Endodontic and Periodontal

Interrelationships

I-Ping Chen

Dept. of Oral Health and Diagnostic Sciences

School of Dental Medicine
 You should learn…

ü  Intercommunication between pulp and periodontium

ü  Classification of endo-perio lesions

ü  Diagnosis of endo-perio lesions

ü  Treatment of endo-perio lesions

 You should learn…

ü  Intercommunication between pulp and periodontium

ü  Classification of endo-perio lesions

ü  Diagnosis of endo-perio lesions

ü  Treatment of endo-perio lesions

Intercommunication: pulp and periodontium

ü  Apical foramen

ü  Lateral canals
ü  Dentinal tubules (when cementum is denuded)
ü  Palatogingival grooves (4.4% lateral incisors)
" " " "Withers et al., 1981
ü  Perforation; vertical root fracture

Courtesy of Dr. Safavi W.Hess 1917

 Incidence of furcation canals

Incidence Techniques References

45% Sectioned teeth Rubach & Mitchell 1965

Max. molars 59% Dissecting Lowman et al., 1973

Mand. molars 55% microscope
76% Radiopaque dye Burch & Hulen 1974

46% Hematoxylin dye Vertucci & Williams 1974

23% Radiopaque dye Kirkhan 1975

Max. molars 28% Safranin dye Gutman 1978

Mand. molars 27%
Pathway of Pulp
 Influences: Pulpal pathology à Periodontium

Microorganisms à pulpitis à pulpal necrosis à apical periodontitis à

osteolysis
à  periodontal pocket formation/bone loss
 Influences: Periodontal pathology à Pulp

Periodontal inflammation à bacterial toxins to accessory canals

/apical foramen/dentinal tubules à pulpitis/pulp necrosis

More support: inflamed/necrotic pulp à periodontium

Controversial: periodontal disease/treatment à pulp
 You should learn…

ü  Intercommunication between pulp and periodontium

ü  Classification of endo-perio lesions

ü  Diagnosis of endo-perio lesions

ü  Treatment of endo-perio lesions

 Classification of endo-perio lesions
Primary endodontic lesions
Primary periodontal lesions

Pathway of Pulp
 You should learn…

ü  Intercommunication between pulp and periodontium

ü  Classification of endo-perio lesions

ü  Diagnosis of endo-perio lesions

ü  Treatment of endo-perio lesions

 Clinical diagnostic tests

ü  Dental history

ü  Etiology
o  restoration, deep cavity, trauma, plaque
ü  Clinical tests
o  Pulp vitality, palpation, percussion
o  Probing
o  Sinus tract: GP tracing
o  Location of gingival abscess
ü  Radiographs
 Differential diagnosis

Pulpal Periodontal
Dental history Pulp infection Periodontal infection

Pulp vitality (-) (+)

Etiology Cavity/restoration Plaque/calculus

Probing Narrow, single Wide, multiple

Radiographs Localized Generalized

Bone loss Apically Coronally

Periapical Radiolucent Not often related

Pathway of Pulp
 Diagnostic cases

#19 #3
Vital pulp Previously RCT treated
Multiple deep pockets No deep pocket depth
Angular bony defect Periapical radiolucency (MB root)
Coronal radiolucency Throbbing, localized pain
Coronal abscess
Shallow restoration
 Diagnostic cases

#19
Previously RCT treated
Spontaneous pain
Percussion, palpation pain
Periapical abscess
Probing depth < 3mm
 Diagnostic cases

#31
Abscess on and off
Previously RCT treated
5mm pocket depths (ML, L, DL surfaces)
Palpation and percussion pain
 Diagnostic cases

#19
Sinus tract with pus discharge between #18 and #19
Deep restoration
In general, no deep pockets except #19 B, DB surface (5mm)
Non-vital pulp, no pain
Gingiva had mild inflammation
 You should learn…

ü  Intercommunication between pulp and periodontium

ü  Classification of endo-perio lesions

ü  Diagnosis of endo-perio lesions

ü  Treatment of endo-perio lesions

 Treatment

ü  Primary endodontic lesions à endo. tx

ü  Primary periodontal lesions à perio. tx
ü  Endo-perio combined lesions
•  Endo. Treatment first
•  Periodontal treatment
•  Prognosis depends on the removal of the individual
etiologic factors
Treatment
Treatment
Treatment alternatives

ü  Resection
•  Eliminate the diseased roots
•  Hemisection/root amputation
ü  Regenerative approaches
•  Restoring the biologic structures
•  Bone replacement grafts/ GTR
ü  Extraction
 Take-home message

ü  Close interrelationship between pulp and periodontium

ü  The major pathways are
•  Apical foramina, lateral canals and dentinal tubules
ü  Diagnosis requires a number of diagnostic tests
ü  Successful treatment depends on a correct diagnosis
ü  Combined lesions will require both endo and perio tx
ü  Alternative treatment
•  Root resection and regenerative techniques