‫ﺑﺴﻢ اﷲ اﻟﺮﺣﻤﻦ اﻟﺮﺣﻴﻢ‬

Today we will talk about very important topic in

dentistry and it should be totally understood and
that’s it endo perio lesion or the relation ship
between periodontics and endodontics .
As we know we are dealing in perio with the
outside of the tooth or the tooth root, however ,
the inside of the tooth is communicating with the
outside of the tooth via 3 main avenues or
passages and these include mainly 1)apical
foramina (The most direct route of communication
between pulp and periodontium) 2)accessory
(lateral) canals 3) dentinal tubules.
Therefore these open passages are 2 direction
passages so there is anatomical variation , so fluid,
bacteria, harmful products of bacteria can move
from the pulp tissue to the periodontal area and
vice versa , it also can go the other way around so
when we are saying endo perio that its mean that
the problem start in the pulp and spread outward
to the periodontal area and that’s the upper
drawing , the lower drawing the arrows coming
from periodontal pocket and going into pulp tissue
that s is perio endo lesion .
 Differential diagnosis is so important, because we
want to know where the problem have started ,
although the sequence is the same, so both perio,
endo lesion can occur in the same tooth either
together (simultaneously) or one may proceede the
other, so they can present at the same time in this
case we call it endo perio lesion.

As we said the endo perio lesion can start as either

endo lesion and move toward periodontal area or
the other way around or it may be both just
happening at the same time and then they merge
together and become as one lesion and pathway of
infection spread in case of endo perio lesion
through 1) apical foramina 2)accessory canals and
as you know in majority of single rooted tooth
they are in apical third of root, but they more
common in the molars in furcation areas .

3)Exposed dentinal tubules whether due to trauma

, tooth brushing , caries , surgical procedures , or
developmentally when cementum and enamel
don’t meet at CEJ thus leaving areas of exposed
dentin.
4)Cracks and fracture lines can communicate all
the way through the root and to the pulp tissue 5)
iatrogenic root perforation for example dentist
trying to do root canal and perforate into
 periodontal area and then bacteria may spread to
pulpal tissues and periodontal area .

Etiology:
when case start in the pulp ,most likely due to 1)
caries, caries will extend into pulp chamber ,
bacteria will go all the way there and from there
they will go either through apical foramen,
accessory canal , if you look to this tooth from the
bottom , restorative procedures , traumatic injury ,
or tooth cracked due to trauma and then we end up
with endo perio lesion.
 If you look to this radiograph for example how do
you know this lesion start as endo or perio lesion ?
In the radiograph still we have a crest there ,but
yet we have a good area of radiolucency .

Perforation , some thing extruding,

or it may be accessory canal and there is extrusion
of material to this canal and most likely its
accessory canal .
 2)Traumatic injury for example and he come with
(‫)واﺣﺪ ﺑﻴﺎآﻞ ﻓﺮﻳﻜﺔ ﺑﻴﻄﻠﻌﻠﻮ ﺣﺠﺮ‬very sever pain
the tooth may not be fractured but pulp
affected from contusion

so there may be reversible pulpitis , if we reversed

the condition ,give to the patient anti
inflammatory, it may come back to its normal form,
but if we have pulpal injury and there is necrosis
there are 2 possibillities :
1- no bacteria , no plaque , no infection so its
unlikely to cause perio problem , pulp will be dead
but without any other symptoms .
2- pulp is infected and there is a problem , endo
bacteria , perio pathogens , we end up in
inflammation , may lead to chronic inflammation or
acute abscess , chronic inflammation may confined
to apical area , or may spread to coronal part of
periodontium , we know that infection try to follow
the path of the least resistance especially if there is
pus formation .

if we have endo abscess where it will drain ?

it can drain 1- through PDL space :we will see

pus oozing from periodontal pocket . deep
periodontal pocket depth , narrow deep pocket
down to the apex , some times there is pus, we
hold the probe and walk through , its normal
depth, suddenely it will go down to the apex , this
is a good indicator that its endo lesion , and we can
confirm that by inserting gutta percha cone , take
 radiograph , and we will see that cone will go all
the way down .

2- it can drain through extraosseous fistulation

and cortical bone , elevate periosteum and soft
tissues and drain through sulcus or it may slide
through the bone , perio probe cant penetrate into
a pocket .
upper left picture perio abscess , look how deep
the probe goes , this true endo lesion with
furcation involvement , we have crown but we
don’t see prober endo filling and if you look to bone
around tooth you can see density is not right, so
that bone eaten away and the last RG after
treatment and there is healing in the furcation area
.
 now what is the influence of PDL disease on the
pulp

as we know plaque is the major external etiologic

factor, so bacteria go through PDL area , then
dentinal tubules or even accessory canals or apical
foramina , then to the tooth , the tooth may be
totally intact , no caries , still we may end up with
pulp necrosis ,due to inflammation by PDL
pathogens which enter through the canals and we
know that dentinal tubules usually covered so they
have to be exposed , but how?
Either by iatrogenic factors , or breakage , when
they exposed and there is no bacteria, reparative
dentine try to take care of it .
Pulp response to long standing periodontitis , the
tooth just die slowly , however perio disease rarely
leads to pulpal involvement , most endo perio
lesion start from endo.

Clinical manifestations of endo perio lesion:

 Notes

1-We check for the vitality by cold test not

electrical , because fluid in necrotic pulp still
conduct electricity, and patient may feel response
but may be its not a true response and I don’t like
term pulp is vital I like tooth is responsive , it may
be delayed response , exaggerated response in
pulpal pathology, some times tooth may be
partially vital , if toy look to this malar its not
proberly filled , some times remnants of pulp tissue
in root will be vital (alive) and the tooth gave you
response but does this mean this tooth is healthy ?
no it does not

2- in the case of sinuses patient will not complain

because there is no pressure.
3- discoloured crowns especially in cases of trauma
, and pulp will have hemorage , blood enter into
dentinal tubules and give this dark colour may be
reddish,black,bluish.

If u cannot finish endodontic treatment completely

at least stabilize the case, disinfect the canal ,put
temporary dressing ,then u can go toward perio
treatment, remember treatment plan and sequence
of treatment .

What the effect of periodontal treatment on the

pulp ?
When we do aggressive root planning ,some time
,we remove the cementum which will open the
dentinal tubules .resulting in tooth sensitivity or
infection even in some cases retrograde pulpitis :
which mean bacteria coming through the dentinal
tubules .
When we do root conditioning with an acidic
material , the pulp may get irritated so these r
some of undesirable side effects of periodontal
treatment.

What is the other way around?

What the effect of endo treatment on periodontium
??
Generally speaking , proper endo treatment will
have favorable results, poor endo treatment will
end up with problem .
1- Inadequate RCT filling or seal which means that
some bacteria still there , and it will leak out and
cause problem .

2-Mechanical irritant.

3- Chemical irritant sometimes material go out side

the tooth and irritate surrounding area and I saw a
case where the dentist was irrigating using sodium
hypochlorite , and it went through the canal to the
tissues and the body react with severe
inflammation.

4- Root perforation : either by post crown or

through instrument and u can tell the result of this
perforation that we have this furcation
involvement and widening and more inflammation
around the mesial root.

Root perforation associate with formation of

periodontal pockets especially in the coronal 1/3.
That’s mean the higher the perforation the worst
the result because that make communication
possible with PDL pockets.
How to detect root perforation ???
1- sudden pain( no LA) ,bleeding coronal to
perforation area .

2- Radiographs.

if the lesion is established we will have increase in

the probing depth , suppuration, mobility , tender
to percussion(TTP) .

Now, this condition one of the most difficult to

diagnose and it is not uncommon and this is what
we call root fracture or vertical root fracture .the
problem is they don’t show on the RG ,but we
suspect it for example, even if the tooth has proper
endo treatment ,and we go around ,suddenly we
notice deep probing , and actually we can not tell
for sure until we open flap see this bone
destruction , it is not due PDL disease, it is due
fracture. This crack communicate the bacteria all
the way to the pulp and the pulp become reservoir
of bacteria . the only treatment is extraction .

For root perforation treatment we should start as

early as possible(A.S.A.P)to prevent or reduce
granulation tissue, we have many methods and
actually that’s the responsibility of endodontist.

Now, if we have multi-rooted tooth we can do

resection, we remove the infected root and leave
the rest , hemisection or extraction.

We can detect that (vertical root fracture) only

clinically, open flap ( healthy periodontium ,
normal bone height ,pain laterally ,pus ,deep
probing depth on the crack area ).

Diagnosis of vertical root fracture:

¤ Clinical manifestation: narrow deep probing .

¤ Radiographic manifestation widening of the PDL ,

horizontal fracture visible on RG , vertical fractures
r not .
¤ Other diagnostic method is:
1- Dies , we use iodine that will show u a line a
long the root surface .

2- Differential in biting on the buccal and the

lingual cusps in multi-rooted tooth , but actually I
borrow from the pediatric clinic the band
seater(the child will bite on so it will go between
teeth when we make space maintainer) .back to
differential biting u wrap piece of gauze aroud the
handle of the mirror ,then u start asking the
patient to bite on one cusp at a time , not the
whole tooth,if he feels pain on biting on one of
these cusps this is an indication that there is
vertical root fracture .

3- Fiber optic light : u can see the crack ,but be

careful not to burn the patient because it produce
intensive heat .

4- flap.

Treatment :
¤ single-rooted tooth: take the tooth out.
¤ multi-rooted tooth: u may have hemisection, root
resection or extraction .
Radiograph may deceive u ,upper RG look like PA
lesion ,however , when u open a flap u find this
tooth is vital or responsive ,but what happen this
destroyed PDL area is overlapped the root, so its
look like PA lesion .

Sometimes we do root canal

treatment even in case of vital pulp and we call this
(elective endo).to avoid something before it
happened , rather than we end up with endo- perio
lesion , we do RCT to prevent future problems.

Now, if u put a mirror , and this is vital tooth ( no

problem in apical area ) we have area of perio
destruction .we take RG , when u look to RG u will
see this part of the destruction and you think its PA
lesion, due to superimposition
Done by: Rania AL Bsoul.

Thanks Amal for help.

THE END

Correction for crowns and bridges lecture #5:

Page 20 .
Posterior MCCs features:
That’s why we prepare functional cusp about 1.5 mm
THE CORRECT is

That’s why we prepare the non functional cusp about

1.5 mm.