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.

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