INDEX

 DEFINITION
 CLASSIFICATION
 PATHWAYS OF COMMUNICATION BETWEEN PULP &
PERIDONTAL DISEASE
 ETIOLOGY OF PULPAL DISEASE
 CLASSIFICATION OF PULPAL DISEASE
 CLASSIFICATION OF PERIODONTAL DISEASE
 CLINICAL FINDINGS OF ENDODONTIC &
PERIODONTIC LESION
 CLINICAL FINDINGS OF COMBINED ENDO- PERIO
LESION
 TREATEMENT
 DEFINITION
 ENDODONTIC LESION :-

IT IS USED TO DENOTE AN
INFLAMMATORY PROCESS IN THE PERIO
DONTAL TISSUES RESULTING FROM
NOXIOUS AGENTS PRESENTS IN THE
ROOT CANAL SYSTEM OF THE TOOTH,
USUALLY A ROOT CANAL INFECTION .
 PRIODONTAL LESION : -

IT IS USED TO DENOTE AN
INFLAMMATORY PROCESS IN THE
PERIODONTAL TISSUE RESULTING FROM
ACCUMULATION OF DENTAL PLAQUE ON
THE EXTERNAL TOOTH SURFACE .
CLASSIFICATION OF ENDO - PERIO
LESIONS
SIMON 1972

1. PRIMARY ENDODONTIC LESION.

2. PRIMARY ENDODONTIC LESION WITH SECONDARY

PERIODONTAL INVOLVEMENT.

3. PRIMARY PERIODONTIC LESION.

4. PRIMARY PERIODONTIC LESION WITH SECONDARY ENDODONTIC

INVOLVEMENT.

5. TRUE COMBINED LESION.

 WEINE 1972

•CLASS I – TOOTH IN WHICH SYMPTOMS CLINICALLY AND

RADIOGRAPHICALLY SIMULATE PERIODONTAL DISEASE BUT ARE IN

FACT DUE TO PULPAL INFLAMMATION AND / OR NECROSIS.

•CLASS II – TOOTH THAT HAS BOTH PULPAL OR PERIAPICAL DISEASE

AND PERIODONTAL DISEASE CONCOMITANTLY.

•CLASS III – TOOTH THAT HAS NO PULPAL PROBLEM BUT REQUIRES

ENDODONTIC THERAPY PLUS ROOT AMPUTATION TO GAIN

PERIODONTAL HEALING.

•CLASS IV – TOOTH THAT CLINICALLY AND RADIOGRAPHICALLY

SIMULATES PULPAL OR PERIAPICAL DISEASES BUT IN FACT HAS

PERIODONTAL DISEASE.
 GROSSMAN 1991
LESIONS THAT REQUIRE ENDODONTIC TREATMENT
PROCEDURES ONLY
•ANY TOOTH WITH NECROTIC PULP AND APICAL GRANULOMATOUS
TISSUE REPLACING PERIODONTIUM AND BONE WITH OR WITHOUT A
SINUS TRACT.

•CHRONIC PERIAPICAL ABSCESS WITH A SINUS TRACT DRAINAGE

THROUGH GINGIVAL CREVICE THUS PASSING THROUGH A SECTION

OF ATTACHMENT APPARATUS ALONG THE ROOT.

•ROOT #s – LONGITUDINAL AND HORIZONTAL.

•ROOT PERFORATIONS – PATHOLOGICAL AND IATROGENIC.

 TEETH WITH INCOMPLETE APICAL ROOT
DEVELOPMENT AND INFLAMED OR NECROTIC
PULP WITH AND WITHOUT PERIAPICAL PATHOSIS.

 ENDODONTIC IMPLANTS.

 REIMPLANTS.

 TRANSPLANTS.

 TEETH REQUIRING HEMISECTION OR

RADISECTION.

 ROOT SUBMERGENCE
LESIONS THAT REQUIRE PERIODONTAL TREATMENT
PROCEDURES ONLY

•OCCLUSAL TRAUMA CAUSING REVERSIBLE PULPITIS.

•OCCLUSAL TRAUMA PLUS GINGIVAL INFLAMMATION CAUSING POCKET

FORMATION.

•SUPRABONY OR INFRABONY POCKET FORMATION TREATED WITH OVER

ZEALOUS ROOT PLANING 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 WITHIN NORMAL LIMITS TO CLINICAL TESTING.

LESIONS THAT REQUIRE COMBINED ENDODONTIC -
PERIODONTAL TREATMENT PROCEDURES

ANY LESION IN GROUP I THAT RESULTS IN

IRREVERSIBLE REACTIONS IN THE ATTACHMENT
APPARATUS AND REQUIRES PERIODONTIC
TREATMENT.
ANY LESION IN GROUP II THAT RESULTS IN
IRREVERSIBLE REACTIONS IN THE PULP AND ALSO
REQUIRES ENDODONTIC TREATMENT.
PATHWAYS OF COMMUNICATION
BETWEEN PULP AND PERIODONTIUM

PATHWAYS OF DEVELOPMENTAL ORIGIN

•APICAL FORAMEN.

•ACCESORY CANALS.

•CONGENITAL ABSENCE OF CEMENTUM EXPOSING DENTINAL

TUBULES.

•PERMEABILITY OF CEMENTUM.

•DEVELOPMENTAL GROOVES.

•DEVELOPMENTAL ANOMALIES SUCH AS ENAMEL PROJECTIONS

PATHWAYS OF PATHOLOGICAL ORIGIN

•EMPTY SPACES ON ROOT CREATED BY DESTROYED SHARPEY’S

FIBRES.

•ROOT FRACTURES FOLLOWING TRAUMA.

•IDIOPATHIC RESORPTION – INTERNAL AND EXTERNAL.

•LOSS OF CEMENTUM DUE TO EXTERNAL IRRITANTS.

PATHWAYS OF IATROGENIC ORIGIN

•EXPOSURE OF DENTINAL TUBULES FOLLOWING ROOT

PLANING.

•ACCIDENTAL LATERAL PERFORATION DURING ENDODONTIC

PROCEDURES.

•ROOT FRACTURES CAUSED DUE TO ENDODONTIC

PROCEDURES.
 ETIOLOGY OF PULPAL
DISEASE
 Instrumentation during periodontal restorative or
prosthetic dentistry
 Progression of dental caries
 Direct or local trauma such as tooth fracture
 Bacteria associated with pulpitis :-

fusobacterium,
prevotella
streptococcus

lactobacillus
 Classification of pulpal diseases

1. Pulpitides

 Reversible --- symptomatic

asymptomatic

 Irreversible pulpitis
acute – abnormally response to cold
abnormal response to heat
chronic – asymptomatic with pulp exposure
hyperplastic pulpitis
internal resorption
2. Pulp degeneration :--- calcific
others

3. Pulp necrosis
 CLASSIFICATION OF
PERIODONTAL DISEASE
 GINGIVAL DISEASES :-
PLAQUE INDUCED GINGIVAL DISEASE
NON PLAQUE INDUCED GINGIVAL DISEASE
 CHRONIC PERIODONTITIS :-
LOCALIZED
GENERALIZED
 AGGRESSIVE PERIODONTITIS
LOCALIZED
GENERALIZED
 PERIODONTITIS AS A MANIFESTATION
 NECROTIZING PERIODONTAL DISEASE :-
NECROTIZING ULCERATIVE GINGIVITIS
NECROTIZING ULCERATIVE PERIODONTITIS

 PERIODONTITIS ASSOCIATED WITH ENDODONTIC

LESION :-
ENDO-PERIO LESION
PERIO-ENDO LESION
COMBINED LESION

 ABSCESS OF PERIODONTIUM
GINGIVAL ABSCESS
PERIODONTAL ABSCESS
PERICORONAL ABSCESS
 EFFECTS OF PULPAL DISEASE ON
PERIODONTIUM
 Necrosis of pulp can result in bone resorption & the
production of radiolucency at the apex of the tooth, in
the furcation or at the point along the root

 Histopathological features of periapical inflammatory

lesion
1. Highly vascularized granulation tissue infiltrate to
varrying degrees by inflammatory cells
2. Nutrophils are present near the apical foramen
3. Plasma cells , macrophages, lymphocytes n fibroblast
are increased in the periphery of the lesion
 Effects of periodontitis on the
periodontal disease

 Bacterial& inflammatory products of

periodontitis could gain access to the pulp via
accessory canals, apical foramina or dentinal
tubules.

 This process , the reverse of effects of necrotic

pulp on the periodontal ligament , has been
referred to as Retrograde Pulpitis
 DIAGNOSIS
•PAIN

•SWELLING

•MOBILITY

•SUPPURATION

•PERIODONTAL PROBING

•PRESENCE OF LOCAL DEPOSITS

•PRESENCE OF CARIES AND RESTORATION

•PERCUSSSION AND PALPATION

•PULP VITALITY TEST

•RADIOGRAPHIC INTERPRETATION
 SIGNS & SYMPTOMS OF
PERIODONTITIS
 LOSS OF ATTACHMENT
 PERIODONTAL POCKET FORMATION
 PERIODONTAL ABSCESS
 BLEEDING ON BRUSHING & FLOSSING
 INCREASED TOOTH MOBILITY
 TENDER ON PERCUSSION
 SIGNS & SYMPTOMS OF PULPAL
DISEASE
 DULL,& DIFFUSED PAIN
 SENSITIVITY TO HOT & COLD FLUIDS
 PERIOD OF DISCOMFORT IS USUALLY
BRIEF IN REVERSIBLEPULPITIS
 THERMAL STIMULI OR PURCUSSION CAN
PROVOKE SEVERE PAIN IN IRREVERSIBLE
PULPITIS
 PAIN IS BRIGHT OR THROBBING
 CLINICAL FINDINGS IN
ENDODONTIC AND
PERIODONTIC
CLINICAL FINDINGS LESIONS
ENDO LESION PERIO LESION

PULPAL RESPONSE ABSENT PRESENT

BONE DEFORMITY TUBULAR ‘U’ TRIANGULAR ‘V’

PLAQUE & CALCULUS ABSENT PRESENT

CARIES/ RESTORATION PRESENT ABSENT

MOBILITY ABSENT PRESENT

GEN PERIODONTITIS ABSENT PRESENT

CLINICAL FINDINGS IN ENDODONTIC AND
COMBINED ENDODONTIC-PERIODONTIC
CLINICAL FINDINGS LESIONS
ENDO LESION COMBINED LESION

PULPAL STATUS NECROTIC NECROTIC

PERIO STATUS NORMAL GEN PERIODONTITIS

PROBING NARROW POCKET WIDE POCKET

PLAQUE & CALCULUS ABSENT PRESENT

TREATMENT ENDODONTIC COMBINED

PROGNOSIS GOOD DEPENDS ON PERIO

 TREATEMENT
 PRIMARY ENDODONTIC LESION –
CONVENTIONAL ENDODONTIC THERAPY

 PRIMARY ENDODONTIC LESION WITH

SECONDORY PERIODONTAL
INVOLVEMENT –
ENDO PERIO THERAPY

 PRIMARY PERIODONTAL LESION -

1. PERIODONTAL THERAPY
2. GUIDED TISSUE REGENERATION
3. ROOT AMPUTATION & HEMISECTION
4. PULP SPACE THERAPY
 PRIMARY PERIODONTAL LESION WITH
SECONDARY ENDO LESION
1. PULP SPACE THERAPY
2. PERIODONTAL THERAPY
3. ROOT AMPUTATION
4. GTR

 TRUE COMBINED LESION

1. ENDO THERAPY
2. PERIO DONTAL THERAPY
3. HEMISECTION
4. BICUSPIDIZATION
5. ROOT AMPUTATION