This document discusses laser induced biostimulation as a potential treatment for endo-perio lesions. It presents a case study of a patient with an endo-perio lesion on tooth #32 who was treated with both endodontic and periodontal procedures in the same appointment using a 980nm diode laser. The laser was used for canal disinfection, new attachment procedure and hemostasis. At the 1 month recall the patient was asymptomatic with healed sinus tract and reduced pocket depths. Follow-ups showed continued healing over 4 years. The conclusion is that laser treatment may be an effective way to simultaneously treat endo-perio lesions in a shorter time.

1. Presented by
Dr.AJINS CB
LASER INDUCED BIO
STIMULATION: A POSSIBLE
HEALING PROSPECT IN ENDO-
PERIO LESION

2. INTRODUCTION
• Endo-perio lesion" are the lesions in which inflammatory products
involves both pulpal and periodontal tissues in varying degrees. The
relationship between endodontic and periodontal diseases was first
described by Simring and Goldberg.
• There are anatomic and non-physiological pathways of communication
between the pulp and the periodontium. The most conventional
classification of endodontic-periodontal lesion was given by Simon et al.
in 1972.
• Lasers have been used successfully in endodontic as well as periodontal
procedures.
It is essential to treat the periodontal defect simultaneously with an
adequate endodontic therapy to improve the functional ability of the
tooth and to prevent its re-occurrence.

3. CASE REPORT
• Chief complaint: A 40yr old male patient reported to the dental
speciality with chief complaint of discomfort and pus discharge
from his mandibular left lateral incisor, which he had experienced
since last few months.
• Intraoral examination: loss of stippling and draining sinus was
observed in the attached gingiva with respect to 32. Periodontal
probing depths were measured using a William’s graduated
periodontal probe with increased probing depth suggesting
localized periodontitis. Electric pulp test and cold test were
performed to check for tooth vitality with a negative response,
which confirmed that the tooth was non-vital.

4. RADIOGRAPHIC EXAMINATION
• Radiographic examination: peri-
apical radiograph showed
radiolucency involving the periapical
area with radiolucency extending to
the lateral surface of the root .

5. DIAGNOSIS
• A diagnosis of endodontic periodontal lesion was
established and classified according to Grossman’s
classification 1988[6] as a primary endodontic
lesion with secondary periodontal involvement in
relation to 32.

6. TREATMENT
• Treatment planning was done taking into consideration that the
tooth was non-vital along with concurrent periodontal lesion.
• Subgingival scaling was performed. Access cavity was prepared
in relation to 32 using endo access bur .

7. • Cleaning and shaping of the canals was done by crown-down
approach using ProTaper — Universal rotary files (Dentsply
Maillefer, with 5.25% of sodium hypochlorite irrigation. Canal
disinfection was done using laser with 200 μm optical fiber
(Kavo Gentleray 980 Diode Laser

8. • The canal was dressed with calcium hydroxide (UltraCal XS; Ultradent, South
Jordan, UT, USA) as intracanal medicament and access cavities were sealed
with intermediate restorative material cement.
• New attachment procedure was performed on the same appointment using a
980 nm Diode laser with optical fiber thickness 300 μm.
• The laser was aligned exactly parallel to the root and the entire interior of
pocket was brushed with the distal end of optical fiber at 1-1.5 W power,
which completed debridement of the pocket, hemostasis was achieved and
created a soft clot and a closed system.

9. The tissue was compressed against the root surface for about 1-2 min to
close the pocket and stabilize the fibrin clot.
No graft was placed. Occlusion was checked.
Post-operative instructions were given to the patient with proper plaque
control and 0.12% of chlorhexidine mouthwash for rinsing twice a day.

10. • Patient was recalled after 2 days. The
absence of pain or signs of
inflammation indicated that the root
canal treatment could be completed.
Obturation was done using Gutta-
percha and AH Plus sealer (De Trey-
Dentsply, Konstanz, Germany).
Access cavity was restored using a
high strength glass ionomer
restoration

11. • Patient was recalled after 1 month.
• At 1 month recall, patient was asymptomatic with
healed sinus tract. Periodontal probing showed pocket
depth within physiological limits as measured by a
Williams graduated periodontal probe. Peri-apical
radiograph after 4 years follow-up revealed increased
apical density indicating healing

12. AT ONE MONTH
RECALL
AT ONE YEAR FOLLOW UP
AT TWO YEARS
FOLLOW UP
AT SIX
YEARS
FOLLOW UP

13. DISCUSSION
• Endo-perio lesions are the clinical
conditions that are often difficult to
diagnose and persistent if not treated
appropriately. The diagnosis must be
based on a combination of the history
obtained from the patient, the clinical
examination findings, the radiographic
observations and the results of all tests
and investigations, in particular, pulp
sensibility tests (both thermal and
electric) and periodontal probing.

14. • A correct diagnosis helps in formulating the correct treatment plan. The risk
of impaired healing due to bacteria and its byproducts in the endo-perio
lesions is reduced if adequate endodontic therapy is done followed by
proper periodontal therapy.
• With endodontic treatment alone, only part of the lesion will heal to the
level of the secondary periodontal lesion. Overall prognosis depends on the
severity of periodontal damage and the efficacy of the periodontal
treatment. Although scaling and root planning remain the initial treatment
modalities in periodontal therapy, the use of a softtissue diode laser can be
considered as an efficacious adjunct to conventional periodontal therapy.

15. • The use of a diode laser in soft-tissue procedures are
advocated because it helps in bacterial decontamination,
promotes reestablishment of connective tissue attachment and
are less invasive nature, which reduces post-operative swelling

16. CONCLUSION
• Based on the above study it can be
concluded that endoperio lesions always
possess a challenge to the clinician for
correct diagnosis and treatment planning.
Although there may be difficulties in
establishing a correct diagnosis, this is the
most important phase of their
management as this will determine the
type and sequence of treatment required.
Soft-tissue diode laser is more effective
and less traumatic than conventional
surgical methods

17. • In this case, both endodontic and periodontal treatments were
carried out in the same appointment resulting in shorter chair
side time. This line of treatment with the biostimulating
properties of lasers may hold better prospects of treating
similar endodontic periodontal lesions more predictably in a
shorter time

18. REFERENCES
• Simring M, Goldberg M. The pulpal pocket approach.
Retrograde periodontitis. J Periodontol
• Zehnder M, Gold SI, Hasselgren G. Pathologic interactions in
pulpal and periodontal tissues.
• Simon JH, Glick DH, Frank AL. The relationship of endodontic-
periodontic lesions. J Periodontol