PULPO-PERIODONTAL
LESIONS
Submitted by,
SWETHA SUSAN JACOB
Final year Part-A
CONTENTS
. Introduction
. Microbiology
. Causes
. Pathways of communication
. Classification
. Diagnosis
. Treatment
. Conclusion
. Reference
INTRODUCTION
• The tooth and periodontium are closely related
and diseases of one tissue may lead to secondary
disease in the other.
• Differential diagnosis of endodontic and
periodontal diseases is of vital importance to make
a correct diagnosis.
• In Pulpo-periodontal lesion, pulpal necrosis
precedes periodontal changes. A periapical lesion
originating in pulpal inflammation and necrosis
may drain to the oral cavity through PDL and
adjacent alveolar bone.
MICROBIOLOGY
• Periodontal disease and pulpal infection are
polymicrobial process and is often anaerobic
in nature.
Organisms are
T.forsythus, T.denticola, P.gingivalis,
F.nucleatum, spirochetes,
Peptostreptococus.
CAUSES
1.Root anatomy :
presence of additional canal in teeth
large no: of accessory canals
2.Root pathology : Root resorption
Root perforation
3.Root fillings : Overfilling root canals
Intracanal medicaments
4.Trauma : Crown fracture
Vertical root fracture
Malpositioned teeth
Combined with gingival inflammation
PATHWAYS OF COMMUNICATION BETWEEN
PULP & PERIODONTIUM
• Developmental origin :
a) Apical foramen
b) Developmental grooves
c) Accessory canals & Lateral canals
d) Enamel projections & pearls
• Pathologic origin :
a) Tooth fracture
b) Idiopathic root resorption
c) Loss of cementum due to external irritants
PATHWAYS OF COMMUNICATION ….
• Iatrogenic origin
a) Accidental lateral perforation
b) Root fracture due to endodontic procedure
c) Exposure of dentinal tubules
ENDONTIC PROCEDURAL COMPLICATION
THAT AFFECT THE PERIODONTIUM
• Perforations
• Root fractures
• Sodium hypochlorite accident
• Improper use of ultrasonic device
CLASSIFICATION
According to Simon, Glick & Frank :
• Primary endodontic lesion
• Primary endodontic lesion with secondary
periodontal involvement
• Primary periodontal lesion
• Primary periodontal lesion with secondary
endodontic involvement
• True combined lesion
According to Grossman
• Lesion that require endodontic procedures
only.
• Lesion that require periodontal procedures
only.
• Lesion that require endodontic -periodontal
treatment procedures.
PRIMARY ENDODONTIC LESION
ETIOLOGY
Infection from a necrotic pulp drains into the
periodontium to produce a periapical abscess
which Spread via:
• Apical foramen to gingival sulcus via
periodontium
• Lateral canal to pocket
• Lateral canal to furcation
• Apex to furcation
CLINICAL FEATURES
Patient is usually asymptomatic
Pulp doesn’t show response to vitality test
Sinus tract may be seen from apical
foramen, lateral canals or furcation
True pocket associated with minimal
plaque & calculus
No periodontal diseases
RADIGRAPHIC FEATURES
Periapical radiolucency
No loss of alveolar bone height
Furcation bone loss b/w molar roots.
DIAGNOSIS
Patient asymptomatic with history of acute
exacerbation
Necrotic pulp draining through PDL into gingival
sulcus
Isolated pockets on side of tooth with minimal plaque
& calculus
PRIMARY ENDODONTIC LESION WITH
SECONDARY PERIODONTAL INVOLVEMENT-
RETROGRADE PERIODONTITIS
ETIOLOGY
Untreated or inadequately managed
endodontic lesion
CLINICAL FEATURES
Gingival inflammation, increased
probing depth, bleeding or pus on probing
Isolated deep pockets
RADIOGRAPHIC FEATURES
Periapical radiolucency
Some resorption of crestal alveolar bone
DIAGNOSIS
Continuous irritation of
periodontium from necrotic pulp or
from failed RCT
Isolated deep pockets
Periodontal breakdown in the
pocket
PRIMARY PERIODONTAL LESION
ETIOLOGY
Periodontal infection which spreads to
involve the periapical tissues
Associated with a local anatomic defect
such as radicular groove on maxillary lateral
incisor
CLINICAL FEATURES
Periodontal pain localized & long
lasting
Presence of plaque & calculus
Generalized periodontal
involvement-due to attachment loss,
tooth may become mobile
RADIOGRAPHIC FEATURES
Localized bone resorption, as horizontal,
vertical,furcation & even apical defects
DIAGNOSIS
Periodontal destruction associated with
plaque and calculus
Pulp may be normal in most cases
PRIMARY PERIODONTAL LESION WITH
SECONDARY ENDODONTIC
INVOLVEMENT-RETROGRADE PULPITIS
ETIOLOGY
Infection spreads from periodontium to
pulp causing pulpitis
CLINICAL FEATURES
Generalized periodontal disease
Tooth is usually mobile when palpated
If severe exposes the root surface,
irreversible pulpal damage can result
RADIOGRAFIC FEATURES
Bone resorption more extensive
DIAGNOSIS
Generalized periodontal disease
Non-vital tooth
Mobile tooth
Pocket may show discharge on
palpation
TRUE COMBINED LESION
ETIOLOGY
A periodontal infection coalescence with a
periapical lesion of pulpal origin
CLINICAL FEATURES
Conical type of probing
At the base of the periodontal lesion the probe abruptly
drops further down the root surfaces & may extend the
tooth apex
RADIOGRAPHIC FEATURES
Bone loss from crestal bone extending down lateral
surface of root.
DIAGNOSIS
1)Patient history
2)Clinical examination
3)Radiographic examination
4)Percussion test
5)Vitality test
6)Fiber optic illumination
Advanced techniques
MRI
Pulp oximetry
Doppler devices
TREATMENT
• Primary endodontic lesion :
Endodontic treatment
• Primary endodontic lesion with
secondary periodontal involvement :
Endodontic treatment followed by
periodontal treatment
• Primary periodontal lesion :
Periodontal treatment
• Primary periodontal lesion with secondary
endodontic involvement :
Endodontic & periodontal treatment
• True combined lesion :
First endodontic treatment followed by
periodontal treatment after 1 month.
CONCLUSION
• It can be stated that in the vast majority of the lesions
involving the pulpo-periodontal complex, the bacterial
etiology dictates the clinical course of the disease &
therefore the treatment plan
• However, the primary goal of all treatment efforts
must be to get rid of the infection. Factors such as
patient cooperation, restorability & economics will
influence treatment decisions
REFERENCES
• CARRANZA’S Clinical periodontology
THANK YOU
