Contents

0 Introduction 0 Classification 0 Etiology 0 Routes of communication 0 Biologic effects of pulpal infection on periodontal

tissues 0 Biologic effects of periodontal infection on dental pulp 0 Differential diagnosis of pulpal and periodontal infection 0 Treatment considerations

Introduction
0 The fact that the periodontium is anatomically

interrelated with the dental pulp by virtue of apical foramina and lateral canals creates pathways for exchange of noxious agents between the two tissue compartments when either or both of the tissues are diseased. 0 The simultaneous existence of pulpal problems and inflammatory periodontal disease can complicate diagnosis and treatment planning and affect the sequence of care to be performed.

Classification
Oliet and Pollock, 1968

Based on treatment procedures

1. Lesions
a) Any

that require procedures only

endodontic

treatment

tooth with necrotic pulp and apical granulomatous tissue replacing periodontium and bone, with or without a sinus tract (Chronic Periapical abscess). b) Chronic peri-apical abscess with a sinus tract draining through a section of the attachment apparatus in its entire length alongside the root. c) Root fractures, longitudinal and horizontal

d) Root perforations a) Pathologic b) Iatrogenic e) Teeth with incomplete apical root development and

inflamed or necrotic pulp, with or without periapical pathosis f) Endodontic implants g) Replants
Intentional or b) traumatic
a)

h) Transplants a) Autotransplants or b) Allotransplants i) Teeth requiring hemisection or radisectomy j)

Root submergence

2. Lesions

that require procedures only

periodontal

treatment

a) Occlusal trauma causing reversible pulpitis b) Occlusal trauma plus gingival inflammation resulting

in pocket formation

Reversible but increased pulpal sensitivity caused by trauma or possibly by exposed dentinal tubules b) Reversible but increased pulpal sensitivity caused by uncovering lateral or accessory canals exiting into the periodontium
a)

c) Suprabony or infrabony pocket formation treated with

overzealous root planing, leading to pulpal sensitivity d) Extensive infrabony pocket formation, extending beyond the root apex and sometimes coupled with lateral or apical resorption, yet with pulp that responds within normal limits to clinical testing

3. Lesions that require combined endodontic-

periodontic treatment procedures

a) Any lesion in group I that results in irreversible

reactions in the attachment apparatus and requires periodontic treatment b) Any lesion in group II that results in irreversible reactions in pulp tissue and also requires endodontic treatment

Classification
0 The following classification system was

developed by Simon, Glick and Frank in 1972:

1. Primary Endodontic Disease

2. Primary Periodontal Disease

3. Primary Endo w/ Secondary Perio 4. Primary Perio w/ Secondary Endo 5. True Combined Lesions

Primary Endodontic Disease

0 Typically, endodontic lesions resorb bone apically

and laterally and destroy the attachment apparatus adjacent to a non-vital tooth

0 It is possible for an acute exacerbation of a

chronic peri-apical lesion on a tooth with a necrotic pulp to drain through the PDL into the gingival sulcus. This clinical presentation mimics the presence of a periodontal abscess, or a deep periodontal pocket.

Primary Endodontic Disease

0 When endodontic infection drains through the PDL,

the pocket is very narrow and deep. In reality, it is a sinus tract of pulpal origin that opens through the PDL, and not breakdown due to periodontal disease.

0 A similar situation can occur where drainage from the

apex of a molar tooth extends coronally into the furcation area. These cases resemble a through-andthrough furcation defect of periodontal disease

Primary Endodontic Disease

0 For diagnosis - trace the sinus tract by inserting a

gutta-percha cone and exposing radiographs to determine the origin of the lesion.

0 The sinus tract of endodontic origin is probed down to

the tooth apex, where no increased probing depth would otherwise exist around the tooth.

Primary Endodontic Disease

0 Primary endodontic disease will heal following root

canal treatment

0 The sinus tract extending into the gingival sulcus or

the furcation area disappears at an early stage once the necrotic pulp has been removed and the root canals are well sealed.

Primary Endodontic Disease

Pre-op - periapical and furcal RL + a deep narrow perio defect

Primary Periodontal Disease

0 Caused by periodontal pathogens 0 It is the result of progression of chronic periodontitis

apically along the root surface

0 Pulp tests yield a clinically normal pulpal reaction

Primary Periodontal Disease

0 Frequently accumulation of plaque and

calculus are seen throughout the dentition

0 Periodontal pockets are wider, and are generalized

Primary Periodontal Disease

Pre-op: alveolar bone loss + a periapical lesion, a deep narrow pocket was traced on the mesial aspect of the root, the tooth tested vital

Primary Periodontal Disease

The tooth was extracted. Note the deep mesial radicular developmental groove

Primary Endo with Secondary Perio

0 This happens with time as suppurating primary

endodontic disease remains untreated, it may become secondarily involved with periodontal breakdown

0 Plaque forms at the gingival margin of the sinus tract

and leads to plaque-induced periodontitis in the area

Primary Endo with Secondary Perio

0 The

pathway of inflammation into the periodontium is through the apical foramen, accessory and lateral canals

Primary Endo with Secondary Perio

0 The treatment and prognosis are now

different than those of teeth simply having endo or perio disease periodontal treatments

0 The tooth requires both endodontic and 0 Root fractures and perforations may also present as primary endo with secondary

periodontal involvement

Primary Endo with Secondary Perio

Pre-op: interradicular defect extends to the apex Post-op

Primary Perio with Secondary Endo

0 Apical progression of a periodontal pocket continues

until the apical tissues are involved

0 The pulp may become necrotic as a result of infection

entering via the apical foramen

Primary Perio with Secondary Endo

0 The progression of periodontitis by way of lateral canal and apex to induce a secondary endodontic lesion

Primary Perio with Secondary Endo

0 In single-rooted teeth the prognosis is usually

poor, as the periodontal breakdown is very severe, necessitating extraction

0 In molar teeth the prognosis may be better, since not all the roots may suffer the same loss of supporting periodontium. Root resection may be considered as a treatment alternative

Primary Perio with Secondary Endo

0 Even though unusual, the treatment of periodontal

disease can also lead to secondary endodontic involvement. Lateral canals and dentinal tubules may be opened to the oral environment by scaling and root planing or surgical flap procedures

Primary Perio with Secondary Endo

At initial presentation shows evidence of horizontal bone loss as well as a periapical radiolucency. The crown was intact, but vitality tests were negative. The post-op radiograph shows that a lateral canal was exposed to the oral environment due to bone loss. That lateral canal could serve as a potential pathway for bacteria.

True Combined Disease

0 True combined endo/perio disease occurs less

frequently than other endo/perio problems

0 It is formed when an endodontic disease progressing coronally joins with an infected

periodontal pocket progressing apically

0 The degree of attachment loss in this type of lesion is large.

True Combined Disease

0 Concomitant endo-perio lesion is an additional classification that has been proposed to describe the presence of endo and perio disease as two separate and distinct entities

True Combined Disease

Radiograph shows separate progression of endodontic disease and periodontal disease. The tooth remained untreated and consequently the two lesions joined together

True Combined Disease

Radiograph shows bone loss in 2/3 of the root with calculus present and a separate periapical radiolucency. Clinical exam revealed coronal color change and pus exuding from the gingival crevice. Pulp vitality tests were negative

True Combined Disease

Etiology
0 0 0 0 0 0 0 0 0 0

Sundqvist et al, 1989; Baumgartner and Falkler, 1991 Eubatcerium sp Peptostreptococcus sp Fusobacterium sp Porphyromonas sp Prevotella sp Streptococcus sp Lactobaclillus sp Wolinella sp Actinomyces sp

Anatomic Considerations
0

There is an intimate relationship between the periodontium and pulpal tissues As the tooth develops and the root is formed, 3 main avenues for communication are created:
1. 2.

3.

Apical Foramen Lateral and Accessory Canals Dentinal Tubules

I. Route of communication
Apical foramina

Pulpal infection
Persistent infection in pulp
Secondary infection and breakdown of tissues in the periodontium Continued bone loss and extension of lesion to external mucosal surface Sinus tract formation

Retrograde periodontitis/Chronic periradicular periodontitis/Chronic radicular abscess

It represents the periodontal tissue breakdown from an apical to cervical direction Most common example of pulpal disease leading to secondary periodontal breakdown

Retrograde periodontitis
Advanced pulpitis Pulp necrosis
Inflammatory bone resorption at the root apex

Severe periodontal disease

Severe periodontal disease Initiate or exacerbate changes in the pulp tissue

Orthograde periodontitis
It results from a sulcular infection

Orthograde periodontitis
0 Typically identified as a peri-apical radiolucency

II. Route of communication

Lateral or accessory canals

Lateral/accessory canals
0 Found along the length of root canals. 0 Vertucci et al, 1974 - Maxillary II premolars 59.5%

have lateral canals out of which

0 Apical regions 78.2%

0 Midroot level 16.2%

0 Cervial regions 4%

Lateral/accessory canals
0 Gutman, 1978 Permanent molar furcation region

28.4% of permanent Ist molars accessory canals in furcation areas.

0 Kirkhan, 1975 out of 100 permanent teeth extracted as

a result of severe periodontal disease, only 2 had accessory canals in the periodontal pocket.

0 Thus likelihood of primary periodontal infection reaching

the dental pulp through accessory canals is rare.

III. Route of communication

Dentinal tubules

Dentinal tubules
0 Torneck, 1998 - Dentinal tubules have tapered

structure along the length from pulpo-dentin complex (PDC) to the dentinoenamel junction (DEJ) with diameter of
0 2.5 m at PDC 0 0.9 m at DEJ

0 Shovelton, 1964 bacterial colonization in tubules

from infected root canals.

Dentinal tubules
0 Guiliana, 1997 bacterial invasion into dentinal

tubules from the periodontal pocket suggesting that dentinal tubules may allow pulpal irritation from chronic periodontal infection.

0 Exposed dentinal tubules in areas of denuded

cementum may serve as communication pathways between the pulp and PDL

Additional Avenues of communication between Pulp & Periodontium

0 Developmental malformations such as

palatogingival grooves of maxillary incisors. These usually begin in the central fossa, cross the cingulum, and extend apically with varying distances

0 Perforations these may result from extensive carious

lesions, resorption, or from operator error

0 Vertical root fractures these can produce deep

periodontal pocketing and localized destruction of alveolar bone. The fracture site provides a portal of entry for irritants from the root canal to the PDL

Biologic effect of pulpal infection on periodontal tissues

Biologic effect of pulpal infection on periodontal tissues

0 Untreated endodontic infection risk factor for

progression of periodontal disease.

Untreated endodontic infection

Periodontal pocket formation, increased bone loss and impaired wound healing

Biologic effects of periodontal infection on dental pulp

Biologic effects of periodontal infection on dental pulp

0 Bender and Seltzer, 1972; Pace et al, 2008 effect

of periodontal disease on dental pulp is controversial compared to effects of pulpal disease on the periodontium.

0 Rubach and Mitchell , 1965; Seltzer et al, 1967;

Seltzer et al, 1963 inflammation and localized pulpal necrosis have been observed next to lateral canals exposed by periodontal disease.

Biologic effects of periodontal infection on dental pulp

0 Czarnecki and Schilder, 1979; Mazur & Massler,

1964; Torabinejad and Kiger, 1985 no correlation between periodontal disease and changes within the pulp.

Differential diagnosis of pulpal and periodontal infection

Differential diagnosis
0 To establish a correct diagnosis and

0 To initiate appropriate therapy.

0 Challenging task.

If lesion is of pulpal origin

Treated by periodontal therapy

Lesion will not resolve

Differential diagnosis

If lesion is of periodontal origin and a vital pulp

Treated by endodontic therapy

Lesion will not resolve

Diagnosis is based on
0 Patients subjective symptoms

0 Coronal integrity
0 Radiographic appearance 0 Tooth vitality and periodontal probing

Different Characteristics of Pulpal & Periodontal Lesions

Primary Pulpal Patient symptom Coronal integrity Varies Primary Periodontal Independent EndodonticPeriodontic Combined EndodonticPeriodontic Varies Mild discomfort Varies

Compromised Intact Crestal bone loss

Compromised Compromised Continuous Separate PARL bony lesions and crestal from alveolar lesions crest to apex Nonvital Non-vital Generalized Generalized bone loss with bone loss narrow probing to apex

PARL Radiographic (Periapical lesions radiolucency)

Vitality
Periodontal probing

Non-vital

Vital

Narrow Generalized probing to apex bone loss

Patients subjective symptoms

0 During initial stage of pulpitis - patient complains of 0 Sensitivity and pain exacerbated by stimuli such as
0 Temperature change, 0 Pressure and/or 0 biting

Reversible pulpitis
0 Symptoms of reversible pulpitis resolve with time

as a result of

0 Closure of dentinal tubules, 0 clearance of microbial irritants and toxins, and 0 reparative dentin formation

Irreversible pulpitis
Persistent inflammation

Irreversible pulpitis

Irreversible pulpitis
0 Sharp and untriggered pain

0 Acute pain to thermal stimuli may subside after

several days as the pulp becomes necrotic, and the bacteria and their by-products migrate apically in the complex canal system.
As infection extends to and then past the apical foramen or a lateral periradicular canal Tooth sensitive to bite pressure and percussion

Necrotic tooth

Elevation of tooth

Tooth feels "high on occlusion

Peri-radicular abscess

0 Patients with irreversible pulpitis or chronic pulpal

infection (i.e. necrosis) may be completely asymptomatic. 0 Thus diagnosis of primary pulpal infection is made with objective findings such as
0 0 0 0 0

percussion, palpation, biting, periodontal probing, and vitality testing

Acute periradicular abscess

Periodontal abscess

1. Extreme pain to 1. Cause less pain because Pressure, there is little or no elevation Bite, of the periosteum Percussion Palpation around the tooth apex if the infection penetrates the bony cortical plate 2. Edema and swelling 2. Edema and swelling confined to the cervical portion of the tooth

Visual Examination
0Extra-oral examination
0 Facial asymmetry

0 Swelling
0 Extra oral sinus tract

Extra-oral Swelling

Visual Examination

Extra oral sinus tracts associated with necrotic teeth

Visual Examination
Intra-oral examination
0Swelling 0Redness 0Sinus tract

Acute apical abscess

Acute apical abscess

Visual Examination

A sinus tract traced with a gutta-percha cone

Visual Examination
Hard tissues
0Caries 0Large or defective restorations 0Discolored/chipped teeth

Discoloration

Percussion Test
0 A very significant test 0 Always compare suspect tooth with adjacent and contralateral teeth 0 Tenderness indicates inflammation in the PDL 0 Cause of inflammation may be pulpal or periodontal

Percussion Test

Vertical percussion

Horizontal percussion

Percussion Test

Tooth Slooth

Used to assess cracked teeth and incomplete cuspal fractures

Palpation

Acute periradicular abscess

3. Redness apically if a pulpal abscess swells and elevates the surrounding tissues. 4. Usually probe normally increased mobility (depending on bone loss).

Periodontal abscess
3. Redness and a smooth appearance of the marginal gingival tissues more common

4. Objective findings bleeding on probing, suppuration, increased pocket depth, Patients describe the tooth as increased tooth mobility, feeling longer or higher than the lymphadenopathy adjacent teeth. (Gonzlezoccasionally (Herrera et al, Moles & Gonzlez, 2004) 2000)

Periodontal Examination

Periodontal Examination

An isolated deep pocket may indicate a root fracture

Transillumination
0 Helps to identify vertical crown fracture 0 Produces light and dark shadows at fracture site

A crack will block and reflect the light when transilluminated

Acute periradicular abscess

Drainage two sites most prevalent site - sinus tract develops when the area of swelling breaks through the mucoperiosteum and exits the mucosal tissue, either near or at some distance from the site of the infection.

Periodontal abscess

Coronal Integrity
Acute periradicular abscess Periodontal abscess
1. loss of coronal integrity, such 1. intact crown structure and as occurs with caries, failing absence of coronal defects restorations, extensive restorations and the existence of cracks or fractures that extend to the pulpal tissues

Radiographic appearance
0 coronal status,

0 crestal bone height and shape,

0 presence of periapical or lateral radiolucency, 0 bony trabeculation, 0 integrity of lamina dura, and 0 careful evaluation of the obturation status of the root

canal space if endodontic therapy has been previously attempted.

Radiographs

Characteristic J-shaped or halo lesion associated with fractured root

Vitality
0 Periodontal abscess - test vital to thermal testing

unless the acute condition is a true combined lesion in which both endodontic and periodontal compartments become diseased

0 Teeth with both a periradicular infection and a

periodontal abscess usually test nonvital.

0 Exceptions to this are either 0 extremely calcified canals, 0 extensively restored teeth, or 0 multirooted teeth in which some canals may be necrotic as the result of either pulpal or periodontal disease. 0 Other canals may still retain vital tissue that respond to thermal or electric pulp testing.

0 Thermal testing is usually the most reliable way of

determining pulpal health or disease.

0 Patients with an irreversible pulpitis often report a

lingering painful response to a thermal stimulus.

0 Keenan et al, 2005 - In later stages of pulpitis, heat

exacerbates the symptom more than the cold, and the application of cold may even cause short-term pain relief.

0 Addy, 2005 - Although thermal testing can be informative

as to the status of the pulp, a patient's response to thermal stimuli may be confused with hypersensitivity resulting from exposed dentin and patent dentinal tubules without pulpitis.

0 Therefore, thermal testing must be combined with other

diagnostic criteria, as discussed previously, to distinguish between the lesions originating from pulpal or periodontal infection.

Thermal Tests
0 Cold always used
0 Heat rarely used 0 Compare reaction with adjacent and

contralateral teeth 0 Refractory period of at least 10 minutes before pulp can be retested accurately

Thermal Tests

Thermal Tests

CO2 Snow

Ice stick

Thermal Tests
0 Isolate area with cotton rolls 0 Dry teeth to be tested 0 Ask patient to:
0 Raise hand on feeling cold 0 Lower hand when cold feeling goes away

0 Record:
0 + or sensitivity to cold 0 Time until cold sensitivity was felt 0 Time that cold sensitivity lingered

Thermal Tests
Classic Responses to Thermal (cold) Testing:
Normal Pulp: Moderate transient pain Reversible Pulpitis: Sharp pain; subsides quickly Irreversible pulpitis: Pain lingers Necrosis: No response (Note false positive and false negative responses common)
0 0 0 0

Electric Pulp Test

0 A direct test of nerve elements of pulpal tissue 0 Vitality versus non-vitality only not whether

vital pulp is normal or inflamed 0 In multi-rooted teeth, where one canal is vital tooth usually tests vital 0 False positives and false negatives may occur

Electric Pulp Test

False positive reading: 0 Electrode contact with metal restoration or gingiva 0 Patient anxiety 0 Liquefaction necrosis 0 Failure to isolate and dry teeth prior to testing

Electric Pulp Test

Electric Pulp Test

False negative reading:
0 Patient is heavily premedicated
0 Inadequate contact between electrode and enamel 0 Recently traumatized tooth 0 Recently erupted tooth with open apex 0 Partial necrosis

Electric Pulp Testing

Treatment Decision-Making and Prognosis

0 Treatment decision-making and prognosis depend

primarily on the diagnosis of the specific endodontic and/or periodontal disease

0 The main factors to consider are pulp vitality and type

and extent of the periodontal defect

Treatment Decision-Making and Prognosis

0 Diagnosis of Primary endo and Primary perio disease usually present no clinical difficulty. In primary endo the pulp is nonvital. In primary perio the pulp is vital 0 However, the diagnosis of the combined

endo/perio lesions could present a challege as they present clinically and radiographically very similar. The diagnosis is often tentative with a definitive diagnosis formulated following treatment

Treatment Decision-Making and Prognosis

0 The prognosis and treatment of each

endo/perio disease type varies

0 Primary endo should only be treated by endodontic therapy and has a good prognosis 0 Primary perio should only be treated by periodontal treatment. The prognosis depends on severity of the perio disease and patient

response to treatment

Treatment Decision-Making and Prognosis

0 Combined lesions should be treated with

endodontic therapy first. Treatment should be evaluated in 2-3 months, and only then should periodontal treatment be considered. This sequence allows for sufficient time for initial tissue healing and better assessment of the periodontal condition to determine if the tooth needs SC/RP or surgical treatmen. Prognosis depends on the periodontal involvement and treatment

0 Cases of True Combined disease usually have a

more guarded prognosis