Endodontic Periodontal Lesions

Anatomic Considerations

There is an intimate relationship between

the periodontium and pulpal tissues

As the tooth develops and the root is

formed, 3 main avenues for
communication are created:
1. Apical Foramen
2. Lateral and Accessory Canals
3. Dentinal Tubules
 Apical Foramen
It is the principal and the most direct route of
communication between the pulp and
periodontium

Bacterial and inflammatory byproducts may exit

readily through the apical foramen to cause
periapical pathosis

The apex may also serve as a portal of entry of

inflammatory byproducts from deep periodontal
pockets to the pulp
 Apical Foramen
SEM of the apical third of a root. Note the opening of an
accessory canal at ninety degrees from the main canal
Lateral and Accessory Canals

These may be present anywhere along the

root

Patent accessory and lateral canals may

serve as a potential pathway for the spread
of bacterial byproducts

30-40% of all teeth have lateral or

accessory canals and the majority of them
are found in the apical third of the root
Lateral Canals
 Dentin Tubules

Exposed dentinal tubules in areas of

denuded cementum may serve as
communication pathways between the pulp
and PDL

In the root, dentinal tubules extend from

the pulp to the dentinocemental junction.
They range in size from 1 to 3 microns in
diameter (bacteria and their toxins are
smaller in size)
 Dentinal Tubules
Scanning electron micrograph of open dentinal tubules
 Dentin Tubules

The tubules may be denuded of their

cementum coverage as a result of perio
disease, surgical procedures or
developmentally when the cementum and
enamel do not meet at the CEJ thus
leaving areas of exposed dentin

Patients experiencing cervical dentin

hypersensitivity are examples of such a
phenomenon
 Additional Avenues of
communication between the Pulp
and the Periodontium
Developmental malformations such as
palatogingival grooves of maxillary incisors. These
usually begin in the central fossa, cross the
cingulum, and extend apically with varying
distances

Perforations these may result from extensive

carious lesions, resorption, or from operator error

Vertical root fractures these can produce deep

periodontal pocketing and localized destruction of
alveolar bone. The fracture site provides a portal
of entry for irritants from the root canal to the PDL
 Additional Avenues of communication
between the Pulp and the Periodontium
 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
 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)

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 (Langeland et al 74 and
Mandi 72)

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
Differential Diagnosis of
Endo/Perio Lesions
Primary Endodontic Disease

Typically, endodontic lesions resorb bone

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

It is possible for an acute exacerbation of a

chronic periapical lesion on a tooth with a
necrotic pulp to drain through the PDL into
the gingival sulcus. This clinical
presentation mimics the presence of a
periodontal abscess, or a deep periodontal
pocket
 Primary Endodontic Disease
Pre-op #30 Post-op 2 yr
follow-up
Primary Periodontal Disease

Caused by periodontal pathogens

It is the result of progression of

chronic periodontitis apically along
the root surface

Pulp tests yield a clinically normal

pulpal reaction
Primary Periodontal Disease

Frequently accumulation of plaque and

calculus are seen throughout the dentition

Periodontal pockets are wider, and are

generalized

The prognosis depends on the stage of

periodontal disease and the efficacy of
periodontal treatment
 Primary Periodontal Disease
Pre-op: alveolar bone loss + a periapical lesion, a deep narrow
pocket was traced on the mesial aspect of the root, the
tooth tested vital
 Primary Periodontal Disease
Referring dentist insisted that endo be done. However, since
the etiology was periodontal disease, no bony healing took
place
 A periapical lesion of
endodontic origin will not
occur in the presence of a
normal vital pulp!!!
 Primary Endo with Secondary
Perio
This happens with time as
suppurating primary endodontic
disease remains untreated, it may
become secondarily involved with
periodontal breakdown

Plaque forms at the gingival margin

of the sinus tract and leads to plaque-
induced periodontitis in the area
Primary Endo with Secondary Perio

The pathway of
inflammation into the
periodontium is
through the apical
foramen, accessory
and lateral canals
 Primary Endo with Secondary
Perio
The treatment and prognosis are now
different than those of teeth simply having
endo or perio disease

The tooth now requires both endodontic

and periodontal treatments

If the endo Tx is adequate, the prognosis

depends on the severity of the plaque-
induced periodontitis and the efficacy of
perio Tx
 Primary Endo with Secondary
Perio
With endo Tx alone, only part of the
lesion will heal to the level of the
secondary periodontal lesion

Root fractures and perforations may

also peresent as primary endo with
secondary periodontal involvement
Primary Endo with Secondary
Perio
Pre-op: interradicular
defect extends to the apex Post-op
 Primary Endo with Secondary
Perio
1 yr follow-up: resolution of most of the periradicular lesion,
however, a bony defect at the furcal area remained. Perio Tx
is necessary for further healing
 Primary Perio with Secondary
Endo
In this case, the apical progression of
a periodontal pocket continues until
the apical tissues are involved

The pulp may become necrotic as a

result of infection entering via the
apical foramen
Primary Perio with Secondary Endo

The progression of
periodontitis by way
of lateral canal and
apex to induce a
secondary endodontic
lesion
 Primary Perio with Secondary
Endo
In single-rooted teeth the prognosis is
usually poor, as the periodontal breakdown
is very severe, necessitating extraction

In molar teeth the prognosis may be

better, since not all the roots may suffer
the same loss of supporting periodontium.
Root resection may be considered as a
treatment alternative
 Primary Perio with Secondary
Endo
Even though unusual, the treatment
of periodontal disease can also lead
to secondary endodontic involvement.
Lateral canals and dentinal tubules
may be opened to the oral
environment by scaling and root
planing or surgical flap procedures
 Primary Perio with Secondary
Endo
At initial presentation #13 shows evidence of horizontal bone
loss as well as a periapical radiolucency. The crown was
intact, but vitality tests were negative. The post-op
radiograph shows that a lateral canal was exposed to the
oral environment due to bone loss. That lateral canal could
serve as a potential pathway for bacteria.
 True Combined Disease
True combined endo/perio disease occurs
less frequently than other endo/perio
problems

It is formed when an endodontic disease

progressing coronally joins with an infected
periodontal pocket progressing apically

The degree of attachment loss in this type

of lesion is large and the prognosis is thus
guarded, particularly for single-rooted
teeth.
 True Combined Disease
Concomitant endo-
perio lesion is an
additional
classification that has
been proposed to
describe the presence
of endo and perio
disease as two
separate and distinct
entities
 True Combined Disease
Radiograph shows separate progression of endodontic disease
and periodontal disease. The tooth remained untreated and
consequently the two lesions joined together
 True Combined Disease
Radiograph shows bone loss in 2/3 of the root with calculus
present and a separate periapical radiolucency. Clinical exam
revealed coronal color change and pus exuding from the
gingival crevice. Pulp vitality tests were negative
True Combined Disease