Endo – Perio lesions.ppt

Endodontic and periodontic lesions

1. Endo –Perio lesions:
An enigma to the clinician?
Dr. Nikhat Fatima
Rama Dental College, Hospital
Research center

2. •It’s the spread of inflammation and
infection from one component to the
other.
First described by Simring and Goldberg in 1964

3. Pulpal and Periodontal problems are responsible
for more than 50% of tooth mortality.
Chen SY,Wang HI,Clickman GN. The influence of
endodontic treatment upon periodontal wound
healing. J Clin periodontal24;449-456,1997
Bender IB. Factors influencing radiographic
appearance of bony lesions. J Endod 8;161-
170,1982

4. •Theperiodontiumandthepulphave
embryonic,anatomicandfunctional
interrelationship.
•Theyareectomesenchymalinorigin,
fromwhichthecellsproliferateto
formthedentalpapillaandfollicle,
whicharetheprecursorsofthepulp
andtheperiodontiumrespectively.

5. perio
endo
Embryonic , anatomic , functional

6. •Pathways are developed that provide
means by which pathological agents pass
between the pulp and the periodontium,
thereby creating the perio –endo lesion.

7. •Three main avenues for communication
are,
•1) Dentinal tubules.
•2) Lateral and accessory canals and
•3) The apical foramen
“The endo-perio lesion: a critical appraisal
of the disease condition”
ILAN ROTSTEIN & JAMES H. SIMON

8. Perio-Endo
Relationship
Dentinal
Tubules
Lateral & Accessory
canals
Apical
Foramen

10. Pathogenesis
Dental caries
Restorative procedures
Trauma
Chemical irritation
Thermal stimulation.
Pulpal inflammation
and necrosis are initiated by:

11. Bacteria Associated with
Pulpitis
•Eubacterium
•Peptostreptococcus
•Fusobacterium
•Porphyromonas
•Prevotella
•Streptococcus
•Lactobacillus
•Wolinella
•Actinomyces

12. •Theseinflammatorylesions
causelocalizedoedemaand
aresultingincreaseinintra-
pulpalpressureandcell
death.

13. Bacteria Associated with Periodontitis
Very strong Strong Moderate
A actinomyecetemcomitansP intermedia S intermedius
P gingivalis C rectus P micros
B forsythus E nodatum F nucleatum
Treponema sp E corrodens
Eubacterium sp

14. Pathogenesis
•Periodontallesionsareinitiatedby
depositsofplaqueandcalculus:
•Thetoxinsproducedbythese
bacteriacanirritatethegumtissues
andcausethebody’simmune
systemto“turnon”(chronic
inflammation)–thisinflammation
canbreakdownanddestroythe
tissuesandbonesupportingthe
tooth.
•Thegumtissuesseparatefromthe
tooth,formingpockets.Asthe
diseaseprogresses,thepockets
deepen,destroyingmoresupporting
tissues.

16. Classification (Simon 1972)
•Based on the primary source of
infection
•PRIMARY ENDODONTIC LESION.
•Chronicapicallesiononatoothwitha
necroticpulpmaydraincoronally
throughtheperiodontalligamentinto
thegingivalsulcus.
•Usuallyhealsfollowingrootcanal
treatment.

17. •These lesionsarecaused
primarily by periodontal
pathogens.Inthisprocess,
chronicperiodontitisprogresses
apicallyalongtherootsurface.In
mostcases,pulpaltestsindicate
aclinicallynormal pulpal
reaction.Thereisfrequentlyan
accumulationofplaqueand
calculusandthepocketsare
deep.
PRIMARY PERIODONTIC LESION

18. Primary endodontic lesion with secondary
periodontal involvement
•Ifitisuntreatedprimaryendodontic
lesioninvolveswithsecondary
periodontalbreakdown.
•Thismayalsooccursasaresultof
rootperforationduringrootcanal
treatment,orwherepinsandpostsmay
havebeenmisplacedduringrestoration
ofthecrown.Rootfracturesmayalso
bepresent.

19. Primary periodontal disease with secondary
endodontic involvement
•Theapicalprogressionofa
periodontalpocketmaycontinue
untiltheapicaltissuesareinvolved.
•Inthiscase,thepulpmaybecome
necroticasaresultofinfection
enteringvialateralcanalsorthe
apicalforamen.

20. True combined lesions
•Occurslessfrequentlythanothers.Itis
formedwhenanendodonticlesion
progressingcoronallyjoinsaninfected
periodontal pocket progressing
apically.
•Inmolarteeth,rootresectioncanbean
alternativetreatment.
•Theprognosisofatrue-combined
perio-endolesionisoftenpoororeven
hopeless,especiallywhenperiodontal
lesionsarechronicwithextensiveloss
ofattachment.

21. Complicate the Diagnosis1
Affect the Sequence of Care3
Complicate the Treatment Plan
2
Periodontic _ Endodontic Relationship

22. Diagnosis
•Pain
•Swelling
•Mobility
•Suppuration
•Periodontal probing
•Presence of local deposits
•Presence of caries and restoration
•Palpation
•Pulp vitality test
•Radiographic interpretation

23. Periodontal Abscesses
A localized purulent infection
that involves the marginal
gingiva or interdental papilla.
Clinical Features
–Smooth, shiny swelling of the
gingiva
–Painful, tender to palpation
–Purulent exudate
–Increased probing depth
–Mobile, percussion sensitive
–Tooth usually vital

24. •Thisfistulaonthelabial
surfacelookslikean
endodonticabscess.
•Diagnosisofanyabscess
mustincludeperiodontal
probing, periapical
radiographs,vitalitytestsand
apatienthistory.

25. This case shows a
combination of periodontitis
and endodontic
inflammation
causing bone loss at the
crest and at the apex.

26. •Aslongasthepulpremains
vital,itisunlikelythat
significantchangeswilloccur
intheperiodontium.
•Theabilityofinflammatory
periodontaldiseasetoaffect
thepulpismuchlesscertain.

27. Clinical findings in endodontic
and periodontic lesions
CLINICAL FINDINGS ENDO LESION PERIO LESION
PULPAL RESPONSE
ABSENT
PRESENT
BONE DEFORMITY TUBULAR ‘U’
TRIANGULAR ‘V’
PLAQUE & CALCULUS ABSENT
PRESENT
CARIES/ RESTORATION
PRESENT
ABSENT
MOBILITY
ABSENT PRESENT
GEN PERIODONTITIS
ABSENT
PRESENT

28. Clinical findings in endodontic and
combined endodontic-periodontic lesions
Clinical findingsEndo lesionCombined lesion
Pulpal status Necrotic Necrotic
Perio status Normal Gen periodontitis
Probing Narrow pocketWide pocket
Plaque and
calculus
Absent Present
Treatment Endodontic Combined
Prognosis Good Depends on perio

29. Treatment
•Primary endodontic lesion
Conventional endodontic therapy
•Primary endodontic lesion with secondary
periodontal involvement –
Endo -perio therapy

30. •Themostimportantfactorinthe
treatmentofperio-endolesionsisthe
correctdiagnosis.

31. Treatment
•Primary periodontal lesion
1-Periodontal therapy
2-Guided tissue regeneration
3-Root amputation & hemisection
4-Pulp therapy

32. Treatment
•Primary periodontal lesion with
secondary endo lesion
1-Pulp therapy
2-Periodontal therapy
3-Root amputation
4-GTR

34. •Incombinedendodontic-periodontic
lesions,itisgenerallywisetotreat
theEndodonticcomponent first,
becauseinmanycasesthiswilllead
tocompleteresolutionofthe
problem.

35. •The location, extension, severity of
inflammation and the degree of
tissue involvement helps the dentist
to select the proper treatment.

36. Conclusion
•Theclinicalcourseofthedisease
involvingthepulpo-periodontal
complexisdictatedbythebacterial
aetiologyandtherebythetreatment
planisdecided.
•Otherfactorssuchaspatientco-
operation,restorabilityandeconomics
willinfluencethetreatmentdecisions.
Howevertheprimarygoalofall
treatmenteffortsmustbetoridthe
patientoftheinfection.