```markdown ENDODONTIC AND PERIODONTAL Diseases Dr Anna Hughes/ Dr Tina Choo ( with special thanks to Prof Paul Abbott) ```  #### Course Instructors - Dr. Anna Hughes - Dr. Tina Choo - Special thanks to Prof. Paul Abbott A dental radiograph showing a cross-sectional view of teeth, highlighting the roots and surrounding bone structure. The image is embedded within an orange circular frame on a blue background, likely used as a visual aid for discussing endodontic and periodontal diseases. # Aim of the lecture - Understand the presentation of endodontic, periodontal & combined or concurrent endodontic-periodontal diseases - How to differentiate between endodontic and periodontal diseases - Understand that other distinct conditions may have endo and perio implications - root perforations / fractures, cracks, caries, root resorption, orthodontic complications, developmental anomalies - each with specific management - The importance of achieving the correct diagnosis, understanding prognosis and management of the presenting condition - Classifications- old and new  #### Clinical Objectives - Understand the presentation of endodontic, periodontal, and combined or concurrent endodontic-periodontal diseases. - Learn how to differentiate between endodontic and periodontal diseases. - Recognize that other distinct conditions may have endodontic and periodontal implications, requiring specific management: - Root perforations and fractures - Cracks - Caries - Root resorption - Orthodontic complications - Developmental anomalies #### Diagnostic and Management Goals - Emphasize the importance of achieving the correct diagnosis. - Understand the prognosis and management of the presenting condition. - Review both old and new classification systems. A dental radiograph showing a tooth with a root canal filling and possible signs of periapical pathology, relevant to the lecture's discussion on endodontic and periodontal diseases. # PERIODONTAL DISEASE ## Diagnosing PERIODONTITIS: signs and symptoms - Attachment loss and deep pockets - Bleeding - Tooth mobility - Plaque & calculus deposits - Positive to cold/pulp tests - Radiographic bone loss - Generally painless  #### Diagnosing Periodontitis: Signs and Symptoms - Attachment loss and deep pockets - Bleeding - Tooth mobility - Plaque and calculus deposits - Positive response to cold/pulp tests - Radiographic bone loss - Generally painless A clinical photograph showing a patient's mouth with advanced periodontal disease, characterized by significant attachment loss, deep periodontal pockets, and visible plaque and calculus deposits on the teeth. The gums appear inflamed and receded, illustrating the severe impact of periodontitis. # PULPAL DISEASE - Signs and symptoms of reversible pulpitis - sensitivity to cold or hot normally which doesn’t linger long - Irreversible pulpitis, severe pain, lasting throbbing; altered response to pulp tests - Inflammation may extend to periodontal ligament tender to pressure, biting or tapping - If left untreated, pulp necrosis and eventual infection- bone resorption, and radiolucency around apex, in furcation or lateral to the root  #### Clinical Presentation of Pulpal Disease - **Reversible Pulpitis**: Sensitivity to cold or hot which does not linger long. - **Irreversible Pulpitis**: Severe pain, lasting throbbing, and an altered response to pulp tests. - **Periodontal Involvement**: Inflammation may extend to the periodontal ligament, making the tooth tender to pressure, biting, or tapping. - **Necrosis**: If left untreated, pulp necrosis occurs, leading to eventual infection, bone resorption, and radiolucency around the apex, in the furcation, or lateral to the root. A dental radiograph showing a tooth with a radiolucent area around the apex, indicative of pulp necrosis and potential infection. The image illustrates the progression of pulpal disease, with bone resorption visible in the periapical region, consistent with the text describing untreated pulp necrosis and radiolucency. Can pulp infections affect the periodontium? - Pulpal disease can cause periodontal changes - Infections in the pulp can spread through lateral canals and accessory canals into the periodontal ligament which could lead to the destruction of bone this can also occur via cracks and dentinal tubules   #### Impact of Pulpal Infection on the Periodontium - Pulpal disease can cause periodontal changes. - Infections in the pulp can spread through lateral and accessory canals into the periodontal ligament. - This spread can lead to the destruction of bone. - Communication can also occur via cracks and dentinal tubules. A diagram illustrating how pulp infections can spread through lateral canals and accessory canals into the periodontal ligament, leading to bone destruction. The image shows a tooth cross-section with arrows indicating the path of infection from the pulp to the surrounding periodontal tissues. A diagram depicting the spread of infection from the pulp through cracks and dentinal tubules into the periodontal ligament. The image shows a tooth cross-section with arrows indicating the path of infection from the pulp through the dentinal tubules to the surrounding periodontal tissues. ```html <table> <tr> <td><img src="https://i.imgur.com/5ZjKQ.png" alt="Figure 1. Some of the potential pathways of communication between pulp and periodontium." /></td> </tr> </table> ```  Potential pathways of communication between the pulp and periodontium are illustrated through various anatomical channels. Figure 1 illustrates potential pathways of communication between the pulp and periodontium, showing structures like furcation root canals, lateral root canals, apical foramen, dentinal tubules, fracture lines within root structure, and internal or external root resorption. The diagram highlights anatomical features and their dimensions, such as the range of furcation root canals (4-720µm) and the tapering of dentinal tubules from 2.0µm at the pulp to 0.9µm at the dentino-cemental junction. ```markdown Communication Pathways <img src="https://i.imgur.com/placeholder.png" alt="Diagram of tooth structure with labeled communication pathways A, B, C, D, E, F."> From: Abbott & Castro Salgado 2009 ```  #### Communication Pathways Specific anatomical pathways (labeled A through F) facilitate communication between the internal pulp chamber and the external periodontal environment (Source: Abbott & Castro Salgado 2009). A detailed anatomical diagram of a tooth showing communication pathways labeled A, B, C, D, E, and F. The main illustration depicts a cross-section of a tooth with arrows indicating pathways through the pulp and surrounding structures, while two smaller diagrams on the right illustrate cross-sectional views of the tooth with pathways E and F highlighted. Can periodontal infections affect the pulp? - The effect of periodontal disease on the pulp is not as clear-cut - Normal pulps observed in majority of teeth with advanced periodontal disease - A small % of teeth with advanced periodontal disease can cause pulp infections if the apical foramina is invaded   #### Impact of Periodontal Infection on the Pulp - The effect of periodontal disease on the pulp is less definitive than the reverse. - Normal pulps are observed in the majority of teeth with advanced periodontal disease. - A small percentage of teeth with advanced periodontal disease may develop pulp infections if the apical foramina is invaded. A diagram illustrating the anatomy of a tooth with periodontal disease, showing the pulp chamber, root canal, and surrounding bone structure, with arrows indicating potential pathways for infection from the periodontal tissues to the pulp. A radiographic image (X-ray) of a tooth showing a periapical lesion, indicative of infection or inflammation at the root tip, consistent with the discussion of pulp involvement in periodontal disease. # Combined periodontic-endodontic disease - Advanced periodontitis can allow bacteria to gain access to pulp via accessory canals or the apex of the root, and lead to infection of the pulp <img src="https://i.imgur.com/7XZJzQl.png" alt="Diagram showing periodontal disease progression"/> <img src="https://i.imgur.com/3XQXzQl.png" alt="Clinical image showing periodontal disease"/> <img src="https://i.imgur.com/9XZJzQl.png" alt="Diagram showing periodontal disease progression with percentages"/>    Advanced periodontitis can allow bacteria to gain access to the pulp via accessory canals or the apex of the root, leading to pulpal infection. A diagram illustrating the progression of advanced periodontitis, showing bacteria gaining access to the pulp through accessory canals or the apex of the root, leading to pulp infection. A clinical image showing a patient's oral cavity with visible signs of periodontal disease, including inflamed gum tissue and potential infection. A diagram depicting the percentage of accessory canals at different levels of the root, with labels indicating 1.6%, 8.8%, and 17% at various points along the root structure. # How to diagnose Combined endo-perio disease - **Diagnosis** of combined lesions can sometimes be tricky - The most important clinical examination tools: - Pulp sensibility test - Periodontal probing/ full chart, suppuration, mobility - Radiographs (PAs, CBCT) - Need a good history –trauma, procedures, symptoms - Visual appearance of soft tissues - Caries, restorations, anatomical factors - Transillumination #### Diagnostic Tools and Requirements Diagnosis of combined lesions can be complex. The most important clinical examination tools include: - Pulp sensibility tests - Periodontal probing (full chart, checking for suppuration and mobility) - Radiographs (Periapicals, CBCT) - Comprehensive history (trauma, previous procedures, symptoms) - Visual appearance of soft tissues - Assessment of caries, restorations, and anatomical factors - Transillumination **Diagnosis-Combined periodontic-endodontic disease can be challenging!** - It is easier to determine the origin of the lesion when a vital pulp test is obtained because the positive result will rule out an endodontic origin – except multi-rooted teeth with partial necrosis of pulp (necrobiosis) When the pulp is found to be non-responsive and the infection can be traced to a lateral canal or apical foramen, then the lesion is suspected to be of endodontic origin #### Determining the Origin of the Lesion - **Vital Pulp Test**: A positive result helps rule out endodontic origin, except in multi-rooted teeth with partial necrosis (necrobiosis). - **Non-responsive Pulp**: When the pulp is non-responsive and the infection is traced to a lateral canal or apical foramen, the lesion is suspected to be of endodontic origin. ```markdown Steps in the management of E-P L Initial Periodontal Therapy (Infection Control) | 1- DIFFERENTIAL DIAGNOSIS BETWEEN EPL WITH OR WITHOUT ROOT DAMAGE | | --- | | - Dental history (check for: recent trauma, endodontic treatment/instrumentation or post-preparation) | | - Clinical assessment of the symptomatic tooth/area (look for: abscess, sinus tract, deep pockets) | | Radiography of symptomatic tooth/area (look for: endodontic treatment, post-retained restorations, peripical lesion, fracture, cracking, perforation, external root resorption, groove) | | Fracture, cracking, perforation, external root resorption detected | No fracture, cracking, perforation, external root resorption | | 2- TAKE DECISION TO EXTRACT OR MAINTAIN THE TOOTH | | Decision is to maintain the tooth | | 3- FULL MOUTH PERIODONTAL ASSESSMENT | | 4- TAKE DECISION TO EXTRACT OR MAINTAIN THE TOOTH, BASED ON THE FOLLOWING PARAMETERS: (i) presence/history of periodontitis; (ii) severity of periodontal destruction around the affected tooth; (iii) if the tooth needs to be involved in an oral rehabilitation treatment | | Decision is to maintain the tooth | | 5- ENDODONTIC AND PERIODONTAL TREATMENTS | | Treatment sequence: (i) root canal treatment; (ii) scaling and root planing; (iii) regenerative procedures (when necessary) | Fig. 31-5 Steps in the management of an endo-periodontal lesion (EPL). ```  #### Management Steps for Endo-Periodontal Lesions (EPL) 1. **Differential Diagnosis**: Distinguish between EPL with or without root damage. - Check dental history for trauma, endodontic treatment, or post-preparation. - Clinical assessment for abscesses, sinus tracts, or deep pockets. - Radiographic review for periapical lesions, fractures, cracks, perforations, or resorption. 2. **Initial Decision**: Determine whether to extract or maintain the tooth. 3. **Full Mouth Periodontal Assessment**: Conducted if the decision is to maintain the tooth. 4. **Secondary Decision**: Re-evaluate maintenance based on: - Presence/history of periodontitis. - Severity of periodontal destruction. - Role of the tooth in overall oral rehabilitation. 5. **Treatment Sequence**: - Root canal treatment. - Scaling and root planing. - Regenerative procedures (when necessary). A flowchart diagram illustrating the steps in the management of an endo-periodontal lesion (EPL), showing a decision-making process that includes differential diagnosis, assessment of root damage, decisions on extraction or maintenance, full mouth periodontal assessment, and final endodontic and periodontal treatments. ```markdown **Diagnosis-Combined endo-periodontic disease-sensibility tests** - **Pulp tests** are not always reliable-2 tests better (cold, CO2 and EPT) - Multi-rooted teeth - partial necrosis of a pulp may allow for +ve response to pulp testing ```    #### Sensibility Test Considerations - Pulp tests are not always reliable; using two tests (e.g., Cold/CO2 and EPT) is preferred. - In multi-rooted teeth, partial necrosis may still allow for a positive response to testing. A photo of a dental pulp testing device labeled 'CyberEndo' with a digital display and a probe, accompanied by a coiled cable, illustrating equipment used for pulp sensitivity testing. A photo of a white aerosol can labeled 'Roeko Endo-Frost,' which is a cold spray used for pulp testing, shown against a neutral background. A close-up photo of a dental procedure showing a dental instrument being applied to a patient's teeth, demonstrating the use of sensitivity testing in a clinical setting. ```markdown Diagnosis: Radiographs ```   Radiographic examination is a critical component in diagnosing the extent and origin of endo-perio lesions. A diagram illustrating a dental radiograph showing a tooth with a periodontal pocket, highlighted in red and yellow, and the surrounding bone structure, with a cross-sectional view of the tooth and its root canal system. A diagram explaining the process of taking a dental radiograph, showing the X-ray beam passing through a periodontal pocket and the film capturing the image, with arrows indicating the direction of the X-ray beam and the film's position. # Radiographic exam  Detailed radiographic assessment is required to identify bone loss patterns and pulpal pathology. Three radiographic images labeled a, b, and c, showing dental X-rays of teeth. The images display the roots and surrounding bone structure, with variations in tooth alignment and potential dental conditions such as root canal treatment or dental implants visible in the middle image (b). # Probing Defects in an endodontic lesion - Probing defect- narrow and long - Usually referred to as a narrow sinus tract-type of probing - Likely an endodontic lesion is draining through the bone (and not the periodontal ligament as originally thought) thus mimicking a periodontal defect <img src="https://i.imgur.com/8ZQ4Xzv.png" alt="Diagram of a narrow sinus tract draining from an endodontic lesion through bone">  #### Characteristics of Endodontic Probing Defects - Probing defects of endodontic origin are typically narrow and long. - These are often referred to as narrow sinus tract-type probing. - The lesion likely drains through the bone rather than the periodontal ligament, mimicking a periodontal defect. A diagram illustrating a narrow sinus tract draining from an endodontic lesion through bone, showing the pathway from the root apex through the bone to the surface, mimicking a periodontal defect. The diagram complements the text describing how an endodontic lesion can drain through bone, rather than the periodontal ligament. ```html <table> <thead> <tr> <th>SIGNS</th> <th>ENDODONTIC</th> <th>PERIODONTAL</th> <th>COMBINED</th> </tr> </thead> <tbody> <tr> <td>LOCALISED TO TOOTH</td> <td>+</td> <td>-</td> <td>+-</td> </tr> <tr> <td>EXTENSIVE CARIES / RESTORATION</td> <td>+</td> <td>-</td> <td>+-</td> </tr> <tr> <td>PULP SENS TESTS</td> <td>-</td> <td>+</td> <td>-</td> </tr> <tr> <td>PROBING DEFECT</td> <td>NARROW</td> <td>WIDE</td> <td>WIDE</td> </tr> <tr> <td>CRESTAL BONE LOSS</td> <td>-</td> <td>+</td> <td>+</td> </tr> <tr> <td>PERCUSSION</td> <td>+-</td> <td>+-</td> <td>+-</td> </tr> <tr> <td>PALPATION</td> <td>+-</td> <td>+-</td> <td>+-</td> </tr> </tbody> </table> ```  #### Differential Diagnosis Table | Signs | Endodontic | Periodontal | Combined | | :--- | :---: | :---: | :---: | | Localized to Tooth | + | - | +/- | | Extensive Caries/Restoration | + | - | +/- | | Pulp Sensibility Tests | - | + | - | | Probing Defect | Narrow | Wide | Wide | | Crestal Bone Loss | - | + | + | | Percussion | +/- | +/- | +/- | | Palpation | +/- | +/- | +/- | A comparative table titled 'PERIODONTAL AND PULPAL DISEASE - DIFFERENTIAL DX' that lists various signs and their presence in endodontic, periodontal, and combined conditions. The table includes criteria such as localized tooth involvement, extensive caries/restoration, pulp sensitivity tests, probing defect, crestal bone loss, percussion, and palpation, with corresponding positive (+), negative (-), or ambiguous (+-) results for each condition. # Transient pulpal response - With periodontal treatment <img src="https://i.imgur.com/3lFm0jL.png" alt="Case Report: Transient Tooth Discoloration After Periodontal Instrumentation of Aggressive Periodontitis: A Case Report" />  #### Transient Pulpal Response Transient pulpal responses, such as tooth discoloration, can occur following periodontal treatment/instrumentation, particularly in cases of aggressive periodontitis. The image contains two photographs showing a patient's teeth, illustrating transient tooth discoloration after periodontal instrumentation. The photos depict the maxillary central incisors before and after treatment, highlighting the discoloration of the root surfaces due to aggressive periodontitis. ```markdown TOOTH DISCOLORATION & AGGRESSIVE PERIODONTITIS-CASE REPORT 17 year old male Black African from Eritrea Referred by ortho department to perio dept in Ohcwa Clear medical history JULY 2010 ```  #### Case Report: Tooth Discoloration and Aggressive Periodontitis - **Patient**: 17-year-old male, Black African from Eritrea. - **Referral**: Orthodontic department to Periodontal department (July 2010). - **Medical History**: Clear. A clinical photograph showing the oral cavity of a 17-year-old male patient, displaying teeth with discoloration and signs of periodontal inflammation. The image is dated July 2010 and is part of a case report on tooth discoloration and aggressive periodontitis. ```html <table border="1" cellpadding="5" cellspacing="0" style="border-collapse: collapse; width: 100%;"> <tr> <td style="text-align: center; vertical-align: middle;"> <img src="https://i.imgur.com/7XZQz6l.jpg" alt="Close-up of upper anterior teeth showing gingival recession and mobility" /> </td> <td style="text-align: center; vertical-align: middle;"> <img src="https://i.imgur.com/2JkQ9hR.jpg" alt="Close-up of lower anterior teeth showing gingival recession and mobility" /> </td> <td style="text-align: center; vertical-align: middle;"> <img src="https://i.imgur.com/3s9f5dN.jpg" alt="Full mouth view showing extensive gingival recession and mobility" /> </td> </tr> </table> ```     #### Clinical Presentation Initial clinical views of the upper and lower anterior teeth show extensive gingival recession and mobility. Close-up view of the lower anterior teeth showing significant gingival recession and tooth mobility, with exposed root surfaces and inflamed gums. Close-up of the upper anterior teeth displaying gingival recession, with visible root exposure and signs of periodontal disease. Close-up of the lower anterior teeth showing extensive gingival recession and mobility, with teeth appearing loose and gums receded. A detailed dental chart illustrating the extent of gingival recession and mobility across all teeth, with color-coded indicators for recession depth and mobility scores on both right and left sides of the mouth. **NOVEMBER** **2010** **PERIODONTAL REVIEW**  #### Periodontal Review (November 2010) Follow-up assessment of the patient's periodontal status. A close-up photograph of a patient's mouth showing dental conditions, including missing teeth and inflamed gums, framed within an oval border. This image is part of a 'Periodontal Review' for November 2010, likely illustrating a case study or clinical finding related to periodontal disease. **SECOND PERIODONTAL REVIEW** **JANUARY 2011** **GREY/ROSY PULP TESTS**    #### Second Periodontal Review (January 2011) Observations included grey/rosy pulp discoloration and results from pulp testing. Close-up intraoral photograph showing teeth with grey/rosey pulp test results, indicating possible pulp vitality issues with discolored and inflamed gingival tissues. Close-up intraoral photograph of anterior teeth with grey/rosey pulp test results, showing discolored enamel and gingival inflammation, likely indicating pulp status. Intraoral radiograph (X-ray) displaying the roots and surrounding bone structure of anterior teeth, used to assess pulp and periodontal health. ```markdown PERIODONTAL MAINTENANCE AUGUST 2011 ```     #### Periodontal Maintenance (August 2011) Long-term follow-up and maintenance phase for the aggressive periodontitis case. A black and white dental X-ray showing the roots of multiple teeth, with a focus on the upper anterior region, likely illustrating periodontal conditions or treatment outcomes. Another black and white dental X-ray, this one showing a lower anterior region with visible root structures, possibly documenting a periodontal maintenance case. A clinical photograph of the upper dental arch, showing teeth with visible gingival inflammation and possible periodontal issues, dated August 2011. A clinical photograph of the lower dental arch, showing teeth with signs of periodontal disease, including gingival recession and possible bone loss. **BEWARE: DIFFERENTIAL DIAGNOSES** - Incomplete coronal fractures (cracked tooth) which extend into the root of a tooth - Crown–root or vertical root fractures - Root resorption - Palatal grooves  #### Diagnostic Pitfalls Clinicians must be aware of conditions that mimic endo-perio lesions: - Incomplete coronal fractures (cracked tooth) extending into the root. - Crown-root or vertical root fractures. - Root resorption. - Palatal grooves. A close-up clinical photograph showing a dental procedure on a tooth, with a dental instrument inserted into the gum tissue near the tooth's root, highlighting a potential issue such as a cracked tooth or root resorption. “Endo-Perio Lesions” - Classification: Simon, Glick & Frank (1972) - 1° Endo lesion - 1° Endo lesion with 2° Perio involvement - 1° Perio lesion - 1° Perio lesion with 2° Endo involvement - “True” Combined lesion  #### Simon, Glick & Frank Classification (1972) - Primary Endodontic lesion. - Primary Endodontic lesion with secondary Periodontal involvement. - Primary Periodontal lesion. - Primary Periodontal lesion with secondary Endodontic involvement. - "True" Combined lesion. A bulleted list outlining the classification of endo-perio lesions by Simon, Glick & Frank (1972), including five categories: 1° Endo lesion, 1° Endo lesion with 2° Perio involvement, 1° Perio lesion, 1° Perio lesion with 2° Endo involvement, and "True" Combined lesion. The text is presented on a dark blue background with colored bullet points and text in yellow, white, and orange. # Problems with previous classification of Endo-Perio lesions - Confusing as we don’t know really know what the primary source of infection is - Are the lesions communicating or separate? - No guidance on prognosis or treatment #### Limitations of Historical Classifications - Difficulty in identifying the primary source of infection. - Ambiguity regarding whether lesions are communicating or separate. - Lack of specific guidance for prognosis or treatment planning. # CLASSIFICATION OF COMBINED PERIODONTIC AND ENDODONTIC DISEASE <table> <thead> <tr> <th colspan="3">TABLE 3 Classification of endo-periodontal lesions</th> </tr> </thead> <tbody> <tr> <td rowspan="3">Endo-periodontal lesion with root damage</td> <td>Root fracture or cracking</td> <td></td> </tr> <tr> <td>Root canal or pulp chamber perforation</td> <td></td> </tr> <tr> <td>External root resorption</td> <td></td> </tr> <tr> <td rowspan="6">Endo-periodontal lesion without root damage</td> <td rowspan="3">Endo-periodontal lesion in periodontitis patients</td> <td>Grade 1 – narrow deep periodontal pocket in 1 tooth surface</td> </tr> <tr> <td>Grade 2 – wide deep periodontal pocket in 1 tooth surface</td> </tr> <tr> <td>Grade 3 – deep periodontal pockets in > 1 tooth surface</td> </tr> <tr> <td rowspan="3">Endo-periodontal lesion in non-periodontitis patients</td> <td>Grade 1 – narrow deep periodontal pocket in 1 tooth surface</td> </tr> <tr> <td>Grade 2 – wide deep periodontal pocket in 1 tooth surface</td> </tr> <tr> <td>Grade 3 – deep periodontal pockets in > 1 tooth surface</td> </tr> </tbody> </table>  #### Modern Classification of Endo-Periodontal Lesions **1. Endo-periodontal lesion with root damage** - Root fracture or cracking - Root canal or pulp chamber perforation - External root resorption **2. Endo-periodontal lesion without root damage** - **In Periodontitis Patients**: - Grade 1: Narrow deep periodontal pocket in 1 tooth surface. - Grade 2: Wide deep periodontal pocket in 1 tooth surface. - Grade 3: Deep periodontal pockets in > 1 tooth surface. - **In Non-Periodontitis Patients**: - Grade 1: Narrow deep periodontal pocket in 1 tooth surface. - Grade 2: Wide deep periodontal pocket in 1 tooth surface. - Grade 3: Deep periodontal pockets in > 1 tooth surface. Table 3 classifies endo-periodontal lesions into two main categories: those with root damage and those without. The table details specific conditions such as root fracture, perforation, and resorption for lesions with root damage, and further subdivides lesions without root damage into grades based on the severity of periodontal pockets in periodontitis and non-periodontitis patients. ```html <table> <tr> <td> <table> <tr> <td>EPL suspected after thorough history, clinical examination and sensibility testing</td> </tr> <tr> <td>Root resorption, pulp chamber perforation or root fracture identifiable clinically</td> </tr> <tr> <td>Yes</td> </tr> <tr> <td>Radiographic evidence of root resorption, pulp chamber perforation or root fracture associated with EPL</td> </tr> <tr> <td>Endo-periodontal lesion with root damage</td> </tr> <tr> <td>Clinical and radiographic evidence of periodontitis affecting other teeth in the mouth</td> </tr> <tr> <td>Endo-periodontal lesion in a periodontitis patient</td> </tr> <tr> <td>Grade 1 – narrow deep periodontal pocket in 1 tooth surface</td> </tr> <tr> <td>Grade 2 – wide deep periodontal pocket in 1 tooth surface</td> </tr> <tr> <td>Grade 3 – deep periodontal pockets in > 1 tooth surface</td> </tr> </table> </td> <td> <table> <tr> <td>Peri-apical radiograph</td> </tr> <tr> <td>No</td> </tr> <tr> <td>No radiographic evidence of root resorption, pulp chamber perforation or root fracture associated with EPL</td> </tr> <tr> <td>Transillumination</td> </tr> <tr> <td>Identification of a fracture / crack</td> </tr> <tr> <td>Endo-periodontal lesion without root damage</td> </tr> <tr> <td>No clinical and radiographic evidence of periodontitis affecting other teeth in the mouth</td> </tr> <tr> <td>Endo-periodontal lesion in a non-periodontitis patient</td> </tr> <tr> <td>Grade 1 – narrow deep periodontal pockets in 1 tooth surface</td> </tr> <tr> <td>Grade 2 – wide deep periodontal pocket in 1 tooth surface</td> </tr> <tr> <td>Grade 3 – deep periodontal pockets in > 1 tooth surface</td> </tr> </table> </td> </tr> </table> ```  #### Diagnostic Decision Tree - **Step 1**: Suspect EPL after history, clinical exam, and sensibility testing. - **Step 2**: Identify root damage (resorption, perforation, fracture) clinically or radiographically. - If **Yes**: Classify as Endo-periodontal lesion with root damage. - If **No**: Use transillumination to check for cracks. - **Step 3**: Assess for systemic periodontitis. - If periodontitis is present in other teeth: Classify as EPL in a periodontitis patient. - If no periodontitis elsewhere: Classify as EPL in a non-periodontitis patient. - **Step 4**: Assign Grade (1, 2, or 3) based on pocket width and number of surfaces involved. A flowchart diagram illustrating the diagnostic pathway for endo-periodontal lesions (EPL). It begins with suspected EPL after history and examination, then branches based on clinical findings of root resorption, pulp chamber perforation, or root fracture. If present, it leads to radiographic evidence and a diagnosis of EPL with root damage. If not present, a peri-apical radiograph is used, followed by transillumination if no radiographic evidence is found. The diagram further differentiates between EPL with and without root damage, and classifies the condition based on periodontal pocket depth and extent in patients with or without periodontitis. ```markdown Establish prognosis - Hopeless - Poor - Favourable - Is it worth treating? - Alternative options must be discussed. - Cost +++ - Time +++ ```  #### Establishing Prognosis Prognosis is categorized as: - Hopeless - Poor - Favourable **Considerations**: - Is the tooth worth treating? - Alternative options must be discussed. - Significant cost and time requirements. A presentation slide with a blue background and white text, titled 'Establish prognosis'. The slide lists three prognosis categories on the left: 'Hopeless', 'Poor', and 'Favourable'. On the right, it poses questions about treatment worthiness, discusses alternative options, and highlights high costs and time requirements with 'Cost +++' and 'Time +++'. ```markdown CLASSIFICATION OF COMBINED PERIODONTIC AND ENDODONTIC DISEASE ``` <img src="https://i.imgur.com/placeholder.jpg" alt="A man with gray hair and glasses, wearing a suit and tie, smiling at the camera." /> ```html <table border="1" cellpadding="5" cellspacing="0"> <tr> <th colspan="2">Strategies for the endodontic management of concurrent endodontic and periodontal diseases</th> </tr> <tr> <td>PV Abbott,* J Castro Salgado*</td> <td>*School of Dentistry, The University of Western Australia.</td> </tr> <tr> <td colspan="2"><strong>ABSTRACT</strong></td> </tr> <tr> <td colspan="2">Endodontic and periodontal diseases can provide many diagnostic and management challenges to clinicians, particularly when they occur concurrently. As with all diseases, a thorough history combined with comprehensive clinical and radiographic examinations are all required so an accurate diagnosis can be made. This is essential since the diagnosis will determine the type and sequence of treatment required. This paper reviews the relevant literature and proposes a new classification for concurrent endodontic and periodontal diseases. This classification is a simple one that will help clinicians to formulate management plans for when these diseases occur concurrently. The key aspects are to determine whether both types of diseases are present, rather than just having manifestations of one disease in the alternate tissue. Once it is established that both diseases are present and that they are as a result of infections of each tissue, then the clinician must determine whether the two diseases communicate via the periodontal pocket so that appropriate management can be provided using the guidelines outlined. In general, if the root canal system is infected, endodontic treatment should be commenced prior to any periodontal therapy in order to remove the intracanal infection before any cementum is removed. This avoids several complications and provides a more favourable environment for periodontal repair. The endodontic treatment can be completed before periodontal treatment is provided when there is no communication between the two disease processes. However, when there is communication between the two disease processes, then the root canals should be medicated until the periodontal treatment has overall prognosis of the tooth has been reassessed as being favourable. The use of non-toxic intracanal therapeutic medicaments is essential to destroy bacteria and to help encourage tissue repair.</td> </tr> <tr> <td colspan="2"><strong>Keywords:</strong> Endo-perio diseases, endodontics, periodontics.</td> </tr> <tr> <td colspan="2"><strong>INTRODUCTION</strong></td> </tr> <tr> <td colspan="2">Although there are many factors that contribute to the development and progression of endodontic and periodontal diseases, the primary cause of both diseases is the presence of bacterial infections with complex microbial flora. Many authors have reported the similarity of the bacterial flora associated with endodontic and periodontal infections<sup>1-5</sup> and it is widely accepted that an untreated infection of one of these tissues can lead to signs or symptoms of disease within the other tissue.<sup>6-12</sup> Cross-seeding of bacteria from one tissue to the other can also occur<sup>10</sup> and this can occur in either direction (i.e., from the root canal to the periodontium, or vice versa) through communication pathways (Fig 1) such as the apical foramen, lateral canals, accessory canals (i.e., small canals that run from the floor of the pulp chamber to the furcation region of multi-rooted teeth), dentinal tubules, developmental defects (e.g., radicular grooves, invaginations) and other disease-related or iatrogenic defects of the tooth root (e.g., caries, cracks, perforations).</td> </tr> <tr> <td colspan="2">Once both the pulp and the periodontal tissues have become involved, the diagnosis and management of the situation may become more complex and will require extra considerations. The prognosis will be less predictable and patients may be unwilling to commit themselves to the treatment, as well as the financial and time burdens required to salvage the tooth, and to retain and maintain it in the long term.<sup>13</sup></td> </tr> <tr> <td colspan="2">Traditional approaches to assessing and managing teeth with concurrent endodontic and periodontal diseases have been somewhat confusing as a result of inconsistent, inaccurate and confusing terminology. Although there has been considerable research about this topic in the past, there has been little research reported in the last decade. The aims of this paper were to review the literature, to develop a rational classification system and to provide a simple approach to managing teeth with concurrent endodontic and periodontal diseases.</td> </tr> </table> ```   #### Strategies for Management (Abbott & Castro Salgado) - **Diagnosis**: Determine if both diseases are present as independent infections or manifestations of one another. - **Communication**: Determine if the diseases communicate via the periodontal pocket. - **Treatment Sequence**: If the root canal is infected, endodontic treatment should precede periodontal therapy to remove intracanal infection before cementum removal. - **Medication**: Use non-toxic intracanal medicaments to destroy bacteria and encourage tissue repair. A portrait photograph of a man with gray hair, glasses, and a beard, wearing a suit and tie, positioned on the left side of the slide. A scanned image of a research article titled 'Strategies for the endodontic management of concurrent endodontic and periodontal diseases,' which includes text discussing the classification and management of combined periodontic and endodontic diseases. # CLASSIFICATION OF COMBINED PERIODONTIC AND ENDODONTIC DISEASE - CONCURRENT ENDODONTIC AND PERIODONTAL DISEASES WITHOUT COMMUNICATION - CONCURRENT ENDODONTIC AND PERIODONTAL DISEASES WITH COMMUNICATION Abbott & Castro 2009     #### Classification by Communication (Abbott & Castro 2009) - Concurrent Endodontic and Periodontal diseases **without** communication. - Concurrent Endodontic and Periodontal diseases **with** communication. A dental radiograph showing a tooth with a large restoration and periapical radiolucency, illustrating concurrent endodontic and periodontal disease without communication. Another dental radiograph depicting a tooth with a large restoration and a periapical lesion, representing concurrent endodontic and periodontal disease with communication. A diagram illustrating a tooth with a vertical root fracture and associated periodontal pocket, showing the communication between endodontic and periodontal disease. A diagram showing a tooth with a vertical root fracture and inflammation in the periodontal ligament, representing the pathway of communication between endodontic and periodontal disease. ```markdown PROGNOSIS - COMBINED PERIODONTIC AND ENDODONTIC DISEASE - PROGNOSIS BETTER WITHOUT COMMUNICATION - COMBINED with communication has WORSE PROGNOSIS ```    #### Prognostic Differences - Prognosis is better for lesions without communication. - Combined lesions with communication have a worse prognosis. X-ray image showing a tooth with a periapical lesion, illustrating a case of combined periodontic and endodontic disease with communication between the periodontal and endodontic lesions. X-ray image displaying a tooth with a root canal filling and a radiolucent area at the apex, indicating a periapical lesion associated with endodontic pathology. X-ray image of a dental arch showing multiple teeth with radiopaque restorations and a radiolucent lesion around the apex of a tooth, demonstrating a case of combined periodontic and endodontic disease. ```markdown **CONCURRENT PERIODONTAL AND ENDODONTIC LESION WITHOUT COMMUNICATION - MANAGEMENT** - Combined periodontal and endodontic therapy - Treat acute condition first - Better to start endo and medicate canals first as infected root canals hinders periodontal healing - prognosis depend on extent of periodontal involvement & cause of pulpal disease ```    #### Management of Lesions Without Communication - Requires combined periodontal and endodontic therapy. - Treat the acute condition first. - Start endodontic treatment and medicate canals first; infected root canals can hinder periodontal healing. - Prognosis depends on the extent of periodontal involvement and the cause of pulpal disease. X-ray image showing a dental structure with a root canal treatment, indicating a periodontal and endodontic lesion without communication. X-ray image labeled '3 YEARS' showing a dental structure with a root canal filling, demonstrating long-term follow-up of a periodontal and endodontic lesion. Anatomical diagram illustrating a tooth with a root canal, highlighting the pulp chamber and surrounding periodontal structures, relevant to concurrent periodontal and endodontic lesions. # Management of concurrent EP disease with communication - Treat acute condition - Remove restoration /caries- is it restorable? - Start endo- clean canals and medicate ( ledermix or 50: 50 ledermix ca(oh)2) - Wait minimum 4 weeks – start perio - Wait 3 months- redress/ repeat perio till prognosis is clear - Interim restoration must be cleansable - Complete endo when the prognosis is established  #### Management Protocol for Lesions With Communication 1. Treat the acute condition. 2. Remove restorations/caries to assess restorability. 3. Initiate endodontic treatment: clean and medicate canals (e.g., Ledermix or 50:50 Ledermix/Calcium Hydroxide). 4. Wait a minimum of 4 weeks before starting periodontal therapy. 5. Wait 3 months; redress canals and repeat periodontal treatment until the prognosis is clear. 6. Ensure interim restorations are cleansable. 7. Complete endodontic treatment only once a favorable prognosis is established. The image displays a slide titled 'Management of concurrent EP disease with communication,' which outlines a step-by-step treatment protocol. It includes bullet points detailing the sequence of actions such as treating acute conditions, removing restorations or caries, starting endodontic treatment with specific medicaments, waiting periods for periodontal therapy, and completing endodontic treatment only after prognosis is established. The diagram emphasizes the importance of an interim restoration that is cleansable and the timing of procedures based on clinical outcomes. **CONCURRENT PERIODONTAL AND ENDODONTIC LESION WITH COMMUNICATION - MANAGEMENT** 6 Months   Management of concurrent periodontal and endodontic lesions with communication requires long-term monitoring, often up to 6 months, to assess healing. Two dental radiographs showing a concurrent periodontal and endodontic lesion with communication, comparing the initial state to a 6-month follow-up. The images depict changes in the periapical region of the tooth, with the right image showing reduced radiolucency and improved bone healing. A dental radiograph taken 6 months post-treatment, showing the resolution of a periodontal-endodontic lesion. The image illustrates significant healing with decreased radiolucency and improved bone structure around the affected tooth. The image contains four dental radiographic images and one clinical photograph. - **Top-left**: A periapical radiograph showing a tooth with a dark area in the root canal, indicating possible infection or necrosis. - **Top-right**: A 3D CT scan image showing a tooth with a distinct lesion or abnormality in the surrounding bone. - **Bottom-left**: A clinical photograph of inflamed gingiva with the number "3" overlaid in yellow. - **Bottom-right**: A periapical radiograph with an arrow pointing to a specific area, possibly indicating a lesion or abnormality. The number "3" in the bottom-left image is highlighted in yellow.     #### Clinical and Radiographic Monitoring Monitoring involves periapical radiographs and potentially 3D CT scans to track bone lesions and gingival inflammation during the healing phase. A clinical photograph showing inflamed gingiva with the number "3" overlaid in yellow, indicating a specific area of concern on the gum tissue. A 3D CT scan image displaying a tooth with a distinct lesion or abnormality in the surrounding bone, highlighted in the radiographic view. A periapical radiograph showing a tooth with a dark area in the root canal, indicating possible infection or necrosis. A periapical radiograph with an arrow pointing to a specific area, possibly indicating a lesion or abnormality in the root structure. # PROGNOSIS - COMBINED PERIODONTAL AND ENDODONTIC LESION - Periodontal prognosis can be difficult to determine initially Prognosis depends on: - Cause of disease and amount of remaining tooth structure left - Amount of attachment loss, mobility, root anatomy, furcation, - Healing response - Oral hygiene - Compliance with spt - Restoration longevity - Skill of clinician #### Factors Influencing Prognosis Periodontal prognosis can be difficult to determine initially and depends on: - Cause of disease and remaining tooth structure. - Amount of attachment loss and mobility. - Root anatomy, furcation involvement, and healing response. - Oral hygiene and compliance with Supportive Periodontal Therapy (SPT). - Restoration longevity and clinician skill. Periodontal regeneration versus extraction and prosthetic replacement of teeth severely compromised by attachment loss to the apex: 5-year results of an ongoing randomized clinical trial Cortellini P, Stalpers G, Mollo A, Tonetti MS: Periodontal regeneration versus extraction and prosthetic replacement of teeth severely compromised by attachment loss to the apex: 5-year results of an ongoing randomized clinical trial. J Clin Periodontol 2011; 38: 915–924. doi: 10.1111/j.1600-051X.2011.01768.x <img src="https://i.imgur.com/1a.png" alt="Periodontal regeneration versus extraction and prosthetic replacement of teeth severely compromised by attachment loss to the apex: 5-year results of an ongoing randomized clinical trial" />  #### Periodontal Regeneration Research Study: *Periodontal regeneration versus extraction and prosthetic replacement of teeth severely compromised by attachment loss to the apex* (Cortellini et al. 2011). A series of clinical and radiographic images showing the progression of periodontal treatment over five years. The figure includes intraoral photos (a, e, h, i, k) and periapical radiographs (b, c, f, g, j, l) illustrating the condition of teeth before and after periodontal regeneration or extraction and prosthetic replacement. The images demonstrate changes in gingival health, surgical intervention, and final restorative outcomes. ```markdown Cortellini 2011 Periodontal regeneration versus extraction and prosthetic replacement of teeth severely compromised by attachment loss to the apex: 5-year results of an ongoing randomized clinical trial Pierpaolo Cortellini¹,², Gabrielle Stalpers², Aniello Mollo³ and Maurizio S. Tonetti² ¹Accademia Toscana di Ricerca Odontostomatologia (ATRO), Florence, Italy; ²European Research Group on Periodontology (ERGOPERIO), Genova, Italy; ³Private Practice, Florence, Italy - 50 hopeless teeth - Perio-endo lesion and/or attachment loss to the apex. - Control (n=25): Extraction + replacement with conventional or implant-supported fixed prosthesis - Test (n=25): Regenerative strategy - 5 years follow-up ```  #### Cortellini 2011 Study Details - **Sample**: 50 "hopeless" teeth with perio-endo lesions and/or attachment loss to the apex. - **Control Group (n=25)**: Extraction and replacement with fixed prosthesis or implants. - **Test Group (n=25)**: Regenerative strategy. - **Follow-up**: 5 years. A dental radiograph showing two adjacent teeth with periapical pathology, likely illustrating a case of a perio-endo lesion or attachment loss to the apex, relevant to the study's focus on periodontal regeneration versus extraction. - After 5 years: - Similar survival rate (92%-100%) - Similar complication rate (16%- 17%) - Conclusions (Cortellini 2011): - Regenerative therapy can change the prognosis of a tooth from “hopeless” to fair or favourable and is a suitable alternative to extraction of severely compromised teeth   #### Study Outcomes (Cortellini 2011) - **Survival Rate**: Similar between groups (92%–100%). - **Complication Rate**: Similar between groups (16%–17%). - **Conclusion**: Regenerative therapy can change the prognosis of a tooth from "hopeless" to fair or favourable, serving as a suitable alternative to extraction. A black and white dental X-ray image showing a tooth with a root canal treatment, positioned next to text discussing survival and complication rates after five years. A black and white dental X-ray image displaying a tooth with a large radiolucent area, likely indicating a lesion or infection, accompanying text about regenerative therapy outcomes. **Other treatment options** - Root resections ( Langer et al 1981- 10 year study ) - Hemisections/ premolarization ( with or without root removal) - Extract and don’t replace or use the crown as a pontic - Fixed or resin retained bridges / dentures/ implant if appropriate #### Alternative Surgical and Prosthetic Options - Root resections (e.g., Langer et al. 1981). - Hemisections or premolarization (with or without root removal). - Extraction without replacement or using the natural crown as a pontic. - Fixed or resin-retained bridges, dentures, or implants. # Endo-Perio + DB root resection **Figure 4.** Pre-operative radiograph UL6. **Figure 6.** Post-operative radiograph following non-surgical root canal treatment UL6. Demonstrates composite plug in the disto-buccal canal. **Figure 3.** Pre-operative presentation – lateral periodontal abscess buccal to UL6 visible. **Figure 5.** Clinical presentation following non-surgical phase of treatment. **Figure 7. (a, b)** Post-operative presentation following surgical phase to resect the disto-buccal root. **Figure 8.** Radiograph after root resection of disto-buccal root UL6.       #### Case Study: Endo-Perio with Disto-Buccal (DB) Root Resection - **Pre-operative**: Lateral periodontal abscess buccal to UL6 and radiographic evidence of infection. - **Non-surgical Phase**: Root canal treatment of UL6 with a composite plug in the disto-buccal canal. - **Surgical Phase**: Resection of the disto-buccal root. - **Outcome**: Post-operative radiographs and clinical presentation following successful root resection. Pre-operative radiograph of UL6 showing the initial condition before treatment, with a focus on the tooth's root structure and surrounding bone. Post-operative radiograph following non-surgical root canal treatment of UL6, demonstrating a composite plug in the disto-buccal canal. Radiograph after root resection of the disto-buccal root of UL6, showing the surgical outcome and the remaining root structure. Pre-operative presentation showing a lateral periodontal abscess buccal to UL6, with visible swelling and inflammation of the gum tissue. Clinical presentation following the non-surgical phase of treatment, showing reduced inflammation and improved gum condition around UL6. Post-operative presentation following the surgical phase to resect the disto-buccal root, showing the tooth after surgery with the root structure altered. # Conclusions - Endodontic & periodontal diseases can be challenging to diagnose and manage - Important to establish a correct diagnosis as it will determine the extent, type and sequence of treatment required as well assigning a reliable prognosis - If the root canal system is infected concurrently with a communicating periodontal infection, endodontic treatment should be commenced at least 4 weeks prior to any periodontal therapy - Treatment of combined endodontic & periodontal diseases can be very successful but usually depends on the periodontal healing- ideally get a perio opinion early to avoid expense and time loss #### Final Summary - Accurate diagnosis is essential to determine the sequence of treatment and a reliable prognosis. - For communicating lesions, endodontic treatment should begin at least 4 weeks before periodontal therapy. - Success often depends on periodontal healing; early periodontal consultation is recommended to optimize outcomes and manage patient expectations. # References for exam study - Lindhe (7th Ed): - Volume 1, p 475-481 - EFP New classification, Systemic and other periodontal conditions, Endo-periodontal conditions - Dental Update-Assessment and management of Endo-Periodontal Lesions —Hoyle et al, 2019;46:930-941 44 #### Core Textbooks and Classifications - **Lindhe (7th Ed):** - Volume 1, p 475-481 - EFP New classification: Systemic and other periodontal conditions, Endo-periodontal conditions #### Journal Articles - **Dental Update:** Assessment and management of Endo-Periodontal Lesions — Hoyle et al, 2019; 46:930-941 # References for exam study ## The periodontal–endodontic controversy **Gerald W. Harrington, David R. Steiner & William F. Ammons, Jr** Over the past century the dental literature has consistently reflected a controversy related to the effect of periodontal disease on the dental pulp and more recently the effect of pulpal necrosis on the initiation and progression of marginal bone loss. Two basic questions have been raised and continue to be matters of dispute. Is periodontal disease a cause of pulp necrosis? Can a pulpless tooth be the cause of periodontal disease? The answers to these basic questions are of utmost clinical importance. The appropriateness of treatment planning hangs in the balance. For example, should root canal treatment be carried out prophylactically for a tooth associated with moderate or advanced periodontal disease? Should a pulpless tooth be retained or should it be removed and replaced with an osseointegrated implant? Many of our clinical impressions related to the dental pulp, and indeed many of our misinterpretations, stem from early histological observations. Adequate fixation of pulp tissue has always been, and continues to be, a challenge, and artefacts resulting from inadequate fixation continue to be described as evidence of pathosis. Stanley & Weaver (39) listed the following progression of tissue breakdown resulting from inadequate fixation: vacuolization in the odontoblastic layer and subsequently in the general body of the pulp, displacement of odontoblasts into the dentinal tubules as vacuolization progresses, 'reticular atrophy', and the appearance of advanced fibrosis in the body of the pulp. Fibrosis and reticular atrophy are historical histological descriptions of pulp pathosis attributed to many causes, including periodontal disease. A classic example of how inadequate pulp fixation effects an attempt to interpret the response of the dental pulp to periodontal disease is the often quoted paper by Mazur & Massler (26). Although it is obvious from the histological description in this paper that many of the pulps suffered from inadequate fixation, the paper continues to be one of the more commonly quoted in the periodontal–endodontic literature (9, 31, 34, 43). Most of the papers written prior to 1975, as well as some written since, need to be reviewed carefully to determine if their descriptions of perceived pulp pathosis are in fact simply histological artefacts. The potential for the dental pulp to survive the various challenges presented during the lifetime of a patient is also by and large related to presumptions made in interpretation of histological data. The histology of a specific dental pulp, however, represents only one frame of a picture in time for that particular pulp. What has occurred before and what will subsequently occur must be a matter of conjecture and interpretation. For example, S werdlow & Stanley (40) report the presence of intrapulpal abscesses at an early time-point in one of their many pulp studies, yet at later time-points in the same study there were no intrapulpal abscesses and healing of pulp lesions was evident. Does this mean that intrapulpal abscesses can resolve and the pulp heal itself? Or is it simply the 'luck of the draw' in a histological study, in that the pulps which had early intrapulpal abscesses would subsequently become completely necrotic if observed over a longer period of time, and the pulps from the later time-points would have shown less evidence of pathosis if observed at the earlier time? While one cannot discount this latter possibility, Stanley's interpretation was that occasionally 'there will occur beneath cavity preparations certain abscess-like conditions which will resolve.' (38) Hence, each pulp studied is from one moment in time, and observations are subject to interpretation and projection beyond that moment. Such projections may or may not conform to fact. Was Stanley correct, or incorrect? We may never know, and such interpretations become 'references to authority'. Most histological interpretations of the past decade have been based on the assumption that the pulp is a closed system, and that any changes observed are a direct result of the disease process. However, this assumption may not always be valid. The pulp is a dynamic tissue that responds to a variety of stimuli, and the interpretation of histological findings must take into account the complex interplay of factors that can influence the outcome. ## Strategies for the endodontic management of concurrent endodontic and periodontal diseases **PV Abbott, * J Castro Salgado*** *School of Dentistry, The University of Western Australia.* **ABSTRACT** Endodontic and periodontal diseases can provide many diagnostic and management challenges to clinicians, particularly when they occur concurrently. As with all diseases, a thorough history combined with comprehensive clinical and radiographic examinations are all required so an accurate diagnosis can be made. This is essential since the diagnosis will determine the type and sequence of treatment required. This paper reviews the relevant literature and proposes a new classification for concurrent endodontic and periodontal diseases. This classification is a simple one that will help clinicians to formulate management plans for when these diseases occur concurrently. The key aspects are to determine whether both types of diseases are present, rather than just having manifestations of one disease in the alternate tissue. Once it is established that both diseases are present and that they are as a result of infections of each tissue, then the clinician must determine whether the two diseases communicate via the periodontal pocket so that appropriate management can be provided using the guidelines outlined. In general, if the root canal system is infected, endodontic treatment should be commenced prior to any periodontal therapy in order to remove the intracanal infection before any cementum is removed. This avoids several complications and provides a more favourable environment for periodontal repair. The endodontic treatment can be completed before periodontal treatment is provided when there is no communication between the disease processes. However, when there is communication between the two disease processes, then the root canals should be medicated until the periodontal treatment has been completed and the overall prognosis of the tooth has been reassessed as being favourable. The use of non-toxic intracanal therapeutic medicaments is essential to destroy bacteria and to help encourage tissue repair. **Keywords:** Endo-perio diseases, endodontics, periodontics. **INTRODUCTION** Although there are many factors that contribute to the development and progression of endodontic and periodontal diseases, the primary cause of both diseases is the presence of bacterial infections with complex microbial flora. Many authors have reported the similarity of the bacterial flora associated with endodontic and periodontal infections¹⁻⁵ and it is widely accepted that an untreated infection of one of these tissues can lead to signs or symptoms of disease within the other tissue.⁶⁻¹⁰ Cross-seeding of bacteria from one tissue to the other can also occur¹⁰ and this can occur in either direction (i.e., from the root canal to the periodontium, or vice versa) through communication pathways (Fig 1) such as the apical foramen, lateral canals, accessory canals (i.e., small canals that run from the floor of the pulp chamber to the furcation region of multi-rooted teeth), dentinal tubules, developmental defects (e.g., radicular grooves, invaginations) and other disease-related or iatrogenic defects of the tooth root (e.g., caries, cracks, perforations). Once both the pulp and the periodontal tissues have become involved, the diagnosis and management of the situation may become more complex and will require extra considerations. The prognosis will be less predictable and patients may be unwilling to commit themselves to the treatment, as well as the financial and time burdens required to salvage the tooth, and to retain and maintain it in the long term.¹¹ Traditional approaches to assessing and managing teeth with concurrent endodontic and periodontal diseases have been somewhat confusing as a result of inconsistent, inaccurate and confusing terminology. Although there has been considerable research about this topic in the past, there has been little research reported in the last decade. The aims of this paper were to review the literature, to develop a simple classification system and to provide a rational approach to managing teeth with concurrent endodontic and periodontal diseases.   #### The Periodontal–Endodontic Controversy **Gerald W. Harrington, David R. Steiner & William F. Ammons, Jr** Over the past century, the dental literature has consistently reflected a controversy related to the effect of periodontal disease on the dental pulp and, more recently, the effect of pulpal necrosis on the initiation and progression of marginal bone loss. Two basic questions have been raised: 1. Is periodontal disease a cause of pulp necrosis? 2. Can a pulpless tooth be the cause of periodontal disease? The answers to these questions are of clinical importance for treatment planning, such as determining if root canal treatment should be carried out prophylactically for teeth with advanced periodontal disease, or if a pulpless tooth should be replaced with an implant. ##### Histological Observations and Artefacts Many clinical impressions stem from early histological observations. Adequate fixation of pulp tissue remains a challenge; artefacts from inadequate fixation—such as vacuolization, displacement of odontoblasts, "reticular atrophy," and advanced fibrosis—have historically been misdescribed as evidence of pathosis. For example, the paper by Mazur & Massler (26) is frequently quoted despite evidence of inadequate fixation. Papers written prior to 1975 must be reviewed carefully to determine if perceived pathosis is simply a histological artefact. ##### Pulp Survival and Interpretation The histology of a specific pulp represents only one moment in time. S werdlow & Stanley (40) reported intrapulpal abscesses at early time-points that were not present later, suggesting healing of pulp lesions. However, such observations are subject to interpretation: did the abscess resolve, or would it have progressed to necrosis if observed longer? Most histological interpretations assume the pulp is a closed system, but it is a dynamic tissue responding to complex stimuli. #### Strategies for the Endodontic Management of Concurrent Endodontic and Periodontal Diseases **PV Abbott, J Castro Salgado** *School of Dentistry, The University of Western Australia* **Abstract** Endodontic and periodontal diseases provide diagnostic challenges when occurring concurrently. A thorough history and comprehensive clinical/radiographic examinations are essential to determine the type and sequence of treatment. This paper proposes a new classification to help clinicians determine if both diseases are present as a result of separate infections and whether they communicate via the periodontal pocket. Key management guidelines include: - If the root canal system is infected, endodontic treatment should commence prior to periodontal therapy to remove intracanal infection before cementum removal. - If there is no communication between the disease processes, endodontic treatment can be completed before periodontal treatment. - If communication exists, root canals should be medicated until periodontal treatment is complete and the prognosis is reassessed as favourable. - Non-toxic intracanal therapeutic medicaments are essential to destroy bacteria and encourage tissue repair. **Introduction** The primary cause of both diseases is bacterial infection with complex microbial flora. Similarity in bacterial flora suggests that an untreated infection in one tissue can lead to disease in the other. Cross-seeding can occur in either direction through communication pathways such as: - Apical foramen - Lateral and accessory canals - Dentinal tubules - Developmental defects (e.g., radicular grooves, invaginations) - Iatrogenic defects (e.g., cracks, perforations) When both tissues are involved, management becomes complex, prognosis is less predictable, and patients may face significant financial and time burdens to salvage the tooth. A scanned page from a dental journal titled "The periodontal-endodontic controversy" by Gerald W. Harrington, David R. Steiner, and William F. Ammons, Jr., discussing the historical and clinical aspects of the relationship between periodontal disease and pulp necrosis. The page includes text discussing histological observations and interpretations related to dental pulp pathology. A scanned page from the Australian Dental Journal titled "Strategies for the endodontic management of concurrent endodontic and periodontal diseases" by P.V. Abbott and J. Castro Salgado, focusing on the diagnostic and management challenges of concurrent diseases in dental tissues. The page includes an abstract and introduction discussing the complexity of diagnosis and treatment planning. ```html <table border="0" cellpadding="0" cellspacing="0"> <tr> <td>THANK</td> </tr> <tr> <td>YOU</td> </tr> </table> ```  THANK YOU A word cloud figure displaying the phrase "THANK YOU" in large, bold letters, surrounded by various translations of "thank you" in different languages such as "GRACIAS," "ARIGATO," "MERCI," and "SHUKRIA." The words are arranged in a visually appealing pattern with varying font sizes to emphasize certain translations.  A 3D illustration of a white humanoid figure standing in front of a large red question mark, set against a blue background with a white circular spotlight. The figure appears to be in a contemplative pose, with one hand on its chin, suggesting thought or confusion. The number '47' is visible at the bottom center of the image. [^1]: Original PDF page 1: [[L3 endo-perio.pdf#page=1|L3 endo-perio, p.1]] [^2]: Original PDF page 2: [[L3 endo-perio.pdf#page=2|L3 endo-perio, p.2]] [^3]: Original PDF page 3: [[L3 endo-perio.pdf#page=3|L3 endo-perio, p.3]] [^4]: Original PDF page 4: [[L3 endo-perio.pdf#page=4|L3 endo-perio, p.4]] [^5]: Original PDF page 5: [[L3 endo-perio.pdf#page=5|L3 endo-perio, p.5]] [^6]: Original PDF page 6: [[L3 endo-perio.pdf#page=6|L3 endo-perio, p.6]] [^7]: Original PDF page 7: [[L3 endo-perio.pdf#page=7|L3 endo-perio, p.7]] [^8]: Original PDF page 8: [[L3 endo-perio.pdf#page=8|L3 endo-perio, p.8]] [^9]: Original PDF page 9: [[L3 endo-perio.pdf#page=9|L3 endo-perio, p.9]] [^10]: Original PDF page 10: [[L3 endo-perio.pdf#page=10|L3 endo-perio, p.10]] [^11]: Original PDF page 11: [[L3 endo-perio.pdf#page=11|L3 endo-perio, p.11]] [^12]: Original PDF page 12: [[L3 endo-perio.pdf#page=12|L3 endo-perio, p.12]] [^13]: Original PDF page 13: [[L3 endo-perio.pdf#page=13|L3 endo-perio, p.13]] [^14]: Original PDF page 14: [[L3 endo-perio.pdf#page=14|L3 endo-perio, p.14]] [^15]: Original PDF page 15: [[L3 endo-perio.pdf#page=15|L3 endo-perio, p.15]] [^16]: Original PDF page 16: [[L3 endo-perio.pdf#page=16|L3 endo-perio, p.16]] [^17]: Original PDF page 17: [[L3 endo-perio.pdf#page=17|L3 endo-perio, p.17]] [^18]: Original PDF page 18: [[L3 endo-perio.pdf#page=18|L3 endo-perio, p.18]] [^19]: Original PDF page 19: [[L3 endo-perio.pdf#page=19|L3 endo-perio, p.19]] [^20]: Original PDF page 20: [[L3 endo-perio.pdf#page=20|L3 endo-perio, p.20]] [^21]: Original PDF page 21: [[L3 endo-perio.pdf#page=21|L3 endo-perio, p.21]] [^22]: Original PDF page 22: [[L3 endo-perio.pdf#page=22|L3 endo-perio, p.22]] [^23]: Original PDF page 23: [[L3 endo-perio.pdf#page=23|L3 endo-perio, p.23]] [^24]: Original PDF page 24: [[L3 endo-perio.pdf#page=24|L3 endo-perio, p.24]] [^25]: Original PDF page 25: [[L3 endo-perio.pdf#page=25|L3 endo-perio, p.25]] [^26]: Original PDF page 26: [[L3 endo-perio.pdf#page=26|L3 endo-perio, p.26]] [^27]: Original PDF page 27: [[L3 endo-perio.pdf#page=27|L3 endo-perio, p.27]] [^28]: Original PDF page 28: [[L3 endo-perio.pdf#page=28|L3 endo-perio, p.28]] [^29]: Original PDF page 29: [[L3 endo-perio.pdf#page=29|L3 endo-perio, p.29]] [^30]: Original PDF page 30: [[L3 endo-perio.pdf#page=30|L3 endo-perio, p.30]] [^31]: Original PDF page 31: [[L3 endo-perio.pdf#page=31|L3 endo-perio, p.31]] [^32]: Original PDF page 32: [[L3 endo-perio.pdf#page=32|L3 endo-perio, p.32]] [^33]: Original PDF page 33: [[L3 endo-perio.pdf#page=33|L3 endo-perio, p.33]] [^34]: Original PDF page 34: [[L3 endo-perio.pdf#page=34|L3 endo-perio, p.34]] [^35]: Original PDF page 35: [[L3 endo-perio.pdf#page=35|L3 endo-perio, p.35]] [^36]: Original PDF page 36: [[L3 endo-perio.pdf#page=36|L3 endo-perio, p.36]] [^37]: Original PDF page 37: [[L3 endo-perio.pdf#page=37|L3 endo-perio, p.37]] [^38]: Original PDF page 38: [[L3 endo-perio.pdf#page=38|L3 endo-perio, p.38]] [^39]: Original PDF page 39: [[L3 endo-perio.pdf#page=39|L3 endo-perio, p.39]] [^40]: Original PDF page 40: [[L3 endo-perio.pdf#page=40|L3 endo-perio, p.40]] [^41]: Original PDF page 41: [[L3 endo-perio.pdf#page=41|L3 endo-perio, p.41]] [^42]: Original PDF page 42: [[L3 endo-perio.pdf#page=42|L3 endo-perio, p.42]] [^43]: Original PDF page 43: [[L3 endo-perio.pdf#page=43|L3 endo-perio, p.43]] [^44]: Original PDF page 44: [[L3 endo-perio.pdf#page=44|L3 endo-perio, p.44]] [^45]: Original PDF page 45: [[L3 endo-perio.pdf#page=45|L3 endo-perio, p.45]] [^46]: Original PDF page 46: [[L3 endo-perio.pdf#page=46|L3 endo-perio, p.46]] [^47]: Original PDF page 47: [[L3 endo-perio.pdf#page=47|L3 endo-perio, p.47]]