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perio-endo lesions

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DrAmnah Ameen

on 10 March 2013

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Transcript of perio-endo lesions

introduction Relation & Communication between pulpal
& periodontal tissues Differences between periodontal and pulpal lesion CLINICAL: objectives D.D between lesions of periodontal origin and
endodontic origin. PERIODONTAL – ENDODONTIC LESIONS introduction Relation & Communication between
pulpal & periodontal tissues The interrelationships between pulpal and periodontal disease primarily occur by way of the intimate anatomic and vascular connections between the pulp and the periodontium ,also they have the same embryonic origin and they share the same function protect, and provide nourishment to the teeth.

And because of these relationship , Diagnosis is often challenging because these diseases have been primarily studied as separate entities, and each primary disease may mimic clinical characteristics of the other disease .

In recent years, periodontal disease has been shown to be related to (and possibly even the cause of) pulpal disease, and pulpal disease may cause periodontal lesions that behave differently from chronic destructive periodontitis 1.Developmental origin Extension of infection and inflammation from pulp to periodontium or vice versa can occur through any of these pathways of communication: A.apical foramen :

•It is the most direct route of communication to the periodontium

•IT'S a direct pathway between pulp and periodontium and typically contain connective tissue and vessels that connect the circulatory system of the pulp with that of the periodontium.

•Any inflammation in the interradicular periodontal tissues may develop following induction of pulpal inflammation B. Accessory canals and lateral canals: Some facts about lateral canals :
* More common in the apical part of the root and lateral canals in the molar furcation region .

* 30-40% of canals have lateral or accessory canals

* Difficult to find radiographically.

*The more progressed the periodontal diseases the more possibility of endodontic involvement .
As the root develops, ectomesenchymal channels get incorporated, either due to dentine formation around existing blood vessels or breaks in the continuity of the Hertwigs root sheath, to become lateral or accessory canals.

normally harbor connective tissue and vessels which connect the circulating system of the pulp with that of the periodontal ligament.

They exist at all levels of the root .

Patent accessory canals are a potential pathway for the spread of microorganisms and their toxic byproducts, as well as other irritants, from the pulp to the PDL and vice versa, resulting in an inflammatory process in the involved tissues .
It is essential that the dentist recognizes and is familiar with canal ramifications and variations. The ideal treatment of periodontal pocket formation associated with untreated accessory root canals is total debride. A, Postoperative radiograph of endodontic treatment in a maxillary central incisor showing radiopaque material extruding through a lateral canal. B, Scanning electron micrograph showing vascular content in lateral canal. C-Dentinal tubules •It is contain cytoplasmic extensions or odontoblastic processes that extend from the odontoblasts at the pulpodentin interface to (DEJ) or (CDJ).

•the pulp chamber can communicate with the external root surface by way of dentinal tubules, especially when the cementum is denuded

D. Developmental grooves

•They are developmental anomalies of maxillary incisor teeth

•These usually begin in the central fossa, cross the cingulum, and extend apically with varying distances. •a developmental abnormality that primarily affects the permanent maxillary lateral incisors

•The base of the pit or deep invagination is composed of a thin, often defective layer of enamel and dentin that is extremely vulnerable to carious destruction

•most teeth with deep invaginations quickly develop pulpitis, pulpal necrosis, and inflammatory periapical disease in what clinically appears to be an intact tooth E. Dens invaginatus They occur most commonly in the furcation area .
Maxillary molars are more commonly affected.
These deposits are occasionally supported by dentin and rarely may have a pulp horn extending into them.

The anomaly is thought to arise as a result of a growth disturbance of Hertwig's sheath resulting in budding of the sheath followed by differentiation of ameloblasts and amelogenesis .

It is often associated with periodontal destruction .
Treatment is not recommended, because it often leads to the development of root caries, external resorption ,or pulpitis . F. enamel pearl 2. Pathological origin : a. Empty spaces on the root created by destruction of sharpey’s fibers.

b. Vertical fibers.

c. Idiopathic resorption – internal and external.

d. Loss of cementum due to external irritants. 3. Iatrogenic origin : A. Exposure of dentinal tubules following root planning. The ability of the pulp and periodontium to communicate via dentinal tubules is possible, specially where cementum was denuded after repeated root planing b. Accdental lateral perforation during endodontic procedure. c. Root fracture due to endodontic procedure. it creates a communication between the root canal system and the periodontal ligament
This may occur as a result of

1- over instrumentation during endodontic procedures,

2_ caries invading through the floor of the pulp chamber
the closer the perforation is to the gingival sulcus, particularly into the coronal third of the root or the furcation region the greater the likelihood of apical migration of the gingival epithelium in initiation of a periodontal lesion.
A vertical root fracture can produce a “halo” effect around the tooth radiographically.
Deep periodontal pocketing and localized destruction of alveolar bone are often related to longstanding root fractures.
The fracture site provides a portal of entry for irritants from the root canal system to the surrounding periodontal ligament.(1) During the course of treatment, clinicians are frequently presented with the dilemma of accurately assessing the contribution of endodontic and periodontal lesions. These lesions may be very separate from each other and present no extraordinary therapeutic consideration. In a few other situations, there is no obvious demarcation between the two lesions, which appear as one, both on radiographs and clinically. In the diagnosis of radiographic osseous lesions, one must resist the temptation to label everything a “combined lesion.”
The following tables summarizes the differential diagnosis between pulpal and periodontal lesions and highlights a number of common characteristics between these lesions: Pulpal Periodontal Pulp infection


Deep or extensive

Not related


Single, narrow

Often acid

Primary or secondary

Few Periodontal infection


Not related

Primary cause


Multiple, wide coronally

Usually alkaline

Contributing factor

Complex RADIOGRAPHIC: Pattern

Bone loss


Vertical bone loss Localized

wider apically


No Generalized

Wider coronally

Not often related

Yes Pulpal Periodontal HISTOPATHOLOGY: Junctional epithelium

Granulation tissues

Gingival No apical migration

Apical (minimal)

Normal Apical migration

Coronal (larger)

Some recession Pulpal Periodontal THERAPY: Treatment Root canal therapy Periodontal treatment Pulpal Periodontal Vertical bone loss in Periodontal Disease Endodontic Treatment Failure of Tooth With Periapical Radiolucency Reference : 1. Cohen's , pathway of the pulp , tenth edition , part II , chapter 18 , page 656.
12. Zehnder M, Gold SI, Hasselgren G. Pathologic interaction in pulpal and periodontal tissues. J ClinPeriodontol. 2002;29:663–71.[PubMed]
13. Solomon C, Chalafin H, Kellert M. The endodontic periodontal lesion, a rational approach to treatment. J Am Dent Assoc. 1995;126:473–9.[PubMed]
14. DeDeus QD. Frequency location and direction of the lateral, secondary and accessory canals. J Endod. 1975;1:361–6.[PubMed]
15. Vertucci FJ, Williams RJ. Furcation canals in the human mandibular first molars. Oral Surg. 1990;69:743.[PubMed]
16. Rahmat A, Barkhordar, Stewart GG. The potential of periodontal pocket formation associated with untreated accessory root canals. Oral Surg Oral Med Oral Pathol. 1990;70:769–72.[PubMed]
17. Mhairi RW. The pathogenesis and treatment of endo-perio lesions. CPD Dent. 2001;2:9–95.
Cawson’s Essentials of oral pathology 7th edition

18. Cohen’s Pathways of the pulp, 10th edition, chapter 18, p661-662. DONE BY

Amnah Ameen Hawsah
Asia Musallam Al Nakhli
Alaa’ Attiah Allah Al Jahni
Aminah Osama Ja’afar
Eman Abdul Salam Khalel
Khawlah Hudiaban Al Shamani
Demah Muneer Al Hamawi
Raood Talal Al Ka’ky
Raghad Abdul Rahman Al Ansari
Rana Mohammed


Dr.Seema Etiology






pH value


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