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Endodontic-Periodontics

Relationship

Malik Hudieb, BDS, PhD

Department of Preventive Dentistry

Faculty of Dentistry

Jordan University of Science and Technology

AAP

1999

Anatomic Considerations

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

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

1. Apical Foramen

2. Lateral and Accessory Canals

3. Dentinal Tubules

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1-Apical Foramen

• It is the principal and the most direct route

• Bacterial and inflammatory byproducts may exit/inter from/ to the root canal system

2-Lateral and Accessory Canals

• May be present anywhere along the root

• Around 30% of all teeth

• Majority are found in the apical third

2-Lateral and Accessory Canals 3-Dentin Tubules

• Extend from the pulp to the dentinocemental junction

• 1 to 3 microns in diameter

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3-Dentin Tubules

• Exposed dentinal tubules serves as communication pathways between the pulp and PDL

Additional Ways of communication

• Developmental malformations –

like the palatogingivalgrooves

Additional Ways of communication

• Perforations – iatrogenic, carious lesions, resorption..

• Vertical root fractures –deep periodontal pocketing and localized destruction of alveolar bone

Endodontic Disease and the

Periodontium

• When the pulp becomes inflamed or

necrotic, inflammatory byproducts may

leach out through the apex, lateral and

accessory canals as well as the dentinal

tubules to trigger an inflammatory vascular

response in the periodontium

Seltzer and Bender 1967

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Periodontal Disease and the Pulp

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

– It has been suggested that periodontal disease has no effect on the pulp, at least until it involves the apex (Czarnecki & Schilder, ‘79)

– It has been reported that pulpal changes resulting from periodontal disease are more likely to occur when the apical foramen is involved (Langland et al ’74)

Differential Diagnosis of

Endo/Perio Lesions

• The following classification system was developed by Simon, Glick and Frank in 1972:

– Primary Endodontic Disease

– Primary Periodontal Disease

– Primary Endo w/ Secondary Perio

– Primary Perio w/ Secondary Endo

– True Combined Lesions

Possible presentations of

Endo/Perio Lesions

1-Primary Endodontic

Disease• Typically, endodontic

lesions resorb bone apically and laterally and destroy the attachment apparatus adjacent to a nonvital tooth

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1-Primary Endodontic

Disease

• Drain through the PDL into the gingival sulcus

• Mimics the presence of a periodontal abscess, or a deep periodontal pocket

• Periapical abscess� sinus tract

� Periodontal pocket (deep pocket)

� Furcation area (furcation defect )

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

1-Primary Endodontic

Disease

Pre-op Post-op follow-up

1-Primary Endodontic

Disease

1-Primary Endodontic

Disease

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1-Primary Endodontic

Disease

2-Primary Periodontal

Disease• Dental plaque

• Pulp tests �(vital tooth)

• Periodontal pockets are wider, and are generalized

Primary Periodontal Disease

Referred for RCT. The tooth tested vital to cold

3-Primary Endo & Secondary Perio

• This happens when a primary endodontic disease remains untreated

• Plaque forms at the gingival margin of the sinus tract and leads to plaque-induced periodontal disease

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3-Primary Endo & Secondary Perio

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

• Endodontic and periodontal treatments

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

4-Primary Perio &Secondary Endo

At initial presentation:

• Horizontal bone loss

• Periapical radiolucency.

• The crown was intact,

• Vitality test was negative

4-Primary Perio &Secondary

EndoPrimary Perio with Secondary Endo

The post-op radiograph:

Lateral canal was exposed to the

oral environment due to bone loss.

That lateral canal could serve as a

potential pathway for bacteria.

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5-True Combined Disease

• Occurs less frequently than other endo/perio problems

• Formed when an endodontic disease progressing coronally joins with an infected periodontal pocket progressing apically

• Attachment loss

True Combined Disease

Clinical exam revealed coronal color change and pus exuding from the

gingival sulcus. Pulp vitality tests were negative

Diagnosis

• A thorough clinical and radiographic examination is imperative for developing a diagnosis

• Data Collecte: – periapical radiographs

– pulp vitality testing

– percussion

– palpation

– pocket probing

– sinus tract tracking

– cracked tooth testing: transillumination, staining..

Treatment, Decision-Making and

Prognosis

• The main factors to consider are:

- Pulp vitality

- Type and extent of the periodontal defect

- Stage of presentaion

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• Primary endo and Primary perio disease: no clinical difficulty

In primary endo � pulp is nonvital. In primary perio � pulp is vital

Treatment, Decision-Making and

Prognosis

• Combined endo/perio lesions present clinically and radiographically very similar.

• The diagnosis is often tentative with a definitive diagnosis formulated following treatment

Treatment, Decision-Making and

Prognosis

• Primary endo: endodontic treatment (RCT) ..has a good prognosis

• Primary perio: periodontal treatment

• Combined lesions: endodontic therapy first then periodontal treatment.

• Treatment should be evaluated in 2-3 months

Treatment