THE PERIO ENDO

INTER-RELATIONSHIP

Dr. Almas Muhammad Arshad

PERIODONTIUMPULP

CONTENTS:

• Introduction

• Pathways of Communication

• Classification

• Symptoms

• Investigation

• Decision Tree

• Case Reports

o Pulp and the periodontium have

embryonic, functional and anatomical

relationship.

o Caused by mixed anaerobic bacteria

(J Clin Periodontol 2002: 29: 663–671)

o Combined Endo-perio lesions are

estimated to cause 50% of tooth

mortality J Conserv Dent. 2008 Apr-Jun; 11(2): 54–62.

PATHWAYS CONNECTING

ENDODONTIC AND PERIODONTAL

TISSUE

ANATOMICAL RELATIONSHIP:

o Dentinal tubules

o Accessory & lateral canals

o Apical foramen

o Developmental grooves

(J Conserv Dent, Apr-Jun 2008, Vol:11, Issue:2)

PATHOLOGICAL RELATIONSHIP:

o Iatrogenic Perforations

o Internal Resorption

o External resorption

DENTINAL TUBULES:o Exposed dentinal tubules will create a

communication between the pulp and

periodontium because of:

• Faulty or aggressive scaling

technique

• Following root planing

• Gap joint between enamel and

cementum

• Gum recessiono The number of dentinal tubules per mm2

decreases from the pulp to the periphery

(Garberoglio & Brännström1976).

o Endo-perio > Perio-endo

J Clin Periodontol 2002: 29: 663–671

PALATOGINGIVAL GROOVE:o In Maxillary central and lateral

incisors

o May contribute to • Periodontal (AND/OR)

• Pulpal pathology

o To detect the effect:• Vitality testing

• Probing

o Radiograph

o Treatment:• Burning out the groove

• Surgical management

INFECTION FROM PDL TO PULP:

Pathogenic

Bacteria and

inflammatory

products of

periodontal

disease

Accessory canal /

Lateral canals /

apical foramen

Pulpal

infection/necrosis

RETROGRADE

PULPITIS

INFECTION FROM PULP TO PDL:

• Pulpal disease

• Procedural

errors in RCT

• Perforations

• Vertical root

fractures

• Dentinal

tubules

• Peri-radicular

inflammation

Bone loss +

CAL +/- Pus

discharge

RETROGRADE

PERIODONTITIS

CLASSIFICATION:

Primary Endodontic Disease

Primary Periodontal disease

Combined Disease

Primary Periodontal Secondary Endodontic

Primary Endodontic Secondary Periodontal

True Combined Lesion

Simon, Glick and Frank in 1972

PRIMARY ENDODONTIC:

Periodontology 2000, Vol. 34, 2004

PRIMARY ENDO SECONDARY

PERIODONTAL:

Periodontology 2000, Vol. 34, 2004

PRIMARY PERIODONTAL:

PRIMARY PERIODONTAL

SECONDARY ENDODONTIC:

TRUE COMBINED

PERIODONTAL & ENDODONTIC:

CLINICAL SYMPTOMS:Swelling

of gingiva

Pus discharge

Pocket formation

Fistula tract

Tender to percussion

Mobility

LESION CHARACTERISTICS:

LESION PAIN SWELLING PROBING

Primary

Endodontic

Moderate to

severe

Possibly when

sinus tract

None unless

sinus tract

Primary

Periodontal

None to

moderate

Possibly Moderate to

severe

Combined

pulpal and

periodontal

Moderate to

severe

Likely Severe, connects

the periapex

INVESTIGATIONS:

History taking

Examination

Periodontal examination

Radiographic evaluation

Pulp testing

Fistula tracking DIA

GN

OS

IS

o Visual Examination• Soft Tissue

Inflammation

Ulceration

Sinus tracts

• Teeth

Caries

Defective restorations

Cracks

Fractures

Discolorations

o Palpation - Peri-radicular abnormality

o Percussion – Peri-radicular inflammation

o Mobility• Loss of periodontal support

• Peri-radicular abscess

• Fractured roots

o Probing

• Deep solitary pocket – Endo

cause

• Broad and deep pockets -

Perio

o Fistula Tracking

• #25 GP/Probe - radiopaque

• Until Resistance is felt

o Pulp Testing (EPT + Cold test):

LESION RESPONSE

Primary Periodontal +

Primary Periodontal Secondary Endodontic +/-

Primary Endodontic +/-

Primary Endodontic Secondary Periodontal -

Combined pulpal -

False Positive response may be interpreted in combined lesion in

multi rooted teeth as either intact vital pulp or partially necrotic

pulp.

DECESION TREE:[History + C/E + Probing + Radiograph]

+ Vitality

+ ive

Perio pockets (+)

Pulpitis & PA (-)

Primary periodontal

Scaling + Root planning

Perio Pockets (+)

Pulpal & PA (False+)

Primary periodontal

Secondary endo

RCT + Scaling cleaning and shaping Follow up

Obturation

- ive

Pulpal & PA (+)

Perio pockets (-)

Sinus tract (+/-)

Primary Endodontic

RCT

Pulpal & PA(+)

Probing (+)

Primary endoSecondary periodontal

RCT + Periodontal

therapy immediately

Pulpal & PA (+)

Probing (++)

Combined perio endo

RCT + Periodontal

therapy

PROGNOSIS:

o Depends on • Patients oral hygiene

• The amount of attachment loss

• Endodontic status

• Effectiveness of the periodontal treatment accomplished

o Primary endo -- Good to excellent prognosis

o Primary perio -- Depends on periodontal therapy

o Combined lesion -- Poor prognosisPeriodontology 2000, Vol. 34, 2004, 165–203

FLOW OF WORK:

• RCTPrimary Endodontic

• Periodontal therapy Primary Periodontal

• RCT + Periodontal therapy immediately/laterPrimary Endodontic

Secondary Periodontal

• Scaling + Immediately followed by cleaning and shaping Follow up & observe pocketing Obturation

Primary Periodontal and Secondary Endodontic

• RCT + periodontal therapyTrue Combined lesion

Prognosticate before treatment

CASE REPORT 1: J Clin Exp Dent. 2014;6(1):e91-5.

oA 42y old male pt presented with a complain of acute pain and

swelling in the left mandibular area.

o Medical history: Non contributory

o Periodontal Examination:

Deep pocket between #37 and #38

o Vitality: -ive (non vital)

o R/E:

Bone loss around distal root of #37

o R/E:

Bone loss around distal root of #37

o Diagnosis ??

o Diagnosis:

Primary periodontal with secondary endodontic

involvement

o Treatment:

1. RCT

2. Scaling and Root planing

3. KIV Extraction of #38

4. Follow Up..

1 YEAR:

6 MONTH:

CASE REPORT 2: J Clin Exp Dent. 2014;6(1):e91-5.

oA 45-years old women presented with a complain of

intermittent pain and periodic discharge of pus from tooth

#36 and wanted to inquire about options for preserving the

tooth.

o Medical status was noncontributory

o I/O:

•Gingival reddening and swelling

at buccal side of 36

o Periodontal Examination:

• The probing depth in the furcal area

was 12mm

• Grade III furcal lesion

o Percussion: +ive

o Mobility: +ive

o Radiographs :

•Bony defect in the furcal and

periapical area of tooth #36 had

unsuccessful RCT

o Diagnosis???

o Diagnosis:

Primary endodontic disease with secondary

periodontal involvement

o Treatment:

•Endodontic retreatment was performed

•Evaluated 3 month later furcation lesion still remain

intact

•Periodontal regenerative surgery was planned for

treatment of furcation defect

3 Month Recall:

2 Year Recall:

CONCLUSION:

The proper diagnosis and complete

treatment of both aspects of perio-

endo lesions is essential for

successful long-term results.

A secondary disease develops due

to an untreated primary one.

Refrences• http://www.ijdr.in/article.asp?issn=0970-

9290;year=2010;volume=21;issue=4;spage=579;epage=585;aulast=Shenoy

• http://www.ijstr.org/final-print/may2013/Endo-perio-Lesions.pdf

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2813095/#sec1-13title

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4190803/

• https://www.scienceopen.com/document/read?vid=02cf1c92-a231-41f8-b1c6-

c4302bbfd2ae

• http://www.ijstr.org/final-print/may2013/Endo-perio-Lesions.pdf

• https://www.hindawi.com/journals/ijd/2014/919173/

• http://semmelweis.hu/konzervalo-fogaszat/files/2014/11/Endodontic-and-

Periodontal-v9-angol.pdf

•http://suffolkrootcanal.co.uk/wp-content/uploads/2015/04/Diagnosis-

prognosis-and-decision-making-in-the-treatment-of-combined-periodontal-

endodontic-lesions-Rotstein-2004.pdf