This document discusses endo-perio lesions, which involve both endodontic (pulp) and periodontal (gum) tissues. It presents a case study of a 34-year-old patient with pain and swelling in their lower right back molar. Diagnostic tests revealed both pulpal and periodontal involvement. The patient underwent root canal treatment followed by subgingival scaling and curettage in the same appointment. Follow-up showed resolution of the abscess and reduced probing depths, indicating the combined treatment was effective for this endo-perio lesion. In conclusion, sequential endodontic and periodontal therapies are important to fully address such lesions.

1. (
•
INDIAN DENTAL ASSOCIATION
WEST DELHI
Endo-Perio Lesion:
An Interdisciplinary Approach To Solve The
Dilemma Of Which Came First
-The Chicken Or The Egg?
Dr. Harpreet Singh Grover, Dr. Shailly Luthra, Dr. ShrutiMaroo
•
ABSTRACT
The interrelation ship bet w een periodonta l and endodontic disease has aroused confusion, queries and
con troversy. The actual re lati onshi p between periodontal and pu lpal disease was first described by Simring and
Goldberg in 1964. Since then, the term "perio·endo" lesion has been used to describe lesions attri butable to
inf lam matory product s found in va rying degrees in both the periodontium and the pulpal tissues. Th e pulp and
period o ntium have embryon ic, anatomic and function al inter·relationsh ips. The simu ltaneou s existence of
pul pal problems and infl ammatory periodonta l disease can obscure diagnosis and treatment planning. A perio'
endo lesion can have a diverse pathogenesis which ranges from qu ite simple to somewhat complex. Knowledge
of th ese disease processes is essentia l in coming to the correct diagnosis. This is achievable by ca reful histo ry
taking, exam ination and the use of radiographs. Th e prognosis and treat'l1ent of each endodontic· periodontal
disease type vari es. Prim ary periodontal disease w ith secondary endodontic involvement and tru e combined
endodontic'periodont al diseases requ ire both en dodontic and periodonta l therapies. The prognosis of the se
cases equally depends on the severity of periodontal disease and the response to pe riodonta l treatmen t . Thi s
"-20Ies the operator to const r uct a suitable t reat ment plan w here unnecessary, prolonged or even detrimental
:",£=:.~ .... : 's avoided.
lCeyword5: ;; ~d "erio Lesions, Periodontal, Pu Ipal, Diagnosis, Treatment
,,- :;oc
-'c 0eriodontallesion t reatment is a ch allenge to the cl inician and treatment often requ ires a combined
therapeutic effort.
The cl assification of periodontal disorders by the American Academy of Periodontology, 1999', co ntain s
'periodontitis in connection with endodontallesions' (commonly referred to as perio-end a lesion s) as one ofthe
total of eight disorder groups. This is comprehended to mean pathological disorders that can be determ ined,
cl inically or through the use of radiographs, to be common t o both t he periodontium and the endodontium of a
tooth.
JIDA West Delhi· Dec. 2012

2. The relationship between periodontal and pulpal disease was fi rst described by simring and Goldberg in
1964-'since then, 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 dental pulp and periodontal
t issues are closely related . The pu lp originates from the dental papilla while the periodontal ligament from the
denta l fo ll icle and is sepa rated by Hertwig's epithelial root sheet As the toot h matu res and the root is formed,
thre e main apertures for exchange of infectious elements and other irrita nts bet ween the t wo compartments
are created by
(1) Dentinal tubules,
(2) l ateral and accessory canals, and
(3) The apica l foramen. When the pulp becomes inflamed/infected, it elicits an inflammatory response of the
pe riodonta l ligament at the apical foramen and/or adjacent to openings of accessory canals.'Noxious ele ments
of pulpal origin, includ ing inflammatory mediators and bacterial byproducts, may leach out through the apex,
lateral and accessory canals, as well as the dentinal tubules, triggering an inflammatory response in the
periodontium including a n early expression of antige n presentation.'
Periodontal and endodontal bacterial disorders are anaerobic mixed infections . In general as well as in
particular cases, this has been evident by, f ind ing extensive bacterial colonisation of periodonta l pocket s and
infected root canals time and again. s" .
Perio-endo lesions are often init ially not clinica lly visible or are accompanied by non-specific discomfort, such as
sensitivity when biting. Sometimes this may lead to fistula formation or an abscess. The diagnosis of perio-endo
lesions often results from coincidenta l findings, e.g. due to conspicuous ra diograph results and in particular du e
to significantly increased exploratory depths at one particular aspect of a tooth .•
The most commonly used classification was given by Simon, Glick and Frank in 1972" According to this
classification, perio-endo lesions can be classified into:
1. Primary endodontic lesion
2.
Primary periodontal lesion
3.
Pri mary endodontic lesion with secondary periodontal involvement
4.
Primary periodontal lesion with secondary endodontic involvement
5. True combin ed lesion
An acute exacerbation of a chronic apical lesion in a tooth with a necrotic pulp may drain coronally through th e
periodontal ligament into the gingiva l sulcus. This condition may clinically mimic a peri odonta l a bscess. Primary
endodontic lesions usua lly hea l follow ing root canal treatment. The sin us tract extending into the gingival sulcus
orfurcation area disappears at an early stage once the affected pulp has been removed and the root canals have
been well cleaned, sh aped and obturated. If, after a period of time, a suppurating primary endodontic disease
remains untreated, it may then become secondarily involved with marginal periodontal breakdown . Plaque
forms at the gingival margin of the si nus tract and leads to marginal periodontitis. The t ooth subseq uent ly
requires both endodontic and periodonta l treatment. Primary endodontic lesions with secondary periodonta l
involvement should first be treated w ith endodontic therapy followed by periodontal therapy. "'This reduces the
JIDA West Delhi- Dec. 2012

3. potential risk of introducing bacteria and their by-products duri ng the initial healing phase." If the endodontic
. treatment is adequate, the prognosis depends on the severity of the marginal periodontal damage and the
efficacy of the periodontal treatment. Wi t h endodontic treatment alone, only part of the lesion wil l heal to the
level ofthe secondary periodontal lesion.
While scaling and root planing remain the initial t reatment modalities in periodontal therapy, subgingival
curettage can be used as an adjunct along with routine endodontic treatment for treatment of this malady.
CASE REPORT
A 34-year-old female patient reported to the outpatient Department of SGT Dental College, Hospital and
Research Institute, Gurgaon with the chief complaint of pain for the last f ifteen days and a swelling since two
days in the lower right back region of the jaw. Patient did not give any releva nt medical history and there were no
underlying systemic conditions .
On intraoral examination, revealed grossly carious 45 along with an intraoral swelling present in relation with 45.
A radiograph was taken. 10PA also showed widening of periodontal ligament space in relation wi th the mesial
root and radiolucency in the furcation area. (Fig 1)
(Fig 1)
(Fig 2)
The horizontal probing depth (HPD) with Naber's probe and vertical probing depth (VPD) with the UNC-15 probe
were measured which were found to be 6 mm and 7 mm, respectively.
Endodontic treatment was taken up first under Local Anesthesia using Xylocaine with Adrenaline 1:200,000.
Access cavities were prepared.Cleaning and shaping of the canals was done w ith 5.25% sodium hypochlorite
irrigation and a single sitting Root Canal Treatment was completed and a temporary dressing was placed (Fig 2).
(Fig 3)
(Fig 4)
(FigS)
This was followed by Subgingival scafing along with subgingival curettage being performed in the same sitting.
(Fig 3) The patient was prescribed Ofloxacilin+ Ornidazole SOOmg B.D. for S days along with Ibuprofen 400 mg
B.D for 5 days .she was advised proper plaque control, using 0.2% chlorhexidine mouthwash twice daily for t wo
weeks. One week post operatively there was complete resolution of the abscess and a reduced probing de pt h or
JIDA West Delhi- Dec. 2012
•

4. 3mm. (Fi g:4) A post- operative 10PA X-ray revea led decreased radio lucency and bone fill in the furcation area in
j ust one week afte r the combined perio-endo treatment.(Fig: 5)
DISCUSSION :
Endo-perio lesions can persist if not treated properly. To obtain excellent results patient's case history with al l
possibl e ro utes, an accurate diagnosis and correct treatment pla n are necessa ry:Based on treatment plan,
Grossman (1988) classified endo -perio lesion s into 3 types:
Type 1- Requ iri ng endodontic treatment o nly;
•
Type 2 - Requiring periodontal treatment only and;
Typ e 3 - Requiring combin ed endo-perio treatm ent. "
As a consequence of the sha red root and anatomica lly predetermined connect ion paths between the
periodontium and the endodontium, a bacterial infection originating in one of these tis sues may tra nsfer to the
other. Endo-Perio lesion always poses a cha llenge to the cl inician for correct diagnosis and treatment planning.
The long-term prognosis after t reatment of perio-endo lesions is determined by correct prima ry diagnosis and
careful endodontic treatment, followed by periodontal treatment. It is imperative that both endodontic lesion
and periodonta Ilesion be addressed in dividually and se quentially.
CONCLUSION
In this case performing endodontic- pe rio dontal treatment of the tooth sequentially the lesion reduced and
subsided com pletely. Hence this case report demonstrates th e nature of periodontal lesion as a seconda ry
involvement to an origina Ily endodontic lesion involving the tooth. In th is case both endodontic and periodonta l
trea t ment s were carried out seq uentially in the same appointment resulting in shorter chair side time,
eliminating the need for a second separate appointment for periodontal surgica l procedures. Thus, t his li ne of
•
treatment may hold better prospect s of treating endodontic periodontal lesions in a shorter time.
BIBLIOGRAPHY
1.
American Academy of Periodontology. International workshop for a classification of periodontal diseases
and co nd itions. Ann PeriodontoI1999;4:1-112 .
2.
Th e pulpal pocket approach: Retrograde Periodontitis . Simring M, Goldberg M ..J PeriodontoI1964:35:2248
3.
The density and branchi ng of dentinal t ubu les in hu ma n teeth. Mjor lA, Nordahl !. Arch Ora l Bioi 1996:41:
401- 412.
4.
Shetty A, Ramachandra BK, Shubhashini NS, Anjali K, Niharika J. Diode Las er Assisted Management of
Endo-perio Lesion in Maxilla ry incisor using LANAP: A Case Report. International Dentistry SA 2010;12: 3843.
5.
Kip ioti A, Nakou M, Legakis N, Mitsis F. M icrobiologica l fi nd ings of infected root cana ls and adjacent
JIDA West Delhi- Dec. 2012
,