The Perio/Endo Lesion

COMBINED LESIONS
The Pulpal Periodontal Lesion
•
A process involving interaction of diseases of the
pulp and periodontium. The etiology, diagnosis
and prognosis classify these interactions or
lesions as follows:
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COMBINED PERIODONTAL/
ENDODONTIC LESIONS
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CLINICAL FEATURES
Smooth, shiny swelling of the gingiva or mucosa
Pain with the area of swelling tender to the touch
Purulent exudate
The tooth may be sensitive to percussion and mobile
A fistulous track maybe present
Rapid loss of the periodontal attachment and periradicular tissues
may occur
Facial swelling and/or cellulitis may be present
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Combined Lesions
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Primary Periodontal Secondary Endodontic
Primary Endodontic Secondary Periodontal
True Combined Lesions
Combined Lesions Etiology
• There are two forms of possible
pathways for bacteria and their
products connecting the two tissues:
• Anatomical
• Non-physiological
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Anatomical Pathways
• apical foramina
• lateral or accessory canals
• dentinal tubes
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Non-Physiological
Pathways
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Immediate Implant Placement
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Final Restoration
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Non-Physiological
Pathways
• Iatrogenic root canal perforations
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Vertical Root Fracture
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Root Fracture and
Silver Point Endo
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PERIODONTAL/PULPAL
DISEASE
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COMBINED PERIODONTAL/ENDODONTIC LESIONS
• DEFINITION
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Combined periodontal/endodontic lesions are localized, circumscribed areas
of infection originating in the periodontal and/or pulpal tissues
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The infections may arise primarily from pulpal inflammatory disease
expressed itself through the periodontal ligament or the alveolar bone to the
oral cavity
•
They also may arise primarily from a periodontal pocket communicating
through accessory canals of the tooth and or apical communication and
secondarily infect the pulp
•
May arise as a sequela of a fractured tooth
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Primary periodontal disease with
secondary endodontic involvement
1. The apical progression of a periodontal pocket
may continue until the apical tissues are involved.
2. In this case, the pulp may become necrotic as a
result of infection entering via lateral canals or
the apical foramen.
3. In single-rooted teeth the prognosis is usually
poor
4. In molar teeth the prognosis may be better
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Primary periodontal disease with
secondary endodontic
involvement
80 year old male with
poor oral hygiene
13 mm mesial probe
depth
(2) Mobility
No pain
Pulp test non-vital
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Primary periodontal disease with
secondary endodontic
involvement
Post endodontic &
perio treatment
5 mm mesial pocket
depth
No mobility
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Primary periodontal disease with
secondary endodontic
involvement
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Pulp Vitality may not be affected by
periodontal disease
•
But there is evidence that periodontal
disease can affect the HEALTH of the pulp
•
Severe Periodontal Bone Loss can allow
pathogens to contaminate the pulp (foci of
inflammation) (Bone Graft issues) Pritchard
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Unless periodontal disease has
progressed to involve the tooth apex,
the effect of periodontal disease on the
pulp appears to be negligible.
•
Prognosis for a tooth involved with
periodontal disease is determined by
the outcome expected from
periodontal therapy.
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Primary Periodontal
Graft Protection
Pre-op
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Post perio graft/endo
1 year recall
Primary periodontal disease with
secondary endodontic
involvement
• Periodontal lesions: These lesions
are strictly of periodontal origin but
may mimic combined lesions and
will resolve with periodontal
treatment alone.
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Classic Example is Root Amputation Case
External Resorption
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External Resorption
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Primary Periodontal Breakdown First
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Through defect, pulpal inflammation and
infection
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Primary Periodontal, Secondary Endodontic
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Etiology starts as an “upregulation of “clastic”
behavior due to lack of precementum
Primary periodontal disease with
secondary endodontic
involvement
•
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Cracked Tooth Syndrome
N
Primary periodontal disease with
secondary endodontic
involvement
•
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Cracked Tooth Syndrome
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•
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Bite tests
Transillumination
History of bruxism/broken teeth
Large restorations
Localized Periodontal disease
Periodontal/Pulpal Lesion
• Primary periodontal lesions with
extension to the pulpal tissues
•
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Classic example is vertical root fracture
Periodontal/Pulpal Lesion
Sinus Tract
No Probing Depth
Halo Lesion
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Placement of
Amalgamcore
Periodontal/Pulpal Lesion
Root Amputation of
MB root
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1 year post op
Radiographic healing
Undetected DB Canal
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Combined lesions: Endo/Periodontal
• Primary pulpal lesions with extension
to the periradicular tissues with
secondary imposition of periodontal
disease
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Pulpal/Periodontal Lesion
• Pulpal lesions: These lesions are strictly of pulpal
origin but may mimic combined lesions and will
resolve with root canal treatment alone.
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Primary endodontic lesions
with secondary periodontal
involvement
Primary endodontic lesions with
secondary periodontal involvement
Post-op
6 month
12 month
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True Combined lesions
• Concomitant pulpal-periodontal
lesions in which disease processes
exist independently in both tissues
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True Combined Lesions
• A necrotic pulp or imminent pulpal
threat (progressive resorptive disease),
plaque, calculus and periodontitis will
be present in varying degrees.
• If the lesions join, they may be
indistinguishable.
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True combined lesion
General Horizontal Bone Loss with Concomitant
Refractory Endontic disease
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True Combined Lesion
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True Combined Lesion
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True Combined Lesion
Pre-op
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Pre-op