This document discusses endo-perio lesions, which involve both endodontic and periodontal tissues. It defines endo-perio lesions as involving pulpal disease and destruction of the attachment apparatus from the gingival sulcus to the apex. There are anatomical and non-anatomical pathways connecting the tissues. Lesions are classified based on whether the primary involvement is endodontic or periodontal. Diagnostic procedures and appropriate treatment depend on accurately distinguishing the primary pathology. Treatment may involve endodontic therapy, periodontal therapy, or both depending on the classification and extent of disease.

1. ENDO-PERIO LESIONS
Mohamed Rabie’ Ahmed

2. INTRODUCTION
• The endodontium and periodontium are closely related and diseases of one tissue
may lead to secondary diseases in the other.
• The differential diagnosis of endodontic and periodontal diseases can sometimes be
difficult but it is important to make a correct diagnosis so that the appropriate
treatment can be provided.

3. • Pulpal infection can drain through the periodontal ligament space and give an
appearance of periodontal destruction, termed retrograde periodontitis.
• Both pulpal and periodontal infections can coexist in the same tooth, termed
combined lesions, where the treatment depends on the degree of involvement of the
tissues.
• Both endodontic and periodontal diseases are caused by a mixed anaerobic infection.

4. DEFINITION
• The tooth involved must have pulpal disease
• 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

5. PATHWAYS CONNECTING ENDODONTIC AND
PERIODONTAL TISSUES
• There are two forms of possible pathways for bacteria and their products connecting
the two tissues:
1. Anatomical pathways
2. Non-physiological pathways

6. ANATOMICAL PATHWAYS
A) Apical foramen
B) Lateral and accessory canals
C) Dentinal tubules

7. NON-PHYSIOLOGICAL PATHWAYS
“IATROGENIC”
A. Iatrogenic root canal perforations

8. NON-PHYSIOLOGICAL PATHWAYS
“IATROGENIC”
B. Vertical root fractures

9. NON-PHYSIOLOGICAL PATHWAYS
“PATHOLOGIC”
A. Externanl Resorption
B. Trauamtic fractures
C. Developmental grooves
A
B
C

10. CLASSIFICATION
• The most conventional classification used for endodontic-periodontal lesions was
given by Simon et al. (1972):
1. Primary endodontic lesions
2. Primary endodontic lesions with secondary periodontal involvement
3. Primary periodontal lesions
4. Primary periodontal lesions with secondary endodontic involvement
5. True combined lesions

11. PRIMARY ENDODONTIC LESION
• An acute exacerbation of a
chronic apical lesion on a
tooth with a necrotic pulp
may drain coronally
through the periodontal
ligament into the gingival
sulcus.

12. PRIMARY ENDODONTIC LESION
• For diagnosis purposes, insert a gutta-percha cone into
the sinus tract and to take one or more radiographs to
determine the origin of the lesion.
• When the pocket is probed, it is narrow and lacks
width.
• Primary endodontic diseases usually heal following
root canal treatment.

13. PRIMARY ENDODONTIC LESIONS WITH
SECONDARY PERIODONTAL INVOLVEMENT
• The root canal system primarily becomes infected as
a result of dental caries, traumatic injuries and
coronal microleakage.
• Pulp inflammation or necrosis may lead to an
inflammatory response in the periodontal ligament
at the apical foramina or at the site of a lateral or
accessory canal.

14. PRIMARY ENDODONTIC LESIONS WITH
SECONDARY PERIODONTAL INVOLVEMENT
• Long-term existence of the defect has
resulted in deposits of plaque and calculus
in the pocket with subsequent advancement
of the periodontal disease.
• After adequate root canal treatment, The
integrity of the periodontium will be
reestablished.

15. PRIMARY PERIODONTAL LESIONS
• These lesions are primarily caused by periodontal pathogens.
• In this process, chronic periodontitis progresses apically along the
root surface.
• In most cases, pulp tests indicate a clinically normal pulpal
reaction.
• There is frequently an accumulation of plaque and calculus and
the pockets are wider.
• The pulp may remain vital but may show some degenerative
changes over time.

16. PRIMARY PERIODONTAL LESIONS WITH
SECONDARY ENDODONTIC INVOLVEMENT
• The apical progression of a periodontal pocket
may continue until the apical tissues are
involved.
• In this case, the pulp may become necrotic as a
result of infection entering via lateral canals or
the apical foramen.

17. PRIMARY PERIODONTAL LESIONS WITH
SECONDARY ENDODONTIC INVOLVEMENT
• Although the pulp is exposed to a bacterial challenge
through patent dentinal tubules, it is quite capable of
repair and healing.
• Production of reparative dentin and reduced canal
diameter may result, but pulp tissue remains
relatively unaffected.

18. TRUE COMBINED LESIONS
• These lesions occur when an endodontically induced
periapical lesion exists at a tooth that is also affected by
marginal periodontitis.
• The tooth has a pulpless, infected root canal system and a co-
existing periodontal defect.
• This is particularly true in single-rooted teeth. In molar
teeth, root resection can be considered as a treatment
alternative if not all roots are severely involved

19. CLINICAL DIAGNOSTIC PROCEDURES
1. Visual examination
• visual examination of the lips, cheeks, oral mucosa,
tongue, palate and muscles should be carried out .
• The alveolar mucosa and the attached gingiva are
examined for the presence of inflammation,
ulcerations or sinus tracts.

20. CLINICAL DIAGNOSTIC PROCEDURES
2. Palpation
• With the index finger the mucosa is pressed
against the underlying cortical bone .
• This will detect the presence of periradicular
abnormalities or ''hot'' zones that produce painful
response to digital pressure .

21. CLINICAL DIAGNOSTIC PROCEDURES
3. Percussion
• An abnormal positive response indicates
inflammation of the periodontal ligament that may
be either from pulpal or periodontal origin .
• The sensitivity of the proprioceptive fibers in an
inflamed periodontal ligament will help identify the
location of the pain .
• This test should be performed gently, especially in
highly sensitive teeth .

22. CLINICAL DIAGNOSTIC PROCEDURES
4. Mobility
• Tooth mobility is directly proportional to the integrity of the attachment
apparatus or to the extent of inflammation in the periodontal ligament.
• Hypermobility is quite common in cases of primary endodontic involvement
and should not be confused with true mobility caused by periodontal
destruction.
• In cases of primary endodontic pathology, the mobility resolves within a
week of initiating endodontic therapy.

23. CLINICAL DIAGNOSTIC PROCEDURES
5. Radiographs
• Identification of proximal crestal bone & its
position in relation to CEJ
• 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

24. CLINICAL DIAGNOSTIC PROCEDURES
6. Pulp testing
• Cold test, electric test, blood flow tests and cavity test.
• The presence or absence of vital tissue in a tooth with a single
canal can be determined with confidence with the current
pulp-testing procedures.
• The same degree of confidence cannot be ascribed to positive
pulp test responses in a tooth with multiple canals.

25. TREATMENT PROTOCOL
• In general, when primary disease of one tissue, i.e. pulp or periodontium, is present
and secondary disease is just starting, treat the primary disease.
• When secondary disease is established and chronic, both primary and secondary
diseases must be treated.
• Periodontal therapy may or may not be required, depending on disease status.
• The complete healing of destroyed periodontal support can be expected following the
treatment of pulpal pathology.

26. TREATMENT PROTOCOL
• The treatment strategy must be first to focus on the pulpal infection and to perform
debridement and disinfection of the root canal system.
• The second phase includes a period of observation, whereby the extent of
periodontal healing resulting from the endodontic treatment is followed.
• Reduced probing depth can usually be expected within a couple of weeks while bone
regeneration may require several months before it can be radiographically detected.

27. MANAGEMENT OF PRIMARY ENDO LESION
• Root canal therapy
• Sinus into gingival sulcus / furcation area disappears once root canals cleaned,
shaped & obturated

28. MANAGEMENT OF PRIMARY PERIO LESION
• Hygiene phase therapy Oral prophylaxis, oral hygiene instructions, Scaling, root
planing, Periodontal surgery
• Removal of cementum will expose dentinal tubules, so minimize use of ultrasonics
and rotary scaling instruments when <2 mm of dentin thickness remaining

29. MANAGEMENT OF PRIMARY ENDO
SECONDARY PERIO
• Root canal therapy >> Multi visit endo.
• Evaluate 2-3mnths >> Perio therapy if required.
• Intracanal medicament found reduce inflammation & favoring repair.
• Aggressive removal of PDL & cementum during interim endodontic therapy may
adversely affect Healing.

30. MANAGEMENT - PRIMARY PERIO
SECONDARY ENDO & COMBINED LESIONS

31. RESECTIVE APPROACHES
A. Root amputation
B. Hemisectioning
C. Bicuspidization

32. REPARATIVE (REGENERATIVE THERAPY)
A. Guided tissue regeneration (GTR).

33. B. Bone grafting

34. REFERENCES
• Jansson L, Ehnevid H, Lindskog S, Blomlφf L. The influence of endodontic infection
on progression of marginal bone loss in periodontitis. J Clin Periodontol
1995;22:729-73.
• Jansson L, Ehnevid H, Blomlφf L, Weintraub A, Lindskog S. Endodontic pathogens
in periodontal disease augmentation. J Clin Periodontol 1995;22:598-602
• Jansson L, Ehnevid H, Lindskog S, Blomlφf L. Relationship between periapical and
periodontal status. A clinical retrospective study. J Clin Periodontol 1993;20:117-
23.
• Simon JH, Glick DH, Frank AL. The relationship of endodontic-periodontic lesions.
J Periodontol 1972;43:202-8.