ENDO PERIO LESIONS WITH DIFFERENT CLINICAL CASES

ENDO PERIO LESIONS

1. Endo- perio lesion DR. MUSTAFA HAJOORI ( PG 3)

2. CONTENTS INTRODUCTION PATHWAYS CONNECTING ENDODONTIC AND PERIODONTAL TISSUES ETIOLOGY OF PULPAL-PERIODONTAL DISEASES CLASSIFICATION OF ENDO-PERIO LESIONS CLINICAL DIAGNOSTIC PROCEDURES DIFFERENTIAL DIAGNOSIS TREATMENT MODALITIES CONCLUSION REFERENCES 2

3. introduction Relationship between pulpal and periodontal disease was first described by Simring and Goldberg in 1969 Grossman's endodontic practice, 13 th edi . 3

4. 4 The endo- perio lesions are characterized by the co-existence of the pulpal and periodontal disease in a same tooth, which makes its diagnosis, as well as management complex , because a single lesion often present signs of endodontic and periodontal involvement. Saha AP, Chakraborty A, Saha S. Endodontic-periodontal lesion: A two way traffic. Int J Appl Dent Sci. 2018;4:223-8. Endo - perio lesion

5. Pulpal and Periodontal problems account for more than 50% of tooth mortality. Studies have shown that shows that the mechanisms involved in periodontal diseases are similar to those involved in periapical lesions. Main differences- original source and the direction of progression. 5 Cohen’s pathways of pulp, 12 th edi

6. 6 There are two forms of possible pathways connecting these tissues : Anatomical / physiological Pathological / non-physiological. PATHWAYS CONNECTING ENDODONTIC AND PERIODONTAL TISSUES

7. A – apical foramen; B – lateral canal; C – dentinal tubules; D – an accessory canal. Grossman's endodontic practice, 13 th edi . , ingle’s 7 th edi . 7

8. Grossman's endodontic practice, 13 th edi . 8 Dental papilla (precursor of dental pulp) Dental follicle (Precursor of PDL) Embryonic stage

9. Apical foramen The principal and most direct route of communication between the pulp and periodontium. Lindhe reported that bacterial infiltrates from periodontal diseases may reach pulp through apical foramen and exposed accessory canals in furcation area . Ingle’s endodontics 7 th edi ., 9

10. Accessory canals Patent accessory canals are a potential pathway for the spread of microorganisms and their toxic byproducts, as well as other irritants, from the pulp to the periodontal ligament. However, not all these canals extend the full length from the pulp chamber to the of the furcation Incidence : 23-76% Ingles Endodontics 7 th edition 10

11. Pineda and kuttler reported that about 30 % of the accessory canals could be identified through the use of 2 view radiographs 1) Mesio -distal 2) bucco -lingual Where as standard radiographs only identified 8% of the lateral canals 11 Pineda F, Kuttler Y. Mesiodistal and buccolingual roentgenographic investigation of 7,275 root canals. Oral Surg .

12. 12 Several clinical aids may also be useful for the identification of lateral canals : Torabinejad M, Rotstein I. Endodontic-periodontic interrelationship. Endodontics: Principles and Practice; Torabinejad , M., Walton, RE, Fouad, AF, Eds. 2014 Jul 16:106-20.

13. Lateral canals 30-40 % of all teeth have lateral canals. De Deus in 1975 studied 1140 teeth and found that 17 % of lateral canals are there in apical 3 rd 8.8% in middle 3 rd and less than 2% in cervical 3rd . However, Kirkham studied 1000 teeth with advanced periodontal involvement reported that only 2% of lateral canals were associated with periodontal pockets. Ingles Endodontics 7 th edition 13

14. Dentinal tubules Exposed dentinal tubules in areas of denuded cementum may serve as communication pathways between the pulp and periodontal ligament. Cohen’s pathways of pulp, 12 th edi 14

15. When the cementum and enamel do not meet at the cemento -enamel junction (CEJ), these tubules remain exposed, thus creating pathways of communication between the pulp and the periodontal ligament. SEM studies have demonstrated that dentin exposure at the CEJ occurred in about 18% of teeth in general and in 25% of anterior teeth. 15 Ingle’s endodontics 7 th edi .

16. Cemental tear : A cemental tear can be either the incomplete or complete detachment of the cementum from the cemento -dentinal junction (CDJ) or its partial detachment along the incremental line within the body of cementum of the tooth root 16 Causes mechanical irritation of PDL due to intermittent movement of fragment during masticatory movement Pedercini A, Weitz DF, Heyse Jr JD, Pedercini C, Kormas I, Koutlas IG, Johnson DK, McClanahan SB. Cemental tear: an overlooked finding associated with rapid periodontal destruction. A case series. Australian Dental Journal. 2021 Mar;66:S82-7.

17. - cemental tears can appear radiographically as hard tissue fragments that are thin sheet/piece like or prickle like. - majority of the teeth presented with an abscess and swelling (66%) - deep isolated periodontal pockets >6mm (65%) - vitality of tooth remains unaffected after cemental tear 17 Pedercini A, Weitz DF, Heyse Jr JD, Pedercini C, Kormas I, Koutlas IG, Johnson DK, McClanahan SB. Cemental tear: an overlooked finding associated with rapid periodontal destruction. A case series. Australian Dental Journal. 2021 Mar;66:S82-7.

18. Palato gingival groove They are developmental anomalies of maxillary incisor teeth Incidence:- CI 0.28% , LI 4.4% These grooves usually begins in the central fossa, cross the cingulum and extend apically for a varying distances. Cohen’s pathways of dental pup 12 th edi . 18

19. 19 Classification of palato gingival grooves 23. Gu YC. A micro-computed tomographic analysis of maxillary lateral incisors with radicular grooves. J Endod . 2011; 37:789–792.

20. Everett and Kramer reported that 0.5% of the teeth examined had a palatogingival groove extension to the apex 20 Cohen’s pathways of dental pup 12 th edi .

21. Dense invaginates ( Dens in dente ) 21 Gallacher A, Ali R, Bhakta S. Dens invaginatus : diagnosis and management strategies. British dental journal. 2016 Oct 7;221(7):383-7.

22. 22 Gallacher A, Ali R, Bhakta S. Dens invaginatus : diagnosis and management strategies. British dental journal. 2016 Oct 7;221(7):383-7.

23. Pathological pathways 23 Root perforations Due to - over instrumentation during endodontic procedures -during post space preparation Prognosis of tooth depends upon -location of perforation -time left unsealed -Ability of material to seal Pereira da Costa R, Quaresma SA, Lopes FC, Camargo R, Domingo, Ginjeira A, Sousa‐Neto MD. Management of a perforating internal root resorption using mineral trioxide aggregate: a case report with 5‐year follow‐up. Australian Endodontic Journal. 2020 Dec;46(3):452-7.

24. 24 Root resorption It is loss of hard tissues due to clastic cell activity. Injury or irritation of root canal wall (odontoblastic or predentin layer ) or root surface ( precementum or PDL) may result in internal or external root resorption respectively Wang N, Zhang M, Zhu J, Zhu Y, Wu J. Multiple idiopathic cervical root resorption: A systematic review. Oral Diseases. 2023 Sep;29(6):2409-22.

25. Vertical root fracture : Longitudinal fracture in root where by fracture segments are incompletely separated which may occur buccolingually or mesiodistally - AAE glossary of endodontic terms Commonly involves endodontically treated tooth than the vital tooth Moisture depletion and loss of proprioception are confounding factors of VRF Khasnis SA, Kidiyoor KH, Patil AB, Kenganal SB. Vertical root fractures and their management. Journal of conservative dentistry: JCD. 2014 Mar;17(2):103. 25

26. 26 Clinical features : Mild pain is present in most of the cases Presence of a sinus tract, pockets , and periodontal abscesses are also one of the findings in VRF There will be deep solitary pocket around one aspect of suspected tooth Khasnis SA, Kidiyoor KH, Patil AB, Kenganal SB. Vertical root fractures and their management. Journal of conservative dentistry: JCD. 2014 Mar;17(2):103.

27. Radiographic features : Diffuse widening of PDL Vertical bone loss Separation or displacement of apical portion of the root Presence of a typical J shaped radiolucency Periapical radiographs can detect fractures only in 35.7% cases 27 Liao WC, Chen CH, Pan YH, Chang MC, Jeng JH. Vertical root fracture in non-endodontically and endodontically treated teeth: current understanding and future challenge. Journal of personalized medicine. 2021 Dec 16;11(12):1375.

28. 28 Methods to Delineate fracture: Prognosis of a tooth with VRF that involves gingival sulcus and periodontal pocket is usually hope less due to continuous bacterial invasion from oral acvity Cohen’s pathways of dental pup 12 th edi .

29. ETIOLOGY OF PULPAL - PERIODONTAL DISEASES 29

30. Grossman's endodontic practice, 13 th edi . 30

31. Micro biology of endo perio lesions Bacteria – Actinobacillus actinomycetemcomitans , Porphyromonas gingivalis , Bacteroides forsythus , Prevotella intermedia Ekinella corrodens , Treponema denticola Fusobacterium nucleatum , Ingle’s endodontics 7 th edi 31 Bacteria Oral cavity contains more than 600 species of microorganisms and out of them Gram negative - anaerobics are directly related to pulpal and periodontal problems

32. Fungi Candida albicans are prevalent both in endodontic infections as well as in subgingivally in many cases of adult periodontitis . Other species such as Candida glabrata, Candida guillermondii , Candida incospicia , and Rodotorula mucilaginosa have also been detected 32 Shenoy N, Shenoy A. Endo- perio lesions: Diagnosis and clinical considerations. Indian Journal of Dental Research. 2010 Oct 1;21(4):579-85.

33. T here are more spirochetes in periodontal pocket than in infected root canal . Spirochetes most frequently found in root canal are treponema denticola and treponema maltophilium It has been stated that presence or absence of oral spirochetes can be used to differentiate between endodontic and periodontal abscess 33 Shenoy N, Shenoy A. Endo- perio lesions: Diagnosis and clinical considerations. Indian Journal of Dental Research. 2010 Oct 1;21(4):579-85.

34. Viruses : Ingle’s endodontics 6 th edi 34

35. Contributing factors Inadequate endodontic treatment : Poor endodontic treatments often results in treatment failures which leads to chronic apical periodontitis and subsequently involvement of periodontium as well. Ingle’s endodontics 6 th edi 35

36. Coronal leakage : Coronal leakage is the major cause of endodontic treatment failure Ray and trope found Defective restoration and adequate root canal filling will have a higher incidence of failure as compared to inadequate root canal filling and adequate restorations. 36 Abramov D, Kaniewski R, Abadi M, Lvovsky A. Periapical status and quality of root canal fillings and different coronal restorations.

37. Classification of endo- perio lesion 37 Saha AP, Chakraborty A, Saha S. Endodontic-periodontal lesion: A two way traffic. Int J Appl Dent Sci. 2018;4:223-8.

38. Simon et al. (1972) . Concomitantendodontic and periodontal lesions Added by belk and gutman Grossman's endodontic practice, 13 th edi . 38

39. A primary endodontic lesion presents a necrotic pulp and a chronic peri-apical abscess with a sinus tract draining through periodontal ligament space or gingival sulcus Etiology : Dental caries ,restorative procedures , traumatic injuries Primary endodontic lesion 39 Cohen’s pathways of pulp, 12 th edi

40. Treatment – RCT will resolve the endodontic infection, and its effects on periodontal tissues (for example sinus tracts). Clinical features : Pain , tenderness to palpation and percussion Sinus tract if present can be traced to the apex of the involved tooth and abnormal response to vitality tests 40 Cohen’s pathways of pulp, 12 th edi

41. Primary periodontal lesion Caused primarily by periodontal pathogens In this process periodontitis progresses apically along root surface but does not involve pulp Etiological factors : Plaque and calculus are primary etiological factors Clinical features : Patients presents with chronic generalized periodontitis Evidence of horizontal or vertical bone loss associated with the tooth mobility normal response to pulp vitality testing procedures Grossman's endodontic practice, 13 th edi . 41

42. 42 Cohen’s pathways of pulp, 12 th edi Treatment : Surgical/ non-surgical periodontal therapy. Re-evaluation must be done periodically to check for retro-infection of pulp.

43. Pulp inflammation or necrosis may lead to an inflammatory response in the periodontal ligament at the apical foramen or foramina at the site of a lateral or accessory canal. Primary endodontic lesions with secondary periodontal involvement 43 Cohen’s pathways of pulp, 12 th edi

44. Etiology : Progression of an untreated or chronic primary endodontic lesion Vertical root fracture, root perforation Clinical Features : Non vital tooth Plaque and calculus accumulation in the sulcus leading to pocket formation Lowering of the epithelial attachment Grossman's endodontic practice, 13 th edi . 44

45. Treatment – RCT will resolve the endodontic and possibly some, but not all, of the periodontal infection. Periodontal therapy will be needed. If endodontic therapy is adequate ,prognosis depends on severity of periodontal involvement and efficacy of periodontal treatment 45 Shenoy N, Shenoy A. Endo- perio lesions: Diagnosis and clinical considerations. Indian Journal of Dental Research. 2010 Oct 1;21(4):579-85.

46. 46 Cohen’s pathways of pulp, 12 th edi

47. In this case, the pulp may become necrotic as a result of infection entering through lateral canals or the apical foramen. Treatment of periodontal disease can also lead to secondary endodontic involvement i.e curretage ,scaling and surgical flap procedures Primary periodontal lesions with secondary endodontic involvement 47 Shenoy N, Shenoy A. Endo- perio lesions: Diagnosis and clinical considerations. Indian Journal of Dental Research. 2010 Oct 1;21(4):579-85.

48. Clinical features: G eneralized pocket formation horizontal/angular bone loss Signs and symptoms of pulpal involvement including episodes of acute pulpal pain Tooth will be non vital Radiographic features: On radiographic these leions may be indistinguishable from primary endodontic lesions with secondary pulpal involvement Grossman's endodontic practice, 13 th edi . 48

49. 49 Cohen’s pathways of pulp, 12 th edi

50. Primary Periodontal with secondary endo – completing RCT will resolve the endo – it will probably not resolve any of the periodontal disease since this was there prior to the endodontic disease. • single rooted teeth have poor prognosis. Multi rooted teeth with only 1 root is involved have better prognosis since the root can be amputated. 50 Shenoy N, Shenoy A. Endo- perio lesions: Diagnosis and clinical considerations. Indian Journal of Dental Research. 2010 Oct 1;21(4):579-85.

51. True combined lesions It is formed when an endodontic lesion progressing coronally joins an infected periodontal pocket progressing apically. Prognosis depends largely on the extent of destruction caused by periodontal disease component Cohen’s pathways of dental pup 12 th edi . 51

52. Clinical features : Similar to that of the primary periodontal lesion In addition , caries ,restoration or wear defects History of endodontic therapy Negative pulp vitality tests Treatment : Same treatment as with Periodontal with secondary endo. Allow 3 months for healing of tissue and resolution of infection following RCT . Hemisection /Radisection can also be considered as alternative treatment options in molar if not all roots are severely injured 52 Cohen’s pathways of dental pup 12 th edi .

53. 53 Cohen’s pathways of pulp, 12 th edi

54. Concomitant pulpal and periodontal disease Here both disease states exist but with different causative factors and with no clinical evidence that either disease state has influenced the other. In actuality, both disease processes must be treated concomitantly, with the prognosis dependent on the removal of the individual etiologic factors and prevention of any further factors that may affect the respective disease processes. Cohen’s pathways of dental pup 12 th edi . 54

55. 55 Cohen’s pathways of pulp, 12 th edi

56. Tsesis et al suggested the use of a three-component categorization scheme : 56 Al- Fouzan KS. A new classification of endodontic-periodontal lesions. International journal of dentistry. 2014 Apr 14;2014.

57. Oliet and pollock’s calassification Grossman (1988) followed the oldest classification by Oliet and Pollock (1968) and classified the endo- perio lesions according to treatment need, as follows: Lesions requiring endodontic treatment only Lesions that require periodontal treatment only Lesions that require combined endodontic & periodontal treatment Grossman's endodontic practice, 13 th edi . 57

58. A. Lesions that require endodontic treatment procedures only 58 Grossman's endodontic practice, 13 th edi .

59. B. Lesions that require periodontal treatment procedures only 59 Grossman's endodontic practice, 13 th edi .

60. Lesions that requires combined endodontic periodontic procedures Any lesion in group I that results in Irreversible reactions in the attachment apparatus and requires periodontal treatment Any lesion in group II that results in Irreversible reactions in pulp tissue and also requires endodontic treatment Grossman's endodontic practice, 13 th edi . 60

61. Torabinejad and Trope (1996) Based on the origin of the periodontal pocket • Endodontic origin • Periodontal origin • Combined endo–perio lesions • Separate endodontic and periodontal lesions • Lesions with communication • Lesions with no communication 61 Shenoy N, Shenoy A. Endo- perio lesions: Diagnosis and clinical considerations. Indian Journal of Dental Research. 2010 Oct 1;21(4):579-85.

62. Khalid al faujan (2014) 62 1 . Retrograde periodontal disease a) Primary endodontic lesion with drainage through periodontal ligament b) Primary endodontic lesion with secondary periodontal involvement 2. Primary periodontal lesion 3. Primary periodontal lesion with secondary endodontic involvement 4. Combined endodontic-periodontal lesion 5. Iatrogenic periodontal lesion Shenoy N, Shenoy A. Endo- perio lesions: Diagnosis and clinical considerations. Indian Journal of Dental Research. 2010 Oct 1;21(4):579-85.

63. Effect Of Periodontal Diseases And Procedures On The Pulp Periodontal disease has seen to exert no effect on pulp until the pocket has extended to the apex ( Czarnecki & Schilder , 1979) ; Initial effect is degenerative inflammatory 1.Reduction in number of pulp cells 2. Dystrophic calcification 3. Fibrosis 4. Reparative dentin formation 5.Inflammation 6. Resorption Cohen’s pathways of dental pup 12 th edi . 63

64. Very deep periodontal pockets which extends beyond apex mimics infected root canal with chronic apical periodontitis. Cohen’s pathways of dental pup 12 th edi . 64

65. Necrotic debris ,bacterial byproducts and toxic irritants can move towards apical foramen and causes periodontal destruction which can potentially move towards gingival margin Investigators termed this as retrograde periodontitis . Effect of Pulpal diseases and Endodontic Procedures on Periodontium 65 Cohen’s pathways of dental pup 12 th edi .

66. Periodontal defects, resulting from attachment breakdown, may occur after procedural mishaps, such as perforations of the floor of a pulp chamber or the root surface apical to the gingival attachment, strip perforations, or root perforations from cleaning and shaping procedures. Endodontically treated teeth may not respond well as compared to untreated tooth to periodontal treatment 66

67. Clinical diagnostic procedures Sunitha Raja, et al: The periodontal endodontic continuum; J Conserv Dent; 2008 67

68. diagnosis Visual examination : EXTRA ORAL EXAMINATION: Extraoral facial swelling of odontogenic origin typically is the result of endodontic etiology because diffuse facial swelling resulting from a periodontal abscess is rare. Sunitha Raja, et al: The periodontal endodontic continuum; J Conserv Dent; 2008 68

69. Swelling : endodontic infections  mucobuccal fold periodontal infections  attached gingiva. Teeth are examined for any caries, defective restoration, erosions, abrasions, cracks, fractures. Oral hygiene status –Plaque, debris, calculus. 69 Sunitha Raja, et al: The periodontal endodontic continuum; J Conserv Dent; 2008

70. palpation In periodontal lesion ,gingiva is soft and edematous, in contrast in pulpal lesion ,gingiva is healthy . Sunitha Raja, et al: The periodontal endodontic continuum; J Conserv Dent; 2008 70

71. Tapped vertically/horizontally. This test does not disclose the condition of the pulp, it only indicates the presence of periradicular inflammation. Percussion Sunitha Raja, et al: The periodontal endodontic continuum; J Conserv Dent; 2008 71

72. Generalized mobility involving many teeth suggest a probable periodontal origin condition MOBILITY Sunitha Raja, et al: The periodontal endodontic continuum; J Conserv Dent; 2008 72

73. Probing In periodontal lesions – pockets are multiple and wide In endodontically origined lesions – single narrow pockets Sunitha Raja, et al: The periodontal endodontic continuum; J Conserv Dent; 2008 73

74. In 1979.Harrington stated A precipitous drop in the probing depth around the tooth indicates an endodontic lesion in contrast to the generalized deep probing which indicates periodontal etiology . A significant pocket if present in the absence of periodontal disease it increases the probability of presence of vertical Fracture. 74 Sunitha Raja, et al: The periodontal endodontic continuum; J Conserv Dent; 2008

75. Radiographs Radiographic changes will only be detected if sufficient demineralization of cortical bone app e ars . Periodontal lesions  Generalized bone loss extending from cervical region towards the apex. Pulpal lesions  Radiolucency in apex of the involved tooth which extends coronally to the CEJ 75 Dwiyanti S. A Multi-Disciplinary Approach in the Management of Endo- Perio Lesions: A 4-year Follow-Up Case Report. Case Reports in Dentistry. 2023 Jan 23;2023.

76. Clinical finding pulpal Periodontal Vitality Non vital Vital Restorative Deep or extensive Not related Plaque biofilm/calculus Not related Primary cause Inflammation Mostly Acute Chronic pocket Single narrow Multiple wide coronally PH value Often acid Usuallly alkaline Trauma Primary or secondary Contributing factor microbial Few complex Differential diagnosis Cohen’s pathways of pulp, 12 th edi 76

77. Radio graphic findings pulpal Periodontal Periapical Radiolucency No often related Bone deformity Wide apically Wide coronally Treatment Root canal therapy Periodontal treatment Radiographic Histopathological finding pulpal periodontal Junctional epithelium No apical migration Apical migration Granulation tissue Apical (minimal) Coronal (larger) gingiva normal Some recession Histopathological Cohen’s pathways of pulp, 12 th edi 77

78. 78 Lateral periodontal cyst Cohen’s pathways of pulp, 12 th edi

79. 79 Most common location mandibular cuspid – bicuspid area Numerous cases have been found in anterior maxilla Cohen’s pathways of pulp, 12 th edi

80. Sequencing of treatment for endo- perio lesion Shenoy N, Shenoy A. Endo- perio lesions: Diagnosis and clinical considerations. Indian Journal of Dental Research. 2010 Oct 1;21(4):579-85. 80 If more periodontal treatment ( e.g surgery ) Required medicate canals again If healing favourable Complete root canal

81. Alternnative treatment modalities Resective procedures( Root resection /Hemisection) : Regenerative procedures: Open flap debridement: Root resection :( Root amputation) - It is defined as surgical removal of root and adherent soft tissues leaving the crown of the tooth intact and supported by the remaining roots.. Corbella S, Walter C, Tsesis I. Effectiveness of root resection techniques compared with root canal retreatment or apical surgery for the treatment of apical periodontitis and tooth survival: A systematic review. International Endodontic Journal. 2023 Oct;56:487-98. 81

82. 82 Proper reshaping of the occlusal table and restoration of the clinical crown are essential Root surface must be recountoured to remove root stump Cohen’s pathways of pulp, 12 th edi

83. 83 Cohen’s pathways of pulp, 12 th edi

84. 84 Endodontic therapy should be performed before or immediately after surgery In one study ,Vital root resections were investigated for 9 years At 1 st year 38% molar teeth remained vital ,but after 5 years only 13% maintained vitality So findings imply that long term prognosis of vital root resection is poor Cohen’s pathways of pulp, 12 th edi

85. Hemisection : Resection of the involved root along with the associated crown portion Indications : Severe vertical bone loss involving only one root Grade 3 and 4 furcation involvement Exposed root due to dehiscence Vertical root fracture Severe destruction of one root due to resorption , trauma, caries or perforations Root fracture is most common complication after Hemisection so occlusal modifications are mandatory to be done to balance forces acting on remaining root 85

86. Cohen’s pathways of dental pup 12 th edi . 86

87. Regenerative procedures: 87 Alqahtani AM. Guided Tissue and Bone Regeneration Membranes: A Review of Biomaterials and Techniques for Periodontal Treatments. Polymers. 2023 Aug 10;15(16):3355.

88. Concept of GTR began in late 80s and was given by Nyman et al based on melcher’s theory GTR barrier prevents contact of connective tissue with osseous wall of defect protecting underlying blood clot and stabilizing wound 88 GTR ( Guided tissue regeneration) Alqahtani AM. Guided Tissue and Bone Regeneration Membranes: A Review of Biomaterials and Techniques for Periodontal Treatments. Polymers. 2023 Aug 10;15(16):3355.

89. First reaction occurring after installation of barrier membrane is tissue-membrane interface to absorb plasma proteins by this way related growth factors and progenitor cells are attracted to surface of membrane with help of proteins. 89 Requirements of GTR Membrane Alqahtani AM. Guided Tissue and Bone Regeneration Membranes: A Review of Biomaterials and Techniques for Periodontal Treatments. Polymers. 2023 Aug 10;15(16):3355.

90. Gottlow (1997) was first to divide membranes in 2 generation 1 st generation - Consists of Non resorbable membranes 2 nd generation - Consists of resorbable membranes Elgali et al reviewed classification and added new group 3 rd generation - its membranes rely on naturally derived sources combined with bone grafts and alternative materials to provide structural support to the defect site 90 Alqahtani AM. Guided Tissue and Bone Regeneration Membranes: A Review of Biomaterials and Techniques for Periodontal Treatments. Polymers. 2023 Aug 10;15(16):3355.

91. 91 Good Space maintainer -Relatively stiff -Longest clinical experience - Pores with submicron (0.2 m) size - Density precludes colonization of the host flora and prevents the infection. - Most stable space maintainer, requires no filler material. - Titanium should not be exposed. -For recession, ridge augmentation 1 st generation

92. 92 - Barrier function At least 6 weeks bioactive Resorption: 26–38 weeks. - Multilayered, long-lasting membrane. - Resorption: 16 weeks . - promoting blood vessel growth, white cell movement, and cell growth. -Ethical concerns and health risks may be associated with the use of human skin. Resorption: 4–8 weeks - Collagen complexed with formaldehyde -Collagen network extends the resorption time Alqahtani AM. Guided Tissue and Bone Regeneration Membranes: A Review of Biomaterials and Techniques for Periodontal Treatments. Polymers. 2023 Aug 10;15(16):3355. 2nd generation

93. 93 Double-layered membrane. - Outer: large pores. - Inner: finer pores Soft Well-adaptable. - Interesting resorptive characteristics. - Customized membrane fabrication wit Relatively soft. - Well adaptable. - Resorption: 4–12 weeks. - Woven membrane. - Four prefabricated shapes. Resorption: 10 weeks. - Functional integrity. - Good space maintainer. - Good tissue integration-Separate suture material 3-layer technology. - Bioresorption : after 6–12 months. - Self-supporting, can be used without support from bone grafting materials.

94. 94 3 rd generation

95. Most commonly used non absorbable membrane is e-PTFE and resorbable is collagen ,polyglactin ,polylactic acid and copolymers of glycolide and lactide The benefits from the adjunctive use of an osseous graft in periapical surgery are controversial. Tobon et al demonstrated that the combined use of bone grafting material in GTR procedures enhanced periapical tissue regeneration W hereas Britain et al and von Arx et a l showed no additional effects. 95

96. Bone formation in grafting is characterized by 3 types of bone growth. Osteogenesis - formation of new bone by osteoblasts derived from the graft material itself. Osteoinduction - Ability of a material to induce the formation of osteoblasts from the surrounding tissue at the graft host site, which results in bone growth Osteoconduction - is the ability of a material to support the growth of bone over a surface 96 Wickramasinghe ML, Dias GJ, Premadasa KM. A novel classification of bone graft materials. Journal of Biomedical Materials Research Part B: Applied Biomaterials. 2022 Jul;110(7):1724-49.

97. 97 Osteogenic Osteoconductive Osteoinductive No immunological reactions Morbidity at donor sites Limited bone volume Osteoinductive Osteoconductive Potential of infection and immunological reaction Osteoconductive Slow resorption or non resorbable Osteoconductive Rapid resorption Osteoconductive Slow resorption or non resorbable

98. Apico marginal defect : Defined as a localized bony defect that is characterized by the absence of alveolar bone over the total root length. 98 Class I and II defects can be subclassified according to presence or absence of bony bridge Dietrich T, Zunker P, Dietrich D, Bernimoulin JP. Apicomarginal defects in periradicular surgery: classification and diagnostic aspects. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2002 Aug 1;94(2):233-9.

99. 99 Class I Class III Class II Dietrich T, Zunker P, Dietrich D, Bernimoulin JP. Apicomarginal defects in periradicular surgery: classification and diagnostic aspects. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2002 Aug 1;94(2):233-9.

100. 100 Class I/3 Class II Class I/2 Class III Dietrich T, Zunker P, Dietrich D, Bernimoulin JP. Apicomarginal defects in periradicular surgery: classification and diagnostic aspects. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2002 Aug 1;94(2):233-9.

101. Managenent of apico marginal defect Best treatment treatment option for apico marginal defect is the endodontic surgery or periodontal surgery using GTR . Matsumoto et al demonstrated an elevated risk of failure when apical lesions were > 5 mm. If distruction >5 mm healing theres significant reduction in healing frequency 101 Parmar PD, Kaur R, Singh N. Surgical Management of combined apico -marginal and through & through peri-radicular lesion with GTR using bio-resorbable membrane, microscope and cone beam computed tomography: a case report. Journal of Advanced Medical and Dental Sciences Research. 2018 Nov 1;6(11):42.

102. 102 Parmar PD, Kaur R, Singh N. Surgical Management of combined apico -marginal and through & through peri-radicular lesion with GTR using bio-resorbable membrane, microscope and cone beam computed tomography: a case report. Journal of Advanced Medical and Dental Sciences Research. 2018 Nov 1;6(11):42.

103. 103 Parmar PD, Kaur R, Singh N. Surgical Management of combined apico -marginal and through & through peri-radicular lesion with GTR using bio-resorbable membrane, microscope and cone beam computed tomography: a case report. Journal of Advanced Medical and Dental Sciences Research. 2018 Nov 1;6(11):42.

104. Discussion It is evident that both pulp and periodontium are closely linked together by apical foramen , accessory canals and dentinal tubules Ribach and Mitchell affirmed that the periodontal disease affects the pulp through accessory canals in the furcation and apical foramen Adriaens et al reported that the bacteria coming from the periodontal pockets can infect the pulp through the dentinal tubules during aggressive periodontal therapy. 104 Al- Fouzan KS. A new classification of endodontic-periodontal lesions. International journal of dentistry. 2014 Apr 14;2014.

105. Seltzer et al contraindicated this idea, because even with the removal of the cementum during SRP in vital teeth, the pulp tissue will be protected against the harmful agents through forming reparative dentin Treatment and prognosis of primary endo and primary perio lesions are straightforward Most guarded prognosis and complex treatment is experienced there with combined lesions. Endodontic therapy is usually more predictable and employment before periodontal procedures imparts better effect on periodontal healing. 105

106. Endo- perio lesion is a complicated disease that requires a meticulous diagnosis and treatment planning. Hence, an interdisciplinary approach is a boon for the management of endo- perio . Conclusion 106

107. references Ingle’s endodontics 7 th edi . Cohen’s pathways of pulp, 12 th edi Grossman's endodontic practice, 13 th Sunitha VR, Emmadi P, Namasivayam A, Thyegarajan R, Rajaraman V. The periodontal - endodontic continuum: A review. Journal of conservative dentistry : JCD 2008;11:54-62.. Abbott PV, Salgado JC. Strategies for the endodontic management of concurrent endodontic and periodontal diseases. Australian Dental Journal. 2009 Sep;54:S70-85. Shenoy N, Shenoy A. Endo- perio lesions: Diagnosis and clinical considerations. Indian Journal of Dental Research. 2010 Oct 1;21(4):579-85. 107

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