62.

5. PATHWAYS CONNECTING
ENDODONTIC AND PERIODONTAL
TISSUE

6. ANATOMICAL RELATIONSHIP:
o Dentinal tubules
o Accessory & lateral canals
o Apical foramen
o Developmental grooves

7. (J Conserv Dent, Apr-Jun 2008, Vol:11, Issue:2)

8. PATHOLOGICAL RELATIONSHIP:
o Iatrogenic Perforations
o Internal Resorption
o External resorption

9. DENTINAL TUBULES:
o Exposed dentinal tubules will create a
communication between the pulp and
periodontium because of:
• Faulty or aggressive scaling
technique
• Following root planing
• Gap joint between enamel and
cementum
• Gum recession
o The number of dentinal tubules per mm2
decreases from the pulp to the periphery
(Garberoglio & Brännström1976).
o Endo-perio > Perio-endo

10. J Clin Periodontol 2002: 29: 663–671

11. PALATOGINGIVAL GROOVE:
o In Maxillary central and lateral
incisors
o May contribute to
• Periodontal (AND/OR)
• Pulpal pathology
o To detect the effect:
• Vitality testing
• Probing
o Radiograph
o Treatment:
• Burning out the groove
• Surgical management

13. INFECTION FROM PDL TO PULP:
Pathogenic
Bacteria and
inflammatory
products of
periodontal
disease
Accessory canal /
Lateral canals /
apical foramen
Pulpal
infection/necrosis
RETROGRADE
PULPITIS

14. INFECTION FROM PULP TO PDL:
• Pulpal disease
• Procedural
errors in RCT
• Perforations
• Vertical root
fractures
• Dentinal
tubules
• Peri-radicular
inflammation
Bone loss +
CAL +/- Pus
discharge
RETROGRADE
PERIODONTITIS

15. CLASSIFICATION:
Primary Endodontic
Disease
Primary Periodontal
disease
Combined Disease
Primary Periodontal
Secondary Endodontic
Primary Endodontic
Secondary Periodontal
True Combined Lesion
Simon, Glick and Frank in 1972

16. PRIMARY ENDODONTIC:
Periodontology 2000, Vol. 34, 2004

17. PRIMARY ENDO SECONDARY
PERIODONTAL:
Periodontology 2000, Vol. 34, 2004

18. PRIMARY PERIODONTAL:

19. PRIMARY PERIODONTAL
SECONDARY ENDODONTIC:

20. TRUE COMBINED
PERIODONTAL & ENDODONTIC:

21. CLINICAL SYMPTOMS:
Swelling
of gingiva
Pus
discharge
Pocket
formation
Fistula
tract
Tender to
percussion
Mobility

22. LESION CHARACTERISTICS:
LESION PAIN SWELLING PROBING
Primary
Endodontic
Moderate to
severe
Possibly when
sinus tract
None unless
sinus tract
Primary
Periodontal
None to
moderate
Possibly Moderate to
severe
Combined
pulpal and
periodontal
Moderate to
severe
Likely Severe, connects
the periapex

23. INVESTIGATIONS:
History taking
Examination
Periodontal examination
Radiographic evaluation
Pulp testing
Fistula tracking
DIAGNOSIS

24. o Visual Examination
• Soft Tissue
 Inflammation
 Ulceration
 Sinus tracts
• Teeth
 Caries
 Defective restorations
 Cracks
 Fractures
 Discolorations
o Palpation - Peri-radicular abnormality
o Percussion – Peri-radicular inflammation

25. o Mobility
• Loss of periodontal support
• Peri-radicular abscess
• Fractured roots
o Probing
• Deep solitary pocket – Endo
cause
• Broad and deep pockets -
Perio
o Fistula Tracking
• #25 GP/Probe - radiopaque
• Until Resistance is felt

26. o Pulp Testing (EPT + Cold test):
LESION RESPONSE
Primary Periodontal +
Primary Periodontal Secondary Endodontic +/-
Primary Endodontic +/-
Primary Endodontic Secondary Periodontal -
Combined pulpal -
 False Positive response may be interpreted in combined lesion in
multi rooted teeth as either intact vital pulp or partially necrotic
pulp.

27. DECESION TREE:
[History + C/E + Probing + Radiograph]
+ Vitality
+ ive
Perio pockets (+)
Pulpitis & PA (-)
Primary
periodontal
Scaling +
Root planning
Perio Pockets (+)
Pulpal & PA
(False+)
Primary
periodontal
Secondary endo
RCT + Scaling 
cleaning and shaping
 Follow up 
Obturation
- ive
Pulpal & PA (+)
Perio pockets (-)
Sinus tract (+/-)
Primary
Endodontic
RCT
Pulpal & PA(+)
Probing (+)
Primary endo
Secondary
periodontal
RCT +
Periodontal
therapy
immediately
Pulpal & PA (+)
Probing (++)
Combined
perio endo
RCT +
Periodontal
therapy

28. PROGNOSIS:
o Depends on
• Patients oral hygiene
• The amount of attachment loss
• Endodontic status
• Effectiveness of the periodontal treatment accomplished
o Primary endo -- Good to excellent prognosis
o Primary perio -- Depends on periodontal therapy
o Combined lesion -- Poor prognosis
Periodontology 2000, Vol. 34, 2004, 165–203

29. FLOW OF WORK:
• RCTPrimary Endodontic
• Periodontal therapyPrimary Periodontal
• RCT + Periodontal therapy immediately/later
Primary Endodontic
Secondary Periodontal
• Scaling + Immediately followed by cleaning and
shaping  Follow up & observe pocketing 
Obturation
Primary Periodontal and
Secondary Endodontic
• RCT + periodontal therapyTrue Combined lesion
Prognosticate before treatment

30. CASE REPORT 1: J Clin Exp Dent. 2014;6(1):e91-5.
o A 42y old male pt presented with a complain of acute pain and
swelling in the left mandibular area.
o Medical history: Non contributory
o Periodontal Examination:
Deep pocket between #37 and #38
o Vitality: -ive (non vital)
o R/E:
Bone loss around distal root of #37

31. o R/E:
Bone loss around distal root of #37
o Diagnosis ??

32. o Diagnosis:
Primary periodontal with secondary endodontic
involvement
o Treatment:
1. RCT
2. Scaling and Root planing
3. KIV Extraction of #38
4. Follow Up..

33. 1 YEAR:
6 MONTH:

34. CASE REPORT 2: J Clin Exp Dent. 2014;6(1):e91-5.
o A 45-years old women presented with a complain of
intermittent pain and periodic discharge of pus from tooth
#36 and wanted to inquire about options for preserving the
tooth.
o Medical status was noncontributory
o I/O:
•Gingival reddening and swelling
at buccal side of 36

35. o Periodontal Examination:
• The probing depth in the furcal area
was 12mm
• Grade III furcal lesion
o Percussion: +ive
o Mobility: +ive

36. o Radiographs :
•Bony defect in the furcal and
periapical area of tooth #36 had
unsuccessful RCT
o Diagnosis???

37. o Diagnosis:
Primary endodontic disease with secondary
periodontal involvement
o Treatment:
•Endodontic retreatment was performed
•Evaluated 3 month later furcation lesion still remain
intact
•Periodontal regenerative surgery was planned for
treatment of furcation defect

38. 3 Month Recall:
2 Year Recall:

39. CONCLUSION:
The proper diagnosis and complete
treatment of both aspects of perio-
endo lesions is essential for
successful long-term results.
A secondary disease develops due
to an untreated primary one.

40. Refrences
• http://www.ijdr.in/article.asp?issn=0970-
9290;year=2010;volume=21;issue=4;spage=579;epage=585;aulast=Shenoy
• http://www.ijstr.org/final-print/may2013/Endo-perio-Lesions.pdf
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2813095/#sec1-13title
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4190803/
• https://www.scienceopen.com/document/read?vid=02cf1c92-a231-41f8-b1c6-
c4302bbfd2ae
• http://www.ijstr.org/final-print/may2013/Endo-perio-Lesions.pdf
• https://www.hindawi.com/journals/ijd/2014/919173/
• http://semmelweis.hu/konzervalo-fogaszat/files/2014/11/Endodontic-and-
Periodontal-v9-angol.pdf
•http://suffolkrootcanal.co.uk/wp-content/uploads/2015/04/Diagnosis-
prognosis-and-decision-making-in-the-treatment-of-combined-periodontal-
endodontic-lesions-Rotstein-2004.pdf