Anatomic Considerations

Clinic, diagnostics, Clinic, diagnostics, differential diagnostics of differential diagnostics of

acute forms of acute forms of periodontitis.periodontitis.

Clinic, diagnostics, Clinic, diagnostics, differential diagnostics, differential diagnostics,

chronic and exacerbation chronic and exacerbation forms of periodontitis. The forms of periodontitis. The

role of X-ray method in role of X-ray method in diagnosticsdiagnostics

Anatomic ConsiderationsAnatomic Considerations

There is an intimate relationship There is an intimate relationship between the periodontium and between the periodontium and pulpal tissuespulpal tissues

As the tooth develops and the root is As the tooth develops and the root is formed, 3 main avenues for formed, 3 main avenues for communication are created:communication are created:

1.1. Apical ForamenApical Foramen

2.2. Lateral and Accessory CanalsLateral and Accessory Canals

3.3. Dentinal TubulesDentinal Tubules

Apical ForamenApical Foramen

It is the principal and the most direct route It is the principal and the most direct route of communication between the pulp and of communication between the pulp and periodontiumperiodontium

Bacterial and inflammatory byproducts may Bacterial and inflammatory byproducts may exit readily through the apical foramen to exit readily through the apical foramen to cause periapical pathosiscause periapical pathosis

The apex may also serve as a portal of entry The apex may also serve as a portal of entry of inflammatory byproducts from deep of inflammatory byproducts from deep periodontal pockets to the pulpperiodontal pockets to the pulp

Apical ForamenApical Foramen

the apical third of a root. Note the opening of an the apical third of a root. Note the opening of an accessory canal at ninety degrees from the main accessory canal at ninety degrees from the main canalcanal

Lateral and Accessory Lateral and Accessory CanalsCanals

These may be present anywhere These may be present anywhere along the rootalong the root

Patent accessory and lateral canals Patent accessory and lateral canals may serve as a potential pathway for may serve as a potential pathway for the spread of bacterial byproductsthe spread of bacterial byproducts

30-40% of all teeth have lateral or 30-40% of all teeth have lateral or accessory canals and the majority of accessory canals and the majority of them are found in the apical third of them are found in the apical third of the rootthe root

Lateral CanalsLateral Canals

Dentin TubulesDentin Tubules

Exposed dentinal tubules in areas of Exposed dentinal tubules in areas of denuded cementum may serve as denuded cementum may serve as communication pathways between communication pathways between the pulp and PDLthe pulp and PDL

In the root, dentinal tubules extend In the root, dentinal tubules extend from the pulp to the dentinocemental from the pulp to the dentinocemental junction. They range in size from 1 to junction. They range in size from 1 to 3 microns in diameter (bacteria and 3 microns in diameter (bacteria and their toxins are smaller in size)their toxins are smaller in size)

Dentinal TubulesDentinal Tubules

Scanning electron micrograph of open dentinal tubulesScanning electron micrograph of open dentinal tubules

Dentin TubulesDentin Tubules

The tubules may be denuded of their The tubules may be denuded of their cementum coverage as a result of cementum coverage as a result of perio disease, surgical procedures or perio disease, surgical procedures or developmentally when the cementum developmentally when the cementum and enamel do not meet at the CEJ and enamel do not meet at the CEJ thus leaving areas of exposed dentinthus leaving areas of exposed dentin

Patients experiencing cervical dentin Patients experiencing cervical dentin hypersensitivity are examples of such hypersensitivity are examples of such a phenomenona phenomenon

Additional Avenues of Additional Avenues of communication between the communication between the Pulp and the PeriodontiumPulp and the Periodontium

Developmental malformations Developmental malformations – such as – such as palatogingival grooves of maxillary incisors. palatogingival grooves of maxillary incisors. These usually begin in the central fossa, These usually begin in the central fossa, cross the cingulum, and extend apically with cross the cingulum, and extend apically with varying distancesvarying distances

PerforationsPerforations – these may result from – these may result from extensive carious lesions, resorption, or extensive carious lesions, resorption, or from operator errorfrom operator error

Vertical root fracturesVertical root fractures – these can produce – these can produce deep periodontal pocketing and localized deep periodontal pocketing and localized destruction of alveolar bone. The fracture destruction of alveolar bone. The fracture site provides a portal of entry for irritants site provides a portal of entry for irritants from the root canal to the PDLfrom the root canal to the PDL

Additional Avenues of Additional Avenues of communication between the Pulp communication between the Pulp

and the Periodontiumand the Periodontium

Endodontic Disease and Endodontic Disease and the Periodontiumthe Periodontium

When the pulp becomes inflamed When the pulp becomes inflamed or necrotic, inflammatory or necrotic, inflammatory byproducts may leach out byproducts may leach out through the apex, lateral and through the apex, lateral and accessory canals as well as the accessory canals as well as the dentinal tubules to trigger an dentinal tubules to trigger an inflammatory vascular response inflammatory vascular response in the periodontiumin the periodontium

Periodontal Disease and the Periodontal Disease and the PulpPulp

The effect of periodontal inflammation on The effect of periodontal inflammation on the pulp is controversial and conflicting the pulp is controversial and conflicting studies exist:studies exist:

It has been suggested that periodontal disease It has been suggested that periodontal disease has has no effectno effect on the pulp, at least until it involves on the pulp, at least until it involves the apexthe apex

On the other hand, some studies suggest that the effect of perio disease on the pulp is degenerative in nature including an increase in calcifications, fibrosis and collagen resorption in the pulp

It has been reported that pulpal changes resulting from periodontal disease are more likely to occur when the apical foramen is involved

Differential Diagnosis of Differential Diagnosis of Endo/Perio LesionsEndo/Perio Lesions

The following classification system The following classification system was developed by Simon, Glick and was developed by Simon, Glick and Frank in 1972:Frank in 1972: Primary Endodontic DiseasePrimary Endodontic Disease Primary Periodontal DiseasePrimary Periodontal Disease Primary Endo w/ Secondary Perio Primary Endo w/ Secondary Perio Primary Perio w/ Secondary EndoPrimary Perio w/ Secondary Endo True Combined LesionsTrue Combined Lesions

Differential Diagnosis of Differential Diagnosis of Endo/Perio LesionsEndo/Perio Lesions

Primary Endodontic Primary Endodontic DiseaseDisease

Typically, endodontic lesions resorb Typically, endodontic lesions resorb bone apically and laterally and destroy bone apically and laterally and destroy the attachment apparatus adjacent to the attachment apparatus adjacent to a nonvital tootha nonvital tooth

It is possible for an acute exacerbation It is possible for an acute exacerbation of a chronic periapical lesion on a tooth of a chronic periapical lesion on a tooth with a necrotic pulp to drain through with a necrotic pulp to drain through the PDL into the gingival sulcus. This the PDL into the gingival sulcus. This clinical presentation mimics the clinical presentation mimics the presence of a periodontal abscess, or a presence of a periodontal abscess, or a deep periodontal pocketdeep periodontal pocket


For diagnostic purposes, it is For diagnostic purposes, it is imperative to trace the sinus tract by imperative to trace the sinus tract by inserting a gutta-percha cone and inserting a gutta-percha cone and exposing one or more radiographs to exposing one or more radiographs to determine the origin of the lesiondetermine the origin of the lesion

The sinus tract of endodontic origin is The sinus tract of endodontic origin is readily probed down to the tooth apex, readily probed down to the tooth apex, where no increased probing depth where no increased probing depth would otherwise exist around the toothwould otherwise exist around the tooth


Primary endodontic disease will Primary endodontic disease will heal following root canal heal following root canal treatmenttreatment

The sinus tract extending into The sinus tract extending into the gingival sulcus or the the gingival sulcus or the furcation area disappears at an furcation area disappears at an early stage once the necrotic early stage once the necrotic pulp has been removed and the pulp has been removed and the root canals are well sealedroot canals are well sealed


Pre-op #30 Post-op 2 yr Pre-op #30 Post-op 2 yr follow-up follow-up


Pre-op #19: periapical and furcal RL + a deep narrow Pre-op #19: periapical and furcal RL + a deep narrow perio defectperio defect


1 yr follow-up: complete healing1 yr follow-up: complete healing

Primary Periodontal Primary Periodontal DiseaseDisease

Caused by periodontal Caused by periodontal pathogenspathogens

It is the result of progression of It is the result of progression of chronic periodontitis apically chronic periodontitis apically along the root surfacealong the root surface

Pulp tests yield a clinically Pulp tests yield a clinically normal pulpal reactionnormal pulpal reaction


Frequently accumulation of plaque Frequently accumulation of plaque and calculus are seen throughout the and calculus are seen throughout the dentitiondentition

Periodontal pockets are wider, and Periodontal pockets are wider, and are generalized are generalized

The prognosis depends on the stage The prognosis depends on the stage of periodontal disease and the of periodontal disease and the efficacy of periodontal treatmentefficacy of periodontal treatment


Pre-op: alveolar bone loss + a periapical lesion, a deep Pre-op: alveolar bone loss + a periapical lesion, a deep narrow pocket was traced on the mesial aspect of narrow pocket was traced on the mesial aspect of the root, the tooth tested vitalthe root, the tooth tested vital


The tooth was extracted. Note the deep mesial The tooth was extracted. Note the deep mesial radicular developmental grooveradicular developmental groove


#31 was referred for RCT. The tooth tested vital to cold#31 was referred for RCT. The tooth tested vital to cold


Referring dentist insisted that endo be done. However, Referring dentist insisted that endo be done. However, since the etiology was periodontal disease, no bony since the etiology was periodontal disease, no bony healing took placehealing took place

A periapical lesion of A periapical lesion of endodontic origin will not endodontic origin will not occur in the presence of a occur in the presence of a

normal vital pulp!!!normal vital pulp!!!

Primary Endo with Primary Endo with Secondary PerioSecondary Perio

This happens with time as This happens with time as suppurating primary endodontic suppurating primary endodontic disease remains untreated, it disease remains untreated, it may become secondarily involved may become secondarily involved with periodontal breakdownwith periodontal breakdown

Plaque forms at the gingival Plaque forms at the gingival margin of the sinus tract and margin of the sinus tract and leads to plaque-induced leads to plaque-induced periodontitis in the areaperiodontitis in the area

Primary Endo with Secondary Primary Endo with Secondary PerioPerio

The pathway of The pathway of inflammation into inflammation into the periodontium is the periodontium is through the apical through the apical foramen, accessory foramen, accessory and lateral canalsand lateral canals


The treatment and prognosis are now The treatment and prognosis are now different than those of teeth simply different than those of teeth simply having endo or perio diseasehaving endo or perio disease

The tooth now requires both The tooth now requires both endodontic and periodontal endodontic and periodontal treatmentstreatments

If the endo Tx is adequate, the If the endo Tx is adequate, the prognosis depends on the severity of prognosis depends on the severity of the plaque-induced periodontitis and the plaque-induced periodontitis and the efficacy of perio Txthe efficacy of perio Tx


With endo Tx alone, only part of With endo Tx alone, only part of the lesion will heal to the level of the lesion will heal to the level of the secondary periodontal lesionthe secondary periodontal lesion

Root fractures and perforations Root fractures and perforations may also peresent as primary may also peresent as primary endo with secondary periodontal endo with secondary periodontal involvementinvolvement


Pre-op: interradicularPre-op: interradicular

defect extends to the apex Post-opdefect extends to the apex Post-op


1 yr follow-up: resolution of most of the periradicular 1 yr follow-up: resolution of most of the periradicular lesion, however, a bony defect at the furcal area lesion, however, a bony defect at the furcal area remained. Perio Tx is necessary for further healingremained. Perio Tx is necessary for further healing

Primary Perio with Primary Perio with Secondary EndoSecondary Endo

In this case, the apical In this case, the apical progression of a periodontal progression of a periodontal pocket continues until the apical pocket continues until the apical tissues are involvedtissues are involved

The pulp may become necrotic The pulp may become necrotic as a result of infection entering as a result of infection entering via the apical foramenvia the apical foramen

Primary Perio with Secondary Primary Perio with Secondary EndoEndo

The progression of The progression of periodontitis by periodontitis by way of lateral canal way of lateral canal and apex to induce and apex to induce a secondary a secondary endodontic lesionendodontic lesion


In single-rooted teeth the prognosis is In single-rooted teeth the prognosis is usually poor, as the periodontal usually poor, as the periodontal breakdown is very severe, breakdown is very severe, necessitating extractionnecessitating extraction

In molar teeth the prognosis may be In molar teeth the prognosis may be better, since not all the roots may better, since not all the roots may suffer the same loss of supporting suffer the same loss of supporting periodontium. Root resection may be periodontium. Root resection may be considered as a treatment alternativeconsidered as a treatment alternative


Even though unusual, the Even though unusual, the treatment of periodontal disease treatment of periodontal disease can also lead to secondary can also lead to secondary endodontic involvement. Lateral endodontic involvement. Lateral canals and dentinal tubules may canals and dentinal tubules may be opened to the oral be opened to the oral environment by scaling and root environment by scaling and root planing or surgical flap planing or surgical flap proceduresprocedures


At initial presentation #13 shows evidence of horizontal At initial presentation #13 shows evidence of horizontal bone loss as well as a periapical radiolucency. The bone loss as well as a periapical radiolucency. The crown was intact, but vitality tests were negative. crown was intact, but vitality tests were negative. The post-op radiograph shows that a lateral canal The post-op radiograph shows that a lateral canal was exposed to the oral environment due to bone was exposed to the oral environment due to bone loss. That lateral canal could serve as a potential loss. That lateral canal could serve as a potential pathway for bacteria. pathway for bacteria.

True Combined DiseaseTrue Combined Disease

True combined endo/perio disease True combined endo/perio disease occurs less frequently than other occurs less frequently than other endo/perio problemsendo/perio problems

It is formed when an endodontic It is formed when an endodontic disease progressing coronally joins disease progressing coronally joins with an infected periodontal pocket with an infected periodontal pocket progressing apicallyprogressing apically

The degree of attachment loss in this The degree of attachment loss in this type of lesion is large and the type of lesion is large and the prognosis is thus guarded, particularly prognosis is thus guarded, particularly for single-rooted teeth.for single-rooted teeth.


Concomitant endo-Concomitant endo-perio lesion is an perio lesion is an additional additional classification that classification that has been proposed has been proposed to describe the to describe the presence of endo presence of endo and perio disease and perio disease as two separate as two separate and distinct entities and distinct entities


Radiograph shows separate progression of endodontic Radiograph shows separate progression of endodontic disease and periodontal disease. The tooth remained disease and periodontal disease. The tooth remained untreated and consequently the two lesions joined untreated and consequently the two lesions joined togethertogether


Radiograph shows bone loss in 2/3 of the root with Radiograph shows bone loss in 2/3 of the root with calculus present and a separate periapical calculus present and a separate periapical radiolucency. Clinical exam revealed coronal color radiolucency. Clinical exam revealed coronal color change and pus exuding from the gingival crevice. change and pus exuding from the gingival crevice. Pulp vitality tests were negativePulp vitality tests were negative

DiagnosisDiagnosis

A thorough clinical and radiographic A thorough clinical and radiographic examination is imperative for developing a examination is imperative for developing a diagnosisdiagnosis

Data Collected must include: Data Collected must include: periapical radiographsperiapical radiographs pulp vitality testing: cold, EPT, cavity testpulp vitality testing: cold, EPT, cavity test percussionpercussion palpation palpation pocket probingpocket probing sinus tract trackingsinus tract tracking cracked tooth testing: transillumination, tooth-cracked tooth testing: transillumination, tooth-

slooth, stainingslooth, staining

Treatment Decision-Making Treatment Decision-Making and Prognosisand Prognosis

Treatment decision-making and Treatment decision-making and prognosis depend primarily on prognosis depend primarily on the diagnosis of the specific the diagnosis of the specific endodontic and/or periodontal endodontic and/or periodontal diseasedisease

The main factors to consider are The main factors to consider are pulp vitality and type and extent pulp vitality and type and extent of the periodontal defectof the periodontal defect


Diagnosis of Primary endo and Diagnosis of Primary endo and Primary perio disease usually present Primary perio disease usually present no clinical difficulty. In primary endo no clinical difficulty. In primary endo the pulp is nonvital. In primary perio the pulp is nonvital. In primary perio the pulp is vitalthe pulp is vital

However, the diagnosis of the However, the diagnosis of the combined endo/perio lesions could combined endo/perio lesions could present a challege as they present present a challege as they present clinically and radiographically very clinically and radiographically very similar. The diagnosis is often similar. The diagnosis is often tentative with a definitive diagnosis tentative with a definitive diagnosis formulated following treatmentformulated following treatment


The prognosis and treatment of each The prognosis and treatment of each endo/perio disease type variesendo/perio disease type varies

Primary endo should only be treated Primary endo should only be treated by endodontic therapy and has a by endodontic therapy and has a good prognosisgood prognosis

Primary perio should only be treated Primary perio should only be treated by periodontal treatment. The by periodontal treatment. The prognosis depends on severity of the prognosis depends on severity of the perio disease and patient response to perio disease and patient response to treatmenttreatment


Combined lesions should be treated with Combined lesions should be treated with endodontic therapy first. Treatment endodontic therapy first. Treatment should be evaluated in 2-3 months, and should be evaluated in 2-3 months, and only then should periodontal treatment only then should periodontal treatment be considered. This sequence allows for be considered. This sequence allows for sufficient time for initial tissue healing sufficient time for initial tissue healing and better assessment of the and better assessment of the periodontal condition to determine if the periodontal condition to determine if the tooth needs SC/RP or surgical treatmen. tooth needs SC/RP or surgical treatmen. Prognosis depends on the periodontal Prognosis depends on the periodontal involvement and treatmentinvolvement and treatment

Cases of True Combined disease usually Cases of True Combined disease usually have a more guarded prognosishave a more guarded prognosis

Anatomic Considerations

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