By: Sarah Kahil

Course: ENDO511

19/12/2015

ENDO-PERIO PROBLEMS
There is a close relationship between endodontics and periodontics.
Endodontics may be thought of as apical periodontics
Periodontal disease is defined as:
A disease of the supporting structures of the tooth, which are:
- Alveolar bone
- Periodontal ligament
- Gingiva
Products of inflammation emanating from the pulp exit into the
periodontal structures through:
Apical foramen
Accessory canals
- A periodontal disease might cause inflammation of the
periodontal ligament, affecting the vessels of the apical foramen.
- Severe mobility in teeth might cause sufficient movement to
crush or tear the apical vessels, leading to alteration of the
nutrition of the pulp.
- Certain procedures required for periodontal therapy may cause
pulp damage.
- Periodontal and pulpal diseases have some common clinical
symptoms, like tenderness to percussion and swelling.
- One disease might mimic the other, clinically or radiographically.
- Therefore an accurate diagnosis of the etiologic factors involved is
needed for the correct course of treatment.

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By: Sarah Kahil

Course: ENDO511

19/12/2015

CLASSIFICATION
- Various classifications have been suggested to divide the types of
cases that may require combined or single therapy.
- Dr. Franklin S. Weine suggested a classification which is based on
the fact that four types of endo-perio cases are commonly
encountered.
- Division of cases is based on the etiology of the disease, which
determines the type of therapy required and the probable
prognosis.
1. Class I: Tooth in which symptoms clinically and radiographically
simulate periodontal disease, but are in fact due to pulpal
inflammation and/or necrosis.
2. Class II: Tooth that has both pulpal or periapical disease +
periodontal disease
3. Class III: Tooth that has no pulpal problem but requires
endodontic treatment plus root amputation to gain periodontal
healing
4. Class IV: Tooth that clinically and radiographically simulate pulpal
or periapical disease, but in fact has periodontal disease.
CLASS I:
Symptoms are similar to periodontal disease:
1.
2.
3.
4.
5.
6.
7.

Mobility
Bone loss in furcation or adjacent crestal bone
Deep pocket
Tenderness to percussion
Chronic draining sinus tract (fistula)
Purulent exudates from the gingival crevice
Foul taste

** In class I, the etiology of the disease is from the pulp, and if

periodontal therapy is performed without consideration of the pulpal
problem, healing will never occur.
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By: Sarah Kahil

Course: ENDO511

19/12/2015

- Root canal treatment should be performed to allow healing.

- The most significant sign that an endodontic rather than a
periodontal problem is found is that the patient does not have
periodontal disease in other areas of the mouth.
- Its rare that a severe periodontal problem is found in only one
isolated tooth, with all other areas relatively normal.
- When this occurs look for pulpal reason.

Class II
What appears to be one lesion may actually be a periodontal and a
periapical lesion that have merged. A severe breakdown of periodontal
tissues may cause pulp damage in a normal pulp. The lesion extending
from the apex toward the crestal bone is periapical, due to pulp
damage.
If endo-treatment is done the periapical lesion will heal to the point
where the perio-lesion begins and vice versa. But if the untreated
lesion in either case is very active with considerable virulence, the
treated lesion will not heal to its full potential.
Prognosis of combined lesions: the prognosis for the periapical
lesion is usually superior to that of the perio-lesion. When a periapical
lesion heals, it isnt recurrent. However, a perio-lesion may recur after
healing unless periodic maintenance is carefully followed.
The criterion for diagnosis of class II is that the patient does have
perio-disease in multiple areas of the mouth. So if pulp damage or
death occurs in a tooth already involved with perio-problem a class II
develops.
A high percentage of teeth that have 2/3 or more periodontal bone loss
will also have pulp damage, even if no restorative work has been done.
If perio-therapy only is done, the damaged pulp tissue may prevent the
full degree of periodontal healing.
By the time that periodontal flaps have been raised, roots, scaled,
crowns prepared, impression taken, temporary fillings placed, and
splints cemented, a considerable degree of pulp damage has occurred.

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By: Sarah Kahil

Course: ENDO511

19/12/2015

If endodontic therapy is needed after splinting this would present a

problem.
There will be no clues from the exterior topography of the crown as to
the true position of the pulp chamber.
So in access opening, much ditching and gouging may be necessary,
particularly if chronic pulpitis has produced pulp recession. Also there
will be weakening in the interior walls of the crown so the treated tooth
might break loose from the splint, becomes susceptible to decay, and
loose periodontal support.

CLASS III
- Endo-therapy followed by root amputation (resection) is required
to gain healing of a periodontal only problem.
- The typical indication for root amputation is severe periodontal
defect around one root of a multirooted tooth while the other
roots have healthy root support.
- In these cases no further perio-therapy may be required in the
area of amputation of the involved root.
- The pulp may appear to be perfectly normal but must be
sacrificed to retain the tooth.
ROOT RESECTION
When a multi-rooted tooth cannot be treated by either conservative or
surgical endodontic treatment.
One line of treatment which is often successful is:
The resection of one root
While the other root (roots) is filled
This technique is most commonly used for the elimination of
furcation involvements, primarily of periodontal origin, but
also those which arise from endodontic infections and do not
respond to conservative treatment.

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By: Sarah Kahil

Course: ENDO511

19/12/2015

In maxillary molars root resection is more applicable, whereas in

mandibular molars hemisection:
- Either accompanied by removal of one half of the tooth or,
- Conversion to two premolars (bicuspidization) tends to be the
method of choice
BICUSPIDIZATION
- Elimination of the furcation and conversion of a lower molar to
two premolars.
- It is a sound technique for dealing with the problem of plaque
control in furcal, periodontal, Infrabony pockets.
- Ultimate success of this technique depends also on the mesiodistal width of the furcation, i.e. the degree of separation of the
roots.
- It is important that both roots should have canals which are
suitable for root treatment.
- Therefore, after definitive periodontal treatment, the canals are
prepared and filled
Hemisection followed by removal of one root is indicated for the
following conditions:
1. Perforation of a root, or bifurcation, by a drill or endodontic
instrument.
2. Internal or external resorption of one root (when conservative
treatment fails)
3. An irremovable fractured instrument in a canal associated with a
periapical area and giving rise to symptoms.
4. Inability to locate or negotiate canals in a root with a periapical
lesion.
5. a deep infra-bony pocket around one root or in the furcation.
6. Deep caries or a fracture through the crown, involving the
bifurcation.
7. A radiolucent area around the root, which is increasing in size
despite root canal therapy, and where it is impossible to remove
the root filling.

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By: Sarah Kahil

Course: ENDO511

19/12/2015

Roots which are to be retained should possess sufficient length of

canal to allow preparation for a post-retained crown.

CLASS IV
- These cases simulate an endo problem but in reality they are due
to periodontal disease
- Although some of these cases might be considered as class II
(combined lesion). Class IV cases are those in which the
periodontal condition is the only or the predominant problem.
- Presence of a fistula suggests endo problem
The difficulties occur when endodontic treatment only is performed
without sufficient recognition of the periodontal disease. In the time
required to complete endodontic treatment the periodontal disease will
continue. Some of the symptoms of pulpal or periapical disease might
be present due to periodontal damage.
A chronic draining sinus tract may lead to a periodontal pocket rather
than a periapical lesion. As bone and soft tissue support is lost because
of the periodontal disease, affected teeth may become sensitive to
temperature changes, which might be misdiagnosed as irreversible
pulpitis.
Tenderness to percussion, mobility, and swelling are other common
symptoms of periodontal disease that might be confused with pulpal or
periapical disease. Any of these clinical conditions might cause the
initiation of root canal therapy. Some of the symptoms might even be
alleviated to some degrees initially and reinforce the idea that a
correct diagnosis has been made.
However, unless periodontal therapy is performed, the disease will
continue and cause further problems. The diagnostic phase is
extremely important to establish etiology prior to the institution of
therapy. The mouth must be examined for periodontal disease in other
areas.
Its presence is an excellent indication that a class II or IV endo-perio is
present. If a chronic sinus is present it must be traced with a guttapercha cone and a radiograph taken. If it fails to point to the apex but

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By: Sarah Kahil

Course: ENDO511

19/12/2015

rather falls into periodontal pocket or cleft, the indication is of

periodontal disease.
If a swelling is present, the pulp must be checked for vitality. A vital
pulp indicates a periodontal reason. The gingival attachment must be
probed and pocket depth examined. If a periodontal disease is present,
exudate will be expressed through the crevice.
Sensitivity to temperature changes is common in early stages of
periodontal disease and after certain phases of therapy.
When pulp damage is still reversible, this sensitivity usually diminishes
in few days and a watch and wait attitude may be followed if the pain
is not severe. A desensitizing tooth paste may be needed.
In contrast to class I, in which healing is fast, class IV cases if treated
endodontically will deteriorate periodontally. This indicates wrong line
of treatment.
Prognosis is poor unless periodontal therapy is initiated as soon as
possible. Root fractures may also present as primary endodontic
lesions with secondary periodontal involvement. These typically occur
on root-treated teeth often with post and crowns.
The signs may range from a local deepening of a periodontal pocket, to
more acute periodontal abscess formation. Root fractures have also
become an increasing problem with molar teeth that have been
treated by root resection.
Types:
1.
2.
3.
4.
5.

Primary endodontic lesions

Primary endodontic lesions with 2ry periodontal involvement
Primary periodontic lesions
Primary periodontic lesions with 2ry endodontic involvement
True combined lesions.

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By: Sarah Kahil

Course: ENDO511

19/12/2015

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