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 Table of Contents  
Year : 2018  |  Volume : 8  |  Issue : 2  |  Page : 128-131

Endo-perio lesions: A diagnostic dilemma

Department of Conservative Dentistry and Endodontics, Dayananda Sagar College of Dental Sciences, Bengaluru, Karnataka, India

Date of Web Publication31-Dec-2018

Correspondence Address:
Dr. Mohd Sibghatullah Khatib
Dayananda Sagar College of Dental Sciences, Bengaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijmd.ijmd_35_18

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Endodontic and dentistry surgical procedure has surpassed the success rates for ancient dental medicine and dentistry surgical procedures. Achieving primary closure with the grafts contains a positive result on guided tissue regeneration (GTR) outcome. New techniques of dentistry microsurgery, such as minimally invasive papilla conserving flaps with passive internal pad stitching, have managed to obtain 90% primary flap closure over grafted sites. Root surface treatment and acquisition has conjointly shown to be helpful for GTR. The present case report describes a case of the localized primary periodontal lesion with secondary endodontic involvement in a mandibular first molar. The case was managed by root canal therapy followed by a periodontal regenerative procedure using GTR technique. Two years follow-up without replacement of the tooth with crown showed healing of the lesion with a minor defect in the restoration which was replaced by tooth-colored restoration.

Keywords: Diagnosis; endo-perio lesions; periodontal; pulpal

How to cite this article:
Khatib MS, Devarasanahalli SV, Nadig RR. Endo-perio lesions: A diagnostic dilemma. Indian J Multidiscip Dent 2018;8:128-31

How to cite this URL:
Khatib MS, Devarasanahalli SV, Nadig RR. Endo-perio lesions: A diagnostic dilemma. Indian J Multidiscip Dent [serial online] 2018 [cited 2021 Jun 22];8:128-31. Available from: https://www.ijmdent.com/text.asp?2018/8/2/128/249122

  Introduction Top

The relationship between the pulp and also the periodontium has been extensively studied; however, queries relating to the diagnosis, prognosis, and treatment are raised time and once more. The pathways for unfold of microorganism between pulpal and periodontal tissues are mentioned with contestation. Each dental disease is caused by a mixed anaerobic infection.[1],[2],[3]

Simring and Goldberg in 1964 first described the relationship between periodontium and root canal. The endodontic–periodontal lesion leads to involvement of pulp and periodontal diseases in the same tooth, which makes it difficult to diagnose and treat.[4],[5] Endo-perio lesions have been classified by many authors in the literature; the most conventional and followed classification is given by Simon et al. into following groups: primary endodontic lesion, primary endodontic lesion with secondary periodontal involvement, primary periodontal lesion, primary periodontal lesion with secondary endodontic involvement, and true combined lesions.

Treatment of endodontic–periodontal lesions requires both endodontic therapy and periodontal regenerative procedures. This article presents a case report of a primary periodontal lesion with secondary endodontic involvement in the lower molar. It was first treated by conventional endodontic treatment followed by periodontal regenerative procedure using guided tissue regeneration (GTR) and bone graft with 2 years of follow-up.

  Case Report Top

A 35-year-old male patient visited the department of conservative and endodontics, with a chief complaint of pain in his lower right back tooth region for 1 month. He gave a history of pain, which was localized, continuous, and increased on mastication and lying down. On clinical examination, 46 was Grade II mobility with draining pus through gingival sulcus. Probing pocket depth of 5, 4, 10, and 4 mm was recorded, respectively, on mesial, buccal, distal, and lingual aspects of the mandibular first molar [Figure 1] and [Figure 2]. Tooth was noncarious, but it did not respond to vitality test with thermal or electric pulp tester. Intraoperative periapical radiograph (IOPAR) showed a deep bony defect on the mesial aspect of tooth 46 extending till root apex. Based on clinical and radiographic examination, a diagnosis of periodontal lesion with secondary endodontic involvement was made for tooth 46 [Figure 3].
Figure 1: Preoperative

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Figure 2: Probing depth

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Figure 3: Preoperative periapical radiograph

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On first appointment, full-mouth scaling was done followed by root canal procedure in relation to 46. Two percent local anesthesia with 1:80,000 adrenalines was administered, and access opening was done under rubber dam. Cleaning and shaping and obturated was done using ProTaper file and GP (size F2) with standardizing procedure [Figure 4]. Re-evaluation of the patient after 1 week showed decrease in swelling. This was followed by periodontal flap surgery for tooth 46. After administration of 2% local anesthesia with 1:200,000 adrenaline, a vertical incision was given and full-thickness mucoperiosteal flap was raised [Figure 5]. Granulation tissue was removed and thorough root planning was done with Hu-Friedy Gracey curettes; hydroxyapatite crystals (Sybograft) were placed in the bone defect and root dehiscence was covered by resorbable collagen membrane (Periocol). Flap was sutured with 3-0 silk sutures and Coe-Pack was placed. Postoperative instruction with medication was given. After 3 months, it was observed that mobility of tooth was reduced from Grade II to Grade I. At 2 years, IOPAR showed good bone formation. Probing pocket depth was reduced to 8, 4, 3, and 4 mm, respectively, on distal, buccal, mesial, and lingual side and fractured of the postendo-restoration [Figure 6] and [Figure 7]. The fractured restoration restored with tooth-colored material [Figure 8].
Figure 4: Postoperative periapical radiograph

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Figure 5: Full-thickness flap raised

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Figure 6: Two years follow-up Radiographically

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Figure 7: Two years follow-up Clinically

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Figure 8: Composite buildup

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  Discussion Top

Inflammatory inter-communication between pulpal and periodontal lesions leads to endo-perio lesion. They are difficult to diagnose and treat because a single lesion may present signs of both endodontic and periodontal involvement.[5]

In the present case, there was no carious lesion in tooth number 46; however, tooth was associated with deep periodontal pockets and tooth was nonvital. Radiographic examination showed advanced periodontal bone loss in relation to 46. These findings were suggestive of periodontal lesion with secondary endodontic involvement according to Simon's Classification. Three main pathways have been implicated in the development of periodontal–endodontic lesions: apical foramen, lateral and accessory canals, and dentinal tubules.[6] The main cause of the periodontal lesions is the presence of bacterial plaque formed by aerobic and anaerobic microorganisms.

Various theories have been suggested in the literature regarding spread of infection from periodontium to pulp.[7] Rubach and Mitchell also suggested the possible role of accessory canals in the pathways of periodontal lesion with secondary endodontic involvement.[8] However, Adriaens et al. demonstrated that dentinal tubules act as a main reservoir for microorganisms.[9]

In the present case also, a possible source of necrosis of pulp in the absence of carious lesion could be ingress of periopathogens from periodontal pocket into pulp via lateral or accessory canals. Treatment of combined endodontic periodontal lesion requires a root canal treatment for healing endodontic component followed by periodontal regeneration. In this case also, similar treatment plan was followed.

GTR therapeutic protocol involves surgical placement of cell occlusive membrane facing the bone surface to physiologically seal off the site and create secluded space.[10] Nonresorbable barrier membrane was used since the start of the concept. However, due to need for second surgical intervention and increased chance of exposure, there has been a preference for biodegradable membrane for GTR procedure.[11]

In the present case, we have used bioresorbable collagen membrane. These membranes have several desirable properties such as cell adhesion, chemotactic properties, and adhesive properties for a regenerative procedure.[12],[13]

The longevity of the posterior teeth with root canal treatment with cuspal coverage seems to be higher; Mannocci et al. evaluated endodontically treated premolars that had been restored (both with and without complete coverage) by either a post or direct composite resin restorations and reported similar success rates for both.[14]

  Conclusion Top

The treatment of the endo perio lesion differ individually but should be judged based on progression of the lesion. There is a need for more such studies in this area and for subclassifying the combined lesion in terms of factors such as crown-root ratio, width of defect crestally, root housing in bone, and mobility to enable comparability of results.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Setzer FC, Shah SB, Kohli MR, Karabucak B, Kim S. Outcome of endodontic surgery: A meta-analysis of the literature – Part 1: Comparison of traditional root-end surgery and endodontic microsurgery. J Endod 2010;36:1757-65.  Back to cited text no. 1
Tsesis I, Faivishevsky V, Kfir A, Rosen E. Outcome of surgical endodontic treatment performed by a modern technique: A meta-analysis of literature. J Endod 2009;35:1505-11.  Back to cited text no. 2
Saunders WP. A prospective clinical study of periradicular surgery using mineral trioxide aggregate as a root-end filling. J Endod 2008;34:660-5.  Back to cited text no. 3
Simring M, Goldberg M. The pulpal pocket approach: Retrograde periodontitis. J Periodontol 1964;35:22-48.  Back to cited text no. 4
Langeland K, Rodrigues H, Dowden W. Periodontal disease, bacteria, and pulpal histopathology. Oral Surg Oral Med Oral Pathol 1974;37:257-70.  Back to cited text no. 5
Simon JH, Glick DH, Frank AL. The relationship of endodontic-periodontic lesions. J Periodontol 1972;43:202-8.  Back to cited text no. 6
Lindhe J, Socransky SS, Nyman S, Haffajee A, Westfelt E. “Critical probing depths” in periodontal therapy. J Clin Periodontol 1982;9:323-36.  Back to cited text no. 7
Rubach WC, Mitchell DF. Periodontal disease, accessory canals and pulp pathosis. J Periodontol 1965;36:34-8.  Back to cited text no. 8
Adriaens PA, De Boever JA, Loesche WJ. Bacterial invasion in root cementum and radicular dentin of periodontally diseased teeth in humans. A reservoir of periodontopathic bacteria. J Periodontol 1988;59:222-30.  Back to cited text no. 9
Polimeni G, Koo KT, Qahash M, Xiropaidis AV, Albandar JM, Wikesjö UM, et al. Prognostic factors for alveolar regeneration: Effect of a space-providing biomaterial on guided tissue regeneration. J Clin Periodontol 2004;31:725-9.  Back to cited text no. 10
Aaboe M, Pinholt EM, Hjørting-Hansen E. Healing of experimentally created defects: A review. Br J Oral Maxillofac Surg 1995;33:312-8.  Back to cited text no. 11
Proussaefs P, Lozada J. The use of resorbable collagen membrane in conjunction with autogenous bone graft and inorganic bovine mineral for buccal/labial alveolar ridge augmentation: A pilot study. J Prosthet Dent 2003;90:530-8.  Back to cited text no. 12
Strietzel FP, Reichart PA, Graf HL. Lateral alveolar ridge augmentation using a synthetic nano-crystalline hydroxyapatite bone substitution material (Ostim): Preliminary clinical and histological results. Clin Oral Implants Res 2007;18:743-51.  Back to cited text no. 13
Mannocci F, Bertelli E, Sherriff M, Watson TF, Ford TR. Three-year clinical comparison of survival of endodontically treated teeth restored with either full cast coverage or with direct composite restoration. J Prosthet Dent 2002;88:297-301.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]


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