PERIODONTAL-ENDODONTIC

RELATIONSHIP

drg. Ade Ismail A.K.,MDSc.,

Sp.Perio
 Overview
Introduction
Patways connecting endodontic and peridodontal tissue
Effect of the pulp on periodontium
 Classifications
Examination
 Etiophatogenesis
 Diagnosis
 Management
 The tooth
(pulp tissue)

One
biological
unit
Supporting
structure

The interrelationship of these structures

influences each other during health, function
and disease.
 Definition

Endodontic Lesions
Inflammatory process in periodontal tissue from the root canal system
(noxious agent)
Periodontal lesion
Inflammatory process in periodontal tissue resulting from accumulation
of dental plaque on the external surface.
 PATHWAYS OF COMMUNICATION

Anatomical pathways :
 Apical foramen
 Lateral and accessory canals
 Dentinal tubules
Non-physiological pathways :
 Iatrogenic root canal perforation
 Vertical root fractures
 Anatomical Pathways

 Apical foramen

 Accessory cannals

 Congenital absence of cementum exposing dentinal tubules

 Permeability of cementum
 Developmental grooves

 Developmental anomalies such as projections and enamel pearl

 Apical Foramen
The apical foramen is the principal and most direct route between
the pulp and perodontium
 Accessory and Lateral Canals

The incident is range from 2-27%, but is unknown

More common in posterior teeth (furcation)
 Dentinal tubules

Exposed dentinal tubules in areas of denuded cementum

may serve as comm.path
Etiology of dentinal tubules exposure :
 Development defects
 Disease
 Periodontal procedure
 PATHWAYS OF IATROGENIC ORIGIN

 Exposure of dentinal tubules following root planing

 Accidental lateral perforation during endodontic procedure
 Root fractures caused by endodontic procedures
 Impact Of Disease Conditions
In TheVital Pulp.
 Caries, restorative procedures and traumatic injuries are the most common
causes.
 Any loss of hard tissue integrity, exposing dentin or the pulp directly, may
allow bacteria and bacterial products elements present in the oral
environment to affect the normal condition of the pulp.
 Important : if pulp still vital (though inflamed/ scared) not suff. to
cause peridontall breakdown no need extirpasi/ pulpectomy to
treat PD
 Impact of pulpal necrosis

 pulp necrosis is frequently associated with inflammatory involvement of

the periodontal tissue.
 located at the apex of the tooth.
 Exit from lateral canal
 Inflam in the periodontium ec nekrosis, similar to PD (infection)
 Impact of endodontic treatment
measures on the periodontium

 Unfilled spaces in endodontically treated root canals can sustain bacterial

growth endodontic re-teatment
 Mechanical/ chemical iritation periodontal inflammed lesion
 If over obturation (medicaments of irrigation/ material for endo
well tolerated
 Root Perforations.

 Accidentally during endo treatment an instrumentation perforation/

wound of periodontal lig.
 Can be made through lateral wall/ pulpal floor
 Vertical Root Fractures

 a fracture of a root that is longitudinally oriented.

 can extend the entire length of a root and then involve the gingival sulcus/pocket
area.
 Clinical sign

 Pain/ abscess formation (active bac in fr space)

 Or limited to mastication (mild pain, dull discomfort)
 INFLUENCE OF THE PERIODONTAL
DISEASE ON THE CONDITION OF
THE PULP.
The formation of bacterial plaque on detached root
surfaces following periodontal disease has the potential
to induce pathologic changes in the pulp along the very
same pathways as endodontic infection :
 Exposed lateral canal
 Apical foramina
 Dentinal tubules
 CLASSIFICATION OF
PERIO-ENDO LESIONS
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
 PRIMARY ENDODONTIC LESION
 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 PERIODONTAL
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 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 PERIODONTAL DISEASE WITH SECONDARY
ENDODONTIC 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.
 COMBINED DISEASES
1. Primary endodontic lesion with secondary periodontal
involvement
2. Primary periodontal disease with secondary endodontic
involvement
3. True combined lesion
 TRUE COMBINED LESION

 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.
 Diagnosis

 A thorough clinical and radiographic examination is imperative for developing a

diagnosis
 Data Collected must include:
 periapical radiographs
 pulp vitality testing: cold, EPT (Electric Pulp Test), cavity test
 percussion
 palpation
 pocket probing
 sinus tract tracking
 cracked tooth testing: transillumination, tooth-slooth, staining
o The diagnosis is often difficult to ascertain because the fracture is
usually not readily detectable by clinical inspection (unless a
separation root)
o The xray beam has to be parallel to the frac line.
o clinical examination should include measures to make fracture lines
visible :
 application of disclosing solutions,
 the use of fiber-optic light,
 inspection by a surgical microscope or endoscope,
 by raising a surgical flap.
 VARIOUS DIAGNOSTIC PROCEDURES THAT
CAN BE USED TO IDENTIFY
PERIO ENDO LESIONS
 Visual o Pulp vitality testing
examination
o Pocket probing
 Palpation
o Fistula tracking
 Percussion
o Cracked tooth
 Mobility testing
 Radiographs
 VISUAL EXAMINATION

Soft tissues: Teeth:

• Inflammation • Caries
• Deffective restorations
• Ulcerations
• Abrasions
• Sinus tracts • Crack
• Fractures
• Discolorations
 PALPATION

 Periradicular abnormalities

 Cannot differentiate between endodontic and

periodontic lesion
 Compare with control teeth
 PERCUSSION

 Compare with control teeth

 Periraducular inflammation
 MOBILITY

 Loss of periodontal support

 Fractured roots

 Recent traumas

 Periradicular abscess
 Radiograph

• Periradicular resorption of endodontic origin not

effective
• Bone loss due to periodontal disease- effective
 Treatment Decision-Making
and Prognosis

 Treatment decision-making and prognosis depend primarily on the diagnosis of the

specific endodontic and/or periodontal disease

 The main factors to consider are pulp vitality and type and extent of the
periodontal defect
 Diagnosis of Primary endo and Primary perio disease usually present
no clinical difficulty. In primary endo the pulp is nonvital. In primary
perio the pulp is vital
 However, the diagnosis of the combined endo/perio lesions could
present a challenge as they present clinically and radiographically
very similar. The diagnosis is often tentative with a definitive
diagnosis formulated following treatment
 The prognosis and treatment of each endo/perio
disease type varies
 Primary endo should only be treated by endodontic
therapy and has a good prognosis
 Primary perio should only be treated by periodontal
treatment. The prognosis depends on severity of the
perio disease and patient response to treatment
 Combined lesions should be treated with endodontic therapy first.
 Treatment should be evaluated in 2-3 months, and only then should
periodontal treatment be considered.
 This sequence allows for sufficient time for initial tissue healing and better
assessment of the periodontal condition to determine if the tooth needs
SC/RP or surgical treatment.
 Prognosis depends on the periodontal involvement and treatment
Treatment Strategies
 Case report

A 32 year old male patient reported to the Department of

Periodontology and Implantology, complaining of mobility
and pus discharge from the lower right anterior region. He
also complains of intermittent throbbing pain which was
aggravated on biting. Patient gave a history of root canal
treatment done with lower right central incisor two years
ago.
 Clinical Examination

Intra-oral examination revealed chronic abscess with draining sinus through

attached gingiva in relation to 31. Pus was expressed though the draining sinus
on digital pressure. Periodontal examination revealed pocket of 9 mm on the
labial aspect of 31 which was extending beyond muco-gingival junction. The
respected tooth was slightly extruded and had grade I mobility.
 Radiographic Examination

Revealed over obturation of the

gutta-percha in the peri-apical area
and peri-radicular pathology in
relation to 31. The lesion was
extending from 32 to 41.
 Treatment
 abscess drainage + antibiotic
 SRP Initial fase
 splinting (2 weeks)

 prepare PRP and PRF

 periodontal flap
 SRP and degranulation Corrective
 Removing over guttap fase
 bone graft and cover by PRF membran
 suturung the flap
 follow up period (6 month) supporting fase
The surgery procedure
 CONCLUSION

 periodontal disease may be responsible for the entire loss of the

supporting apparatus around a tooth and may in addition be the
cause of the breakdown of the pulpal tissue
 The primary goal of all treatment efforts must be to rid the patient
of the infection. Factors such as cooperation, restorability and
economics will influence treatment decisions.
HATUR NUHUN