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10 © Archives of Dental Sciences
Vol.3, Issue 1, Jan.-Mar., 2012
http:www.archdent.org

REVIEW

Endo-Perio Lesion: Part II (The Treatment) – A Review

Vishal Anand1, Vivek Govila2, Minkle Gulati3
1.Department of Periodontics, Faculty of Dental Sciences, Chhatrapati Shahuji Maharaj Medical University, Lucknow,
Uttar Pradesh. 2.Dept. of Periodontics, Babu Banarasi Das College of Dental Sciences, Babu Banarasi Das University,
Lucknow, Uttar Pradesh. 3.Department of Periodontics, Babu Banarasi Das College of Dental Sciences, Babu Banarasi
Das Campus, Akhilesh Das Nagar, Faizabad Road, Lucknow, Uttar Pradesh.

Treatment decision-making and prognosis depend primarily on the diagnosis of the

specific endodontic and/or periodontal disease. The main factors to consider are pulp
vitality and type and extent of the periodontal defect.

Key Words: Endodontology, periodontology, endo-perio lesion,.

Introduction for obtaining correct diagnosis and differentiating

The relationship between periodontal and pulpal
disease was first described by Simring and Goldberg
in 1964.1 Since the term ‘perio-endo lesion’ has been
used to describe lesions due to inflammatory products
found in varying degrees in both the periodontium
and the pulpal tissues.
The periodontal complex comprises alveolar bone,
periodontal ligament, root cementum and the
overlying linked with the periodontal tissues is he
dental pulp, which may communicate with the
periodontium via:2
Š The apical foramen
Š Dentine tubules
Š Lateral root canals
Š Furcation root canals
Š Fractures lines within the root
TREATMENT DECISION MAKING AND
PROGNOSIS
Treatment: Diagnosis
The most important factor in the treatment of
perio-endo lesions is a correct diagnosis. This is
achieved by careful history taking, examination and
the use of special tests.3 Specific things to look for in
the history include past disease, trauma and pain.
In clinical examination check the dental and
periodontal status. Sensibility and vitality testing
should be carried status. Clinical tests are imperative
Correspondence: Vishal Anand, Senior Resident, B 103,
Gautum Buddha Hostel, KGMC/ CSMMU Chowk, Lucknow,
Uttar Pradesh. Email: drvishalanand@hotmail.com.
between endodontic and periodontal disease. The
extraoral and intraoral tissues are examined for the
presence of any abnormality or disease. One test is
usually not sufficient to obtain a conclusive diagnosis.
A thorough visual examination of the lips, cheeks,
oral mucosa, tongue, palate and muscles should be
done routinely. The alveolar mucosa and attached
gingiva are examined for the presence of
inflammation, ulcerations or sinus tract. The teeth
are examined for abnormalities such as caries,
defective restorations, erosions, abrasions, cracks,
fractures and discoloration. A discoloured permanent
tooth may often be associated with a necrotic pulp.
Palpation is performed by applying firm digital
pressure to the mucosa covering the roots and apices.
With the index finger the mucosa is pressed against
the underlying cortical bone. However, this test does
not indicate whether the inflammatory process is of
endodontic or periodontal origin. Also as with any
other clinical test, the response should be compared
to control teeth. Percussion is performed by tapping
on the incisal or occlusal surfaces of the teeth either
with the finger or with a blunt instrument such as
the back end of a mirror handle. The tooth crown is
tapped vertically and horizontally. Although this test
does not disclose the condition of the pulp, it indicates
the presence of a periradicular inflammation. Mobility
testing can be performed using two mirror handles
on each side of the crown. Pressure is applied in a
facial-lingual direction as well as in a vertical
direction and the tooth mobility is scored. Tooth
mobility is directly proportional to the integrity of
the attachment apparatus or to the extent of
inflammation in the periodontal ligament,4 indicating
that the primary cause may be periodontal disease.

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Radiographs are essential for detection of anatomic
landmarks and a variety of pathological conditions.
In additions, radiographs are of utmost importance
for documentation and legal purposes. Radiograph
examination will aid in detection of carious lesions,
extensive or defective restoration, pulp caps,
pulpotomies, previous root canal treatment and
possible mishaps, stage of root formation, canal
obliteration, root resorption, root fracture,
periradicular radiolucencies, thickened periodontal
ligament and alveolar bone loss. The integrity of the
dental pulp cannot be determined by radiograph
images alone. Radiographic changes will only be
detected once the inflammation or bacterial byproducts
originating from the dental pulp cause sufficient
demineralization of the cortical bone.5,6 Sensibility
and pulp vitality testing like cold test, electric test,
blood flow test, cavity test7,8,9,10 should be carried out
on relevant teeth as well as radiographic examination
- paying close attention to shape, location and
extension of any lesion, crestal and furcation
involvement and signs of fracture or perforation.11
Surgical exposure may be necessary to confirm the
present of fracture.
These aids as well as an understanding of the
pathogenesis and a clear classification, such as the
one provided by Simon, Glick and Frank,13 will give
enough information to prevent inappropriate
treatment plans being instituted. It may well be
enough to provide a definitive diagnosis although can
be confirmed after treatment.
Treatment: Initial Consideration
Before the commencement of any kind of
advanced restorative work to treat a perio-endo lesion,
extraction of the tooth should be considered as an
alternative. The prognosis of the tooth should be
considered carefully. Consideration includes whether
there is a functional need for the tooth or if it is possible
to provide an adequate root filling (i.e. negotiable
canals are present). Other important considerations
are whether the tooth is restorable after the lesion
has been treated and patient suitability for lengthy,
costly, invasive treatment with a need for high patient
motivation. If any these factors are deemed negative
extraction is the treatment of choice.14
Diagnosis of primary endodontic disease and
primary periodontal disease usually present no
clinical difficulty. In primary endodontic disease the
pulp is infected and nonvital. In primary periodontal
Endo-Perio Lesion: Part II (The Treatment) – A Review 11
Vishal Anand, Vivek Govila, Minkle Gulati
disease the pulp is vital and responsive to testing.
However, primary endodontic disease with secondary
periodontal involvement, primary periodontal disease
with secondary endodontic involvement, or true
combined diseases are clinically and radiographically
very similar. If a lesion is diagnosed and treated as
primarily endodontic disease due to lack of evidence
of plaque-induced periodontitis, and there is soft-
tissue healing on clinical probing and bony healing
on a recall radiograph, a valid retrospective diagnosis
can then be made. The degree of healing that has
taken place following root canal treatment will
determine the retrospective classification. In the
absence of adequate healing, further periodontal
treatment is indicated. The prognosis and treatment
of each endodontic–periodontal disease type varies.
Primary endodontic disease should only be treated
by endodontic therapy and has a good prognosis.
Primary periodontal disease should only be treated
by periodontal therapy.2,15
Treatment: Endodontic Lesion
For primary endodontic lesions conventional
endodontic therapy alone will resolve the lesion. A
review of 4-6 months post-operatively should show
healing of the periodontal pocket and bony repair.14
Surgical endodontic therapy has been shown to be
unnecessary even in the presence of large
periradicular radiolucencies and periodontal
abscesses.16 Invasive periodontal procedures should
be avoided as this may cause further injury to the
attachment-possibly delaying healing.17
If primary endodontic lesions persist despite
extensive endodontic treatment it should arouse
suspicions of an incorrect diagnosis. The lesion may
have secondary periodontal involvement or be a true
combined lesion, the treatment for which is outlined
later.18 In this case, the prognosis depends on severity
of the periodontal disease and patient response.
Primary endodontic disease with secondary
periodontal involvement should first be treated with
endodontic therapy. Treatment results should be
evaluated in 2-3 months and only then should
periodontal treatment be considered. This sequence
of treatment allows sufficient time for initial tissue
healing and better assessment of the periodontal
condition.2,15 It also reduces the potential risk of
introducing bacteria and their by-products during the
initial healing phase. In this regard, it was suggested
that the periodontal healing was adversely affected
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12 Endo-Perio Lesion: Part II (The Treatment) – A Review
Vishal Anand, Vivek Govila, Minkle Gulati
by aggressive removal of the periodontal ligament
and underlying cementum during interim endodontic
therapy.19 Areas of the roots that were not aggressively
treated showed unremarkable healing.19
Primary endodontic lesions with secondary
periodontal involvement will not completely resolve
with endodontic treatment alone. Root/re-root canal
treatment is instituted immediately and the cleaned
and shaped root canal filled with calcium hydroxide
paste. As it is bactericidal, anti-inflammatory and
proteolytic, it inhibits resorption and favors repair.
It also inhibits periodontal contamination of
instrumented canals via patent channels connecting
the pulp and periodontium before periodontal
treatment removes the contamination. The canals
are eventually filled with a conventional obturation
when there is clinical evidence of improvement.17
Hygiene phase therapy should be initiated
immediately although deep scaling and periodontal
surgery to resolve the part of the lesion sustained by
periodontal disease should be postponed until the part
of the lesion sustained by pulpal infection has had
time to resolve and a conventional root-filler is in
place, again to prevent possible delays in healing.12
The prognosis for primary endodontic lesions is
good but worsens in the advanced stages of secondary
periodontal involvement. The prognosis then depends
on the effectiveness of periodontal treatment and with
advancement becomes comparable to that of a true-
combined lesion.18 Prognosis of primary endodontic
disease with secondary periodontal involvement
depends primarily on the severity of periodontal
involvement, periodontal treatment and patient
response.
Treatment: Periodontal Lesions
Primary periodontal lesions are treated by
hygiene phase therapy in the first instance.
Subsequently poor restorations and development
grooves that are involved in the lesion are removed
as these are difficult areas to treat successfully.
Periodontal surgery is performed after the completion
of hygiene phase therapy if deemed necessary.
It is important to bear in mind that pulpal
pathology may be induced while carrying out
periodontal therapy especially in lesions which involve
the furcation area. 18
Early stage periodontal lesions with secondary
endodontic involvement where involvement may be
limited to reversible pulpal hypersensitivity may be
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treated purely by periodontal therapy. Periodontal
treatment removes the noxious stimuli and secondary
mineralization of dentinal tubules allows the
resolution of pulpal hypersensitivity.16 If pulpal
inflammation is irreversible root/re-root treatment
is carried out followed by periodontal treatment - in
some cases surgical intervention is advantageous.14
The prognosis of periodontal lesions is poorer than
endodontic lesions and is dependent on the apical
extension of the lesion. As the lesion advances the
prognosis approaches that of true-combined lesion.18
The treatment of the periodontal lesion involves
appropriate instruction in oral hygiene, root surface
debridement and monitoring of the pulp vitality
during and after periodontal therapy. Even
periodontal lesions which appear to be close to the
apex should resolve with adequate periodontal
debridement, although with deeper defects a tissue
regeneration procedure may be indicated. Scaling and
root planing will often expose root dentine and dentine
tubules, into which periodontal bacteria can pass and
sequestrate.20 Most of the bacteria appear in the
outermost third of the root dentine20 and it is thus
unlikely that they would be able to cause significant
pulpal irritation, although reinfection of treated
periodontal pockets from such bacterial reservoirs is
thought to be a potential periodontal problem.2
Treatment: True-Combined Lesions
True-combined lesions are treated initially as
for primary endodontic lesion with secondary
periodontal involvement. Periodontal surgical
procedures are almost always called for. The prognosis
of a true-combined perio-endo lesion is often poor or
even hopeless, especially when periodontal lesions are
chronic with extensive loss of attachment.21 Root
amputation, hemisection or separation may allow the
root configuration to be changed sufficiently for part
of the root structure to be saved. Prior to surgery,
palliative periodontal therapy should be completed
and root canal treatment carried out on the roots to
be saved.16
The prognosis of an affected tooth can also be
improved by increasingly bone support which can be
achieved by bone grafting22 and guided tissue
regeneration.23 This is due to the most critical
determinant of prognosis being a loss of periodontal
support.18
These advanced treatment plans are based on
response to conventional periodontal and endodontic
treatment over an extended time period.22

Primary periodontal disease with secondary
endodontic involvement and true combined
endodontic-periodontal diseases require both
endodontic and periodontal therapies. It has been
demonstrated that intrapulpal infection tends to
promote epithelial downgrowth along a denuded
dentin surface.19
The prognosis of primary periodontal disease
with secondary endodontic involvement and true
combined diseases depends primarily upon the
severity of the periodontal disease and the response
to periodontal treatment. Cases of true combined
disease usually have a more guarded prognosis than
the other types of endodontic-periodontal problems.
In general, assuming the endodontic therapy is
adequate, what is of endodontic origin will heal. Thus
the prognosis of combined diseases rests with the
efficacy of periodontal therapy.24
In most cases the root canal therapy should be
performed before the periodontal treatment, because
periodontal lesions sometimes resolve following
successful endodontics but the reverse is rarely true.
Furthermore, performing periodontal treatment alone
in the presence of a true combined lesion may lead to
initial healing of the periodontal pocket, but it will
break down rapidly if the pulpal source of infection is
not removed. Indeed, if repeated debridement of a
localized periodontal pocket fails to remove
suppuration then pulpal necrosis should always be
suspected and investigated before embarking on
periodontal surgery.2 Vitality tests used to establish
pulpal viability are useful special investigations, but
results obtained should be interpreted with care and
in the light of all other clinical and radiographic
information available. The reason for this is that false
positive and false negative results frequently occur,
even when the most reliable or sophisticated devices
are used.2
The ideal therapeutic sequence for the true
combined lesion is:2
1. Root canal therapy;
2. Review after 2 to 3 months;
3. If lesion is not showing signs of resolving
(clinically and radiographically) perform
appropriate periodontal therapy;
4. Review 2 to 3 months after periodontal therapy
and re-evaluate radiographically.
Where bone loss is terminal around one root it
may be possible to perform a hemisection for
Endo-Perio Lesion: Part II (The Treatment) – A Review 13
Vishal Anand, Vivek Govila, Minkle Gulati
mandibular molars or a root amputation for
maxillary molars. If either of these procedures is to
be contemplated, endodontic therapy should ideally
be completed before the surgical resection. The root
that is to be removed may not necessarily require
endodontics, but the remaining canals should be
obturated and sealed at their most coronal aspect to
isolate them from the infected canal before
amputation or resection of the diseased root. In
emergency cases, it may be possible only to
temporarily fill the canals that are to remain with a
non-setting calcium hydroxide paste.2
Treatment: Iatrogenic Lesions
Iatrogenic lesions are also treated in the same
way as primary endodontic lesions. Although the first
priority is to close the iatrogenic communication –
the aim is to produce a seal.14 Root perforations are
treated according to their aetiology. Root resorption
perforation s cause complex problems due to their
size and location as do carious perforations.
Perforations during root canal instrumentation or
post hole preparation often need a surgical approach.
Methods of scaling include direct scaling, facilitated
through an access cavity, with a zinc oxide eugenol,
glass ionomer or mineral trioxide aggregate (MTA)
filling material. Smaller perforations following root
resorption and those in the apical third of the root
may be sealed as part of a conventional root filling. A
perforated canal be measured, cleaned, shaped and
filled using the same techniques as conventional root
canal treatment.18
Success depends on access to the apical portion
of the root canal to enable a seal to be placed. Palatal
perforations are difficult to manage, even surgically
and frequently lead to extraction. The successful
treatment of root perforations depends principally on
early detection and sealing. Although the prognosis
is deemed poor it appears that a successful outcome
can frequently be achieved.3
Lesions attributed to over-filling of root canals
an intra-canal medicaments can usually be resolved
by periradicular surgery, probably accompanied by a
retrograde root filling. Teeth with lesions caused by
vertical root fractures have a hopeless prognosis and
should be extracted.17
Local antiseptic and antibiotics
Periodontal and endodontic lesions can be treated
locally with antimicrobial agents used in
concentrations that will ensure strong microbicidal
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14 Endo-Perio Lesion: Part II (The Treatment) – A Review
Vishal Anand, Vivek Govila, Minkle Gulati
activity.25,26,27 Root canal treatment has an apparent
advantage, because antimicrobial agents can be
applied in the canal for prolonged periods of time. On
the other hand, antimicrobial agents in the root canal
exert little or no effect periapically.25 In the acute
phase, placement in a vehicle of local antimicrobial
agents is not recommended because of potential
interference with drainage. Periodontal abscesses can
be successfully treated by a combination of drainage
and systemic antibiotics.28
Herrera et al. found a similar response using
either azithromycin or amoxicillin and clavulanic
acid. In the periodontal-endodontic lesions, the value
of local antimicrobial agents has not been studied.
However, it is recommended that the acute
periodontal-endodontic lesion be drained and
irrigated.29
Systemic antibiotics
Systemic antibiotic treatment of dental
abscesses aims at preventing bacterial spreading and
serious complications. The concentration of antibiotics
in the abscess is considerably lower than that in blood,
and because of poor blood supply the concentration
peaks later in the abscess than in blood. In addition
to antibiotics, a dental abscess should always receive
surgical and mechanical therapy.30,31
Antimicrobial treatment is of secondary
importance to surgical incision and drainage of
abscesses.32 Antimicrobial agents are indicated when
the patient shows signs of fever and general
discomfort, indicating that the infectious process is
at risk of spreading. Antimicrobial treatment in
immunocompromised patients is especially
important and should be considered for all
dentoalveolar abscesses.32 The choice of antibiotics
should be based on sound pharmacological and
microbiological principles and include the following
three situations: 33
Š The emergency case. Penicillin is still considered
to be the primary choice of antibiotics. Since
resistance to penicillin is increasing,
metronidazole or amoxicillin/clavulanic acid may
serve as alternative antibiotics. In case of
penicillin allergy, metronidazole is the drug of
choice.
Š The failing case in which a microbiological
diagnosis has been made. Change of drug
regimen should be based on the clinical
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situation, the microbiological profile and
antibiotic susceptibility testing.
Š The failing case in which no microbiological
diagnosis has been made. Change of antibiotic
to one with a broader spectrum is recommended.
Amoxicillin/clavulanic acid or clindamycin are
alternative antibiotics. Clindamycin is
recommended in penicillin allergy cases.
The duration of antibiotic therapy has become
steadily shorter over the years. Seven to 10 days of
antibiotics is no longer recommended. Most dentists
prescribe 5 days of penicillin or 3 days of metronidazole
for acute orofacial infections.34,35
Absence of a definitive diagnosis
When a clinician cannot make a definitive
diagnosis, it may be prudent for him or her to initiate
endodontic therapy and hope for repair. After complete
instrumentation, calcium hydroxide should be used
as an intracanal medicament. It is an excellent
medicament in general, because it is bactericidal, anti-
inflammatory and proteolytic; it inhibits resorption;
and it favors repair.36 It is especially effective in endo-
perio cases because its temporary obturating action
will inhibit periodontal contamination of the
instrumented canals via patent channels of
communication. When the etiology is purely
endodontic, this regimen usually will resolve the
pseudopocket within a few weeks. 17
The prevalence of accessory canals in the floor
of multirooted teeth commonly produces furcal lesions
in teeth with necrotic pulps37,38 commonly produces
furcal lesions in teeth with necrotic pulps. Endodontic
therapy resulted in dramatic closure of the pocket
within two weeks. Because lesions of endodontic origin
usually are reversible with endodontic treatment
alone, the temptation to perform invasive periodontal
procedures should be resisted; such procedures might
cause further injury to the attachment and possibly
delay healing.17
When marginal lesions fail to respond to
endodontic treatment, additional instrumentation and
continuation of calcium hydroxide therapy may be
necessary. Clinical judgment should determine the
duration of such treatment. If endodontic lesions
persist despite exhaustive endodontic treatment, it
may be that the diagnosis was incorrect, there is a
true combined lesion or there is periodontal
involvement secondary to the endodontic lesion. This

involvement may occur when the prolonged loss of
the sulcular attachment promotes secondary invasion
of plaque and calculus. In such cases, either
periodontal therapy or extraction would be indicated.
Summary
The localization of the abscess and the possibility
of obtaining drainage are essential consideration for
successful treatment. Antibiotics should be prescribed
in case of general symptoms or if complications can
be suspected. A perio-endo lesion can have a varied
pathogenesis which ranges from quite simple to
relatively complex. The knowledge of these disease
processes is essential in coming to correct diagnosis.
This enables the construction of a suitable treatment
plan where unnecessary, prolonged or even
detrimental treatment is avoided.
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