by: Aleia S.Guzman DDM-6A

ENDO-PERIO RELATIONSHIP

Periodontal therapy deals with many aspects of the supporting

structures, including the prevention and repair of lesions of the gingival

sulcus. Endodontics deals primarily with disease of the pulp and periapical

tissues. The success of both periodontal and endodontic therapy depends on

the elimination of both disease processes, whether they exist separately or as a

combined lesion. The relationship between periodontal and endodontic

disease has been a subject of speculation for many years. This paper aims at

presenting a comprehensive review of several aspects of perio-endo lesions.

The tooth, the pulp tissue within it and its supporting structures should

be viewed as one biologic unit. The interrelationship of these structures influences

each other during health, function and disease. The interrelationship between

periodontal and endodontic diseases has aroused much speculation, confusion and

controversy. The relationship between the periodontium and the pulp was first

discovered by Simring and Goldberg in 1964. The periodontium and pulp have

embryonic, anatomic and functional interrelationship. Ectomesenchymal cells

proliferate to form the dental papilla and follicle, which are the precursors of the

periodontium and the pulp respectively. This embryonic development gives rise to

anatomical connections, which remain throughout life.

INTRODUCTION

IT IS USED TO DENOTE AN INFLAMMATORY PROCESS IN

THE PERIO DONTAL TISSUES RESULTING FROM NOXIOUS

AGENTS PRESENTS IN THE ROOT CANAL SYSTEM OF THE

TOOTH, USUALLY A ROOT CANAL INFECTION .

WHAT IS ENDODONTIC LESION?

IT IS USED TO DENOTE AN INFLAMMATORY PROCESS IN

THE PERIODONTAL TISSUE RESULTING FROM ACCUMULATION

OF DENTAL PLAQUE ON THE EXTERNAL TOOTH SURFACE .

WHAT IS PERIODONTAL LESION?

Pulpal and periodontal problems are responsible for more

than 50% of tooth mortality. Periodontal disease is a slowly

progressing disease that may have an atrophic effect on the dental

pulp. Periodontal treatments such as deep root planning, usage of

localized medicaments and periodontal injury or wounding may

accelerate pulpal inflammation and provoke the interrelated

disease process.

• Apical foramen

• Accessory cannals

• Congenital absence of cementum exposing dentinal tubules

• Permeability of cementum

• Developmental grooves

• Developmental anomalies such as projections and enamel pearl

PATHWAYS OF COMMUNICATION

• Empty spaces on root created by destroyed shrpey’s fibers

• Root fractures following trauma

• Idiopathic resorption- internal and external

• Loss of cementum due to external irritants

PATHWAYS OF PATHOLOGICAL ORIGIN

These comprise dentinal tubules which contain the odontoblastic

process that extends from the odontoblast at the pulpal dentin border to the

dentino-enamel junction or the cement-dentinal junction. Passage of

microorganisms between the pulp and periodontal tissues is possible through

these tubules, when the dentinal tubules are exposed in areas of denuded

cementum.

TUBULAR PATHWAYS

• Exposure of dentinal tubules following root planing

• Accidental lateral perforation during endodontic procedure

• Root fractures caused by endodontic procedures

PATHWAYS OF IATROGENIC ORIGIN

1. Primary endodontic lesion

2. Primary periodontal lesion

3. Primary endodontic lesion with secondary periodontal

involvement

4. Primary periodontal lesion with secondary endodontic

involvement

5. True combined lesion

CLASSIFICATION OF PERIO-ENDO LESIONS

An acute exacerbation of a chronic apical lesion on a tooth with a

necrotic pulp may drain coronally through the periodontal ligament into the

gingival sulcus. This condition may clinically mimic the presence of a

periodontal abscess. In reality, however, it would be a sinus tract originating

from the pulp that opens into the periodontal ligament. Primary endodontic

lesions usually heal following root canal therapy. The sinus tract extending

into the gingival sulcus or furcation area disappears at an early stage, if the

necrotic pulp has been removed and the root canals are well sealed.

PRIMARY ENDODONTIC LESION

These lesions are caused primarily by periodontal pathogens. In this

process, chronic periodontitis progresses apically along the root surface. In

most cases, pulpal tests indicate a clinically normal pulpal reaction. There is

frequently an accumulation of plaque and calculus and the presence of deep

pockets may be detected.

PRIMARY PERIODONTAL LESION

1. Primary endodontic lesion with secondary periodontal involvement

2. Primary periodontal disease with secondary endodontic involvement

3. True combined lesion

COMBINED DISEASES

Primary endodontic lesion with secondary periodontal involvement

may also occur as a result of root perforation during root canal treatment, or

where pins and posts may have been misplaced during restoration of the

crown. Symptoms may be acute, with periodontal abscess formation

associated with pain, swelling, pus or exudates, pocket formation, and tooth

mobility. A more chronic response may occur without pain, and involves the

sudden appearance of a pocket with bleeding on probing or exudation of pus.

PRIMARY ENDODONTIC LESION WITH SECONDARY PERIODONTAL

INVOLVEMENT

The apical progression of a periodontal pocket may continue until

the apical tissues are involved. In this case, the pulp may become necrotic as a

result of infection entering through lateral canals or the apical foramen. In

single-rooted teeth, the prognosis is usually poor. In molar teeth, the

prognosis may be better. Since not all the roots may suffer the same loss of

supporting tissue, root resection can be considered as a treatment alternative.

PRIMARY PERIODONTAL DISEASE WITH SECONDARY

ENDODONTIC INVOLVEMENT

True combined endodontic periodontal disease occurs less frequently

than other endodontic-periodontal problems. It is formed when an

endodontic lesion progressing coronally joins an infected periodontal pocket

progressing apically.The degree of attachment loss in this type of lesion is

invariably large and the prognosis guarded. This is particularly true in single-

rooted teeth. In molar teeth, root resection can be an alternative treatment.

The radiographic appearance of combined endodontic periodontal disease

may be similar to that of a vertically fractured tooth. If a sinus tract is present,

it may be necessary to raise a flap to determine the etiology of the lesion.

TRUE COMBINED LESION

Bacteria associated with pulpitis:

1. Fusobacterium

2. Prevotella

3. Streptococcus

4. lactobacillus

ETIOLOGY OF PULPAL DISEASE

Reversible pulpitis

• Symptomatic

• asymptomatic

Irreversible pulpitis acute – abnormally response to cold

abnormal response to heat

chronic – asymptomatic with pulp exposure

hyperplastic pulpitis

internal resorption

CLASSIFICATION OF PULPAL DISEASES

GINGIVAL DISEASES :

• Plaque induced gingival disease

• Non plaque induced gingival disease

CHRONIC PERIODONTITIS :

• Localized

• Generalized

AGGRESSIVE PERIODONTITIS:

• Localized

• Generalized

PERIODONTITIS AS A MANIFESTATION

CLASSIFICATION OF PERIODONTAL DISEASE

NECROTIZING PERIODONTAL DISEASE :

• Necrotizing ulcerative gingivitis

• Necrotizing ulcerative periodontitis

PERIODONTITIS ASSOCIATED WITH ENDODONTIC LESION :

• Endo-perio lesion

• Perio-endo lesion

• Combined lesion

ABSCESS OF PERIODNTIUM

• Gingival abscess

• Periodontal abscess

• Pericoronal abscess

• Bone resorption

• Radiolucency at the apex of the root

• Highly vascularized granulation tissue infiltrate to varrying

degrees by inflammatory cells

• Nutrophils are present near the apical foramen

• Plasma cells , macrophages, lymphocytes in fibroblast are

increased in the periphery of the lesion

EFFECTS OF PULPAL DISEASE ON PERIODONTIUM

• Visual examination

• Palpation

• Percussion

• Mobility

• Radiographs

• Pulp vitality testing

• Pocket probing

• Fistula tracking

• Cracked tooth testing

VARIOUS DIAGNOSTIC PROCEDURES THAT CAN BE

USED TO IDENTIFY PERIO ENDO LESIONS

Soft tissues:

• Inflmmation

• Ulcerations

• Sinus tracts

Teeth:

• Caries

• Deffective restorations

• Abrasions

• Crack

• Fractures

• Discolorations

VISUAL EXAMINATION

• Periradicular abnormalities

• Cannot differentiate between endodontic and periodontic

lesion

• Compare with control teeth

PALPATION

• Compare with control teeth

• Periraducular inflammation

PERCUSSION

• Loss of periodontal support

• Fractured roots

• Recent traumas

• Periradicular abscess

MOBILITY

• Periradicular resorption of endodontic origin- not

effective

• Bone loss due to periodontal disease- effective

RADIOGRAPHS

• Abnormal response- degenerative changes

• No response- pulp necrosis

• Modern transient response- normal vital pulp

• Quick painful response- reversible pulpitis

• Lingering painful response- irreversible pulpitis

PULP VITALITY TESTING

• Probing depth

• Clinical attachment level

• Sinus tracking

POCKET PROBING

• Semi-rigid radiopaque material (gutta percha)

FISTULA TRACKING

• Transillumination

• Wedging

• staining

CRACKED TOOTH TESTING

PRIMARY ENDODONTIC LESION –

conventional endodontic therapy

PRIMARY ENDODONTIC LESION WITH SECONDORY PERIODONTAL INVOLVEMENT –

endo-perio therapy

PRIMARY PERIODONTAL LESION -

Periodontal therapy

Guided tissue regeneration

Root amputation and hemisection

Pulp space therapy

TREATEMENT

PRIMARY PERIODONTAL LESION WITH SECONDARY ENDO LESION:

Space therapy

Periodontal therapy

Root amputation

GTR

TRUE COMBINED LESION

Endo therapy

Perio therapy

hemisection

bicuspidization

Root amputation

TREATMENT

THANK YOU !!!

• https://docs.google.com/presentation/d/1-

yp7WAURWOyETkyKhts8xAFMFpC0-

_4ra7Q8FqzCDYA/edit?pli=1#slide=id.p42

• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2813095/

SOURCES: