Clinical Endodontics Fifth Year

1. ENDO-PERIO RELATIONSHIP

2.  It has long been recognized that an intimate relationship
exists between the pulp of a tooth and the surrounding
periodontium
 The periodontium communicates with pulp tissues through
many channels or pathways.
Pulpal infections
↔
Periodontium
 Thus, lesions of the periodontal ligament and adjacent
alveolar
bone
may
originate
from
infections
periodontium or tissues of the dental pulp.
of
the

3.  The simultaneous existence of endodontic and
inflammatory periodontal lesions can complicate
•
Diagnosis
•
Treatment planning
•
Sequence of treatment

4. Pulpal and periodontal inter-relationship
The pulp and periodontium have
•
Embryonic
•
Anatomic
•
Functional inter- relationships
They are ectomesenchymal in origin

5. Ectomesenchyme
Dental follicle
Periodontal Ligament
Dental papilla
Pulp

6. Dental follicle

7.  The
embryonic
development
gives
rise
to
anatomical
connections which remain throughout the life of the tooth.
 The apical foramen decreases in size as the proliferation of
the Sheath of Hertwig continues. It remains patent and serves
as the communication on which the pulpal tissues rely for
nutrition and nervous innervation
 As
the
root
develops,
ectomesenchymal
channels
get
incorporated, either due to dentine formation around existing
blood vessels or breaks in the continuity of the Sheath of
Hertwig, to become accessory or lateral canals

8.  Tubular communication between the pulp and periodontium
may occur when dentinal tubules become exposed to the
periodontium by the absence of overlying cementum
 These are the pathways that may provide a means by which
pathological agents pass between the pulp and periodontium,
thereby creating the perio-endo lesion

9. Pathways for the communication of the Dental Pulp
with the Periodontium
PATHWAYS OF DEVELOPMENTAL ORIGIN [ANATOMIC]
 APICAL FORAMEN.
 ACCESORY CANALS/ LATERAL CANALS
 CONGENITAL ABSENCE OF CEMENTUM EXPOSING DENTINAL
TUBULES.
 PERMEABILITY OF CEMENTUM.
 DEVELOPMENTAL GROOVES.
 DEVELOPMENTAL ANOMALIES SUCH AS ENAMEL PROJECTIONS
AND ENAMEL PEARL.

11. PATHWAYS OF PATHOLOGICAL ORIGIN
 ROOT FRACTURES FOLLOWING TRAUMA
 EMPTY SPACES ON ROOT CREATED BY DESTROYED SHARPEY’S
FIBRES [ ESPECIALLY AFTER REIMPLANTATION OF AVULSED
TEETH]
 IDIOPATHIC RESORPTION – INTERNAL AND EXTERNAL.
 LOSS OF CEMENTUM DUE TO EXTERNAL IRRITANTS [PLAQUE
OR CALCULUS ACCUMULATION]

12. PATHWAYS OF IATROGENIC ORIGIN
 EXPOSURE OF DENTINAL TUBULES FOLLOWING ROOT PLANING.
 ACCIDENTAL PERFORATIONS OF THE ROOT DURING ENDODONTIC
PROCEDURES.
 ROOT
FRACTURES
CAUSED
DUE
TO
ENDODONTIC
/
PROSTHODONTIC PROCEDURES.
 FRACTURED/ DEFECTIVE RESTORATIONS OF ENDODONTICALLY
TREATED TEETH
CORONAL LEAKAGE

13. Effects of Pulpal Disease and Endodontic Procedures on
the Periodontium
PULPAL DISEASE
 Pulp inflammation or necrosis may lead to an inflammatory
response in the periodontal ligament at the apical foramina or
at the site of a lateral or accessory canal.

14.  The resulting inflammatory lesion can be
•
a
minimal
inflammatory
process
confined
to
the
periodontal ligament
•
extensive destruction of the periodontal ligament, tooth
socket, and surrounding bone

15.  A lesion related to pulpal necrosis may also result in a
draining sinus tract that drains through

alveolar mucosa

attached gingiva,

the gingival sulcus of the involved tooth or

through the gingival sulcus of an adjacent tooth

17. ENDODONTIC PROCEDURES
1. Technical procedures involved in root canal treatment, irrigants,
medicaments, dressings, sealers, and filling materials have the
potential to cause an inflammatory response in the periodontium.
2. An inflammatory response resulting from commonly used root
canal treatment methods and materials, however, is usually
transient in nature and resolves quickly if filling materials are
confined within the canal space

18.  Procedural errors during root canal treatment
▬► major
destructive inflammatory processes in the periodontium.

Breakdown of the attachment resulting in a periodontal
defect may occur after procedural errors such as
•
access perforations in the floor of a pulp chamber
•
perforations on the root surface apical to the gingival
attachment,
•
strip perforations or root perforations related to cleaning and
shaping procedures, and
•
vertical root fractures

19. Effects of Periodontal Disease and Procedures on the Pulp
PERIODONTAL DISEASE
1. Periodontal disease must extend all the way to the apical
foramen or an opening of the lateral/ accessory canals to
cause significant pulp involvement.
2. Bacterial & inflammatory products of periodontitis could
gain access to the pulp via accessory canals, apical
foramina or dentinal tubules.
3. This process , the reverse of effects of necrotic pulp on the
periodontal ligament , has been referred to as Retrograde
Pulpitis

20. PERIODONTAL PROCEDURES

All treatment modalities for periodontal disease have the
potential to adversely affect the pulp.

Increased hypersensitivity is one of the common sequelae
of nonsurgical and surgical periodontal therapy.

21. 
This
hypersensitivity
is
caused
by
the
complete
removal of cementum and the subsequent exposure of
dentinal tubules to the oral environment.

22.  Periodontal surgery affects the pulp to the extent that it is
exposed
to
endotoxin
or
bacteria
via
lateral
canals,
dentinal tubules, or in extreme cases the apical foramen

23. ENDO- PERIO LESIONS
PRIMARY ENDODONTIC
DISEASE
COMBINED DISEASES
PRIMARY PERIODONTAL DISEASE
PRIMARY ENDODONTIC DISEASE
WITH SECONDARY PERIODONTAL
INVOLVEMENT
PRIMARY PERIODONTAL DISEASE
WITH SECONDARY ENDODONTIC
INVOLVEMENT
TRUE COMBINED DISEASES

24. Primary endodontic lesions
• 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 mimic clinically the presence of
a
periodontal abscess. In reality, it is a sinus tract from pulpal
origin that opens through the periodontal ligament area

26. Diagnosis :
•
Insert a gutta-percha cone into the sinus tract and take one
or more radiographs to determine the origin of the lesion.
•
When the pocket is probed, it is narrow and lacks width.
•
A similar situation occurs where drainage from the apex of
a molar tooth extends coronally into the furcation area. This
may also occur in the presence of lateral canals extending
from a necrotic pulp into the furcation area.

27. Radiographic changes:
No noticeable changes in the early stages
As the disease continues → widening of PDL → periapical
radiolucency → bony lesion
Primary endodontic diseases usually heal following root
canal treatment

28. Primary periodontal lesions
•
These
lesions
are
caused
primarily
by
periodontal
pathogens.
•
In most cases, pulp tests indicate a clinically normal
pulpal reaction
•
There is frequently an accumulation of
calculus and the pockets are wider
plaque and

30. Radiographs :
•
Show angular bone loss extending from the cervical
regions of the tooth.
•
The prognosis depends upon the stage of periodontal
disease and the efficacy of periodontal treatment
•
Treatment : periodontal therapy

31. Primary
endodontic
lesions
with
secondary
periodontal
involvement
•
If after a period of time a suppurating primary endodontic
disease remains untreated, it may become secondarily
involved with periodontal breakdown.
•
Plaque forms at the gingival margin of the sinus tract and
leads to plaque-induced periodontitis in the area.

33. •
When plaque or calculus is detected, the treatment and
prognosis of the tooth are different than those of teeth
involved with only primary endodontic disease.
•
Probing may show a solitary but wider pocket
•
The tooth now requires both endodontic and periodontal
treatments

34. •
Primary
endodontic
lesions
with
secondary
periodontal
involvement may also occur as a result of root perforation
during root canal treatment, or where pins or posts have been
misplaced during coronal restoration.
•
Symptoms may be acute, with periodontal abscess formation
associated
with
pain,
swelling,
formation, and tooth mobility.
pus
or
exudate,
pocket

35. •
A more chronic response may sometimes occur without
pain, and involves the appearance of
bleeding on probing or exudation of pus.
a pocket with

36. Primary periodontal lesions with secondary endodontic
involvement
•
The apical progression of a periodontal pocket may continue
until the apical tissues are involved.
•
The pulp may become necrotic as a result of infection
entering via lateral canals or the apical foramen.
•
In single-rooted teeth the prognosis is usually poor.

38. •
In molar teeth the prognosis may be better. Since not all the
roots may suffer the same loss of supporting tissues, root
resection can be considered as a treatment alternative

39. •
The treatment of
periodontal disease can also lead to
secondary endodontic involvement.
•
Lateral canals and dentinal
tubules may be opened to the
oral environment by scaling and root planing or surgical flap
procedures.
•
It is possible for a blood vessel within a lateral canal to be
severed by a curette and for microorganisms to be pushed
into the area during treatment, resulting in pulp inflammation
and necrosis.

40. Pulp tests may show an abnormal response or complete
absence of any response.
Treatment : Endodontic therapy + periodontal therapy
[ root resections if indicated]

41. True combined lesions
•
A true combined lesion is said to be present when an endodontic
lesion extends and communicates with a pre-existing periodontal
lesion.
•
True
combined
endodontic–periodontal
disease
occurs
less
frequently than other endodontic–periodontal problems. It is
formed when an endodontic disease progressing coronally joins
with an infected periodontal pocket progressing apically

43. •
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 considered as a
treatment alternative if not all roots are severely involved

44. • Treatment :
• Endodontic therapy [ apical surgery if indicated]
• Periodontal therapy
• Root resections / hemisections /bicuspidisations

45. Diagnosis:

Diagnosis of
combined periodontal-endodontic lesions can
prove difficult.

Often
characterized
attachment
and
by
alveolar
extensive
bone,
loss
and
of
their
periodontal
successful
management depends on careful clinical evaluation, accurate
diagnosis, and a structured approach to treatment planning for
both the endodontic and periodontic components.