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Presented by
Reham Hassan
Associate Professor of Endodontics
Intercommunication between pulpal and periodontal tissues.
Influence of pulpal disease and endodontic procedures on the
periodontium.
Influence of periodontal inflammation on the pulp
Endo-perio lesions
Differential diagnosis of endodontic periodontal lesions.
Treatment alternatives.
CHAPTER OUTLINE
ENDO PERIO LESIONS
A. APICAL FORAMEN
B. LATERAL CANALS
C. DENTINAL TUBULES
D. Palato-gingival Grooves
ETIOLOGIC FACTORS CONTRIBUTING FACTORS
A. IN ADEQUATE ENDODONTIC TREATMENT
B. CORONAL LEAKAGE
C. TRAUMATIC INJURIES
D. LINGUAL DEVELOPMENTAL GROOVE
E. DEVELOPMENTAL MALFORMATION
1. LIVINGAGENTS:
A. BACTERIA
B. FUNGI
C. VIRUSES
2. NON LIVING AGENTS
A. FORGIEN BODIES
PHYSIOLOGICAL PATHWAY
A. VERTICAL ROOT FRACTURES
B. PERFORATIONS
NON PHYSIOLOGICL PATHWAYS
ENDO PERIO LESIONS
ANATOMIC COSIDERATIONS
A. APICAL FORAMEN
B. LATERAL CANALS
C. DENTINAL TUBULES
ENDO PERIO LESIONS ANATOMIC COSIDERATIONS
RADICULAR TUBULES run a STRAIGHT COURSE FROM THE
PULP TO THE CDJ
Size:
1micron at the periodontum to 3microns AT PULP
Number: The density of
per square millimeter at the CDJ in the cervical portion
of the root,
dentin tubules 15,000 tubules per square millimeter at the
CDJ in the cervical portion
8000 AT APICAL of the root,
57000 per square millimeter AT PULP END
Cementum acts as a protective barrier
A. DENTINAL TUBULES
ENDO PERIO LESIONS
30 to 40% of all teeth have lateral or accessory
Location:
1. 17 % in the apical third of the root.
2. 9 % in the middle third.
3. Less than 2% in the coronal third .
Accessory canals contain connective tissue and blood
vessels that connect the pulp with the periodontium .
Several clinical aids for their identification:
(1)Radiographic of a discrete lateral lesion.
(2)Radiographic of a "notch" on the lateral root surface
(3)Demonstration of root canal fill material, or sealer, extruding
LATERAL CANALS
ENDODONTIC PERIODONTAL COMUNICATION
The apical foramen IS
………….
the principal route of communication
between the pulp and periodontium
Pulp inflammation or pulp necrosis extends into
the periapical tissues, causing a local
inflammatory response often associated with
bone and root resorption.
Palato-gingival Grooves
Developmental anomalies of the
maxillary incisors, with lateral incisors
more often affected than central incisors,
Begin in central fossa, cross the
cingulum and extend apically with
varying distances.
A vertical root fracture can produce a "halo" effect around the tooth radiographically.
Vertical root fracture:
Deep periodontal pocketing and
localized destruction of alveolar
bone are often related long
standing root fractures.
Perforation of the root creates a communication between the
root canal system and periodontal ligament
this may occur due to over instrumentation during endodontic
procedures, internal or external root resorption or caries
invading through the floor of the pulp chamber.
Perforation:
EFFECT OF PULPAL DESEASE ON PERIODONTAL TISSUE: FROM MILD INFLAMATION confined to the periodontal
ligament TO SEVER DESTRUCTION OF THE LIGAMENTS
SOCKET AND BONE
Irrigants
Intra-canal medicaments
Sealers
Filling materials
Procedural mishaps, such as:
Perforations pulp chamber
Strip perforations, or lateral
perforations
Vertical root fractures
EFFECT OF ENDO. PROCEDURES ON PERIODONTAL TISSUE:
response is usually temporary
After adequate root canal treatment, lesions resulting from pulpal necrosis resolve, the integrity of the periodontium are reestablished
lesion can result in a localized or diffuse swelling that may involve the gingival attachment, sinus tract formation that may drain through alveolar mucosa or attached gingiva and drain through the gingival sulcus
difficult to attain reattachment after a periodontal defect
EFFECT OF PERIODONTAL DESEASE ON PULPAL TISSUE: There is speculation on the effect of periodontal disease on the health of the pulp,
as the accumulated evidence suggests that there is no or little effect on the
pulp ,
there is some evidence that periodontal disease must extend all the way to the
apical foramen before the accumulation of plaque can cause significant pulp
involvement.
Scaling, Curettage, or/& periodontal surgery
EFFECT OF PERIO. PROCEDURES ON PULPAL TISSUE:
EXPOSE:
LATERAL & ACCESSORY CANALS
DENTINAL TUBULES
Unless dentin removal is excessive, pulp response is
Negligible
because even if the pulp is exposed to bacterial challenge, but it is capable of
REPAIR AND HEALING repair and healing
If periodontal treatment is to considered for managing periodontal disease that extend around the apical foramen
curetting the periodontal lesion as a part of treatment will sever the blood supply to the pulp and require
prophylactic endodontic treatment .
CLASSIFICAT
ION PRIMARY
ENDODON
TIC
DISEASE
PRIMARY
PERIODON
TAL
DISEASE TRUE
COMBINE
D
LESIONS PRIMARY
PERIODON
TAL WITH
SECONDAR
Y
ENDODONT
IC DISEASE
PRIMARY
ENDODON
TIC WITH
SECONDA
RY
PERIODON
TAL
DISEASE
Primary Endodontic Lesion
1. Pulp testing :negative due to necrotic pulp.
2. Drainage through PL in gingival sulcus.
3. Periodontal probing: narrow deep isolated pocket
(pseudo-pocket-sinus tract.)
4. History of acute exacerbation
5. Sharp,acute pain
6. Tenderness to pressure and percussion.
7. Slight tooth mobility
8. Localized osseous destruction
Characteristics and Diagnostic Findings
An acute exacerbation of a chronic apical lesion in a tooth
with a necrotic pulp may drain coronally through the PDL into
the gingival sulcus
Treatment : Root canal treatment only
Pre-operative:
Periapical and furcal radiolucency
and a deep narrow periodontal
defect 1 year follow-up :
Complete healing of
radiolucency and buccal defect
Primary Endodontic Lesion
Primary Endodontic Lesion with
2ry periodontal involvement
1. Pulp testing :negative (necrotic pulp or failed RCT)
2. Continuous irritation of periodontium from necrotic
pulp or failed root canal treatment.
3. Isolated deep pocket and attatchment loss.
4. Purulent pocket resulting in periodontal breakdown.
5. Superimposition of plaque & calculus.
Characteristics and Diagnostic Findings
Treatment
First: Root canal treatment
Then: Periodontal treatment
Pre-operative interradicular defect extends to the apex
Post-operative
1 year follow-up
Primary Endodontic Lesion with
2ry periodontal involvement
When only endodontic therapy is provided then only part of
the lesion expected to heal.
Characteristics and diagnostic findings
1. Pulp test: positive (vital pulp)
2. Generalized bone loss
3. Plaque or calculus build up
4. Broad based pockets that bleed easily when
probed.
5. Tooth mobility
6. Receding gums that expose the root of the
tooth .
Primary Periodontal lesion.
Treatment:
• Oral hygiene instructions
• Scaling and root planning
• Periodontal surgery to remove granulation
tissues
Primary Periodontal lesion.
Characteristics and Diagnostic
Findings
• Periodontal destruction.
• History of periodontal disease
• Generalized periodontal disease..
• Tooth mobility
• Deep pocketing (the apical
progression
of a periodontal pocket continues until
the apical tissues are involved)
Treatment:
1) Root Canal Treatment
2) Periodontal surgery
Primary periodontal lesion with
2ry endodontic involvement.
True Combined Endo-Perio Lesions
Characteristics
-Separate progression of endodontic disease and periodontal disease
-The tooth remained untreated and consequently the two lesions joined
together.
Treatment:
- Root Canal Treatment
- Periodontal Treatment
- Apical microsurgery to remove granulation tissue
- Resective approaches
- Regenerative therapy
True Combined Concomitant
True combined perio-endo lesion.
❑Procedure to eliminate the weak, diseased root to allow the stronger root (s) to survive.
Root resection
(Amputation:)
Treatment Alternatives:
Hemisection.
Surgical division of multi-rooted teeth & the removal of the defective half.
Regenerative treatment
Reproduction or reconstruction of a lost or
injured part .”
Guided Tissue Regeneration Procedures
attempting to regenerate lost periodontal
structures
Guided bone regeneration typically refers to ridge
augmentation or bone regenerative procedures.
THANK YOU
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