This document discusses endo-perio (endodontic-periodontal) lesions. It begins by comparing apical and marginal periodontitis and listing pathways of communication between the pulp and periodontium, such as lateral canals. It then covers diagnosis of endo-perio lesions using history, clinical signs/symptoms, probing, and radiographs. Causes of endo-perio lesions include primary endodontic or periodontal lesions that later involve the other tissue. The document outlines classifications of endo-perio lesions and management approaches, including root canal treatment, periodontal treatment, or extraction depending on the specific case. Regenerative techniques and tooth resections like root amputation or hemisection are
Endo perio interrelation 1 /certified fixed orthodontic courses by Indian dental academy
1. ENDO PERIO RELATION
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2. Comparison of presentation of apical and marginal
periodontitis
Causes for attachment loss
Pathways of communication between pulp and
periodontium
*
Lateral and
accessory canals
*Dentinal tubules
*Developmental defects
*Cementum defects
*Iatrogenic perforations and root
fracture
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3. Diagnosis of endo perio lesions
*history of dentinal pulpal and periapical pain
*history of periodontal symptoms
*signs and symptoms of pulpal or periapical
disease
*periodontal charting(probing profile)
*radiographic pattern of bone loss
Possible causes of endo perio lesions
Definition and classification of endo perio lesions
Single isolated endo perio lesions
Multiple endo perio lesions
Management of endo perio lesions
*estimation of prognosis
*treatment of endo perio cases
*root resection
*role of regenerative techniques
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11. Case report I: primary endo lesion with
secondary perio
lesion
Abscess irt 23
Radiolucency irt 23
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12. Flap reflected, curettage done
Bone graft placed
Post treatment view after
augmentation of 23 with composite
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Post surgical radiograph
13. Case report II: Primary perio lesion with
secondary endo lesion
Bone loss up to apex of 44
Pre operative probing
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Flap reflected, curettage done
Bone graft placed
14. Post operative probing
after 9 months
Post operative radiograph
after 9 months
Case report III: True combined periodontal
endodontic lesion
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15. Per operative probing
Horizontal bone loss and
periapical radiolucency
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Flap reflected, curettage done
Bone graft placed
16. Post operative after 6
months
Post operative radiograph
after 6 months
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17. Combined lesions:
Two separate lesions: “pulpo periapical” and
“periodontal with no communication between
them
Single lesion that involves both endodontic and
periapical problem
Separate endodontic and periodontal lesion that
later communicate “concomitant pulpo periapical
lesion”
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26. Development defects
Palatogingival
groove in the
maxillary central
incisor
Cementum defects
Iatrogenic perforations and
root fractures
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After infilling of bony defect
27. Effect of pulp disease and its
treatment on the periodontium
Periodontal inflammation and bone loss
Sub marginal bone loss
Horizontal bone loss
Furcation involvement
Periodontal wound healing
Gingival tissue thickness
Alveolar bone level
Surgical trauma to flap
Effective flap repositioning
Root canal treatment
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28. This is why many periodontist’s insist on RCT on teeth
with “ doubtful" pulp status when regenerative surgery
is planned…….the rationale is to eliminate possible
sources of infection to maximize the potential for
successful outcome
Extrusion of root filling material causing delayed healing
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29. Effect of iatrogenic problem
Perforations
Reparative dentine
defending the pulp space
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30. Effect of periodontal disease and its
treatment on the pulp
Effect of periodontal disease on the pulp
Pulpal and periodontal
involvement of maxillary premolar
Progression of the two separate
lesion to give a combined
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31. Effect of periodontal disease and its
treatment on the pulp
Effect of periodontal treatment on the pulp
Scaling and root planning may sometimes result
in removal of excessive cementum and exposure of
the dentinal tubules, leading to pulp inflammation
--Micro flora
--Host defense
Pulpal inflammation adjacent
to open dentinal tubules
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32. Endo perio lesions
Definition
An isolated, usually narrow, deep probing
depth of pulpal or periodontal origin
Lesion with sub marginal or intrabony
periradicular bone loss of pulpal and/or
periodontal origin that communicates with the
oral cavity via probing defect
A localized periodontal probing depth of
pulpal or periodontal origin
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33. Classification
According to SIMON GLICK FRANk (cohen)
Primary endodontic lesion
Primary endodontic lesion with secondary periodontal involve
Primary periodontal lesion
Primary periodontal lesion with secondary endodontic involve
rue combined lesion
According to WEINE
I. Tooth in which symptoms clinically and radiographically
simulate periodontal disease but are due to pulpal
inflammation
II. Tooth that has both pulpal and periodontal disease
concomitantly
III.Tooth has no pulpal problem but require endodontic
therapy plus root amputation to gain periodontal healing
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34. According to OLIET, POLLOCK (Grossman
Lesions that require endodontic procedures onl
necrotic pulp and apical granulomatous tissue
replacing periodontium with or without sinous tract
Chronic periapical abscess with sinus tract
Longitudinal and horizontal root fractures
Pathologic and iatrogenic root perforations
Teeth with incomplete apical root development
Endodontic implants
Teeth that require hemisection
Root submergence
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35. II.Lesions that require periodontal
procedures only
Occlusal trauma causing reversible pulpitis
Occlusal trauma plus gingival inflammation resulting
in pocket formation and reversible pulpitis
Suprabony or infrabony pocket formation treated
with overzealous root planning and curettage leading
to pulpal sensitivity
Extensive infrabony pocket formation extending
beyond the root apex and sometimes coupled with
lateral or apical resorption yet with pulp that responds
with in normal limits to clinical testing
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36. III. lesions that require combined endodontic and
periodontic treatment
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 to the pulp tissue and also requires
endodontic treatment
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37. Diagnosis of endo perio lesions
History of dentinal / pulpal pain
History of periodontal symptoms (bleeding,
mobility)
Signs and symptoms of pulpal / periapical
disease (vitality)
Periodontal charting (probing profile)
Radiographic pattern of marginal and
periradicular bone loss
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38. Diagnosis of endo perio lesions
Distopalatal
Midpalatal
Mesio palatal
Three point probing depths
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41. Long narrow pockets: endodontic origin
“Blow out” lesion
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Lateral endodontic abscess: wide and deep pocket
42. Radiographic patterns
( angularity and presence of marginal bone)
Bone loss and absence of periodontal ligament space
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43. Possible causes of endo perio
lesions
Single isolated endo perio lesions
Bone loss on one side because of lateral canal
Resolution after re treatment
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44. GP points used to trace localized deep probing defects
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45. Fractures in teeth with vital pulp
Definitive treatment is placement of cusp
covered cast restoration
Suspected cuspal fracture
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Tooth preparation with
occlusal reduction
46. Root Fractures
Bucco palatal fracture
Mesio distal fracture
Following removal of fractured root
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47. Fracture of mesial root
of vital molar
Bone loss related to
fracture of mesial root of
vital molar
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48. Fracture at middle third
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RCT of whole incisor
58. Max : lateral incisor with two roots
and a palato gingival groove
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59. Orthodontic Treatment
Loss of periodontal attachment on the
distal side of a maxillary canine following
orthodontic treatment
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60. Tooth transplantation and replantation
poorly designed restorations
Localized periodontal
breakdown related to a
poorly placed restoration
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61. Management Of Endo Perio
Lesions
Estimation of prognosis
Treatment of endo perio cases
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62. Endo perio lesion :
usually isolated, narrow localized pocket
Check endodontic status
Causes:
o Endo
o Perio
o Fracture
o Resorption
o Anatomy
Root treated
Not root treated
Evaluate adequacy
Vitality tests
Preparation:
Obturation:
oUnder prepared
oOver prepared
oPerforation
oZipping
oledges
oUnder filled
oOverfilled
oPoor adaptation
Is root canal re-treatment feasible?
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63. Feasible re-treatment?
No
Yes
Try OHI + debridement
OHI
Resolution?
Resolution?
No
Yes
No
Yes
oDo first stage endo
oClean and shape canals
Extract
oDress with calcium hydroxide
Resolution?
No
Yes
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Extract
64. Vitality tests
Negative
Positive
Root canal treatment
Resolution?
No
Yes
Check
Check vitality again:
OHI and perio
If in doubt- do RCT
Still no resolution: look for other causes
Perio treatment
Resolution?
No
Yes
Extract, resect , hemisect
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65. Tooth resections:
Classification of degree of Furcation
involvement
I. Horizontal loss of periodontal support< one
third of tooth width
II.Horizontal loss of periodontal support> one
third but not encompassing the total width of
the tooth
III.Horizontal through and through destruction
of the periodontal tissue in the furcal area
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66. Root Amputation : Removal of one or more
roots of a multi rooted tooth while the others
are retained
Hemisection : Removal or separation of root
with its accompanying crown portion of
mandibular molars
Radisection : Newer terminology for removal
of roots of maxillary molars
Bisection / Bicuspidization : Separation of
mesial and distal roots of mandibular molar
along with its crown portion, where both
segments are then retained individually
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67. Indications for Resections
Periodontal indications
Severe vertical bone loss involving only
one root of a multi rooted tooth
Through and through furcation
destruction
Unfavorable proximity of roots of
adjacent teeth, preventing adequate hygiene
maintenance in proximal areas
Severe root exposure due to dehiscence
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68. Restorative and endodontic indications:
Prosthetic failure of abutments within a
splint
Endodontic failure: perforations, over
extension , obstructed canals, separated
instrument , root resorption
Vertical fracture of one root
Restorative reasons: sub gingival caries,
erosion of large part of crown and root,
traumatic injury
Combination of these
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69. Contraindications
Root fusion making separation impossible
Angulation or position of tooth in the arch: if
the tooth is buccally or lingually, mesially or
distally cannot be resected
Root morphology: short conical roots are
difficult to resect
Improperly shaped occlusal contact may
convert occlusal forces in to destructive forces
and cause failure of hemisection
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70. Surgical exposure of
Furcation prior to
sectioning of disto
buccal root
Initial cut with a
diamond instrument
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Widened cut to allow
instrumentation
71. Appearance of tooth
following the removal
of disto buccal root
Elevation of disto buccal root
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Surgical closure
72. Vertical bone loss
around distal root
Retained mesial root
Vertical cut towards
the bifurcation
Full coverage cast restoration
of hemisected molar
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73. Role of regenerative techniques in treatment
of endo perio lesions
Histological section showing
new attachment formation
using a barrier
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74. References
o Management of periodontitis associated with
endodontically involved teeth: The journal of dental practice,
volume 6, No2 2005
oWeine FS: endodontic therapy
oStepten Cohen : Pathways of pulp
oJan Lindhe : clinical implantology
oGlickman : periodontology : periodontology
oStock : endodontics
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75. Conclusion
A
concise knowledge of both pulpal and
periodontal disease is necessary for
proper identification of the lesion.
Thus with adequate tender love and
care we can nourish it for a peaceful
coexistance……. Between the tooth and
gums
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