Endo-Perio Seminar 1

Endo-Perio
Lesions 101
Presentation by
Doble, Kyla Mariah T.
Introduction to
Endodontics and
Periodontics

Endo-Perio Seminar 1
Introduction to
Endodontics and
Periodontics

Endo-Perio Seminar 1
 Definition of Endodontics
The word endodontics comes from the Greek prefix “endo-”
meaning 'within' and “odont" meaning 'tooth.
That branch of dentistry concerned with the morphology,
physiology, and pathology of the human dental pulp and
periradicular tissues.
Its study and practice encompass the basic and clinical sciences
including biology of the normal pulp, the etiology, diagnoses,
prevention, and treatment of diseases and injuries of the pulp and
associated periradicular tissues.

Endo-Perio Seminar 1
Objectives of
Endodontics
Objective #1
To know the importance and
significance of endodontic therapy.

Objective #2
To know the different ways of
assessing success and failure in
endodontic treatment.

Endo-Perio Seminar 1
Objectives of
Endodontics
Objective #3 Objective #4
To know how endodontic therapy
To recognize the importance of
has evolved into what it is today.
patient recall.

Objective #5
To define each principle in
endodontic therapy and give an
overview of its significance in
endodontic treatment.

Endo-Perio Seminar 1
 Endodontics includes, but is not limited to:
Differential Diagnosis
Treatment of oral pains of pulpal and/or periapical origin

Scope of
(orthograde /conventional RCT)
Vital pulp therapy
Pulp capping
Endodontics Pulpotomy
Nonsurgical treatment of root canal systems with or
without periradicular pathosis of pulpal origin
Selective surgical removal of pathological tissues resulting
from pulpal pathosis
Intentional replantation and replantation of avulsed teeth
Surgical removal of tooth structure:
Root-end resection
Bicuspidization
Hemisection
Apicoectomy (retrograde/non-conventional
endodontics)
Bleaching of discolored dentin and enamel
Retreatment of teeth
Treatment procedures related to coronal restorations
 Definition of Periodontics
The word “periodontics” comes from two Greek words, “peri” which
means around and “odons” which means tooth.
It is a branch of dentistry that deals with the supporting structures
located around the teeth which are known collectively as the
periodontium.
Periodontics is a dental specialty that focuses on the diagnosis,
treatment, and management of diseases and conditions affecting
the tissues surrounding and supporting the teeth.

Endo-Perio Seminar 1
The periodontium is composed of the following:
Gingiva - A firm masticatory mucosa which covers the alveolar
bones and the investing tissues at the neck of the tooth
Cementum - Mineralized, non-homogenous connective tissue
which covers the CEJ to the apical foramen. It is the only tooth
tissue considered as a component of both tooth and periodontium
Periodontal Ligaments - An extraordinary fiber-rich, cell-rich,
dense connective tissue located between the alveolar bone proper
and the root surfaces of the tooth. It binds the cementum of the
roots to the alveolar bone
Alveolar Bone - A tooth dependent structure that is the extension
of the mandible and the maxilla, forming the sockets wherein the
roots of the teeth are embedded.

Endo-Perio Seminar 1
 Objectives of
Periodontal Therapy
Objective #1 Objective #2
To preserve the periodontium, as
To preserve the natural dentition.
well as peri-implant tissues.

Objective #3
To maintain and improve peri-
implant health, comfort, esthetics
and function.

Endo-Perio Seminar 1
 Scope of
Periodontics Periodontics is inclusive of the following:
Diagnosis and assessment of periodontal disease
Non-surgical periodontal therapy
Surgical periodontal therapy
Dental implant therapy
Maintenance and supportive therapy
Oral medicine and oral pathology
Orthodontic and orthopedic therapy
Esthetic periodontal therapy
Relationship of
the Pulp and
Periodontium

Endo-Perio Seminar 1
 Relationship of the
Pulp and
Periodontium
There is an intimate inter-relationship of the dental pulp and the
periodontium. Anatomically there is a pathway between the pulp
and the periodontium, via the apical foramina, dentinal tubules,
and lateral or accessory canals.
Because of the inter-relationship between the pulp and the peri-
radicular tissues, pulpal inflammation causes inflammatory
changes in the periodontal ligament even before the pulp
becomes totally necrotic. Infective organism and their toxins,
tissue debris, and products of tissue necrosis from the pulp
reach the periapical area through the various foramina of the
root canals and give rise to inflammatory and immunologic
reactions.
 Relationship of the
Pulp and
Periodontium
The periodontium and the dental pulp are closely associated,
sharing embryonic, functional, and anatomical
interrelationships.
A century ago, Turner and Drew described for the first time the
effect of periodontal diseases on the pulp tissue. Then, in 1964
Simiring and Goldberg [2] described a disease of the
periodontium caused by a pulpal disease, termed “Retrograde
periodontitis.”
 What is Retrograde
Periodontitis?
Unlike marginal periodontitis, in which the disease
proceeds from the gingival margin as the source of
infection toward the tooth apex, in “retrograde
periodontitis” the pulp is the source of the
pathogens affecting the periodontium, potentially
causing a periodontal disease, contributing to a
periodontal disease, or preventing healing of a
periodontal disease.
Simiring and Goldberg also explained that these
two processes generally exist side by side, and may
have the same signs and symptoms. Thus, they
may be difficult to distinguish.

Endo-Perio Seminar 1
Differential
Diagnosis

Endo-Perio Seminar 1
 Diagnosis
The purpose of a diagnosis is to determine what problem the patient is having, and why
the patient is having that problem. Ultimately, this will directly relate to what treatment, if
any, will be necessary.
To arrive at an accurate diagnosis, the following must be obtained:
a. Chief Complaint - A subjective statement, provided by a patient that describes the
most significant or serious symptoms that caused him to seek dental care, and is
generally recorded in the patient's own words.
b. History of Present Illness -A chronological description of the development of the
patient's present illness from the first sign and/or symptom or from the previous
encounter to the present.
c. Medical History - Includes the current medical conditions of the patient which can
influence both the diagnosis and course of treatment.
d. Dental History - The chronology of events that lead up to the chief complaint is
recorded as the dental history. This information will help guide the clinician as to which
diagnostic tests are to be performed.

Endo-Perio Seminar 1
Differential
Diagnosis
between
Pulpal and
Periodontal
Disease
 Diagnostic
Procedures

Endo-Perio Seminar 1
Visual Examination

This involves the examination of the teeth, the

gingiva and anything that can be seen clinically.
The presence of caries, extensive restorations,
discolored crowns are commonly associated with
an endodontic lesion.
The absence of coronal defect in the tooth in
conjunction with plaque, calculus, and a
generalized gingivitis or periodontitis are
suggestive of a periodontal lesion.
 Radiographic
Examination

Radiographic examination can elicit useful

information that would play a role in treatment
planning.
Pathological anomalies can easily be seen through
radiographs, however a definitive diagnosis should
not solely be derived from this diagnostic
procedure alone.
 Vitality Tests

Heat Test
Heat testing is most useful when a patient’s chief
complaint is intense dental pain on contact with
any hot liquid or food.
Heat test is done by applying heated gutta percha
or compound stick to the surface of the tooth. If
this method is used, a light layer of lubricant
should be placed onto the tooth surface before
applying the heated material to prevent the hot
gutta-percha or compound from adhering to the
dry tooth surface.
 Vitality Tests

Cold Test
The most popular method of performing cold
testing is with a refrigerant spray. The sprayed
cotton pellet should be applied to the midfacial
area of the tooth or crown.
As with any other pulp testing method, adjacent or
contralateral “normal” teeth should be tested to
establish a baseline response.
 Vitality Tests

Electric Pulp Test (EPT)

The response of the pulp to electric testing does
not reflect the histologic health or disease status
of the pulp. A response by the pulp to the electric
current only denotes that some viable nerve fibers
are present in the pulp and are capable of
responding.
The tip of the testing probe that will be placed in
contact with the tooth structure must be coated
with a water- or petroleum-based medium. The
coated probe tip is placed in the incisal third of
the facial or buccal area of the tooth to be tested.
 Palpation Test

In the course of the soft tissue examination, the

alveolar hard tissues should also be palpated.
Emphasis should be placed on detecting any soft
tissue swelling or boney expansion, especially
noting how it compares with and relates to the
adjacent and contralateral tissues.
 Percussion Test
If the patient is experiencing acute sensitivity or
pain on mastication, this response can typically be
duplicated by individually percussing the teeth,
which often isolates the symptoms to a particular
tooth.
Pain to percussion does not indicate that the
tooth is vital or nonvital, but is rather an indication
of inflammation in the periodontal ligament.
The test should be performed using the blunt end
of a mouth mirror handle. The teeth should first be
percussed occlusally, and if the patient discerns
no difference, the test should be repeated,
percussing the buccal and lingual aspects of the
teeth.
 Mobility Test

An increase in tooth mobility is not an indication of

pulp vitality. It is merely an indication of a
compromised periodontal attachment apparatus.
The back ends of two mirror handles should be
used, one on the buccal aspect of the tooth, and
one on the lingual aspect of the tooth.
Any mobility over +1 mobility should be considered
abnormal. However, the teeth should be evaluated
on the basis of how mobile they are relative to the
adjacent and contralateral teeth.
Periodontal Probing
The measurement of periodontal pocket depth is
an indication of the depth of the gingival sulcus,
which corresponds to the distance between the
height of the free gingival margin and the height
of the attachment apparatus below.
The periodontal probe is “stepped” around the
long axis of the tooth, progressing in 1-mm
increments.
Periodontal bone loss that is wide, as determined
by a wide span of deep periodontal probings, is
generally considered to be of periodontal etiology
and is typically more generalized in other areas of
the mouth.
Sinus Tract Tracing

On occasion a chronic endodontic infection will

drain through an intraoral communication to the
gingival surface and is known as a sinus tract.
To trace the sinus tract, a size #25 gutta-percha
cone is threaded into the opening of the sinus
tract. Although this may be slightly uncomfortable
to the patient, the cone should be inserted until
resistance is felt.
After a periapical radiograph is exposed, the
termination of the sinus tract is determined by
following the path taken by the gutta-percha
cone.
 Cavity Test

This method is used only when all other test

methods are deemed impossible or the results of
the other tests are inconclusive.
This is accomplished with a high-speed #1 or #2
round bur with proper air and water coolant. The
patient is not anesthetized while this procedure is
performed, and the patient is asked to respond if
any painful sensation is felt during the drilling
procedure.
 Cavity Test

This method is used only when all other test

methods are deemed impossible or the results of
the other tests are inconclusive.
This is accomplished with a high-speed #1 or #2
round bur with proper air and water coolant. The
patient is not anesthetized while this procedure is
performed, and the patient is asked to respond if
any painful sensation is felt during the drilling
procedure.
 Staining and
Transillumination

To determine the presence of a crack in the

surface of the tooth, the application of a stain to
the area is often of great assistance.
Applying a bright fiberoptic light probe to the
surface of the tooth is also helpful.
Etiology of Pulpal
and Periodontal
Diseases

Endo-Perio Seminar 1
 Etiology of Pulpal
Diseases
According to Grossman:
Physical Bacterial
Mechanical Toxins
Trauma Direct Invasion of Pulp
Pathologic Wear Anchoresis
Cracked Tooth Syndrome
Barodontalgia
Thermal
Chemical
Phosphoric Acid
Acrylic Monomers
Erosion
 Etiology of Pulpal
Diseases
According to Ingle: Radicular Ingress
Bacterial
Caries
Coronal Ingress
Retrogenic Infection
Caries - the most common cause
Periodontal Pocket
of ingress of bacteria to pulp.
Periodontal Abscess
Fracture
Hematogenic Infection
Complete
Traumatic
Incomplete (E.g., Cracks,
Acute
Infraction)
Coronal Fracture
Non-fracture Trauma
Radicular Fracture
Anomalous Tract
Vascular Stasis
Dens Invaginatus
Luxation
Dens Evaginatus
Avulsion
 Etiology of Pulpal
Diseases
Chronic
Bruxism Rhinoplasty
Attrition Osteotomy
Abrasion Chemical
Erosion Restorative Materials
Iatrogenic Cements
Cavity Preparation Plastics
Restoration Etching Agents
Intentional Extirpation and Root Cavity Liners
Canal Filling Dentin Bonding Agents
Orthodontic Movement Tubule Blockage Agents
Periodontal Curettage Disinfectants
Electrosurgery Silver Nitrate
Phenol
Etiology of Pulpal
Diseases

Desiccants
Alcohol
Ether
Idiopathic
Aging
Internal Resorption
External Resorption
Hereditary Hypophosphatemia
 Etiology of
Periodontal Diseases

Local Factors Systemic Factors

Poor oral hygiene leading to plaque Genetics
and calculus build-up Autoimmune or systemic diseases
Tobacco use Endocrine disorders (i.e., Diabetes
Bruxism Mellitus)
Malocclusion Hormonal changes in the body
Poorly designed dentures Certain medications (i.e., Calcium
channel blockers such as Nifedipine)
 Pathways of
Communication
between the Pulp
and Periodontium

Endo-Perio Seminar 1
 Direct communication between the pulp and periodontal ligament
exists by way of the dentinal tubules, the lateral and/or accessory
Communication canals and the apical foramina. These pathways of communication
may be divided into 3 categories.
Pathways of

1 Developmental

2 Pathological

3 Iatrogenic
 Apical Foramina
It is the most direct route of communication between pulp
and periodontium.
Entrance of irritants (bacteria, toxins, etc.) through the
apical foramen can cause an inflammatory response in the

Developmental periapical area which in turn leads to destruction of apical

periodontal ligaments, and resorption of bone, cementum,
and dentin.

Lateral Accessory Canals

These can be found anywhere in the root. However, they
present more frequently in posterior teeth than in anterior
teeth, and more in apical portion than coronal portion.
Due to direct vascular communication between pulp space
and periodontium through lateral canals, infection can
spread from pulp to periodontium and cause destruction of
periodontal ligaments and subsequent periodontal pocket
formation.
However, spread of infection from periodontium to pulp
through lateral canals rarely occur, due to high vascularity
and defense system of vital pulp.
 Furcation Accessory Canals
Furcation canals are classified as lateral canals located at
the pulp chamber floor or on the coronal aspect of a root
canal of premolars and molars.
They are physiological communication pathways between

Developmental the endodontic and the periodontal tissues alongside

apical foramen and dentinal tubules.
Although rarely identified clinically, they are an important
anatomic entity, as they can be responsible for the
presence of an inter-radicular lesion and an endo-
periodontal lesion.

Dentinal Tubules
Odontoblasts have cytoplasmic extensions called
odontoblastic processes that run horizontally from the pulp
to the cementum and to the enamel.
When there is congenital loss of cementum or presence of
caries, or removal of cementum due to recent periodontal
treatment, infection can reach the periodontium.
Pathological Iatrogenic
Empty spaces created by Exposure of dentinal tubules
destroyed Sharpey’s fibers following root planning
Root fracture following Accidental lateral perforation
trauma/endodontic therapy during endodontic therapy
Idiopathic resorption
Internal/ External
Classification
of Pulpal
Diseases
Endo-Perio Seminar 1
Pulpitis

01 Reversible Pulpitis
One of the earliest forms of pulpitis.
Referred to as “pulp hyperaemia”.
Pain is not spontaneous and it occurs due to the stimulation of A
delta nerve fibers.
Can be classified into 2:
Symptomatic
Thermal stimuli, usually cold, causes a quick, sharp,
hypersensitive response that subsides as soon as stimulus
is removed.
Asymptomatic
Pain is absent, but incipient caries on the enamel may be
seen.
Pulpitis
02 Irreversible Pulpitis
A persistent inflammatory condition of the pulp
caused by a noxious stimulus.
Pain occurs spontaneously and it persists for
several minutes to hours and lingers on even
after removal of stimulus.
Early symptoms may include sharp, and
piercing pain and it may be intermittent or
continuous which occurs due to stimulation of
C- fibers.
Can be classified into 2:
Acute
Abnormally Responsive to Cold
Abnormally Responsive to Heat
Pulpitis

02 Irreversible Pulpitis

Chronic
Asymptomatic with Pulp Exposure
Hyperplastic Pulpitis
A reddish cauliflower like growth of
pulp tissue through & around a carious
exposure of young pulp characterized
by development of granulation tissue.
Pulpitis

02 Irreversible Pulpitis

Internal Resorption
It is an idiopathic slow or fast
progressive resorptive process
occurring in the dentin of the pulp
chamber or root canals of the tooth.
It is a painless condition stimulated by
trauma which produces dentin
destruction.
Tooth is asymptomatic but on
perforation of root pain occurs.
Pulp Degeneration
Generally present in older people.
It may be the result of persistent, mild irritation and can also
be induced by attrition, abrasion, erosion, bacteria, etc.
It presents in 3 forms:
Calcific
It occur when part of pulp tissue is replaced by calcific
materials
Examples include Pulp Stones (denticles).
Atrophic
Decrease in size occurs slowly as the tooth grows old.
Fewer stellate cells are present & intracellular fluid is
increased.
Fibrous
A condition wherein replacement of cellular elements
with fibrous tissue occurs.
Pulp Necrosis
Death of the pulp.
There are 2 Types of Pulp Necrosis:
Coagulation Necrosis - The soluble part of tissue is
converted into solid material.
Caseation - A form of coagulation necrosis in which
the tissue is converted into a cheesy mass consisting
chiefly of coagulation proteins, fats and water.
Liquefaction Necrosis - Necrosis which results when
proteolytic enzymes convert the tissue into a softened
mass, a liquid, or amorphous debris.
Classification
of Periodontal
Diseases
Endo-Perio Seminar 1
Gingivitis
01 Plaque Induced Gingivitis
An inflammatory response of the gingival tissues
resulting from bacterial plaque accumulation located
at and below the gingival margin.
Some of the symptoms include bleeding during
brushing the teeth, swelling and redness of the gingiva,
as well as halitosis in established forms.
The severity of plaque-induced gingivitis can be
influenced by tooth and root anatomy, restorative and
endodontic considerations, and other tooth-related
factors.
Gingivitis
02 Non-plaque Induced Gingivitis
These are often manifestations of systemic
conditions, but they may also represent
pathologic changes limited to gingival tissues.
Although these lesions are not directly caused by
plaque, their clinical course may be impacted by
plaque accumulation and subsequent gingival
inflammation.
Non-plaque Induced Gingivitis may be associated
with the following:
Genetic/ Developmental Disorders
Specific Infection
Inflammatory and Immune Conditions
Neoplasms
Endocrine and Metabolic Disorders
Chronic Periodontitis
Can be defined as “an infectious disease resulting in
inflammation within the supporting tissues of the
teeth, progressive attachment loss, and bone loss.”
Previously known as adult periodontitis or chronic
adult periodontitis.
Occurs as a result of extension of inflammation from
the gingiva into deeper periodontal tissue.
May be classified into 2:
Localized - <30% of sites affected
Generalized - >30% of sites affected
Aggressive Periodontitis
Aggressive periodontitis refers to periodontal disease
of an aggressive and rapid nature that usually occurs
in patients younger than 30 years.
The severity of the disease appears to be an
exuberant reaction to a minimum amount of plaque
accumulation and may result in early tooth loss.
May be classified into 2:
Localized - <30% of sites affected
Generalized - >30% of sites affected
Necrotizing Ulcerative
Gingivitis
The infection is caused by an abnormal overgrowth of
the bacteria that normally exist harmlessly in the
mouth.
Poor oral hygiene usually contributes to the
development of ANUG, as do physical or emotional
stress, poor diet, and lack of sleep.
Symptoms include gingival bleeding, excessive saliva
production, halitosis, and the presence of ulcers
covered with a layer of necrotic tissue.
Necrotizing Ulcerative
Periodontitis
It is characterized by its aggressive nature and rapid
onset, leading to extreme pain, gingival necrosis,
interdental ulceration, and in more advanced stages,
osteonecrosis.
A condition wherein there is attachment loss in the
gingiva, the periodontal ligament, and the alveolar
ligament, caused by infection.
Periodontitis Associated
with Endodontic Lesion
This may be classified into 3:
Endo-Perio lesion
Perio-Endo lesion
Combined Lesion
Abscess of Periodontium
Gingival Abscess
Gingival abscesses tend to involve the marginal
gingiva and result from entrapment of food and
plaque debris and subsequent bacterial
overgrowth.
Localized swelling, erythema, tenderness, and
fluctuance in the space between the tooth and
gingiva ensue. There may be spontaneous purulent
drainage from the gingival margin, or an area of
abscess pointing. .
Abscess of Periodontium

Periodontal Abscess
They usually present as tenderness to percussion or
pain with chewing over the involved tooth.
A parulis may also simulate a gingival abscess;
however, a parulis represents the cutaneous
manifestation of a deeper periapical abscess.
Abscess of Periodontium
Pericoronal Abscess
A partially erupted or impacted 3rd molar (wisdom
tooth) is the most common site of pericoronitis and
pericoronal abscesses.
The accumulation of food and debris between the
overlying gingival flap and crown of the tooth
creates a focus for pericoronitis and subsequent
abscess formation.
Diagnosis of Pulpal
and Periodontal
Diseases

Endo-Perio Seminar 1
Pulpal Diseases
Can be divided into 7:
Normal Pulp
Reversible Pulpitis
Symptomatic Irreversible Pulpitis
Asymptomatic Irreversible Pulpitis
Pulp Necrosis
Previously Treated
Previously Initiated Therapy

Endo-Perio Seminar 1
 Normal Pulp

Teeth with normal pulp do not exhibit any spontaneous symptoms. The
pulp will respond to pulp tests, and the symptoms produced from such
tests are mild, do not cause the patient distress, and result in a
transient sensation that disappears in seconds.
Radiographically, there may be varying degrees of pulpal calcification
but no evidence of resorption, caries, or mechanical pulp exposure.
No endodontic treatment is indicated for these teeth.
 Reversible Pulpitis

When the pulp within the tooth is irritated so that the stimulation is
uncomfortable to the patient but reverses quickly after irritation, it is
classified as reversible pulpitis.
Conservative removal of the irritant will resolve the symptoms.
Confusion can occur when there is exposed dentin, without evidence of
pulp pathosis, which can sometimes respond with sharp, quickly
reversible pain when subjected to thermal, evaporative, tactile,
mechanical, osmotic, or chemical stimuli. This is known as dentin (or
dentinal) sensitivity (or hypersensitivity).
 Symptomatic
Irreversible Pulpitis
Teeth that are classified as having symptomatic irreversible pulpitis exhibit
intermittent or spontaneous pain. Rapid exposure of teeth in this category to
dramatic temperature changes (especially to cold stimuli) will elicit heightened
and prolonged episodes of pain even after the thermal stimulus has been
removed.
The pain in these cases may be sharp or dull, localized, diffuse, or referred.
Typically there are minimal or no changes in the radiographic appearance of the
periradicular bone.
With advanced irreversible pulpitis a thickening of the periodontal ligament may
become evident on the radiograph, and there may be some suggestion of pulpal
irritation by virtue of extensive pulp chamber and root canal space calcification.
Deep restorations, caries, pulp exposure, or any other direct or indirect insult to
the pulp, recently or historically, may be present, may be seen radiographically or
clinically.
 Asymptomatic
Irreversible Pulpitis

On occasion, deep caries will not produce any symptoms, even though
clinically or radiographically the caries may extend well into the pulp.
Left untreated, the tooth may become symptomatic or the pulp will
become necrotic.
In cases of asymptomatic irreversible pulpitis, endodontic treatment
should be performed as soon as possible so that symptomatic
irreversible pulpitis does not take place and result in severe pain and
patient distress.
 Pulp Necrosis

When pulpal necrosis (or nonvital pulp) occurs, the pulpal blood supply is
nonexistent and the pulpal nerves are nonfunctional.
It is the only clinical classification that directly attempts to describe the
histologic status of the pulp (or lack thereof). This condition is subsequent to
symptomatic or asymptomatic irreversible pulpitis.
Radiographic changes may occur, ranging from a thickening of the
periodontal ligament space to the appearance of a periapical radiolucent
lesion.
 Previously Treated

This classification refers to a tooth that has been treated with root canal
therapy and the root canal system has been filled with some type of root
canal obturating material.
In this situation the tooth may or may not present with signs or symptoms but
will require additional nonsurgical or surgical endodontic procedures to
retain the tooth.
 Previously Initiated
Therapy

This refers to cases in which a partial endodontic therapy was performed.

Teeth in this category would include cases where only a pulpotomy or
pulpectomy had been performed before presenting for root canal therapy.
Periodontal Diseases
Can be divided into 6:
Normal Apical Tissues
Symptomatic Apical Periodontitis
Asymptomatic Apical Periodontitis
Acute Apical Abscess
Chronic Apical Abscess
Condensing Osteitis

Endo-Perio Seminar 1
 Normal Apical Tissues

In this category the patient is asymptomatic and the tooth responds

normally to percussion and palpation testing.
The radiograph reveals an intact lamina dura and periodontal ligament
space around all the root apices.
 Symptomatic Apical
Periodontitis

A tooth with symptomatic apical periodontitis will have an acutely painful

response to biting pressure or percussion.
This tooth may or may not respond to pulp vitality tests, and the radiograph
or image of this tooth will generally exhibit at least a widened periodontal
ligament space and may or may not have an apical radiolucency associated
with one or all of the roots.
 Asymptomatic Apical
Periodontitis

A tooth with asymptomatic apical periodontitis generally presents with no

clinical symptoms.
This tooth does not respond to pulp vitality tests, and the radiograph or
image will exhibit an apical radiolucency.
This tooth is generally not sensitive to biting pressure but may “feel different”
to the patient on percussion.
 Acute Apical Abscess

A tooth with an acute apical abscess will be acutely painful to biting

pressure, percussion, and palpation.
This tooth will not respond to any pulp vitality tests and will exhibit varying
degrees of mobility.
The radiograph or image can exhibit anything from a widened periodontal
ligament space to an apical radiolucency.
Swelling will be present intraorally and the facial tissues adjacent to the tooth
will almost always present with some degree of swelling. The patient will
frequently be febrile, and the cervical and submandibular lymph nodes will
exhibit tenderness to palpation.
 Chronic Apical Abscess

A tooth with a chronic apical abscess will not generally present with clinical
symptoms. This tooth will not respond to pulp vitality tests and the
radiograph or image will exhibit an apical radiolucency.
The tooth is generally not sensitive to biting pressure but can “feel different”
to the patient on percussion.
This entity is distinguished from asymptomatic apical periodontitis because
it will exhibit intermittent drainage through an associated sinus tract.
 Condensing Osteitis

Condensing osteitis is a variant of chronic apical periodontitis and represents

a diffuse increase in trabecular bone in response to irritation.
Radiographically, a concentric radio-opaque area is seen around the
offending root.
Treatment is only required if symptoms/pulpal diagnosis indicate a need.
 Condensing Osteitis

Condensing osteitis is a variant of chronic apical periodontitis and represents

a diffuse increase in trabecular bone in response to irritation.
Radiographically, a concentric radio-opaque area is seen around the
offending root.
Treatment is only required if symptoms/pulpal diagnosis indicate a need.
Endodontic-Periodontal
Lesions

Endo-Perio Seminar 1
 Primary Endodontic
Lesion
Its clinical manifestation and the diagnosis is
usually consistent with chronic or acute apical
abscess.
A sinus tract originating from the apex or lateral
canal of the tooth may form along the root surface
and exit or drains through the gingival sulcus.
Radiographically, the drainage is seen as a
radiolucency along the side of the tooth or in the
bifurcation area.
Clinically, the pus is oozing through the sulcus area
with the presence of localized swelling in the
gingival area.
Vitality tests should reveal a necrotic tooth or in
multirooted teeth one of the root canal necrotic.

Endo-Perio Seminar 1
 Primary Endodontic
Lesion with Secondary
Periodontal Involvement
If the primary endodontic lesion is untreated, it
may become involved with periodontal infection.
Clinically, a presence of a necrotic root canal with
evidence of plaque and calculus can be observed.

Endo-Perio Seminar 1
 Primary Periodontal
Lesion
It is clinically consistent with severe periodontal
disease, involving a great part of the root/s
surface.
Presents a loss of clinical attachment and
formation of a periodontal pocket.
These are usually associated with tooth mobility,
and the affected teeth respond positively to pulp
testing.
Radiographically, there is lateral bone loss
indicating a periodontal pocket.

Endo-Perio Seminar 1
 Primary Periodontal
Lesion with Secondary
Endodontic Involvement
Periodontal disease can have an effect on the pulp
through dentinal tubules, lateral canals, or both.
The tooth with primary periodontal and secondary
endodontic disease exhibits deep pocketing, with a
history of extensive periodontal disease. When the
pulp is involved, the patient experiences pain and
clinical signs of pulpal disease.
This situation exists when the apical progression of
periodontal disease is sufficient to open and
expose the pulp to the oral environment by way of
lateral canals or dentinal tubules.
Radiographically, these lesions cannot be
distinguished from primary endodontic lesions
with secondary periodontal involvement.

Endo-Perio Seminar 1
 True Combined
Lesions
Pulpal and periodontal disease may occur
independently or concomitantly in and around the
same tooth.
Once the endodontic and periodontal lesions join,
they may be clinically indistinguishable.

Endo-Perio Seminar 1
 Management of
Endodontic-Periodontal
Lesions

Endo-Perio Seminar 1
 Management
Both pulpal and periodontal lesions of short duration are often reversed when the cause is
eliminated.
Also, periodontal lesions of short duration from pulpal infection often close following
endodontic, and even those of longer duration which do not close following endodontic
treatment will often heal with minimum periodontal treatment.
When the pulpal periodontal lesion is from periodontal disease of long duration,
endodontic therapy, while necessary, will not correct the periodontal lesion. In such cases,
periodontal management usually requires surgical correction in addition to controlling the
cause of the disease.
While periodontal furcation lesions of short duration secondary to pulpal disease may be
successfully managed by endodontic therapy, most often the cause is periodontal disease
and the management is difficult. Hemi section or root amputation may either simplify the
configuration for cleaning or make regenerative periodontal therapy possible by
increasing the osseous surface ratio to tooth surface in the area of the periodontal
problem.

Endo-Perio Seminar 1
 Treatment Sequence
It is important to determine the origin of the lesion and the duration of the disease. But
sometimes it is difficult or impossible to determine the nature and chronology of the lesion.
A good rule in establishing the differential diagnosis for this situation is to consider the
lesion endodontic in origin for treatment planning procedures. The sequence of treatment
is a controversial aspect and it is suggested that the endodontic treatment should precede
periodontal therapy regardless of the cause of the disease.
In general, when primary disease of one tissue (pulp or periodontium) is present and
secondary disease is just starting in the other, treatment of the primary disease will cure
the secondary. When the secondary disease is established and chronic, both primary and
secondary disease must be treated. Lesions of endodontic origin with secondary
periodontal involvement should first be treated endodontically to take advantage of the
normally excellent healing potential of an endodontic lesion. Residual periodontal lesions
can then be treated after the response to endodontic therapy is evaluated combined
periodontal – endodontic lesions should also undergo endodontic therapy first.

Endo-Perio Seminar 1
 Treatment of Primary
Endodontic Lesion
In this condition, only endodontic treatment is indicated. Complete
resolution is usually anticipated after routine endodontic treatment.
A fistulous tract usually heals following instrumentation and
irrigation of root canals. No root planning should be done when the
fistulous tract is along the periodontal ligament.
Healing is usually completed within 3 to 6 months.

Endo-Perio Seminar 1
Treatment of Primary Endodontic
Lesion with Secondary Periodontal
Involvement
In this condition, both periodontal and endodontic therapies are
indicated. Endodontic therapy should be performed before the
periodontal therapy.
One can expect the healing of bone loss due to endodontic lesion
following conventional root canal therapy. Periodontal therapy
should not be initiated until complete debridement of root canal
system has been performed to allow for maximum reattachment.
Prognosis of the lesion depends on the periodontal therapy.

Endo-Perio Seminar 1
 Treatment of Primary
Periodontal Lesion
Only periodontal therapy is indicated since the pulpal tissue is vital.
Treatment depends on the extent of periodontal disease and on the
patient’s ability to complete the possible long term treatment and
maintenance.
Prognosis of these lesions depends entirely on the efficacy of
periodontal therapy that is based on the duration of the disease
process and extent of bone loss. The prognosis of the pulp is usually
good, unless lateral canals are exposed to the oral environment.

Endo-Perio Seminar 1
Treatment of Primary Periodontal
Lesion with Secondary Endodontic
Involvement
The treatment of periodontal lesion with secondary pulpal
involvement should be first directed to the most acute component
of the condition. Frequently this is the endodontic problem which
must be then followed by periodontal therapy.
Prognosis of such lesions depends mainly on the extent of the
periodontal condition and the outcome of periodontal therapy. It is
important to evaluate the restorability of the tooth before beginning
endodontic and periodontal treatment.

Endo-Perio Seminar 1
 Treatment of True-Combined
Lesion
reatment may be done prior to, during or after the endodontic
therapy, depending on the lesion. But usually endodontic treatment
should be provided first with the view to eliminate all bacteria and
antigens from the infected root canal system.
After combined therapy, the patient has to maintain an impeccable
level of oral hygiene.
This may be virtually impossible when bifurcation or trifurcation
bone loss exists. Other reasons include, a localized periodontal
defect, inability to perform adequate root canal therapy or an
iatrogenic problem which makes the clinician think about other
treatment options. These include root amputation, bicuspidization
and hemisection.

Endo-Perio Seminar 1
 Treatment of True-Combined
Lesion
Prognosis of a combined endo-perio lesion is usually moderate to
poor considering the chronic nature of the lesion and the amount of
alveolar bone loss. As with the other combined lesions, the
endodontic aspect heals with adequate root canal therapy and the
prognosis ultimately depends on the success of periodontal therapy.
The prognosis is poorer for a long standing combined lesion.

Endo-Perio Seminar 1
 Other Treatment
Options
Root Amputation
Defined as the surgical removal of one or more
root(s) of a multi‐rooted tooth, at the level of the
cementoenamel junction, without the removal of the
overhanging portion of the crown.
Bicuspidization
It is a surgical procedure performed on the
mandibular molars for the separation of the mesial
and distal roots with their respective crown portions;
this separation eliminates the existence of a
furcation and facilitates effective oral hygiene
practice.

Hemi-Section
Defined as the surgical separation of a multi‐rooted
tooth (generally a mandibular molar), through the
furcation thus permitting the subsequent removal of
both the crown and root of the sectioned tooth as
one entity.
Endo-Perio Seminar 1
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