1. The Perio-Endo Relationship
-DR AISHWARYA PANDEY
-DEPARTMENT OF PERIODONTOLOGY
-BANARAS HINDU UNIVERSITY

2. PERIODONTIUM
PULP

3. CONTENTS:
• Introduction
• Pathways of Communication
• Classification
• Symptoms
• Investigation
• Decision Tree

4. o Pulp and the periodontium have embryonic, functional
and anatomical relationship.
o Endodontic and periodontal diseases are both
polymicrobial anaerobic infections.
o The term ‘‘endo-perio’’ lesion describes diseases
due to inflammatory products found in varying
degrees in both the periodontium and the pulpal
tissues.
o Combined Endo-perio lesions are estimated to
cause 50% of tooth mortality.
Introduction

5. PATHWAYSCONNECTING
ENDODONTIC AND PERIODONTAL
TISSUE

6. ANATOMICAL RELATIONSHIP:
o Dentinal tubules
o Accessory & lateral canals
o Apical foramen
o Developmental grooves

7. PATHOLOGICAL RELATIONSHIP:
o Iatrogenic Perforations
o Internal Resorption
o External resorption

8. 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 recession

9. 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

10. Palatogingival
groove

11. INFECTION FROM PDL TO PULP:
Pathogenic
Bacteria and
inflammatory
products of
periodontal
disease
Accessory canal /
Lateral canals /
apical foramen
Pulpal
infection/necrosis
RETROGRADE
PULPITIS

12. 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

13. Classification

14. Simon, Glick and Frank (1972)
Primary Endodontic
Disease
Primary Periodontal
disease
Combined Disease
Primary Periodontal
Secondary Endodontic
Primary Endodontic
Secondary Periodontal
True Combined Lesion

15. PRIMARYENDODONTIC:

16. PRIMARY ENDO SECONDARY
PERIODONTAL:

17. PRIMARY PERIODONTAL:

18. PRIMARY PERIODONTAL SECONDARY
ENDODONTIC:

19. TRUE COMBINED
PERIODONTAL & ENDODONTIC:

20. Grossman (1982)
Teeth requiring endodontic
therapy only
Teeth requiring periodontal
therapy only
Teeth requiring both
endodontic-periodontal
procedures

21. Teeth requiring endodontic therapy only
It includes
a) Necrotic pulp and peri-apical lesion
with/without sinus tract
b) Chronic peri-apical abscess with sinus tract
c) Root fracture
d) Root resorption
e) Root perforation
f) Replantation
g) Intentional endodontic therapy
h) Teeth requiring hemisection
i) Incomplete closure of apex

22. Teeth requiring periodontal therapy only
It includes
a) Occlusal trauma causing reversible pulpitis
b) Occlusal trauma plus inflammation of gingiva
resulting in pocket
c) Overzealous periodontal therapy causing pulpal
sensitivity
d) Deep and extensive infra-bony pocket, extending
beyond apex, sometimes coupled with root
desorption, yet with a vital pulp.

23. Teeth requiring both endodontic-periodontal
procedures
It includes:
a) Any type 1 lesion causing irreversible reaction to
a/a, and hence require periodontal therapy
b) Any type 2 lesion causing irreversible reaction to
pulp, and hence require endodontic therapy

24. CLINICALSYMPTOMS:
Pus
discharge
Pocket
formation
Fistula
tract
Tender to
percussion
Mobility
Swelling
of gingiva

25. LESIONCHARACTERISTICS:
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

26. INVESTIGATIONS:
History taking
Examination
Periodontal examination
Radiographic evaluation
Pulp testing
Fistula tracking
DIAGNOSIS

27. o Visual Examination
• Soft Tissue
 Inflammation
 Ulceration
 Sinus tracts
• Teeth
 Caries
 Defective restorations
 Cracks
 Fractures
 Discolorations
o Palpation - Peri-radicular abnormality
o Percussion – Peri-radicularinflammation

28. 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

29. o Pulp Testing (EPT + Coldtest):
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.

30. DECISION TREE:
[History + C/E + Probing + Radiograph]
+ Vitality
+ ve
Perio pockets (+)
Pulpitis & PA(-)
Primary
periodontal
Scaling +
Root planing
Perio Pockets (+)
Pulpal & PA
(False+)
Primary
periodontal
Secondary endo
RCT + Scaling 
cleaning and shaping
 Follow up 
Obturation
- ve
Pulpal & PA (+)
Perio pockets (-)
Sinus tract (+/-)
Primary
Endodontic
RCT
Pulpal & PA(+)
Probing (+)
Primary endo
Secondary
periodontal
RCT +
Periodontal
therapy
immediately
Pulpal & PA(+)
Probing (++)
Combined
perio endo
RCT +
Periodontal
therapy

31. 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 prognosis

32. FLOW OF WORK:
• RCT
Primary Endodontic
• Periodontal therapy
Primary Periodontal
• RCT + Periodontal therapy immediately/later
Primary Endodontic
Secondary Periodontal
• Scaling + Immediately followed by cleaning and
shaping  Follow up & observe pocketing 
Obturation
Primary Periodontal and
Secondary Endodontic
• RCT + periodontal therapy
True Combined lesion

33. 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.