1. THE PERIODONTIC-ENDODONTIC CONTINUUM
Dr. Logien Al Ghazal
15/12/2015

2. Introduction
Existence of pulpal problems and inflammatory periodontal disease can complicate diagnosis and treatment planning and affect the sequence of care to be performed.
This is often seen in a patient with advanced periodontitis, tooth loss and pulpal disease.

3. ETIOLOGIC FACTORS OF PULPAL DISEASE

4. The major causes of pulpal inflammation are:
1) instrumentation during periodontal, restorative or prosthetic dentistry.
2) the progression of dental caries.
3) direct, local trauma such as tooth fracture.
Minor injury such as periodontal root planing or the conservative preparation of a tooth for a restoration may lead to pulpal symptoms
A transient hypersensitivity to thermal stimuli is the most common symptom noted.
The application of a thermal stimulus results in a brief, painful response that varies in intensity from mild to severe.

5. CLASSIFICATION OF PULPAL DISEASE
Reverisble pulpitis
Irreversible pulpitis
Hyperplastic pulpitis
Pulpal Necrosis

6. Reversible pulpitis
A transient inflammatory response can lead to the deposition of reparative dentin if odontoblasts are destroyed. Reversibility of inflammation and symptoms occurs, without permanent pulpal damage.
Irreversible pulpitis
If the pulp is so affected that the inflammatory lesion cannot be resolved, even though the source of the trauma is eliminated, a progressive degeneration of the pulp results.

7. EFFECTS OF PULPAL DISEASE ON THE PERIODONTIUM

8. Necrosis of the pulp, however, can result in bone resorption and the production of radiolucency at the. apex of the tooth, in the furcation or at points along the root.
The lesion that results may be an acute apical lesion or abscess, a more chronic periradicular lesion (cyst or granuloma); or a lesion associated with a lateral or accessory canal.
The lesion may remain small, or it can expand sufficiently to destroy a substantial amount of the attachment of the tooth and/or to communicate with a lesion of periodontitis.

9. Classification of Periradicular Lesions
Acute apical periodontitis
Chronic apical periodontitis
Condensing osteitis
Acute apical abscess
Chronic apical abscess

10. EFFECT OF PERIODONTITIS ON THE DENTAL PULP

11. Although the effects of pulpal disease on the periodontium are well documented, a clear-cut relationship between periodontitis and pulpal involvement is less evident.
Bacterial and the inflammatory products of periodontitis could gain access to the pulp via accessory canals, apical foramina, or dentinal tubules.
This process, the reverse of the effects of a necrotic pulp on the periodontal ligament, has been referred to as retrograde pulpitis.
Periodontitis rarely produces significant changes in the dental pulp through the accessory canals.

12. Frequency of accessory canals

13. It has been suggested that the presence of an intact layer of cementum may protect the pulp from injurious elements produced by plaque microbiota.
Severe breakdown of the pulp apparently does not occur until periodontitis has reached a terminal state, when bacterial plaque has involved the main apical foramina.
The pulp has a good capacity for defense as long as the blood supply via the apical foramina is intact.

14. Lesion in this case turned out to be associated with an accessory canal.

15. Types of endoperiodontal problems

16. Different types of endoperiodontal problems
Retrograde periodontitis
originally endodontic problem
Originally periodontal
problem
Two independent lesions
periodontal pocket through a lateral canal

17. An originally endodontic problem with fistulization from the apex and along the root to the gingiva. Pulpal infection can also spread through accessory canals to the gingiva or to the furcation.
A long-standing periapical lesion draining through the periodontal ligament can become secondarily complicated, leading to a retrograde periodontitis.
A periodontal pocket can deepen to the apex and secondarily involve the pulp.
A periodontal pocket can infect the pulp through a lateral canal, and this, in turn, can result in a periapical lesion.
Two independent lesions, periapical and marginal, can coexist and eventually fuse with each other.

18. The tract may exit through the periodontium and dissect along the root to empty into the gingival sulcus and the interfurcal area. It then goes through the periodontal ligament of an adjacent tooth or into an existing periodontal pocket When the latter occurs, the resulting defect is a true combined lesion.

19. Radiographs of suspected combined lesion (pero-endo lesion) on a maxillary cuspid and lateral incisor
Pre-treatment response
Post-treatment response

20. DIFFERENTIATION OF PERIODONTAL AND PULPAL LESIONS

21. The Signs and Symptoms of Periodontitis

22. Periodontitis is a chronic inflammatory lesion, which begins in the marginal gingiva and extends apically causing attachment loss and periodontal pocket formation.
In general the progression rate of attachment loss is slow, unless an acute incident such as a periodontal abscess occurs.
Teeth with chronic periodontal lesions are commonly free of acute symptoms.
Inflammatory process extends to involve the periodontal ligament, then the affected tooth can become tender to pressure, biting, or light tapping with an instrument.

23. The patient may be unaware of the condition.
With the exception of bleeding on brushing and flossing, or bad breath, until sufficient attachment is lost.
Increased tooth mobility.
The pocket may be tender to probing and extensive deposits may be present on the root(s)of the tooth/teeth.
Bleeding on probing and suppuration when the periodontal disease advances.

24. The Signs and Symptoms of Pulpal Disease

25. The pulp has the ability to respond to stimulation through enamel or dentin interpret these sensations as pain.
Stimulation of dentin is usually fast, sharp, and severe and is mediated by A-delta myelinated fiber.
Sensation from the core of the pulp is slower, duller, and more diffuse is initiated by smaller unmyelinated C fibers.
Reversible pulpitis may report is a sensitivity to hot or cold fluids.
Thermal stimuli or percussion applied to teeth with irreversible pulpitis can provoke severe pain.

26. DIFFERENTIATION BETWEEN PULPAL AND PERIODONTAL ABSCESSES

27. Periodontal abscess
Pulpal abscess
Pain
not usually severely
Severe
Before the completion of the tract, the patient commonly experiences acutely painful symptoms
position
They occur in the pocket or sulcus at the level of the connective tissue attachment
At the apex of the tooth
Symptom
sensitive to touch, mastication, or toothbrushing and/or flossing.
Extremely sensitive to percussion
Fistula
The formation of a fistula is less common than with apical periodontitis.
fistula does form, it may be found in both the gingiva and mucosa.
commonly communicate endodontic sinus tract is usually a narrow, constricted lesion directed from the apex of the tooth laterally.

28. THERAPEUTIC MANAGEMENT OF PULPAL AND PERIODONTAL DISEASE

29. ENDODONTIC LESION PRIMARY
Patients with pulpal disease present only performing root canal therapy are sufficient to result in healing of the lesion.
Pulpal abscesses and apical lesions generally resolve with conventional therapy, although apical surgery may be required in certain instances.
Periodontal treatment is not required in the absence of any periodontal involvement.

30. 2. INDEPENDENT PERIODONTAL AND ENDODONTIC LESIONS
Management of the pulpal lesion is the primary concern.
Therapy for gingivitis or early periodontitis may be delayed until acute symptoms are resolved.
Chronic periodontitis experiences a loss of pulpal vitality. The involvement of the apical periodontium by a pulpal lesion may obscure the symptoms of periodontitis. Therefore the ability to determine the independence of the two lesions on any tooth or area is a key consideration in the sequence of therapy.

31. 3. COMBINED LESIONS (PERIO-ENDO)
The true combined lesion results from the development and extension of an endodontic lesion into an existing periodontal lesion (pocket).
Rare occasions a developing periodontal lesion, associated with a developmental groove, may extend apically to connect with an apical or lateral endodontic lesion.
The loss of pulpal vitality is the most common presenting complaint of patients with combined lesions.

32. Contaminated root surface with plaque and calculus and the associated osseous defect is the major complication to treatment of combined lesions.
The extent to which the periodontal lesion contributes to the loss of bone is a key consideration in diagnosis and treatment planning.
Endodontic treatment is highly predictable, and when appropriately performed, the alterations in radiographic appearance and clinical probing disappear.
Endodontic treatment when appropriately performed, the alterations in radiographic appearance and clinical probing disappear.

33. Even with periodontal treatment, the periodontal defect commonly does not resolve to the same extent that the endodontic lesion does.
If the majority of the bony support has been lost from periodontitis, regardless of the predictability of endodontic therapy, the tooth may have a hopeless prognosis.
periodontal treatment may include scaling and root planing, as well as various surgical treatments.

34. PROGNOSIS OF COMBINED LESIONS

35. The prognosis for teeth with combined lesions varies with the extent that each lesion contributes to the loss of attachment.
Lesions resulting from pulpal disease tend to resolve with endodontic therapy, whereas the repair/regeneration of attachment loss from periodontitis is less predictable.
The long-term prognosis for a tooth with a combined lesion is therefore closely related to the extent and configuration of the periodontal attachment loss.
Horizontal attachment loss, even an optimal endodontic result may not be sufficient to retain the tooth as a functioning member of the dentition.

36. combined periodontal and endodontic lesions should be carefully considered in regard to the overall dental treatment plan as the time and cost of combined defect treatment may be considerable.

37. The performance of the root canal has resulted in repair of the endodontic component of the defect. The periodontal component of the defect shows little change. The residual bony defect will require periodontal therapy.

38. POTENTIAL COMPLICATIONS TO ENDODONTIC THERAPY

39. Iatrogenic nature such as perforations of the floor of the pulp chamber or the root during access, canal instrumentation or preparation for a post.
If the perforation occurs in the cervical area of the tooth, a surgical flap approach may provide sufficient access to expose the perforation and allow a successful seal. However, because of the difficulty in sealing a lateral perforation of the root, a guarded prognosis should be given to such a tooth.
Root resorption and vertical root fracture.
Vertical root fracture generally results in a hopeless prognosis for the affected root.

40. RESTORATIVE IMPLICATIONS OF ENDODONTIC THERAPY

41. Restoration is complicated by the extent of crown loss from caries, fracture, and the size and placement of the access to the pulp chamber.
Additional factors are the type of restoration to be used, the configuration and number of the pulp canals, root form, and the need for a post and core.
Complex interdisciplinary treatment should be confined to teeth that are of critical importance to the overall treatment plan after due consideration of alternate treatment methods.