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2. INDIAN DENTAL ACADEMY
Leader in continuing dental education
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www.indiandentalacademy.com

3. CONTENTS
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INTRODUCTION
DEFINITION
CLASSIFICATION
ETIOLOGY
CONTROVERSIES REGARDING THE COMBINED LESION
PATHWAYS OF SPREAD
COMPARISION OF CLINICAL PRESENTATION B/W APICAL &
MARGINAL PERIODONTITIS
DIFFERENTIAL DIAGNOSIS
EFFECT OF PULP & ITS TREATMENT ON PERIODONTIUM
EFFECT OF PERIO. DISEASE & TREATMENT ON PULP
PERIODONTAL EVALUATION
LESIONS
DIAGNOSIS
TREATMENT
REFERENCES
CONCLUSION
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4. DEFINITION
•An isolated, usually narrow, deep probing depth of
pulpal or periodontal origin.
•Lesion with sub marginal or intrabony periradicular
bone loss of pulpal and/or periodontal origin that
communicates with the oral cavity via probing defect.
•A localized periodontal probing depth of pulpal or
periodontal origin.
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STOCK

5. COHEN
•
Primary endodontic lesion
•
Primary endodontic lesion with secondary periodontal
involvement
•
Primary periodontal lesion
•
Primary periodontal lesion with secondary endodontic
involvement
•
True combined lesion
•
Concomitant pulpal & periodontal lesion
DIA PG 654
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6. WEINE

Tooth in which symptoms clinically and radiographically
simulate periodontal disease but are due to pulpal inflammation

Tooth that has both pulpal and periodontal disease
concomitantly
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Tooth has no pulpal problem but require endodontic therapy
plus root amputation to gain periodontal healing

Tooth that clinically and radiographically simulated pulpal or
periapical disease but infact has periodontal disease
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7. LESIONS REQUIRING ENDODONTIC TREATMENT ONLY
 necrotic pulp and apical granulomatous tissue replacing
periodontium with or without sinous tract
 Chronic periapical abscess with sinus tract
 Longitudinal and horizontal root fractures
 Pathologic and iatrogenic root perforations
 Teeth with incomplete apical root development
 Endodontic implants
 Teeth that require hemisection
 Root submergence
GROSSMAN
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8. LESIONS REQUIRING PERIODONTAL TREATMENT ONLY
 Occlusal trauma causing reversible pulpitis
 Occlusal trauma plus gingival inflammation resulting in pocket
formation and reversible pulpitis
 Suprabony or infrabony pocket formation treated with overzealous
root planning and curettage leading to pulpal sensitivity
 Extensive infrabony pocket formation extending beyond the root
apex and sometimes coupled with lateral or apical resorption yet
with pulp that responds with in normal limits to clinical testing
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9. LESIONS REQUIRING COMBINED ENDO – PERIO TREATMENT
 Any lesion in Group I That results in irreversible reactions in the
attachment apparatus and requires periodontal treatment
 Any lesion in Group II that results in irreversible reactions to the
pulp tissue and also requires endodontic treatment
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10. ATYPICAL ANATOMIC FACTORS
Malaligned tooth
Multirooted teeth / additional root
Additional canal
Cervical enamel projection
Large lateral / accessory canal
TRAUMA
With gingival inflammation
Tooth fracture
Pulp / perio involvement + sinus tract
Cellular changes - resorption
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11. MISCELLANEOUS
Iatrogenic
systemic
SINUS TRACT
INFRABONY POCKET
•From canal
•From gingival crevice
•Narrow
•wide
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12. CONTROVERSIAL ASPECT CONCERNING THE COMBINED
LESION
 PULPAL
 PERIODONTAL
Chacker
Massler
Czarnecki & Schilder
PERIODONTAL
PULPAL ?
Venous blood flow outward
Drawback
Lateral / accesory canal - flow bothways
Seltzer & bender
Stahl
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13. Physiologic :
• Apical foramen
• Lateral canals
• Dentinal tubules
• Periodontal ligament
• Alveolar bone
• Neural pathways
• Vasculolymphatic pathway
Iatrogenic :
• Palatogingival grooves
• Cementum defect
• Vertical root fractures
• Perforations
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14. COMPARISION
MARGINAL
PERIODONTITIS
APICAL
PERIODONTITIS
Cervical
Apex
Plaque
Pulpal inflammation
Horizontal / Vertical bone loss - Seldom bone loss – localized
generalized
& deep
Open
Contained
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15. Attachment loss asso. with
 Anatomic defect on root
 Nature of pathogenic flora
 Necrotic & infected pulp
 Host defense mechanism defect.
Aggresiveness asso with
 Lateral & apical foramen
 Nature of flora
 Apical host defense
Periodontal probing &
radiographic examination
Radiographic examination
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16. DIFFERENTIAL DIAGNOSIS
PULPAL
PERIODONTAL
Cause
pulp infection
periodontal
Vitality
non vital
vital
Restorative
deep or extensive
not related
Plaque /calculus
not related
primary cause
Inflammation
acute
chronic
Pockets
single and narrow
multiple and wide
pH value
acidic
alkaline
Trauma
primary or secondary
contributing factor
Microbial
few
CLINICAL
coronally
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complex

17. RADIOGRAPHIC
Pattern
Bone loss
Periapical
Vertical bone loss:
localized
wider apically
radiolucent
no
generalized
wider coronally
not related
yes
HISTOPATHOLOGY
Junctional epithelium
Granulation tissues
Gingival
no apical migration
apical (minimal)
normal
present
coronal (larger)
recession
TREATMENT
Therapy
RCT
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Periodontal therapy

18. Problems in
diagnosis :
Vertical root fracture:
varied radiographic picture
Different angulations
Surgical exposure
lateral condensation excessive
Post placement
Cause
Extensive restorations
Older patients
Gingival sulcus & pocket area
Single rooted teeth
multirooted teeth
Developmental grooves
In doubt ? – Biopsy / Histological analysis
Systemic diseases mimic lesion on radiograph :
Scleroderma
Metastatic carcinoma
Osteosarcoma
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19. EFFECT OF PULP AND ITS TREATMENT ON PERIODONTIUM
Periodontal inflammation & bone loss
Sub marginal bone loss
Horizontal bone loss
Vertical intrabony pockets
Furcation involvement
Periodontal wound healing
Traumatized necrotic pulp
RC infection – compromised healing
Gingival tissue thickness
Alveolar bone level
Surgical trauma to flap
Effective flap repositioning
Root canal treatment
Doubtful pulpal status
Iatrogenic problems
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20. EFFECT OF PERIODONTAL DISEASE & ITS TREATMENT ON PULP
Periodontal disease & pulp
•Limited
•Channels closed + dystrophic calcification- chronic
•Sufficient viurlence – pulpal disease
•Poor prognosis
•Extraction / Root resection
Periodontal treatment & pulp
•Scaling & root planing – excessive cementum removal
•Compromised pulp
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21. Thank you
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Leader in continuing dental education
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