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ABSTRACT
The interrelationship between endodontic and periodontal diseases has been a subject of speculation, confusion and controversy
for many years. Pulpal and periodontal problems are responsible for more than 50% of tooth mortality today. An endoperio
lesion can have a varied pathogenesis which ranges from quite simple to relatively complex one. These lesions often present
challenges to the clinician as far as diagnosis and prognosis of the involved teeth are concerned. It is very essential to make a
correct diagnosis so that the appropriate treatment can be provided. To make a correct diagnosis the clinician should have a
thorough understanding and scientific knowledge of these lesions and may need to perform restorative, endoontic or periodontal
therapy, either singly or in combination to treat them. Therefore, this presentation will highlight the diagnostic, clinical guidelines
and decisionmaking in the treatment of these lesions from an Endodontists point of view to achieve the best outcome.
INTRODUCTION
he pulpperiodontal interrelationship is a
unique one and can consider them as a
single continuous system or as one biologic unit in
which there are so many paths of communication.
The interrelationship of these structures influences
each other during health, function and disease.
They can get affected individually or combined;
when both systems are involved they are called true
endoperio lesions. Endodonticperiodontal problems
are responsible for more than 50% of tooth mortality
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DOI:
10.4103/2229-5194.120514
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CLASSIFICATION OF
PERIODONTALENDODONTIC LESIONS
The first classification of endodonticperiodontal lesions
based on pathology of origin was proposed by Simon
etal.[18] as follows:
Primary endodontic lesions
Primary periodontal lesions
Primary endodontic lesions with secondary periodontal
involvement
Primary periodontal lesions with secondary endodontic
involvement
True combined lesions.
Though Simon etal. have classified these lesions into
five types but actually three, four and five can be
considered as combined lesions. There have been many
classifications suggested by several other authors such
as independent periodontal and endodontic lesions[19]
or concomitant pulpal and periodontal lesions[20,21] to
describe endoperio lesions. In contrast to combined
perioendo lesions, concomitant pulpal and periodontal
lesions reflect the presence of two separate and distinct
disease states with different causative factors and with
no clinical evidence that one disease state has influenced
4
DIAGNOSIS
Nomenclature distinguishes between lesions caused by
periodontal pathogens, as seen in chronic periodontitis,
and lesions of the apical periodontal tissues associated with
endodontic pathology. When the location is distinct and the
lesion is discrete, the two are easy to differentiate. When
they simultaneously affect the marginal and apical areas of
the periodontium, thus making it essential to ascertain their
true cause through differential diagnosis.[25] If a patient has
been monitored over a period of time diagnosis of primary
endodontic disease and primary periodontal disease
usually can be easily done; once the lesions progress
to their final stage, they usually give similar clinical and
radiographic appearance and the differential diagnosis
becomes more challenging. For example, a similar in
clinical and radiographic features will be seen with both, a
growing periapical lesion with secondary involvement of
periodontal tissues and a longstanding periodontal lesion
that has progressed to the apex.
It is easier to determine the origin of the lesion when a
pulp vitality test is positive because this will rule out an
endodontic etiology. However, pulp tests may not be
always reliable. This consideration is particularly relevant
when challenges to pulpal status arise from periodontal
diseases such as partial necrosis of a pulp in a multirooted
tooth due to long standing periodontal lesions. If pulpal
necrosis is associated with inflammatory involvement of
the periodontal tissue, it presents a greater diagnostic
problem. In this situation, the location of these pulpal
lesions is most often at the apex of the tooth, but they may
also occur at any site where lateral and furcal canals exit
into the periodontium.[26] Therefore, accurate diagnosis can
be made by careful history taking, thorough oral hard and
Journal of Interdisciplinary Dentistry / Jan-Apr 2013 / Vol-3 / Issue-1
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Primary periodontal
lesion
Primary endodontic
secondary periodontal
Primary periodontal
secondary
endodontic
Presence of plaque,
subgingival calculus
and swelling around
multiple teeth
Presence of pus,
exudate
Presence of
localized/
generalized gingival
recession and
exposure of root
Usually dull ache
Sharp only in acute
periodontal abscess
Pain on palpation
True combined
lesionorconcomitant pulpal
and periodontal lesions
Plaque, calculus and
periodontitis will be
present in varying degrees
Swelling around single or
multiple teeth
Presence of pus, exudate
Visual(magnifying loupes
and operative microscope
can be effective)
Inflamed gingiva/gingival
recession around multiple
teeth
Accumulation of plaque
and subgibgival calculus
around multiple teeth
Intact teeth
Presence of swelling
indicating periodontal
abscess
Pain
Sharp
Palpation(a positive
response to palpation may
indicate active periradicular
inflammatory process)
Percussion(it indicates the
presence of a periradicular
inflammation that may be
either from pulpal or PDL
origin)
Mobility(tooth mobility is
directly proportional to the
integrity of the attachment
apparatus or to the extent
of inflammation in the PDL
ligament)
Pulp vitality using cold test,
electric test, blood flow
tests, and cavity test(an
abnormal response may
indicate degenerative
changes in the pulp)
Pocket probing
Tender on percussion
Tender on
percussion
Tender on percussion
Localized mobility
Presence of
solitary wide
pocket[Figure2ad]
but if periodontal
lesion is due to
fracture of root then
solitary deep narrow
pocket(mainly
localized)
Presence of multiple
wide and deep
periodontal pockets
Radiographs
Presence of deep
carious lesions/
extensive or defective
restorations/previous
poor root canal
treatment/diminution
of the pulp canal space/
possible mishaps/root
fractures[Figure3a and
b]/root resorption with a
wide base radiolucency
around the apex of the
root[Figure4ae]
No symptoms
A lingering
responseirreversible pulpitis
No responsenecrotic
pulp(nonvital)
No symptoms
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b
Figure3: Primary endodontic secondary periodontal lesion. (a) Intraoral
periapical radiograph showing root canal treated maxillary left first
premolar with radiolucency along the root. Clinically, a deep narrow
pocket was found on the mesial aspect of the root suggesting the
presence of vertical root fracture.(b) Clinical view of the extracted tooth
showing two fractured fragments of the tooth
7
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Figure4: Patient complained of pus discharge from gums in between central incisors. Patient gave a history mild impact trauma on mandibular
anterior 10years ago.(a) Clinical picture showing the presence of sinus opening in between central incisors.(b) Radiograph of mandibular
anterior teeth showing the presence of large radiolucency in between central incisors with a wide base at the apex suggesting primary endodontic
lesion(both centrals did not respond to vitality tests).(c) Radiograph showing initiation of root canal therapy and placement of calcium hydroxide
as an intracanal medicament.(d) Radiograph showing completion of root canal treatment.(e) Radiograph showing healing after 1year
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CONCLUSION
A perioendo lesion can have a varied pathogenesis which
ranges from quite simple to relatively complex one. To
make a correct diagnosis the clinician should have a
thorough understanding and scientific knowledge of these
lesions. Despite the segmentation of dentistry into the
various areas of specialization, a clinician needs to perform
restorative, endodontic or periodontal therapy, either
singly or in combination. Therefore, to achieve the best
outcome for these lesions, a multidisciplinary approach
should be involved.
REFERENCES
1. Simring M, Goldberg M. The pulpal pocket approach: Retrograde
periodontitis. JPeriodontol 1964;35:2248.
2. Mjr IA, Nordahl I. The density and branching of dentinal tubules
in human teeth. Arch Oral Biol 1996;41:40112.
3. Zehnder M, Gold SI, Hasselgren G. Pathologic interactions in pulpal
and periodontal tissues. JClin Periodontol 2002;29:66371.
4. Sunitha VR, Emmadi P, Namasivayam A, Thyegarajan R, Rajaraman
V. The periodontalendodontic continuum: Areview. JConserv Dent
2008;11:5462.
5. Rotstein I, Simon JH. Diagnosis, prognosis and decisionmaking
in the treatment of combined periodontalendodontic lesions.
Periodontol 20002004;34:165203.
6. Jaoui L, Machtou P, Ouhayoun JP. Longterm evaluation of
endodontic and periodontal treatment. Int Endod J 1995;28:24954.
7. Torabinejad M, Kiger RD. Ahistologic evaluation of dental pulp
tissue of a patient with periodontal disease. Oral Surg Oral Med
Oral Pathol 1985;59:198200.
9
[Downloaded free from http://www.jidonline.com on Monday, January 18, 2016, IP: 5.14.30.141]
JEndod 2003;29:5656.
33. Evanov C, Liewehr F, Buxton TB, Joyce AP. Antibacterial efficacy of
calcium hydroxide and chlorhexidine gluconate irrigants at 37C
and 46C. JEndod 2004;30:6537.
34. Khan AA, Sun X, Hargreaves KM. Effect of calcium hydroxide
on proinflammatory cytokines and neuropeptides. JEndod
2008;34:13603.
35. Mhairi RW. The pathogenesis and treatment of endoperio lesions.
CPD Dent 2001;2:77104.
36. Carrotte P. Endodontics: Part9. Calcium hydroxide, root resorption,
endoperio lesions. Br Dent J 2004;197:73543.
37. Paul BF, Hutter JW. The endodonticperiodontal continuum revisited:
New insights into etiology, diagnosis and treatment. JAm Dent
Assoc 1997;128:15418.
38. Chapple IL, Lumley PJ. The periodontalendodontic interface. Dent
Update 1999;26:3316, 338, 340.
39. Blomlf L, Lindskog S, Hammarstrm L. Influence of pulpal
treatments on cell and tissue reactions in the marginal periodontium.
JPeriodontol 1988;59:57783.
40. Parir okh M, Torabinejad M. Mineral trioxide aggr egate:
Acomprehensive literature reviewPart III: Clinical applications,
drawbacks, and mechanism of action. JEndod 2010;36:40013.
41. Tsatsas DV, Meliou HA, Kerezoudis NP. Sealing effectiveness
of materials used in furcation perforation invitro. Int Dent J
2005;55:13341.
42. Weldon JK Jr, Pashley DH, Loushine RJ, Weller RN, Kimbrough WF.
Sealing ability of mineral trioxide aggregate and superEBA when
used as furcation repair materials: Alongitudinal study. JEndod
2002;28:46770.
43. Solomon C, Chalfin H, Kellert M, Weseley P. The endodonticperiodontal
lesion: Arational approach to treatment. JAm Dent Assoc
1995;126:4739.
44. Moule AJ, Kahler B. Diagnosis and management of teeth with vertical
root fractures. Aust Dent J 1999;44:7587.
45. Tamse A, Fuss Z, Lustig J, Kaplavi J. An evaluation of endodontically
treated vertically fractured teeth. JEndod 1999;25:5068.
46. Unver S, Onay EO, Ungor M. Intentional replantation of a vertically
fractured tooth repaired with an adhesive resin. Int Endod J
2011;44:106978.
47. zer SY, nl G, Deer Y. Diagnosis and treatment of endodontically
treated teeth with vertical root fracture: Three case reports with
twoyear followup. JEndod 2011;37:97102.
48. Hanada T, Quevedo CG, Okitsu M, Yoshioka T, Iwasaki N,
Takahashi H, etal. Effects of new adhesive resin root canal filling
materials on vertical root fractures. Aust Endod J 2010;36:1923.
49. Oh SL, Fouad AF, Park SH. Treatment strategy for guided tissue
regeneration in combined endodonticperiodontal lesions: Case
report and review. JEndod 2009;35:13316.
50. Kim E, Song JS, Jung IY, Lee SJ, Kim S. Prospective clinical
study evaluating endodontic microsurgery outcomes for cases
with lesions of endodontic origin compared with cases with
lesions of combined periodontalendodontic origin. JEndod
2008;34:54651.
51. Nyman S, Gottlow J, Karring T, Lindhe J. The regenerative potential
of the periodontal ligament: An experimental study in the monkey.
JClin Periodontol 1982;9:25765.
52. Nyman S, Lindhe J, Karring T, Rylander H. New attachment following
surgical treatment of human periodontal disease. JClin Periodontol
1982;9:2906.
53. Taschieri S, Del Fabbro M, Testori T, Saita M, Weinstein R.
Efficacy of guided tissue regeneration in the management of
throughandthrough lesions following surgical endodontics:
Apr eliminary study. Int J Periodontics Restorative Dent
2008;28:26571.
54. Britain SK, Arx TV, Schenk RK, Buser D, Nummikoski P, Cochran
DL. The use of guided tissue regeneration principles in endodontic
Journal of Interdisciplinary Dentistry / Jan-Apr 2013 / Vol-3 / Issue-1
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