Presented by :

Dr. SAYAK GUPTA

 CONTENTS
INTRODUCTION
DEFINITION
CLASSIFICATION
ETIOLOGY
CONTROVERSIES REGARDING THE COMBINED LESION
PATHWAYS OF SPREAD
COMPARISION OF CLINICAL PRESENTATION B/W APICAL &
MARGINAL PERIODONTITIS
DIFFERENTIAL DIAGNOSIS
EFFECT OF PULP & ITS TREATMENT ON PERIODONTIUM
EFFECT OF PERIO. DISEASE & TREATMENT ON PULP
LESIONS
DIAGNOSIS
TREATMENT
REFERENCES
CONCLUSION
 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.

STOCK
 COHEN
• Primary endodontic lesion
• Primary endodontic lesion with secondary periodontal
involvement
• Primary periodontal lesion
• Primary periodontal lesion with secondary endodontic
involvement
• True combined lesion
• Concomitant pulpal
• & periodontal lesion
 WEINE

Type I - Tooth in which symptoms clinically and radiographically

simulate periodontal disease but are due to pulpal inflammation

Type II - Tooth that has both pulpal and periodontal disease

concomitantly

Type III - Tooth has no pulpal problem but require endodontic therapy
plus root amputation to gain periodontal healing

Type IV - Tooth that clinically and radiographically simulate pulpal or

periapical disease but infact have periodontal disease
LESIONS REQUIRING ENDODONTIC TREATMENT ONLY

GROUP I
 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

GROSSMAN
 LESIONS REQUIRING PERIODONTAL TREATMENT ONLY

GROUP II
 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
LESIONS REQUIRING COMBINED ENDO – PERIO TREATMENT

GROUP III
 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
ATYPICAL ANATOMIC FACTORS

Malaligned tooth
Multirooted teeth / additional root
Additional canal
Cervical enamel projection
Large lateral / accessory canal

TRAUMA

With gingival inflammation

Tooth fracture
Pulp / perio involvement + sinus tract
Cellular changes - resorption
MISCELLANEOUS

Iatrogenic
systemic

SINUS TRACT INFRABONY POCKET

•From canal •From gingival crevice

•Narrow •wide
Causes : ( Stock )

Root fractures – Root perforation

Root canal infection crown / root ( vital / non vital )

Anatomical anomalies ( palatogingival

Orthodontic treatment
Root resorption groove,enamel pearls , root division ,
fused teeth , invagination )

Localized periodontal disease

Transplantation & replantation

Poorly designed restorations

 Multiple endo perio lesion

•Isolated lesion upon gen. periodontitis

•Chronic periodontitis

•Aggressive periodontitis
CONTROVERSIAL ASPECT CONCERNING THE COMBINED
LESION

 PULPAL PERIODONTAL
 PERIODONTAL PULPAL ?
Chacker
Massler Venous blood flow outward
Czarnecki & Schilder
Drawback
Lateral / accesory canal - flow bothways

Seltzer & bender

Stahl
Physiologic :
• Apical foramen
• Lateral canals
• Dentinal tubules
• Periodontal ligament
• Alveolar bone
• Neural pathways
• Vasculolymphatic pathway

Iatrogenic :
• Palatogingival grooves
• Cementum defect
• Vertical root fractures
• Perforations
 COMPARISION

MARGINAL APICAL
PERIODONTITIS PERIODONTITIS

Cervical Apex

Plaque Pulpal inflammation

Horizontal / Vertical bone loss - Seldom bone loss – localized

generalized & deep

Open Contained
Attachment loss asso. with Aggresiveness asso with
 Anatomic defect on root  Lateral & apical foramen
 Nature of pathogenic flora  Nature of flora
 Necrotic & infected pulp  Apical host defense
 Host defense mechanism defect.

Periodontal probing & Radiographic examination

radiographic examination
 DIFFERENTIAL DIAGNOSIS

PULPAL PERIODONTAL
CLINICAL

Cause pulp infection periodontal

Vitality non vital vital
Restorative deep or extensive not related
Plaque /calculus not related primary cause
Inflammation acute chronic
Pockets single and narrow multiple and wide

coronally
pH value acidic alkaline
Trauma primary or secondary contributing factor
Microbial few complex
 RADIOGRAPHIC

Pattern localized generalized

Bone loss wider apically wider coronally
Periapical radiolucent not related
Vertical bone loss no yes

HISTOPATHOLOGY

Junctional epithelium no apical migration present

Granulation tissues apical (minimal) coronal (larger)
Gingival normal recession

TREATMENT

Therapy RCT Periodontal therapy

Problems in
diagnosis :

Vertical root fracture:

varied radiographic picture
Different angulations
Surgical exposure
lateral condensation excessive
Post placement
Cause Extensive restorations
Older patients
Gingival sulcus & pocket area
Single rooted teeth
multirooted teeth
Developmental grooves
In doubt ? – Biopsy / Histological analysis
Systemic diseases mimic lesion on radiograph :
Scleroderma
Metastatic carcinoma
Osteosarcoma
EFFECT OF PULP AND ITS TREATMENT ON PERIODONTIUM

Periodontal inflammation & bone loss

Sub marginal bone loss

Horizontal bone loss
Vertical intrabony pockets
Furcation involvement

Periodontal wound healing

Traumatized necrotic pulp
RC infection – compromised healing
Gingival tissue thickness
Alveolar bone level
Surgical trauma to flap
Effective flap repositioning
Root canal treatment
Doubtful pulpal status

Iatrogenic problems
EFFECT OF PERIODONTAL DISEASE & ITS TREATMENT ON PULP

Periodontal disease & pulp

•Limited
•Channels closed + dystrophic calcification- chronic
•Sufficient viurlence – pulpal disease
•Poor prognosis
•Extraction / Root resection

Periodontal treatment & pulp

•Scaling & root planing – excessive cementum removal

•Compromised pulp
PRIMARY ENDODONTIC LESION

Caries / trauma / restorative procedure

Pulp Inflammation

Apical / lateral / Furcation / Attachment apparatus

Pain , swelling , tenderness , marginal gingiva swelling

Suppurative process – Sinus tract

Pdl / Patent channels Ging. Sulcus

( GP / Probe to apex)
Multirooted Teeth

Gr. III thru & Thru Furcation defect

Diagnosis : Necrotic / Vitality test
Treatment : RCT
PRIMARY ENDODONTIC WITH SECONDARY PERIODONTAL

Unchecked endo lesion

Periapical alveolar bone destruction

Interradicular area Hard / soft tissue

Drainage Plaque / Calculus

Apical attachment migration ( perio disease)

Diagnosis : Necrosis / Calculus accumulation

Treatment : Both
 PRIMARY PERIODONTAL LESION
Sulcus Plaque / Calculus Apex
Inflammation
Alv. Bone / Pdl

Clinical attachment loss

acute
Abscess

Lateral root / Furcation / TFO ( isolated lesion ) osseous defects

Diagnosis : Tooth mobility

positive pulp test
Broad based pocket / Plaque & calculus
Generalized
Treatment : Periodontal therapy
 PRIMARY PERIODONTAL & SECONDARY ENDODONTIC

Periodontium Pulp Oral cavity

Dentinal tubules
Lateral canals
Diagnosis : Deep pocket
H/O extensive periodontal disease
Past treatment
Treatment : Both

TRUE COMBINED LESIONS

CONCOMITANT LESIONS
 DIAGNOSIS OF ENDO PERIO LESIONS

History of dentinal / pulpal pain

History of periodontal symptoms (bleeding, recur. Infection , mobility)
- nature / duration
- risk factors
Signs and symptoms of pulpal / periapical disease (vitality)
Periodontal charting (probing profile)
- Recession
- Mobility
- Furcation involvement
- Attachment loss
Clinical signs of pocket formation :

Bluish red marginal gingiva /

vertical zone extending from
marginal to attached gingiva.
“Rolled” edge separating gingival
margin form tooth surface.
Enlarged edematous gingiva.
Bleeding, suppuration, loose
extruded teeth.
Symptoms of pocket formation

Usually painless
Localized or radiating pain or sensation of pressure after
eating which gradually diminishes.
Foul taste in localized areas.
Sensitivity hot and cold
Tooth ache in absence of caries are present
BIOLOGIC DEPTH

PROBING DEPTH

FORCE : 0.75N

POCKET DEPTH

LEVEL OF ATTACHMENT

GINGIVAL RECESSION

6 POINT CHARTING

DISTOPALATAL MID PALATAL MESIOPALATAL

CONTINUOUS PROBING PROFILE
LONG NARROW POCKETS: ENDODONTIC ORIGIN

LATERAL ENDODONTIC ABSCESS

WIDE AND DEEP POCKET

“BLOW OUT” LESION

 RADIOGRAPHIC PATTERN OF BONE LOSS

•Apical extent of bone loss

•Definite Pdl space absent
•Shape of bone defect ( angularity /
marginal bone )

Bone defect contributed by pulp infection :

- Periodontal intrabony defect – 2/3 root length
- Horizontal bone loss - 2/3 root length
- periodontal bone loss involving root end

Acute pain generally absent in endo perio – open nature

30 – 60 % spirochaetes - perio origin

0 – 10 % spirochaetes - endo origin
 Endo perio lesion Causes:
usually isolated, narrow localized pocket o Endo
o Perio
o Fracture
o Resorption
o Anatomy
Check endodontic status

Root treated
Not root treated

Evaluate adequacy
Vitality tests

Preparation: Obturation:
oUnder prepared oUnder filled
oOver prepared oOverfilled
oPerforation oPoor adaptation
oZipping
oledges
MANAGEMENT
Is root canal re-treatment feasible?
 Feasible re-treatment?
No
Yes
Try OHI + debridement
OHI

Resolution?
Resolution?
Yes No
Yes No
oDo first stage endo
oClean and shape canals
oDress with calcium hydroxide
Extract

Resolution?

No Extract
Yes
 Vitality tests

Positive Negative

Perio treatment Root canal treatment

Resolution? Resolution?

No Yes No
Yes

Check
Check vitality again:
OHI and perio
If in doubt- do RCT

Still no resolution: look for other causes

Extract, resect , hemisect

 TREATMENT ALTERNATIVES

ROOT RESECTION

REGENERATIVE TECHNIQUES

ROOT RESECTION :
“ Sectioning & removal of one or two roots of a
multirooted teeth with accompanying odontoplasty.”

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.”
 ROOT RESECTION

Furcation involvement.
( Maxillary / Mandibular - 3 point / Nabers probe )

Classification of degree of Furcation involvement

Class I - Horizontal loss of periodontal support< one

third of tooth width

Class II - Horizontal loss of periodontal support> one

third but not encompassing the total width of the
tooth

Class III - Horizontal through and through destruction of

the periodontal tissue in the furcal area
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
Severe root exposure due to dehiscence
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
Contraidications

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

Factors

Tooth related :
- tooth restorability
- strategic value
- endo feasibility
- post treatment stability
- shape , size , posn. Of adj. tooth

Root related :
- length of the root trunk
- divergence b/w the roots
- curvature

Bone related factors :

- residual bone
- localised deep attachment loss

Final restoration :
- resection nature
- amt. of remaining tooth structure
- perio. Status
- pt. occlusion
 Poor prognosis
 Retained roots

SURGICAL CONSIDERATIONS
 Buccal + Palatal flaps
 Releiving incision
 Intracrevicular incision
 Full thickness flap
 Undersurface of crown - bevelled
.
Envelop Type Flaps
Little Or No Attached Gingiva
Flap Edges - Sutured
Full Flap - Periodontal Disease - Scaling, Curettage Or Osseous
Contouring Procedures
Endodontic Implants
Root Amputation – Max. Molars
REGENERATIVE TECHNIQUES

GTR – Differential tissue development

Barrier Resorbable Collagen

Synthetic
Non resorbable

Enamel matrix derived protein

Barrier – principle - stiff

Combined lesion – poor prognosis

 ANTIBIOTICS FOR ENDO PERIO LESION

 Tetracycline 250 mg (4 times a day)

 Doxycycline 100 mg (2 times on first day and once

thereafter)

 Metronidazole 250 mg (3 times a day for 7 days)

 Chlorhexidine
THANK YOU !