A detailed description about endo perio interrelationship, including introduction, development and etiology, historical aspects, definition, classification, diagnosis, differential diagnosis, management, special consideration in management,controversies prognosis, conclusion.

1. ENDO
PERIO
RELATIONSHIP

2. DEEPA JINAN
BAPUJI DENTAL
COLLEGE & HOSPITAL

3. CONTENTS
• Introduction
• History
• Definition of Endo-perio lesion
• Pathways connecting endodontic & periodontal tissues
• Effect of pulpal disease & endodontic procedures on
periodontium
• Effect of periodontal disease & procedures on pulp
• Classifications of endo - perio problems
• Clinical diagnosis
• Probing patterns & radiographic appearance of clinical
situations that can be identified

4. CONTENTS
• Endodontic periodontic decision tree
• Case presentations & differential diagnosis
• Management of endo perio lesions
• Prognosis of endo perio lesions
• Discussion of Clinical considerations
• Conclusion
• References

5. INTRODUCTION
PeriodontiumPulp
EMBRYONIC ANATOMIC FUNCTIONAL
Confusion & controversy
Pathways of
spread of disease
Diagnosis, prognosis,
treatment
Simon JH, Glick DH, Frank AL. The Relationship of Endodontic–Periodontic Lesions. J Endod. 2013 May;39(5):e41-6.
1

6. INTRODUCTION
PeriodontiumPulp
Embryonic
Dental papilla
Dental Sac
Anatomic Functional
Cementum
PDL
Alveolar bone
Gingiva
Simon JH, Glick DH, Frank AL. The Relationship of Endodontic–Periodontic Lesions. J Endod. 2013 May;39(5):e41-6.
2

7. HISTORY
The relationship between periodontal and pulpal disease was
first described by Simring and Goldberg -1964
Lesions due to inflammatory products found in varying degrees in
both periodontium and pulpal tissues
Endo-perio lesion
Term used
indiscriminately
Hence accurate diagnosis
& classification critical
Walton RE, Torabinejad M. Periodontal endodontic Considerations. Principles and Practice of Endodontics. 3rd Ed. WB Suanders;2002. Pg 466-84
3

8. DEFINITION OF ENDO-PERIO LESION
The tooth involved must have pulpal necrosis
There must be destruction of the attachment apparatus from
gingival sulcus to either apex of tooth or of an involved
lateral canal
Both root canal treatment & periodontal therapy are required
to resolve the entirety of the lesion
Walton RE, Torabinejad M. Periodontal endodontic Considerations. Principles and Practice of Endodontics. 3rd Ed. WB Suanders;2002. Pg 466-84
4

9. PATHWAYS CONNECTING ENDODONTIC AND PERIODONTAL TISSUES
PATENT DENTINAL
TUBULES
LATERAL &/ ACESSORY
CANALS
APICAL FORAMEN/
FORAMINA
Anatomic pathways
Non physiologic pathways
Walton RE, Torabinejad M. Periodontal endodontic Considerations. Principles and Practice of Endodontics. 3rd Ed. WB Suanders;2002. Pg 466-84
5

10. PATHWAYS CONNECTING ENDODONTIC AND PERIODONTAL TISSUES
VERTICAL ROOT FRACTURES IATROGENIC PERFORATIONS
Non physiological pathways - Iatrogenic
EXPOSURE OF DENTINAL TUBULES
DURING ROOT PLANING
Walton RE, Torabinejad M. Periodontal endodontic Considerations. Principles and Practice of Endodontics. 3rd Ed. WB Suanders;2002. Pg 466-84 6

11. PATHWAYS CONNECTING ENDODONTIC AND PERIODONTAL TISSUES
EXTERNAL RESORPTION TRAUMATIC FRACTURES
Non physiological pathways - Pathologic
DEVELOPMENTAL
GROOVES
7

12. PeriodontiumPulp
Pathways of communication
Disease/pathology
Disease/pathology
PATHWAYS CONNECTING ENDODONTIC AND PERIODONTAL TISSUES
Endodontic therapy
Periodontal therapy
Trabest KC, Kang MK. Diagnosis and management of endodontic periodontal lesions. Carranza’s clinical periodontology. Nrewman MG, Takei HH, Klokkevold PR,
Carranza FA. 11TH ed. Elsivier:2011.Pg 507-510
8

13. EFFECTS OF PULPAL DISEASE ON PERIODONTIUM
Pulpal inflammation/ necrosis
Inflammatory response in PDL
Minimal response
confined to PDL
Severe – destruction of
PDL, tooth socket, bone
Localized swelling Diffuse swelling
Draining sinus tract
1
Alveolar mucosa
Attached gingiva
Gingival sulcus of involved
tooth
Gingival sulcus of adjacent
tooth
2
3
4
Gingival sulcus of involved
tooth
Gingival sulcus of adjacent
tooth
Walton RE, Torabinejad M. Periodontal endodontic Considerations. Principles and Practice of Endodontics. 3rd Ed. WB Suanders;2002. Pg 466-84
9

14. EFFECTS OF PULPAL DISEASE ON PERIODONTIUM
Walton RE, Torabinejad M. Periodontal endodontic Considerations. Principles and Practice of Endodontics. 3rd Ed. WB Suanders;2002. Pg 466-84
10
Pulpal pathosis
Acessory
canal/apical
foramen
Retrograde
periodontitis

15. • Integrity of periodontium – reestablished
• Resolution of probing defects and sinuses
RCT
EFFECTS OF ENDODONTIC PROCEDURES ON PERIODONTIUM
• Technical procedures
• Irrigants
• Medicaments
• Dressings
• Sealers
• filling materials
Inflammatory
response in
periodontium
Usually
transient
Procedural errors
• Access perforations –
floor of PC, apical to
gingival attachment
• Strip perforations
• Vertical root #
Major destructive
inflammatory
process in
periodontium
Reattchment
difficult to
attain
Acceptable – procedures
contained within the canal
Access perforation with
extrusion of filling
material
Walton RE, Torabinejad M. Periodontal endodontic Considerations. Principles and Practice of Endodontics. 3rd Ed. WB Suanders;2002. Pg 466-84
11

16. Walton RE, Torabinejad M. Periodontal endodontic Considerations. Principles and Practice of Endodontics. 3rd Ed. WB Suanders;2002. Pg 466-84
12
Pathogenic bacteria
& inflammatory
products of
periodontal disease
Acessory
canal/lateral
canals,apical
foramen
Retrograde
pulpitis
EFFECTS OF PERIODONTAL DISEASE ON PULP

17. EFFECTS OF PERIODONTAL DISEASE ON PULP
Pulp of caries free, periodontally
involved teeth – histologically
normal regardless of severity of
pdl disease
Periodontal disease must extend
all the way to the apical foramen
before accumulation of plaque
can cause pulp involvement
Accumulated evidence – little / no effect
Calcifications
Fibrosis
Collagen resorption
Walton RE, Torabinejad M. Periodontal endodontic Considerations. Principles and Practice of Endodontics. 3rd Ed. WB Suanders;2002. Pg 466-84
Trabest KC, Kang MK. Diagnosis and management of endodontic periodontal lesions. Carranza’s clinical periodontology. Nrewman MG, Takei HH, Klokkevold PR, Carranza FA.
11TH ed. Elsivier:2011.Pg 507-510
13

18. EFFECTS OF PERIODONTAL PROCEDURES ON PULP
Pulpal response – remaining dentin
thickness
Root planing removes
cementum & dentin,
exposing patent dentinal
tubules
Negligible response
Repair & healing
• Reparative dentin
• Dentinal sclerosis
Periodontal disease extending
to root apex - Periodontal
curettage at root apex sever
blood supply to pulp
Pulpal response
Necrosis
Prophylactic root canal treatment to
be completed before periodontal
treatment
Walton RE, Torabinejad M. Periodontal endodontic Considerations. Principles and Practice of Endodontics. 3rd Ed. WB Suanders;2002. Pg 466-84
14

19. ETIOLOGY
Bacterial plaque
Microorganisms
Actinomyces sp
F. Nucleatum
P. Intermedia
P. Gingivalis
Treponema sp
C.Albicans
Amalgam filling
Root canal filling
material
Dentin or cementum
chips
Calculus deposits
Malpositioned
teethcausing trauma
Missed canals
Vertical root fracture
Crown #
Root resorption
Perforation
Systemic factors
Simon JH, Glick DH, Frank AL. The Relationship of Endodontic–Periodontic Lesions. J Endod. 2013 May;39(5):e41-6.
15
Foreign bodies Contributing factors

20. CLASSIFICATION
Simon et al – 1972
Primary
endodontic
Primary
periodontal
Primary endo with
secondary
periodontal
Primary perio
with secondary
endodontic
involvement
True combined
lesions
1
2
3
4
5
Simon JH, Glick DH, Frank AL. The Relationship of Endodontic–Periodontic Lesions. J Endod. 2013 May;39(5):e41-6.
16

21. CLASSIFICATION
Primary perio
Primary endo
secondary perio
Simon JH, Glick DH, Frank AL. The Relationship of Endodontic–Periodontic Lesions. J Endod. 2013 May;39(5):e41-6
Garg N, Garg N. Endodontic periodontal relationship. Textbook of Endodontics. 3rd ed. Pg 413-27..
17
Primary endo

22. CLASSIFICATION
Primary perio with secondary
endodontic involvement
True combined lesions
Simon JH, Glick DH, Frank AL. The Relationship of Endodontic–Periodontic Lesions. J Endod. 2013 May;39(5):e41-6
Garg N, Garg N. Endodontic periodontal relationship. Textbook of Endodontics. 3rd ed. Pg 413-27..
18

23. CLASSIFICATION
Grossman - 1988
Lesions requiring endodontic
treatment only
• Tooth with necrotic pulp
reaching apical periodontium
• Root perforations
• Root fractures
• Chronic periapical abcess with
sinus tract
• Replants
• Transplants
• Teeth requiring hemisection
Type
- I
Lesions that require periodontal
treatment only
• Occlusal trauma causing reversible pulpitis
• Supra/infra bony pockets caused during
periodontal treatment resulting in pulpal
inflammation
• Occlusal truma and gingival inflammation
resulting in pocket formation
Type
II
Lesions that require combined
endodontic & periodontal treatment
• Any lesion of type I which result in
irreversible reaction to periodontium
requiring periodontal treatment
• Any lesion of type II which results in
irreversible damage to pulp tissue requiring
endodontic therapy
Type
IIII
19

24. CLASSIFICATION
Weine
Symptoms clinically &
radiographically simulate
periodontal disease but in fact
due to pulpal inflammation
&/necrosis
Cl - I
Tooth that has no pulpal
problem but requires
endodontic therapy plus root
amputation to gain periodontal
healing
Cl - III
Tooth that has both
pulpal or periapical disease
and periodontal disease
concomittantly
Cl - II
Tooth that clinically &
radiographically simulates
pulpal/periapical disease but
in fact has periodontal
disease
Cl - IV
20

25. CLASSIFICATION
Edoardo Foce - 2011
Crown-down plaque-induced
periodontal lesion – lesion arises at
gingival margin and progress apically,
charch by colonisation of plaque &
calculus
Cl - I
Down-crown periodontal lesion of
endodontic
origin –begins apically and progresses
coronally
Cl - 2
Combined lesions
Cl - 3
Pseudo endo perio lesion-
initial clinical & radiologic
exam points to both endo & perio
sources , pulp vitality & periodontal
probing resolve the diagnostic doubt
concerning lesion’s true nature
Cl - 4
Foce E. Endo-Periodontal lesions. Quintessence Publishing Company, Incorporated, 2011.Pg 24-57. 21

26. CLINICAL DIAGNOSIS
Pulp vitality
Radiograph
Periodontal probing
Visual examination
History
Palpation
Mobility
Percussion
Walton RE, Torabinejad M. Periodontal endodontic Considerations. Principles and Practice of Endodontics. 3rd Ed. WB Suanders;2002. Pg 466-84
24

27. CLINICAL DIAGNOSIS
Visual
examination
HistoryPalpationMobilityPercussion H/o pain & swelling, type of painAttached gingiva & alveolar mucosa
presence of swelling & sinus
Detect presence of periradicular
abnormalities & hot zones
Detection & localisation of Inflammation
of PDL
Determine extent of inflammation in PDL
PULPAL
PERIRADICULAR
PERIODONTAL
Severe, Sharp lancinating - moderate to
severe, not easily localized
Dull continuous – moderate to severe
easily localized
Dull pain – moderate, severe in case
acute, easily localised
No sinus/ swelling
Localised/generalised swelling, Sinus –
fistula tracking to be done, heals after RCT
Acute Periodontal abscess, sinus can present,
fistula tracking to be done, heals only after
perio therapy
No response
May give painful response to digital
pressure
Painful response to digital pressure
common
No response
May be Sensitive, unless chronic
Usually not sensitive
Mobility may be present, resolves with
RCT
Varying degree of mobility, resolution
depends on response to periodontal
therapy
Within normal
Walton RE, Torabinejad M. Periodontal endodontic Considerations. Principles and Practice of Endodontics. 3rd Ed. WB Suanders;2002. Pg 466-84 25

28. CLINICAL DIAGNOSIS
Pulp vitality
PULPAL
PERIRADICULAR
PERIODONTAL
Cold test, EPT, test cavity
Lingering response /
reduces pain
No response
Normal response
Delayed/normal/
Hyper- response
No response
Normal response
Tooth with single canal
Tooth with multiple canals
Status of vitality can be
determined with certainty
Limitations – due to
possibility of presence of
vital tissue
Walton RE, Torabinejad M. Periodontal endodontic Considerations. Principles and Practice of Endodontics. 3rd Ed. WB Suanders;2002. Pg 466-84
26

29. CLINICAL DIAGNOSIS
Radiograph
Identification of proximal crestal bone & its
position in relation to CEJ
The more apical margin of the superimposed
trabecular pattern over the root – to identify the
level of bone loss on one side of the tooth
Interpretation of discrete periapical/lateral lesions
– suggest cause of lesion
Radiograph is is of little value when bone loss
extends from crestal bone to/near apex
Walton RE, Torabinejad M. Periodontal endodontic Considerations. Principles and Practice of Endodontics. 3rd Ed. WB Suanders;2002. Pg 466-84
27

30. CLINICAL DIAGNOSIS
Periodontal probing
Discrimination of endo-perio lesions made primarily
on basis of examination with periodontal probe
Periodontal probing to be done with
• Small diameter tip instrument (0.05)
• Uniform pressure
• Slight angling of tip towards root surface
By acute tactile discrimination nature & cause of lesion determined from level
of epithelial attachment - probing all the way around the external root
surface
Walton RE, Torabinejad M. Periodontal endodontic Considerations. Principles and Practice of Endodontics. 3rd Ed. WB Suanders;2002. Pg 466-84 28

31. CLINICAL DIAGNOSIS– Probing Patterns
Acute/ blow out lesions Localized swelling , Tooth non vital
At edge of swelling,
probe drops to near
apex
Width of detached gingiva – broad - entire buccal/lingual surface
At times intact crestal bone felt – rapid reattachment expected
Treatment by RCT
In furcation – healing
proceed to “sinus tract
type probing “ first
Walton RE, Torabinejad M. Periodontal endodontic Considerations. Principles and Practice of Endodontics. 3rd Ed. WB Suanders;2002. Pg 466-84
29

32. CLINICAL DIAGNOSIS– Probing Patterns
Acute/ blow out lesions
Typical swelling
of blow out type
Probe in lesion at
initial exam
Reduced to
narrow sinus tract
Complete resolution
after RCT
Walton RE, Torabinejad M. Periodontal endodontic Considerations. Principles and Practice of Endodontics. 3rd Ed. WB Suanders;2002. Pg 466-84 30

33. CLINICAL DIAGNOSIS –Probing patterns
Typical periodontal lesions
Probing starts from sulcus depth within
normal limit
Slope of lesion – vary depending on coronal
width
Conical shaped probing
Lesion conical in contour
Gradually step down a slope to apical
extent of lesion
Then step up again to normal sulcus
depth
Occasionally – sloping contour on one side but
precipitous sharp drop off on the other side
Walton RE, Torabinejad M. Periodontal endodontic Considerations. Principles and Practice of Endodontics. 3rd Ed. WB Suanders;2002. Pg 466-84 31

34. CLINICAL DIAGNOSIS– Probing Patterns
Typical periodontal lesions
Distal – normal
sulcus depth
Mesial – normal
sulcus depth
Walton RE, Torabinejad M. Periodontal endodontic Considerations. Principles and Practice of Endodontics. 3rd Ed. WB Suanders;2002. Pg 466-84
32

35. CLINICAL DIAGNOSIS– Radiographic appearance
Typical periodontal lesions
Bone loss on mesial of
mandibular 1st molar
5 years later bone loss
progressed to a deeper level
Bone loss ALWAYS begins at crestal bone
level & progresses apically
Pretreatment radiograph
of a periodontal lesion
2 yr recall radiograph of
successful periodontal
treatment
33

36. CLINICAL DIAGNOSIS – Probing patterns
Radiolucent lesions with gingival
sulcus intact
Tooth with necrotic pulp + gingival sulcus
intact
Eliminates periodontal
disease as cause of lesion
Non surgical RCT – resolve radiolucent lesion
that extends up the lateral root surface to
involve crestal bone/ radiolucent lesion in
furcation
Tooth without necrotic pulp in at least one
canal + gingival sulcus intact
Biopsy
34

37. CLINICAL DIAGNOSIS-Radiographic appearance
Radiolucent lesions with gingival
sulcus intact
Radiographic appearance
of a periodontal lesion
Eliminates periodontal
disease as cause of lesion
4 yr recall – resolution of
radiolucency
RCT completed
Walton RE, Torabinejad M. Periodontal endodontic Considerations. Principles and Practice of Endodontics. 3rd Ed. WB Suanders;2002. Pg 466-84
35

38. CLINICAL DIAGNOSIS – Probing patterns
Lesions with narrow
sinus type probing
Usually break in attachment only 1mm
wide, probing either side will be within
normal limits
Tooth – pulpless, Lesion – sinus tract
Sulcus depth within normal limits with exception of one
narrow area that can be probed some distance down
the root surface of the tooth
Occasionally sinus tract widerupto5/6mm wide, but no swelling
Walton RE, Torabinejad M. Periodontal endodontic Considerations. Principles and Practice of Endodontics. 3rd Ed. WB Suanders;2002. Pg 466-84 36

39. CLINICAL DIAGNOSIS – Probing patterns
Probing furcation Special consideration for probing the furcations of
multirooted teeth
Grade IV – A through-and-through lesion that has sustained enough bone loss to
make it completely probeable
Grade I - Incipient lesion. The pocket primarily affects the soft tissue.
Early bone loss may have occurred but is rarely evident radiographically.
Grade II - There is a definite horizontal component to the bone loss between roots
resulting in a probeable area, but sufficient bone still remains attached to at the
dome of the furcation), multiple areas of furcal bone loss, do not communicate.
Grade III - Bone no longer attached to the furcation of the tooth, resulting in a
through-and-through tunnel. soft tissue may still occlude the furcation involvement
Irving Glickman graded furcation involvement into
following four classes
Vertical component – furcation
down distal aspect of the mesial
root, mesial aspect of distal root
Horizontal component – height
of soft tissue & contour of
furcation, special curved probe
required
Walton RE, Torabinejad M. Periodontal endodontic Considerations. Principles and Practice of Endodontics. 3rd Ed. WB Suanders;2002. Pg 466-84 37

40. CLINICAL DIAGNOSIS – Radiographic appearance
Lesions with narrow sinus type probing
Bone loss from crest
around apices & furcation
RCT completed
1yr recall, resolution of
radiolucency
Walton RE, Torabinejad M. Periodontal endodontic Considerations. Principles and Practice of Endodontics. 3rd Ed. WB Suanders;2002. Pg 466-84 38

41. CLINICAL DIAGNOSIS – Probing patterns
Independent periodontal &
periapical lesions that do not
communicate
Tooth with periodontal disease may
also be pulpless with radiographic
evidence of discrete periapical/lateral
lesion
Perodontal lesion
probing - conical
Tooth is pulpless – with
periapical lesion
No demonstrable communication
between 2 lesions
Walton RE, Torabinejad M. Periodontal endodontic Considerations. Principles and Practice of Endodontics. 3rd Ed. WB Suanders;2002. Pg 466-84 39

42. CLINICAL DIAGNOSIS – Radiographic appearance
Independent periodontal & periapical
lesions that do not communicate
Radiolucency involving distal
root surface & extends around
apices up mesial root, angular
coronal radiolucency at mesial
root surface
Completed root canal
treatment
8 Month recall – marked
reduction of distal
radiolucency caused by
necrotic pulp, mesial lesion
same as before
Walton RE, Torabinejad M. Periodontal endodontic Considerations. Principles and Practice of Endodontics. 3rd Ed. WB Suanders;2002. Pg 466-84 40

43. CLINICAL DIAGNOSIS – Probing patterns
True combined perio-endo lesions
Independent periodontal and
periapical or lateral lesions are
present & communicate
Typical conical periodontal type of probing
except that at base of periodontal lesion
probe will abruptly drop down root surface
Communication between
periodontal lesion & a lesion
caused by a necrotic pulp
Walton RE, Torabinejad M. Periodontal endodontic Considerations. Principles and Practice of Endodontics. 3rd Ed. WB Suanders;2002. Pg 466-84 41

44. CLINICAL DIAGNOSIS – Radiographic appearance
True combined perio-endo lesions
Mandibular incisor with large
lesion
11 year recall shows
resolution of lesion around
apex. Angular defect remains
42

45. PERIO- ENDODONTIC DECISION TREE
Radiographs-
Bone loss from CEJ
To /near apex
Pulp
test
Probing
Probing
Conical with narrow probing
Conical
WNL
Broad precipitous
Narrow
Conical
WNL
Narrow
True combined endo
perio
Pulpless tooth with
perio defect
Endo only
Endo only
Endo only, possible
vertical fracture
Perio only
Pathosis, possible
biopsy
Exceptions – enamel
spurs, developmental
grooves, defect after
trauma
Walton RE, Torabinejad M. Periodontal endodontic Considerations. Principles and Practice of Endodontics. 3rd Ed. WB Suanders;2002. Pg 466-84
43
-
+

46. CASE PRESENTATIONS & DIFFERENTIAL DIAGNOSIS
Periodontal Lesions of Bone that Can Be
Confused With
Pulpally Induced Bony Lesions
• Acute periodontal abscess
• Lesions of chronic periodontitis
• Periodontal lesions involving the
furcation
• Lesions associated with aggressive
forms of periodontitis
• External root resorption
• Cemental tears
Pulpally Induced Lesions that Can Be
Confused With Periodontal Lesions
• Furcation or lateral lesions without loss
of attachment
• Acute periapical abscess
• Chronic sinus tracts of pulpal origin with
drainage through the gingival sulcus
• Chronic sinus tracts of pulpal origin with
permanent periodontal attachment loss
• Response of the periodontium to
mechanical root perforations
Gutmann JL, Lovdahl p. Problem Solving in the Differential Diagnosis of BonyDefects Resulting from Pulpal and Periodontal PathosisProblem Solving in Endodontics:
Prevention,Identification and Management. 5th ed. Mosby;2010.pg 70-96
44

47. CASE PRESENTATIONS & DIFFERENTIAL DIAGNOSIS
Bony Lesions of the Periodontium that Do Not Originate from Either Periodontal or
Pulpal Pathosis
• Deep coronal fractures
• Vertical root fractures
• Developmental lingual groove on maxillary lateral incisors and
similar lesions
• Other possible rare lesions
Gutmann JL, Lovdahl p. Problem Solving in the Differential Diagnosis of BonyDefects Resulting from Pulpal and Periodontal PathosisProblem Solving in Endodontics:
Prevention,Identification and Management. 5th ed. Mosby;2010.pg 70-96
45

48. Acute periodontal abcess
Acute facial swelling
Clinically identical to acute periapical abscesses
of pulpal origin. Severe swelling, pain, fever,
malaise, swelling near the gingival margin
same acute periodontal
abscess
bone loss b/W molars,
lack of PA involvement
PERIODONTAL LESIONS OF BONE THAT CAN BE CONFUSED
WITH PULPALLY INDUCED BONY LESIONS
Gutmann JL, Lovdahl p. Problem Solving in the Differential Diagnosis of BonyDefects Resulting from Pulpal and Periodontal PathosisProblem Solving in Endodontics:
Prevention,Identification and Management. 5th ed. Mosby;2010.pg 70-96
46

49. PERIODONTAL LESIONS OF BONE THAT CAN BE CONFUSED
WITH PULPALLY INDUCED BONY LESIONS
Lesions of chronic periodontitis
Surgical exposure – altered contours of
crestal bone
Surgical exposure of apical lesion-normal
crestal bone contours
Lesions of chronic periodontitis confused
with lesions of pulpal origin because of a
draining sinus tract
Periodontal etiology Pulpal etiology
Gutmann JL, Lovdahl p. Problem Solving in the Differential Diagnosis of BonyDefects Resulting from Pulpal and Periodontal PathosisProblem Solving in Endodontics:
Prevention,Identification and Management. 5th ed. Mosby;2010.pg 70-96
47

50. Lesions of chronic periodontitis
Localized lesion of
advanced chronic
periodontitis - tooth
opened for rct
PERIODONTAL LESIONS OF BONE THAT CAN BE CONFUSED
WITH PULPALLY INDUCED BONY LESIONS
Occasionally,
lesions - advanced
periodontitis cause
severe bone loss in
a local area
There is both apical
and periodontal pathosis
evident on the second
premolar
clinical examination – complete dehiscence of lingual
surface of root to apex. RCT would be of no benefit
Both apical
& periodontal pathosis
evident on second PM
Sinus tract exploration
with GP cone- source of
drainage is periodontal
lesion
Completed root canal
treatment will only
resolve the periapical
lesion
Gutmann JL, Lovdahl p. Problem Solving in the Differential Diagnosis of BonyDefects Resulting from Pulpal and Periodontal PathosisProblem Solving in Endodontics:
Prevention,Identification and Management. 5th ed. Mosby;2010.pg 70-96
48

51. Periodontal lesions
involving furcation
Furcation lesion in bone,
suspected to be result of
extension of pulp
pathosis into
periodontium.
Surgical exposure confirms
chronic periodontitis. Bone
loss in entire furcation &
loss of buccal plate
Difficult to distinguish from bone loss due to a
necrotic pulp
Periodontal defects tend to affect the furcation more or less
symmetrically
periodontal defects probe
vertically & horizontally
Sinus tracts of pulp origin tend
to probe in a vertical direction
only, but in some cases tract
may take a tortuous path
PERIODONTAL LESIONS OF BONE THAT CAN BE CONFUSED WITH
PULPALLY INDUCED BONY LESIONS
Need for
straight & curved probes
Gutmann JL, Lovdahl p. Problem Solving in the Differential Diagnosis of BonyDefects Resulting from Pulpal and Periodontal PathosisProblem Solving in Endodontics:
Prevention,Identification and Management. 5th ed. Mosby;2010.pg 70-96
49

52. Lesions asosciated with aggressive forms of periodontitis
Deep periodontal defect
discovered on a
12-year-old patient
Radiograph of same lesion.
Diagnosis is
aggressive periodontitis.
PERIODONTAL LESIONS OF BONE THAT CAN BE CONFUSED WITH
PULPALLY INDUCED BONY LESIONS
Aggressive periodontitis - young people, Due to rarity of periodontal pathosis in children,
a necrotic pulp with a periapical lesion is sometimes suspected as the cause of this disease
Gutmann JL, Lovdahl p. Problem Solving in the Differential Diagnosis of BonyDefects Resulting from Pulpal and Periodontal PathosisProblem Solving in Endodontics:
Prevention,Identification and Management. 5th ed. Mosby;2010.pg 70-96
50

53. External root resorption
External resorption in
marginal periodontium,
resembling internal
resorption
External resorption occurs in the marginal
periodontium. Root canal treatment is often
necessary because of pulp exposure or near
exposure during repair of the defect
PERIODONTAL LESIONS OF BONE THAT CAN BE CONFUSED WITH
PULPALLY INDUCED BONY LESIONS
Probings suggest a
periodontal defect.
Surgical exposure
confirms diagnosis of
external resorption
Gutmann JL, Lovdahl p. Problem Solving in the Differential Diagnosis of BonyDefects Resulting from Pulpal and Periodontal PathosisProblem Solving in Endodontics:
Prevention,Identification and Management. 5th ed. Mosby;2010.pg 70-96
51

54. Cemental tears
Radiograph of a
mandibular right lateral
incisor 1 half yrs after RCT
Surgical exposure of
defect, revealing cemental
tear
Rare periodontal condition associated with a root-
treated tooth, clinically- periodontal infection with
rapid loss of attachment.
6 mnths post treat, (area
recontoured,
treated with citric acid)
indicating normal probings.
PERIODONTAL LESIONS OF BONE THAT CAN BE CONFUSED
WITH PULPALLY INDUCED BONY LESIONS
Gutmann JL, Lovdahl p. Problem Solving in the Differential Diagnosis of BonyDefects Resulting from Pulpal and Periodontal PathosisProblem Solving in Endodontics:
Prevention,Identification and Management. 5th ed. Mosby;2010.pg 70-96
52

55. PULPALLY INDUCED LESIONS CONFUSED WITH PERIO LESIONS
Acute periapical abcess
Local swelling secondary to acute
periapical abscess, narrow defect
into the furcation was probed
1 week following endo procedures,
swelling subsided, and reattachment in
the furcation had occurred
Difference b/w acute periapical and periodontal
abscesses-attachment loss in endo cases
recovered, often within 1 week
Pulp sensibility – Negative response
Radiograph – may show PA radiolucency
Probing – loss of attachment & purulent drainage
Gutmann JL, Lovdahl p. Problem Solving in the Differential Diagnosis of BonyDefects Resulting from Pulpal and Periodontal PathosisProblem Solving in Endodontics:
Prevention,Identification and Management. 5th ed. Mosby;2010.pg 70-96
53

56. PULPALLY INDUCED LESIONS CONFUSED WITH PERIO LESIONS
Chronic sinus tracts of pulpal origin
with drainage through gingival sulcus
Local swelling on mesial
Palatal surface of
maxillary molar, presumed
to be periodontal
Probing normal except
narrow tract. sinus tract
explored using a sectioned
periodontal probe
The tissue reflected
sinus tract observed to be
small defect without change
in general contour of bone
Confusion arises when the tract
exits through gingival sulcus
Gutmann JL, Lovdahl p. Problem Solving in the Differential Diagnosis of BonyDefects Resulting from Pulpal and Periodontal PathosisProblem Solving in Endodontics:
Prevention,Identification and Management. 5th ed. Mosby;2010.pg 70-96
54

57. PULPALLY INDUCED LESIONS CONFUSED WITH PERIO LESIONS
Furcation/lateral lesions with loss of attachment
Mandibular molar with large radiolucent
lesion. Bone loss appears to extend from
distal interproximal
crest to apex, clinically-no break in the
sulcular attachment
Reevaluation at 15 months, indicating
healing of periapical
lesion and restoration of interproximal
bony architecture.
Large Periapical
approach crestal bone - Radiographically, the
appearance similar to periodontal lesions with
advanced bone loss,-because of the loss of crestal or
furcation bone
Careful circumferential probing
indicate that there is no loss of attachment in the
sulcus.
Gutmann JL, Lovdahl p. Problem Solving in the Differential Diagnosis of BonyDefects Resulting from Pulpal and Periodontal PathosisProblem Solving in Endodontics:
Prevention,Identification and Management. 5th ed. Mosby;2010.pg 70-96
55

58. PULPALLY INDUCED LESIONS CONFUSED WITH PERIO LESIONS
Chronic sinus tracts of pulpal origin with drainage with permanent
attachment loss
Calculus on apex of a root with history
of chronic drainage from a periapical
lesion of pulpal origin.
Biofilm & calculus can form on the root
surfaces, within sinus tracts,on the apices of
roots in chronically draining PA lesions
Outcome of RCT - uncertain.
Many cases will regain attachment after
débridement of the root canal, but some
will not
Gutmann JL, Lovdahl p. Problem Solving in the Differential Diagnosis of BonyDefects Resulting from Pulpal and Periodontal PathosisProblem Solving in Endodontics:
Prevention,Identification and Management. 5th ed. Mosby;2010.pg 70-96
56

59. PULPALLY INDUCED LESIONS CONFUSED WITH PERIO LESIONS
Chronic sinus tracts of pulpal origin with drainage
permanent attachment loss
Radiograph indicating
furcation bone loss. Normal
bone levels around
adjacent teeth
Probing indicating horizontal
bone loss. The prognosis for
healing in the furcation is
guarded
Gutmann JL, Lovdahl p. Problem Solving in the Differential Diagnosis of BonyDefects Resulting from Pulpal and Periodontal PathosisProblem Solving in Endodontics:
Prevention,Identification and Management. 5th ed. Mosby;2010.pg 70-96
57

60. PULPALLY INDUCED LESIONS CONFUSED WITH PERIO LESIONS
Response of periodontium to mechanical root
perforations
Perforation during access
cavity preparation
into furcation with
periodontal breakdown
Strip perforation in the
course of canal shaping.
Strip perforation resulting
from intraradicular
post placement
Localized swelling in
attached gingiva of
canine opened for endo
Rx
interruption of crestal
bone, preoperative
probings normal
RCT completed after surgical repair.
, Eight-month reexamination,
indicating complete healing.
Gutmann JL, Lovdahl p. Problem Solving in the Differential Diagnosis of BonyDefects Resulting from Pulpal and Periodontal PathosisProblem Solving in Endodontics:
Prevention,Identification and Management. 5th ed. Mosby;2010.pg 70-96
58
If the periodontal attachment is normal preoperatively, attachment will
most likely return following surgical repair.

61. LESIONS OF PERIODONTIUM THET DO NOT ORIGINATE FROM PULPAL OR
PERIODONTAL PATHOSIS
Deep coronal fractures
Mandibular molar with deep,
unrestorable coronal fracture
Fractured crown of canine
extending subgingivally
Mandibular right first molar
presenting with
acute periodontal abscess
Occlusal view with
fracture lines
on distal and lingual
Fracture of distal-lingual
cusp
Gutmann JL, Lovdahl p. Problem Solving in the Differential Diagnosis of BonyDefects Resulting from Pulpal and Periodontal PathosisProblem Solving in Endodontics:
Prevention,Identification and Management. 5th ed. Mosby;2010.pg 70-96
59
In some cases, coronal fractures result in
mobility of the coronal segments - Mobility is
a good Clue to the severity of depth.

62. LESIONS FROM PERIODONTIUM THET DO NOT ORIGINATE FROM PULPAL OR
PERIODONTAL PATHOSIS
Vertical root fractures
Surgical exposure of
typical vertical root
fracture
Unusual vertical root # on
endodontically untreated
tooth
Vertical root # caused by
excessive spreader
pressures
Radiograph indicating previous
root canal treatment and
periapical lesion on a mandibular
central incisor
Normal probing depth
on mesial-labial line
angle.
Normal probing on distal-
labial line angle
Sinus tract–type probing
diagnostic for vertical root
fracture
Gutmann JL, Lovdahl p. Problem Solving in the Differential Diagnosis of BonyDefects Resulting from Pulpal and Periodontal PathosisProblem Solving in Endodontics:
Prevention,Identification and Management. 5th ed. Mosby;2010.pg 70-96
61

63. LESIONS FROM PERIODONTIUM THET DO NOT ORIGINATE FROM PULPAL OR
PERIODONTAL PATHOSIS
Vertical root fractures
Radiograph indicating periodontal
bone loss on mesial and distal
surfaces, extending to midroot level
Probing on the mesial
demonstrates deep, narrow defect,
indicating periodontal defect
Clinical examination showed draining
tracts & deep Interproximal probing
view of extracted tooth,
showing fracture line extending
from crown to midroot level
Gutmann JL, Lovdahl p. Problem Solving in the Differential Diagnosis of BonyDefects Resulting from Pulpal and Periodontal PathosisProblem Solving in Endodontics:
Prevention,Identification and Management. 5th ed. Mosby;2010.pg 70-96
60

64. LESIONS FROM PERIODONTIUM THET DO NOT ORIGINATE FROM PULPAL OR
PERIODONTAL PATHOSIS
Developmental grooves
Groove evident on
radiographic image of tooth
Sinus tract on labial surface of
maxillary lateral incisor
Circumferential probings are
normal except
location of lingual develt groove
Lingual groove demonstrated
on an extracted tooth
Gutmann JL, Lovdahl p. Problem Solving in the Differential Diagnosis of BonyDefects Resulting from Pulpal and Periodontal PathosisProblem Solving in Endodontics:
Prevention,Identification and Management. 5th ed. Mosby;2010.pg 70-96.
62

65. LESIONS FROM PERIODONTIUM THET DO NOT ORIGINATE FROM PULPAL OR
PERIODONTAL PATHOSIS
Other possible rare lesions
After traumatic injury,
some maxillary incisors
will be found
to have a deep probing
defect in the Usually in
palatal sulcus
Result of luxation and will
generally close
spontaneously
without treatment
Gutmann JL, Lovdahl p. Problem Solving in the Differential Diagnosis of BonyDefects Resulting from Pulpal and Periodontal PathosisProblem Solving in Endodontics:
Prevention,Identification and Management. 5th ed. Mosby;2010.pg 70-96
63

66. LESIONS FROM PERIODONTIUM THET DO NOT ORIGINATE FROM PULPAL OR
PERIODONTAL PATHOSIS
Other possible rare lesions
Periodontal defects
associated with enamel
pearls are generally
found in the furcation
areas of molars.
Prognosis - the possibility
of periodontal treatment
Gutmann JL, Lovdahl p. Problem Solving in the Differential Diagnosis of BonyDefects Resulting from Pulpal and Periodontal PathosisProblem Solving in Endodontics:
Prevention,Identification and Management. 5th ed. Mosby;2010.pg 70-96
64

67. MANAGEMENT
Endodontic periodontal lesion
Primary endo lesion Primary perio lesion Combined lesion
Endodontic therapy Perio therapy
Primary endo
secondary Perio
Primary perio
secondary endo
First endo,
evaluate, if
required perio
Perio surgery, palliative
RCT, Regenerative
procedures
Parolia, et al. Endo-perio lesion: A dilemma from 19th until 21st century. Journal of Interdisciplinary Dentistry:Jan-Apr 2013;3 (1).
Carranza FA. Treatment of furcation involvement and combined perio-endp therapy. Glickman’s clinical periodontology. 6th ed. WB saunder;1984. Pg 774-781
65

68. MANAGEMENT - PRIMARY ENDO LESION
Root canal therapy
Tooth with large periapical lesion,
orthograde endodontic therapy
Sinus into gingival sulcus / furcation
area disappears once root canals
cleaned, shaped & obturated.
Calcium hydroxide found to be very
effective
Parolia, et al. Endo-perio lesion: A dilemma from 19th until 21st century. Journal of Interdisciplinary Dentistry:Jan-Apr 2013;3 (1). 66

69. MANAGEMENT - PRIMARY PERIO LESION
Hygiene phase therapy
Scaling, root planing
Oral prophylaxis, oral
hygiene instructions
Periodontal surgery, root
amputation in advanced
cases if necessary
1
2
3
Poor restorations &
developmental
grooves to be removed
Intact cementum
important for pulp,
minimize use of
ultrasonics and
rotary scaling
instruments when
<2 mm of dentin
thickness remaining
Other clinical considerations
Parolia, et al. Endo-perio lesion: A dilemma from 19th until 21st century. Journal of Interdisciplinary Dentistry:Jan-Apr 2013;3 (1). 67

70. MANAGEMENT- PRIMARY ENDO SECONDARY PERIO
Root canal therapy
Multi visit endo,
simple hygiene
therapy
Iatrogenic, perforation/root
fracture
Evaluate 2-3mnths
Perio therapy if required
Seal
perforation
Manage
fracture
Extract if prognosis poor
1
2
3
Clinical considerations
Intracanal medicament found
reduce inflammation & favoring
repair
Aggressive removal of PDL &
cementum during interim
endodontic therapy may
adversely affect
Healing - should be avoided
Parolia, et al. Endo-perio lesion: A dilemma from 19th until 21st century. Journal of Interdisciplinary Dentistry:Jan-Apr 2013;3 (1). 68

71. MANAGEMENT - PRIMARY PERIO SECONDARY ENDO & COMBINED LESIONS
Regenerative procedures
Palliative PDL therapy & RCT
Tooth- > 1
grade mobility
Periapical resolution
PDL pocket <4mm
Non surgical
maintenance
Evaluate 2-3mnths
No Periapical resolution
No mobility
PDL pocket <6,
>4mm – osseous
surgery
PDL pocket >6, GTR
Resection/bicuspidiza
tion/hemisection
Extraction
Splinting
Parolia, et al. Endo-perio lesion: A dilemma from 19th until 21st century. Journal of Interdisciplinary Dentistry:Jan-Apr 2013;3 (1).
Carranza FA. Treatment of furcation involvement and combined perio-endp therapy. Glickman’s clinical periodontology. 6th ed. WB saunder;1984. Pg 774-781
69

72. MANAGEMENT - PRIMARY PERIO SECONDARY ENDO
Regenerative procedures
Bone grafting
Guided tissue regeneration
Cell stimulation
70

73. MANAGEMENT - REGENERATIVE PROCEDURES
Bone grafting
Bone graft material
Reflected flap
Bone
Placing bone graft
Suture
Gingiva
Bone graft material
Flap sutured after bone graft
Patients bone regenerates in response to bone graft
71
Surgical procedure that replaces missing bone in order to repair
bone
Autografts
Allografts
Xenografts
Alloplasts

74. MANAGEMENT - PRIMARY PERIO SECONDARY ENDO
Guided tissue regeneration
Membrane
Bone missing
flap
Suture
Membrane isolating
damaged area of
bone
New bone forming
Membrane
dissolving
Healing &
regeneration
The principle of GTR is - give preference to certain cells to
repopulate the wound area to form a new attachment apparatus.
Clinically this is accomplished by placing a barrier over the defect
thereby excluding gingival tissues from the wound during early
healing
72

75. MANAGEMENT - PRIMARY PERIO SECONDARY ENDO
Guided tissue regeneration
73
Pre op probing depth Apicomarginal defect
Collagen membrane
postoperative probing
depth taken at 12 months
Postsurgical
radiograph
The 1-year
radiograph

76. MANAGEMENT - PRIMARY PERIO SECONDARY ENDO
Cell stimulation
Periodontal
breakdown &
bone loss
Cell stimulating
material
applied
Gum sutured
Bone
regenerated
74
use of proteins to induce formation of tooth supporting
structures lost
BMP
Enamel matrix proteins
Platelet rich plasma

77. MANAGEMENT - PRIMARY PERIO SECONDARY ENDO
Cell stimulation
75
Pre op probing depth Apicomarginal defect
Postsurgical
radiograph
PRP Placed over defect
postoperative probing
depth taken at 12 months
The 1-year
radiograph

78. PROGNOSIS
Pimary endo
Generally
excellent
Pimary perio
Goyal B, Tewari S, Duhan J, Sehgal P. Comparative evaluation of platelet-rich plasma and guided tissue regeneration membrane in the healing of apicomarginal defects: a
clinical study. J Endod. 2011 Jun;37(6):773-80
76
Endodontic
prognosis is
always better
Poor as
disease
advances
Pimary endo
secondary perio
Depends on
extent of
periodontal
involvement
Pimary perio
secondary endo
Depends on
periodontal
prognosis
Combined
Poor to
hopeless
Endodontic
lesion is
primarily a
closed
environment
wound
The periodontal
defect
is mostly an
open wound

79. CLINICAL CONSIDERATIONS
New diagnostic aids
CBCT
Spiral computed
tomography
Gandhi A, Kathuria A, Gandhi T. Endodontic-periodontal management of two rooted maxillary lateral incisor associated with complex radicular lingual groove by using spiral
computed tomography as a diagnostic aid:
a case reportInt Endod J. 2011 Jun;44(6):574-82.
77
‘Conventional radiographic approaches assessing alveolar bone structure
often limits distinction between palatal or buccal structures. Bony defects on
the palatal side may be supraprojected by buccal bone, hindering
interpretation and adequate treatment planning. However, SCT can produce 3-
D images of bone, allowing for detailed analysis of bone architecture.’
“Role of imaging has expanded from diagnosis to image
guidance of operative and surgical procedures”

80. CLINICAL CONSIDERATIONS
Sequence of treatment
Acute cases
Diagnose the
source of pain
&/or swelling -
endodontic or
periodontal –
treat as priority
Follow soon
after with other
treatment
Combined
lesions - do not
commmunicate
Complete the
endodontic
therapy first
Initiate
periodontal
treatment soon
after
Combined
lesions -
commmunicate
Commence
endodontic
treatment
Medicate canals
until prognosis is
known
ISSUES WITH INITIATING PERIODONTAL
TREATMENT FIRST
Removal of cementum during root
scaling
Exposure of dentinal tubules
Bacteria in the canal - inflammatory
resorption
Exposure of periodontal tissues to toxic
medicaments if used in canal
Pocket depth reduction is significantly
lesser in the presence of canal infection
More marginal epithelium over cemental
defects if the canals are infected
Shenoy N, Shenoy A. Endo-perio lesions: diagnosis and clinical considerations. Indian J Dent Res. 2010 Oct-Dec;21(4):579-85. 78

81. CLINICAL CONSIDERATIONS
Multi visit RCT
Teeth with guarded prognosis -
complete root canal
treatment is not advisable until a
prognosis has been established
Cases - Risk of Reinfection-prudent to
delay the root filling until the
periodontal infection has been
eliminated
Shenoy N, Shenoy A. Endo-perio lesions: diagnosis and clinical considerations. Indian J Dent Res. 2010 Oct-Dec;21(4):579-85.
Gutmann JL, Lovdahl p. Problem Solving in the Differential Diagnosis of BonyDefects Resulting from Pulpal and Periodontal Pathosis. Problem Solving in Endodontics:
Prevention,Identification and Management. 5th ed. Mosby;2010.pg 70-96
Prichard JF. Advanced periodontal disease, surgical and prosthetic management. 2nd ed. Philadephia: Saunders; 1972:547-8.
Prichard JF. The diagnosis and management of vertical bony defects. J Periodontol 1983;54:29-35.
79
Concern that the leakage of
endodontic sealer would hinder
repair, regeneration or both

82. CLINICAL CONSIDERATIONS
Intracanal medicament
Teeth with guarded
prognosis
If delay in periodontal
therapy
Sterility is more likely while
there is a medicated dressing
like calcium hydroxide in the
canal
Acts as a physical barrier - fills
space within canal & prevents
ingress of bacteria into the root
canal system
BONE
EMPTYCANALCALCIUMHYDROXIDE
Kills the remaining micro-
organisms by withholding
substrates for growth & limiting
space for multiplication
Damages the microbial
cytoplasmic membrane,
suppresses enzyme activity,
Disrupts the cellular metabolism
Shenoy N, Shenoy A. Endo-perio lesions: diagnosis and clinical considerations. Indian J Dent Res. 2010 Oct-Dec;21(4):579-85.
Parolia, et al. Endo-perio lesion: A dilemma from 19th until 21st century. Journal of Interdisciplinary Dentistry:Jan-Apr 2013;3 (1).
80

83. CLINICAL CONSIDERATIONS
Other Antimicrobial agents
Chlorhexidine tetracycline
BONE
Partial antimicrobial activity -
when chlorhexidine &
tetracycline solutions where
used within the canal
Calcium hydroxide
Silva MR, Chambrone L, Bombana AC, Lima LA. Early antimicrobial activity of intracanal medications on the external root surface of periodontally compromised teeth.
Quintessence Int. 2010 May;41(5):427-31.
81EMPTYCANALCHLORHEXIDINE/TETRACYCLINE

84. CLINICAL CONSIDERATIONS
Accomplishing Regeneration
GTR
Singh SManagement of an endo perio lesion in a maxillary canine using platelet-rich plasma concentrate and an alloplastic bone substitute. J Indian Soc Periodontol. 2009
May;13(2):97-100.
Bashutski JD, Wang. Periodontal and endodontic regeneration. (J Endod 2009;35:321–328.
Bashutski JD, Wang. Periodontal and endodontic regeneration. J Endod 2009;35:321–328.
Needleman IG, Worthington HV, Giedrys-Leeper E, Tucker RJ. Guided tissue regenerationfor periodontal infra-bony defects. Cochrane Database Syst Rev 2006;(2): CD001724.82
Alloplasts
Allografts
PRP
PRP + Allograft
PRP + GTR
GTR + Allogrfts
Emdogain +
connective
tissue
autograft
+allograft
PRF membrane
+ PRF Gel +
allograft
Lesions not responsive to conventional methods of
treatment & in cases of multi rooted teeth (grade II
furcation involment and above
Local
application of
Gf’s/cytokines
& host
modulating
agents
hormones
including PRF
BMPs, PDGF,
PTH, EMD

85. CLINICAL CONSIDERATIONS
Accomplishing Regeneration
Singh SManagement of an endo perio lesion in a maxillary canine using platelet-rich plasma concentrate and an alloplastic bone substitute. J Indian Soc Periodontol. 2009
May;13(2):97-100.
Bashutski JD, Wang. Periodontal and endodontic regeneration. (J Endod 2009;35:321–328.
Bashutski JD, Wang. Periodontal and endodontic regeneration. J Endod 2009;35:321–328.
Needleman IG, Worthington HV, Giedrys-Leeper E, Tucker RJ. Guided tissue regenerationfor periodontal infra-bony defects. Cochrane Database Syst Rev 2006;(2): CD001724.83
THERE IS STILL NO DEFINITIVE AGREEMENT ON
WHAT THE PREFERRED TREATMENT IS FOR
PERIODONTAL REGENERATION
BONE GRAFT WITH &
WITHOUT MEMBRANE

86. CLINICAL CONSIDERATIONS
Follow up period
Before root
filling
Goyal B, Tewari S, Duhan J, Sehgal P. Comparative evaluation of platelet-rich plasma and guided tissue regeneration membrane in the healing of apicomarginal defects: a
clinical study. J Endod. 2011 Jun;37(6):773-80.
Parolia, et al. Endo-perio lesion: A dilemma from 19th until 21st century. Journal of Interdisciplinary Dentistry:Jan-Apr 2013;3 (1).
Gutmann JL, Lovdahl p. Problem Solving in the Differential Diagnosis of BonyDefects Resulting from Pulpal and Periodontal Pathosis. Problem Solving in Endodontics:
Prevention,Identification and Management. 5th ed.
84
After
regenerative
procedures
1o days - 1
month Minimum 1
year
2-3 months
If no significant reattachment has
not occurred approximately 1
month after treatment, it is not
likely to occur at all

87. CONCLUSION
85
CLINICAL
EXAMINATION
DIAGNOSTIC
TESTS &
RADIOGRAPHS
TREATMENT
FOLLOW - UP
Controversies remain unanswered….
Can periodontal disease bring
about pulpal necrosis ??
why does the incidence of drainage of
primary endodontic lesions through the
periodontal ligament appear to be low ??
At present –
ACCUMULATED EVIDENCE
NOT CONCLUSIVE EVDIDENCE

88. • Gutmann JL, Lovdahl p. Problem Solving in the Differential Diagnosis of BonyDefects
Resulting from Pulpal and Periodontal Pathosis. Problem Solving in Endodontics:
Prevention,Identification and Management. 5th ed. Mosby;2010.pg 70-96
• Walton RE, Torabinejad M. Periodontal endodontic Considerations. Principles and Practice
of Endodontics. 3rd Ed. WB Suanders;2002. Pg 466-84
• Foce E. New terminology & classification. Endo-Periodontal lesions. Quintessence
Publishing, 2009.Pg 51-68.
• Gandhi A, Kathuria A, Gandhi T. Endodontic-periodontal management of two rooted
maxillary lateral incisor associated with complex radicular lingual groove by using spiral
computed tomography as a diagnostic aid: a case reportInt Endod J. 2011 Jun;44(6):574-82.
• Prichard JF. Advanced periodontal disease, surgical and prosthetic management. 2nd ed.
Philadephia: Saunders; 1972:547-8.
REFERENCES

89. • Silva MR, Chambrone L, Bombana AC, Lima LA. Early antimicrobial activity of intracanal
medications on the external root surface of periodontally compromised teeth.
Quintessence Int. 2010 May;41(5):427-31.
• Paul BF, Hutter JW. The endodontic-periodontal continuum revisited: new insights into
etiology, diagnosis and treatment. J Am Dent Assoc. 1997 Nov;128(11):1541-8.
• Solomon C, Chalfin H, Kellert M, Weseley P. The endodontic-periodontal lesion: a rational
approach to treatment. J Am Dent Assoc. 1995 Apr;126(4):473-9.
• Parolia, et al. Endo-perio lesion: A dilemma from 19th until 21st century. Journal of
Interdisciplinary Dentistry:Jan-Apr 2013;3 (1).
• Shenoy N, Shenoy A. Endo-perio lesions: diagnosis and clinical considerations. Indian J
Dent Res. 2010 Oct-Dec;21(4):579-85.
REFERENCES

90. • Goyal B, Tewari S, Duhan J, Sehgal P. Comparative evaluation of platelet-rich plasma and
guided tissue regeneration membrane in the healing of apicomarginal defects: a clinical
study. J Endod. 2011 Jun;37(6):773-80.
• Prichard JF. The diagnosis and management of vertical bony defects. J Periodontol
1983;54:29-35.
• Bashutski JD, Wang. Periodontal and endodontic regeneration. J Endod 2009;35:321–328.
• Simon JH, Glick DH, Frank AL. The Relationship of Endodontic–Periodontic Lesions. J Endod.
2013 May;39(5):e41-6
REFERENCES

91. LONG ESSAY
Endo perio lesions and its management
Management of endo perio lesions in detail
SHORT ESSAY
Discuss Endo-periodontics & it’s management
QUESTIONS ASKED

92. THE ENDO
PERIO
CONTINUUM