ETIOPATHOGENESIS OF PERIO-ENDO

LESIONS

The term “perio-endo” lesion has been used to describe lesions due to inflammatory
products found in varying degrees in both the periodontal tissue and the pulpal tissues. As
the pulp and the periodontal tissue are related, there are many avenues of
communications present between them.

Pathways of pulpal and periodontal communications:

These are classified in to

1- Anatomical pathways:
a. Dentinal tubules: exposed dentinal tubules in area of denuded cementum may serve
as communication pathways between pulp and periodontal ligament. This may occur due
to developmental defect ( when the cementum and enamel do not meet at CEJ leaving an
area of exposed dentine) , caries or periodontal procedures.

b. Lateral and accessory canal: which may present any where along the root. However
the majority of them are found in the apical third of the root and the furcation area of
molars. These canals contain connective tissue and vessels. However the presence of
patent canal is a potential pathway for the spread of microorganisms and toxic product
resulting in a direct inflammatory changes in the periodontal ligament and vice versa.

c. Apical foramen: it is the principal and the most direct route for communication
between the pulp and the periodontal tissue in which the bacterial and inflammatory
byproducts may exit directly through it causing periapical or periodontal pathosis.

2- Non-physiological pathways:
a. Root resorption: Which removes the protecting cementum layer. Also It may extend
deeply reaching the pulp and creating a new pathway of communication.

b. Root caries: carious lesion with accumulated bacteria and denuded dentine increase
the possibility of communication through dentinal tubules.

3- Iatrogenic pathways:
a. Root perforation: which is undesirable clinical complications that may lead to
treatment failure. It may occur due to operator error during root canal instrumentation or
post preparation as well as extensive carious or resorptive lesions.
b. Root fracture: either vertical or horizontal fracture. This will lead to a communicating
pathway between the pulp and the peridontium . The closer the fracture line to the sulcus
the worst the prognosis.

The effect of peridontium on the pulp

A- Effect of periodontal lesions on the pulp:

The effect of periodontal lesions on the pulp can result in either atrophic changes,
inflammation or resorption.

Atrophic changes: Due to impaired nutrition, the pulp cells slowly degenerate leading to
localized areas of coagulative necrosis in the pulp. These areas are eventually walled off
from the rest of the healthy pulp tissue by collagen.
However, With slowly advancing periodontal disease, cementum deposition may act to
obliterate lateral canals before pulpal irritation occurs. This may explain why periodontally
involved teeth demonstrate pulpal atrophy and canal narrowing.

Inflammatory changes: Microbial agents are the main cause in the evolution of perio-endo
lesions thus the formation of bacterial plaque on denuded root surfaces, following
periodontal disease, has the potential to induce pathologic changes in the pulp. This
process has been referred to as retrograde pulpitis

Resorption: When the periodontal lesions are deep, resorption may found on the sides of
the roots or within the root canals, often opposite lateral canals, and at the apical foramen.

B- Effects of periodontal treatment procedures on the dental pulp:

Scaling and root planing – This procedure removes the bacterial deposits. However,
improper root planning procedures can also remove cementum and the superficial parts of
dentin, thereby exposing the dentinal tubules to the oral environment. Subsequent
microbial colonization of the root dentin may result in bacterial invasion of the dentinal
tubules.

Acid etching : Root conditioning using citric acid during periodontal regenerative therapy
helps to remove bacterial endotoxin and anaerobic bacteria and to expose collagen
bundles to serve as a matrix for new connective tissue attachment to cementum.Though
beneficial in the treatment of periodontal disease, citric acid removes the smear layer, an
important pulp protector.

Effect of pulp on the peridontium:

A- Effects of endodontic infection on the periodontium:
Pulp degeneration together with the presence of microorganisms and their byproduct can
reach the periodontal ligament through the apical foramen and / or the lateral canals.
However, these are actually depend on the virulence of the microorganism, the duration of
infection and the host defense. This situation was named as retrograde periodontitis.
Also inadequate endodontic treatment with poor obturation that lack adequate seal will
also leads to periodontal disease.

B- The effect of endodontic procedures on the peridontium:

Intracanal medicaments: If improperly used in excess amount or in high concentration will
have a toxic effect on the surrounding tissues.

Root perforation: either during coronal/ radicular access, root canal instrumentation or post
preparation creating a direct route of communication.

CLASSIFICATION OF PERIO-ENDO LESIONS

Perio-endo lesions can be classified into:

A. PRIMARY ENDODONTIC LESION:

Cause:
Caries, restorative procedures and traumatic injuries cause inflammatory changes in the
pulp . Accumulation of inflammatory products leads to bone resorption apically and
laterally with destruction of attachment apparatus adjacent to the infected non vital tooth.
In these condition the tooth simulates peridontal disease but in fact it is due to pulpal
inflammation and/ or necrosis.

Diagnosis of primary endodontic lesion:

Signs and symptoms: this condition may or may not present with clinical signs of
inflammation such as pain, tenderness to percussion, increased tooth mobility and swelling
of the marginal gingiva (simulating periodontal abscess).
The most significant sign is the the presence of a deep solitary pocket in the absence of
periodontal problem in any other area in the mouth.
Pulp vitality: Non vital tooth

Radiographic examination:
Periapical radiolucency that may extend to along the lateral surface of the root and in the
furcation area of molars.
Tracing with gutta percha points to the root apex

Treatment endodontic treatment only.

Prognosis:
Excellent prognosis with complete resolution is usually anticipated after conventional
endodontic therapy.
B. PRIMARY PERIODONTAL LESION

These lesions are caused primarily by periodontal pathogens. In this process, the
peridontal disease will affect the pulp through dentinal tubules, lateral canals or both.

Signs and symptoms:

The presence of deep pocket together with a history of extensive peridental disease in the
form of numerous defects throughout the mouth and subgingival calculus is usually
detected. The patient may reports accentuated pain and clinical signs of pulpal disease.

Vitality test:
Teeth are vital and will react to cold test with sharp brief pain response that usually does
not last more than few seconds.

Radiographic examination:
These lesions may be indistinguishable from primary endodontic disease with secondary
periodontal involvement.
Tracing gutta percha points to the lateral surface of the root.

Prognosis:
The prognosis depends upon the stage of periodontal disease and the efficacy of peri-
odontal treatment..
C. COMBINED DISEASES:

1- Primary endodontic lesion with secondary periodontal involvement:

Causes:
- If a primary endodontic lesion remains untreated, the pathosis may continue and distract
the surrounding alveolar bone causing secondary involvement of periodontal tissues.

- 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.

- Root fractures may also present as primary endodontic lesions with secondary
periodontal involvement.

Signs and symptoms:

Plaque or calculus accumulation, with the presence of single and narrow pocket.
The tooth is non vital .

Radiographic examination:
Generalized periodontal disease with angular defect at the initial site of the endodonticly
affected tooth.

Treatment and prognosis:

Resolution of the primary endodontic and secondary periodontal lesions relies on the
treatment of both conditions.

2- Primary periodontal disease with secondary endodontic involvement:

Cause:
Plaque and calculus accumulation with periodontal disease can affect the pulp through
dentinal tubules, lateral canals or both.

Signs and symptoms:

Deep pocket with the history of periodontal disease. The patient often reports pain and
clinical signs of inflammation.

Radiographic examination:
These lesions are indistinguishable from primary Primary endodontic lesion with
secondary periodontal involvement.

Treatment:
Both endodontic and periodontal treatment are required .

3- True combined lesion:

Cause:
True combined endodontic periodontal disease occurs less frequently than other
endodontic-periodontal problems. It is formed when an pupal and periodontal disease
occur independently in and around the same tooth. Once the endodontic and periodontal
lesions coalesce, they may be clinically indistinguishable.

Clinical examination:
A necrotic pulp or failing endodontic treatment, plaque, calculus and peridontitis are
present in a varying degree.

The prognosis depends largely on the extent of the destruction caused by periodental
disease.

4- Concomitant pulpal snd periodontal lesions:

Both pulpal and periodontal diseases exit with different causative factors and with no
clinical evidence that either disease state had influenced the other.
Both diseases should be treated concomitantly, with the prognosis dependent on the
removal of the individual etiological factors and prevention of any further factors that may
affect the respective disease processes.
 Pulpal disease Periodental disease
Cause Pulpal infection Periodontal infection
Pain
- acute stage Severe Moderate
- chronic stage Moderate Moderate
Swelling Apical to the In the attached gingiva
mucogingival junction
Sinus tract Should be traced using gutta percha point
Restoration Deep or extensive Not related
Plaque or calculus Not related Primary cause
Inflammation Acute Chronic
Pocket Single and narrow Multiple, wide coronally
Radiograph

- pattern Localized Generalized

- bone loss Wide apical Wide coronal
- periapical Radiolucent Not often related
- vertical bone loss No Yes
Vitality Non vital Vital
Histopathology
- junctional epithelium No apical migration Apical migration
- granulation tissue
- gingiva Apical Coronal
Normal Recessed
Treatment Root canal treatment Periodontal treatment

If the traditional endodontic and periodontal treatments are insufficient

to stabilize the affected tooth, the clinician must consider treatment
alternatives such as:
- Regenerative approach:
Recently the concept of GTR or guided bone regeneration (GBR) has been
used to promote bone healing after endodontic surgery. Theoretically, the
GTR barrier prevents contact of connective tissue with the osseous walls of
the defect, protecting the underlying blood clot and stabilizing the wound.

- Root resection / amputation:

It is considered as a corrective surgery in which the the diseased root ( in which root
fracture, caries, resorption, or blocked canal is present) is surgically removed followed by
restoration of the remaining tooth structure.
It usually depends on the amount of the remaining tooth structure, the amount of occluding
forces on the tooth and the periodontal condition.

INDICATIONS FOR ROOT AMPUTATION:

1. Existence of periodontal bone loss to the extent that periodontal therapy and patient
maintenance do not sufficiently improve the condition.
2. Destruction of a root through resorptive processes, caries, or mechanical perforations.
3. Surgically inoperable roots that are calcified, contain separated instruments, or are
grossly curved.
4. The fracture of one root that does not involve the other.

CONTRAINDICATIONS FOR ROOT AMPUTATIONS:

1. Lack of necessary osseous support for the remaining root or roots.
2. Fused roots or roots in unfavorable proximity to each other.
3. Remaining root or roots endodontically inoperable.
4. Lack of patient motivation to properly perform home-care procedures.

Two different approaches to resection are available.

One approach is to amputate horizontally or obliquely the involved root at the point where
it joins the crown, a process termed root amputation.
The other approach is to cut vertically the entire tooth in half from mesial to distal of the
crown in the maxillary molars, and from buccal to lingual of the crown in the mandibular
molars removing in either case the pathologic root and its associated portion of the crown.
This procedure is termed hemisection.