ENDO-PERIO INTERACTIONS

From Endo to perio From Perio to endo

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INTRODUCTION
Endo-perio problems are responsible for more than 50% of tooth mortality today.

In 1919 Turner and Drew first described the effect of periodontal disease on the pulp. The
relationship between the periodontium and the pulp was first discovered by Simring and
Goldberg in 1964.

Since then, the term ‘endo- perio lesion’ has been used to describe lesions due to
inflammatory products found in varying degrees in both periodontium and pulpal tissues.

The pulp and periodontium have embryonic, anatomic and functional interrelationship.
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PATHWAYS CONNECTING ENDODONTIC &
PERIODONTAL TISSUES
 Anatomical pathways:
 Apical foramen, accessory canals /lateral canals
 Congenital absence of cementum exposing
dentinal tubules

 Developmental grooves
 Non-physiological pathways:
 iatrogenic root canal perforations
 vertical root fractures caused by trauma,
pathway created due to resorption etc.
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ETIOLOGICAL AND CONTRIBUTING FACTORS
IN ENDO-PERIO LESIONS
 BACTERIA ASSOCIATED WITH
5/27 PULPITIS

Eubacterium sp. 59 Gram-positive nonmotile

Peptostreptococcus sp. 54 Gram-positive nonmotile

Fusobacterium sp. 50 Gram-negative nonmotile

Porphyromonas sp. 32 Gram-negative nonmotile

Prevotella sp. 45 Gram-negative nonmotile

Streptococcus sp. 28 Gram-positive nonmotile

Lactobacillus sp. 24 Gram-positive nonmotile

Wolinella sp. 18 Gram-negative motile

Actinomyces sp. 14 Gram-positive nonmotile rods
 CLASSIFICATION OF ENDO- PERIO
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LESIONS
I. Based on etiology, diagnosis, treatment and prognosis (by Simon,
1972)
Primary endodontic lesions

Primary endodontic lesions with secondary

periodontal involvement
Primary periodontal lesions

Primary periodontal lesions with secondary

endodontic involvement
True combined lesions
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II. Based on clinical presentation strategies for each (by Weine, 1982)
Class 1-Tooth in which symptoms clinically and radiographically
simulate periodontal disease but are in fact due to pulpal
and/or necrosis.

Class II – Tooth that has both pulpal or periapical disease and

periodontal disease

Class III –Tooth that has no pulpal problem but requires endodontic
therapy plus root amputation to gain periodontal healing.

Class IV- Tooth that clinically and radiographically simulates pulpal or

periapical diseases but in fact has periodontal disease.
10/27 IV. Based on treatment plan (Grossman classification,1991)

Type 1 – Requiring endodontic treatment only.

Type II – Requiring periodontal treatment only.

Type III – Requiring combined endo-perio treatment

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V. Classification as recommended by the World Workshop for Classification
Periodontal Diseases (1999)

Endodontic-periodontal lesion

Periodontal-endodontic lesion

Combined lesion
 DIAGNOSTIC PROCEDURES USED TO
12/27 IDENTIFY THE ENDO-PERIO LESION
Examination/ 1º endodontic 1º periodontal 1º endodontic 1º periodontal True combined
tests lesion lesion 2º periodontal 2º endodontic lesion

Visual  Soft tissue -  Inflamed  Plaque forms  plaque,  Plaque,

sinus opening gingiva/ at the subgingival calculus &
 Tooth - recession gingival margin calculus & periodontitis will
decay/ large (multiple of the sinus tract swelling be present in
restoration/ teeth) leads to (multiple varying degrees
fractured  Plaque & inflammation teeth)  Swelling
restoration or subgingival of marginal  pus, exudate around single
tooth/ calculus gingiva  localized/ or multiple
erosions/abrasio (multiple  exudate generalised teeth
ns/cracks/ teeth)  Root recession &  pus, exudate
discolorations/  swelling perforation/ exposure of
poor RCT indicating fracture root
periodontal
abscess
Examination/ 1º endodontic 1º periodontal 1º endodontic 1º periodontal True combined
tests lesion lesion 2º periodontal 2º endodontic lesion

Pain Sharp  Usually dull  Usually sharp  Usually dull  Dull ache
ache shooting ache usually
 Sharp only in  Dull ache in  Sharp only in  Only in acute
acute chronic acute conditions it
condition conditions periodontal is severe
abscess
Palpation does not indicate Pain on Pain on Pain on Pain on
whether
the inflammatory
process is
of endodontic or
periodontal
origin
Percussion Normally tender Tender on Te nder on Tender on Tender on
percussion percussion percussion percussion percussion

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Examination/ 1º endodontic 1º periodontal 1º endodontic 1º periodontal True combined
tests lesion lesion 2º periodontal 2º endodontic lesion

Mobility Fractured roots and Localized to Localized Generalized Generalized

recently generalized mobility mobility mobility with
traumatized teeth mobility of teeth higher grade of
often present high mobility related
mobility to the involved
tooth
Pulp vitality  A lingering pulp is vital and Pulp vitality tests Pulp vitality may Usually negative
test, response- responsive to negative be positive in because
rreversible pulpitis testing multirooted teeth of non-vital pulp.
 No response -
Necrotic pulp
(non-vital)
Pocket probing A deep narrow Multiple wide Presence of Presence of Probing reveals
solitar y pocket* deep solitary wide multiple typical conical
pockets pocket wide and deep periodontal type
periodontal of probing
pockets

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Examination/ 1º endodontic 1º periodontal 1º endodontic 1º periodontal True combined
tests lesion lesion 2º periodontal 2º endodontic lesion

Sinus tracing A radiograph with Sinus tract mainly Sinus tract mainly Sinus tract mainly Difficult to trace
GP points to apex at the at the apex/ at the lateral out the origin of
or furcation area in lateral aspect of furcation aspect of the root the lesion *
molars the root area

Radiographs

Cracked tooth Painful response on No symptoms Painful response No symptoms Painful response
testing chewing on chewing on chewing

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DIFFERENCES BETWEEN PERIODONTAL AND
PERIAPICAL ABSCESS
PERIODONTAL ABSCESS PERIAPICAL ABSCESS

Periodontal pocket is present caries/ fracture is present

May occur after periodontal treatment May occur after endodontic or restorative

Tooth is vital Tooth is non - vital

Pain is usually dull and localized Pain is severe and difficult to localize

Swelling is present on the lateral surface of root Swelling is present at the apical portion of tooth
usually without fistulous track as abscess usually which drains by formation of a fistulous track.
drains from pocket opening.
Tender on lateral percussion Tender on vertical percussion

Usually not visible on radiographs Appears as a periapical radiolucency

 ENDO – PERIO –
17/27 CONTROVERSY

• Two basic questions have been raised and continue

to be a matter of dispute :

1) Is periodontal disease a cause of pulp necrosis?

2) Can a pulpless tooth be the cause of

periodontal disease?
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EFFECT OF PULPAL DISEASE ON THE
PERIODONTIUM
Early inflammatory changes in the pulp very little effect on the
periodontium
Necrotic pulp produces inflammatory response
transverse into
periodontal tissues.

Nature and extent of periodontal destruction depends on:

1. Virulence of pathogens in the canal system

2. Duration of the disease

3. Defense mechanism of the host.

CARRANZA 12TH EDITION, 2016

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INFLUENCE OF ENDODONTIC
PROCEDURES ON PERIODONTIUM
 Aggressive removal of PDL and underlying cementum during interim endodontic therapy
adversely affects periodontal healing.

 Precautions to be taken when periodontal therapy to follow endodontic treatment.

 Induce less mechanical trauma
 Use more biocompatible sealers
 EFFECT OF PERIODONTITIS ON THE
21/27 PULP
Result in atrophic and other degenerative changes like
reduction in the number of pulp cells,
dystrophic mineralization,
fibrosis,
reparative dentin formation,
inflammation and
resorption.
CAUSE:
Disruption of blood flow through the lateral canals localized areas of coagulation
necrosis in the pulp.

CARRANZA 12TH EDITION, 2016

24/27 EFFECT OF PERIODONTAL PROCEDURES
ON PULP
Scaling and root planing: removes the
bacterial plaque and calculus. However,
Acid etching: citric acid removes the smear
improper root planing procedures can also layer, an important pulp protector.
remove cementum and the superficial parts Application of citric acid may have a
of dentin, thereby exposing the dentinal detrimental effect on the dental pulp.
tubules to the oral environment.
TREATMENT
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TREATMENT
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CONCLUSION