Dr.

kareem Galal
.Associate Professor of Endodontics, Endodontic Dept

ENDODONTIC
PERIODONTAL
RELATIONSHIP
 I) Intercommunication between Pulpal
and Periodontal tissues
1)Physiological
pathways:
A. Apical foramen
B. Lateral (accessory)
canals
C. Dentinal tubules
2)Non-physiological
pathways:
D. Root perforations
E. Vertical root fracture
1) Physiological pathway
A) Apical foramen:
 The main location where pulp and periodontal
tissues communicate.
 Egress of irritants from diseased or necrotic pulp
through the apical foramen into the periradicular
tissues, will initiate inflammatory response
leading to periodontal tissue destruction.
 If plaque covers the entire length of the root and
reaches the apical vessels, it will lead to pulp
inflammation and necrosis.
Physiological pathway )1
B) Lateral (accessory canals):
 Exist in up to 40% of teeth, in posterior more than
anterior teeth. mainly in apical third of the root and
in furcation of molars.
 Contain blood vessels that connect circulatory
system of the pulp with the periodontium.
 Through patent lateral canals:

 irritants within pulp can induce periodontal

inflammation leading to probing defect.
Or  irritants from periodontal lesion are carried into
the pulp to induce inflammation.
Physiological pathway )1
C) Dentinal tubules:
 Normally, the cementum is an effective barrier to the
penetration of bacteria and their by-products.
 When there is an absence or discontinuity in the
cementum (10%), patent dentinal tubules will carry
toxins produced during pulpal or periodontal diseases in
both directions.
 Other non-physiological causes may be due to:

a) Developmental defect as in Palato-gingival groove

(developmental anomaly)
b) Removal during periodontal treatment.
c) Damage during traumatic injuries.
Non-Physiological pathway )2
A) Root perforations:
 Artificial communication between the root canal
system and the periodontium caused by caries,
resorption or iatrogenic.
 The closer the perforation to the gingival sulcus, the
greater the chances of apical migration of the gingival
epithelium creating a periodontal lesion.

B) Vertical root fracture:

 The fracture site provides an entry of the bacteria and
their toxins from the root canal to the surrounding
periodontium.
 II) Influence of pulpal disease and endodontic
procedures on the periodontium

Pulpal disease :
 Irritants from necrotic pulp can induce pathological
alteration or destruction in the periodontium, the
extent of which depends on:
a)Virulence of irritating substance
b)Duration of the disease
c)Host defense mechanism
 These alterations or destruction are not confined to
apical tissues, but may migrate towards the gingival
margin (Retrograde Periodontitis) causing deep
probing defect. (DD from Marginal Periodontitis)
 II) Influence of pulpal disease and endodontic
procedures on the periodontium

In most cases, the inflammation in the

periodontium occurs without permanent loss
of the connective tissue attachment to the
root surface and following root canal
treatment, the periodontium heals.
Endodontic infection is regarded as Risk
Factor for periodontitis progression if left
untreated.
With proper root canal treatment, periodontal
disease of pulpal origin Should Heal.
 II) Influence of pulpal disease and endodontic
procedures on the periodontium

Endodontic procedures
 Iatrogenic errors as :
• Extension of files or obturating materials
• Perforations
• Vertical root fracture
 Can cause various degrees of damage
in the periodontium.
 III) Influence of periodontal disease and
periodontal procedures on the pulp

Periodontal disease:
 Infection from periodontal disease can spread to the pulp via
accessory root canals, opened dentinal tubules or
accumulation of plaque close to or at the apex

Periodontal procedures:
 Invasive periodontal treatment as deep curettage, may
severe the blood vessels supplying the pulp by the way of
accessory canals.
 Scaling and root planning may lead to removal of cementum
and exposure of dentinal tubules
 Both can cause inflammatory response with various degrees
within the pulp.
 III) Influence of periodontal disease and
periodontal procedures on the pulp

Generally, pathologic changes occurring

in the pulp as result of periodontal
disease and procedures, do not cause
degeneration of the pulp. The insult may
lead to focal areas of necrosis related to
the lateral canals, fibrosis, or various
forms of mineralization, as long as the
main canal is not involved and the blood
supply through the apical foramen is
intact.
IV) Classification of Endo-Perio lesions
 Theoretic pathways of osseous lesion
formation (according to Origin):
1. Primary endodontic lesions
2. Primary endodontic lesion with
secondary periodontal involvement.
3. Primary periodontal lesions
4. Primary periodontal lesion with
secondary endodontic involvement
5. Combined lesions
Primary endodontic lesions )1
Clinically:
1. Caries , restoration
2. Tenderness to percussion
3. Increased mobility
4. The suppurative process may drain coronally
through the periodontal ligament into the gingival
sulcus causing single narrow probing defect
(pseudo-pocket) and causing:
A. Swelling the marginal gingiva.
B. Sinus tract that can be traced with Gutta-percha
down to tooth apex or lateral canal.
C. In multi-rooted teeth the sinus tract can drain
into the furcation area
Primary endodontic lesions )1
5) No increase in probing depth elsewhere around
the tooth  only single narrow probing defect.
6) Few or no plaque or calculus
7) Negative pulp test.
Radiographically:
Apical Radiolucency
Treatment:
Only Root canal treatment
Prognosis:
Good if proper root canal treatment is done.
 Primary endodontic lesion with)2
secondary periodontal involvement
 When a lesion of endodontic origin is not treated,
destruction of periapical alveolar bone will
progress into the inter-radicular area causing
breakdown of hard and soft tissues.
Clinically:
1) The affected tooth with necrotic pulp or failed
root canal treatment.
2) As drainage persists through the gingival sulcus:
® accumulation of plaque and calculus
® Presence of probing defects around the affected tooth.
Primary endodontic lesion with secondary)2
periodontal involvement
Radiographically:
Periradicular and Angular bone defects
Treatment:
Both, root canal and periodontal treatment are
required.
Prognosis:
If root canal treatment is properly done, then the
prognosis depends on:
a) severity of periodontal involvement.
b) efficacy of periodontal treatment.
 3) Primary periodontal lesion
 Periodontal disease has a progressive nature,
it starts in the sulcus and migrates to the apex
as accumulation of plaque and calculus
produce inflammation, causing loss of
surrounding alveolar bone and surrounding
periodontal soft tissues. This leads to loss of
clinical attachment and formation of periodontal
abscess during the acute phase of destruction.
Clinically:
1. Intact teeth with various degrees of mobility.
2. Accumulation of plaque and calculus.
3. Positive pulp test.
4. Probing reveals pocket formation.
5. Tenderness to percussion
 3) Primary periodontal lesion
Radiographically:
Widespread vertical and horizontal
bone loss along root surfaces at
various levels
Treatment:
Long term periodontal treatment.
Prognosis:
Depends on the extent of periodontal
disease and patient’s ability to follow
and maintain long term therapy.
 Primary periodontal lesion with )4
secondary endodontic involvement
 Prolonged periodontal pathosis can permit bacteria or
bacterial byproducts to invade the pulpal tissues starting a
sequence of pulpal pathosis.
 These lesions may be indistinguishable from primary
endodontic lesions with secondary periodontal involvement.

Clinically:
1. Teeth with deep pockets, extensive periodontal disease
and possible history of past periodontal therapy.
2. When pulp becomes involved, pain increases and clinical
signs and symptoms of pulpal diseases may appear (acute
pulpitis with acute apical periodontitis).
3. In long standing cases, patient may be asymptomatic.
 4) Primary periodontal lesion with
secondary endodontic involvement
Radiographically:
Similar to primary endodontic lesions with
secondary periodontal involvement.
Treatment:
Both, root canal treatment and periodontal
treatment are required.
Prognosis:
Depends on continuing periodontal treatment
subsequent to endodontic treatment.
 5) Combined lesions
 In and around the same tooth, pulpal and periodontal
diseases may occur independently
 if both diseases do not communicate with no
evidence either disease state has influenced the
other : Concomitant pulp and periodontal lesions.
 if each disease progress until they merge: True
combined lesions.
 Clinically:
1. Necrotic pulp or failed root canal treatment.
2. Accumulation of plaque and calculus, periodontal
disease in other areas.
 Combined lesions )5
Radiographically:
 Crestal bone loss of periodontal disease and an
independent periradicular lesion of pulpal origin
Concomitant pulp and periodontal lesions.
 Crestal bone loss of periodontal disease
continuous with periradicular lesion of pulpal origin
True combined lesions.
Treatment:
Requires both root canal and periodontal treatments.
Prognosis :
Depends on severity of periodontal disease.
Concomitant pulp and True combined lesion
periodontal lesion
 Periodontal pulpal
Clinical
Periodontal infection Pulp infection Etiology
Vital Non vital Vitality
Not related Deep Restoration
Primary cause Not related Plaque/calculus

Chronic Acute Inflammation

Multiple, wide Single, narrow Pockets
coronally
Radiograph
Generalized Localized Pattern
Wider coronally Wider apically Bone loss
Yes No Vertical bone loss
Not related radiolucent Periapical bone
Histopathology
Apical migration No apical migration Junctional
epithelium
Recession Normal Gingiva