|Year : 2011 | Volume
| Issue : 2 | Page : 119-124
Combined endodontic - Periodontal lesion: A clinical dilemma
Pushpendra Kumar Verma1, Ruchi Srivastava2, KK Gupta2, Amitabh Srivastava2
1 Department of Conservative Dentistry and Endodontics, Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Periodontology and Implantology, Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh, India
|Date of Web Publication||17-Sep-2011|
Pushpendra Kumar Verma
Department of Conservative Dentistry and Endodontics, Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Endodontic-periodontal combined lesion is a clinical dilemma because making a differential diagnosis and deciding a prognosis are difficult. Lesions of the periodontal ligament and adjacent alveolar bone may originate from infections of the periodontium or tissues of the dental pulp. Periradicular bone loss secondary to endodontic pathosis is typically seen in teeth with necrotic pulps. The ultimate goal of periodontal therapy is not only to maintain the natural dentition, but also to restore lost periodontium. Combined periodontal and endodontic diseases involve the periodontal attachment apparatus. The treatment of endodontic-periodontal combined lesions requires both endodontic therapy and periodontal regenerative procedures. With advancements in new techniques and materials different treatment choices are available, providing a superior prognosis. This article includes case reports of combined endo-perio lesions which were first treated with conventional endodontic therapy and then followed by periodontal surgery. This combined treatment resulted in a radiographical evidence of alveolar bone gain. This case report demonstrates that proper diagnosis, followed by removal of etiological factors and utilizing the combined treatment modalities will restore health and function to the teeth with severe attachment loss caused by an endo-perio lesion.
Keywords: Combined endodontic-periodontal lesion, guided tissue regeneration, periradicular surgery
|How to cite this article:|
Verma PK, Srivastava R, Gupta K K, Srivastava A. Combined endodontic - Periodontal lesion: A clinical dilemma. J Interdiscip Dentistry 2011;1:119-24
|How to cite this URL:|
Verma PK, Srivastava R, Gupta K K, Srivastava A. Combined endodontic - Periodontal lesion: A clinical dilemma. J Interdiscip Dentistry [serial online] 2011 [cited 2019 Jun 19];1:119-24. Available from: http://www.jidonline.com/text.asp?2011/1/2/119/85034
| Introduction|| |
Preservation of the natural dentition is the ultimate goal of dental therapy. In periodontics, the goal is not only to maintain the natural dentition, but also to restore lost periodontium. Lesions of the periodontal ligament and adjacent alveolar bone may originate from infections of the periodontium or tissues of dental pulp.  Periradicular bone loss secondary to endodontic pathosis is typically seen in teeth with necrotic pulps. Combined periodontal and endodontic diseases involve the periodontal attachment apparatus. Pulpal necrosis may lead to destruction of the attachment apparatus by extension through the apical foramen or through accessory canals that may be located at different levels on the root surface. An acceptable treatment results, for combined endodontal and periodontal (endo-perio) lesions may be obtained by endo-perio therapy. However, when a significant loss of the periodontal attachment apparatus and osseous structure occurs, the long-term prognosis becomes poor. 
Formulating a differential diagnosis among combined lesions has been challenging. Therefore, diagnostic steps should include thorough patient-reported dental history, visual inspection for presence of sinus tract and severe inflammation in association with large restoration and anatomic anomalies such as palatal grooves,  radiographical confirmation with tracing the sinus track, results of clinical findings including percussion and palpation, routine periodontal assessment for presence of mobility or deep probing depth, testing for coronal cracks and pulp vitality testing.  These tests are customarily accepted as being reliable in differentiating between pulpal and periodontal disease.
This report presents a few cases in which no bone remained around the facial and apical areas of maxillary teeth, when a flap was raised. It was treated first with conventional endodontic therapy combined with periodontal regenerative procedures.
| Case Reports|| |
A 34-year-old female presented to Department of Periodontology and Implantology, Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh, with a complaint of pus discharge from maxillary central incisors. She was systemically healthy and medical history was not contributory to this dental problem. On clinical examination, probing depth was 12 mm on mesial aspect of 11 [Figure 1] and 8 mm on mesial of 21 [Figure 2]. Mobility was grade II in both teeth. The buccal gingiva showed slight swelling and clear signs of inflammation. The teeth did not respond to percussion and palpation tests. It neither responded to the electrical pulp test nor thermal tests. Periapical radiograph showed a deep bony defect extending to root apex of 11, 21, in addition to the periapical radiolucency [Figure 3]. Initial diagnosis was pulp necrosis and asymptomatic apical periodontitis, and the teeth were thought to have primary endodontic involvement. However, the pattern of periodontal bone loss, with a wide base, coupled with generalized marginal periodontitis, suggested that there was also primary periodontal involvement in this case.  Therefore, considering the dental history, clinical tests and radiographs, the diagnosis of this case was an endodontic-periodontal combined lesion, according to Simon classification 1972. 
First conventional root canal treatment was done, which was followed by periodontal surgery after 2 days. After local anesthesia, a mucoperiosteal papilla preservation flap was raised from distal to 12 to distal to 23. After raising the flap, severe osseous destruction was observed on facial surface of 11, 21 [Figure 4]. The buccal and mesial root surfaces and the apical area were root planed. The teeth had periodontal attachment remaining on lingual and distal surfaces. Transillumination revealed no apparent cracks or fracture. After thorough root planing and apical curettage, the large osseous defect was filled in a presutured flap with alloplastic bone graft (Periobone-G TM , Top-Notch Healthcare, Aluva, Kerala, India) covering the root surface [Figure 5]. The flap was repositioned and interrupted suturing was done with nonresorbable 3-0 silk suture material [Figure 6]. Antibiotics and analgesics were prescribed for 1 week. Patient was monitored on weekly schedule postoperatively, to ensure good oral hygiene in the surgerized area [Figure 7]. Supportive periodontal maintenance at 3 months was prescribed to maintain periodontal health and to re-evaluate this area. At 1-yr recall, the teeth were asymptomatic with successful healing, mobility was reduced to less than grade I and probing depth was minimal. The radiograph after 1yr follow-up, showed evidence of apparent bone fill with resolution of the osseous defect [Figure 8].
A 42-year-old female presented to Department of Conservative Dentistry and Endodontics, Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh, with a complaint of discoloration and pus discharge from right maxillary lateral incisor. She had no contributory medical history. On clinical examination, probing depth on distal aspect of the tooth was 12mm [Figure 9], mobility was grade I. The buccal gingiva showed sinus opening in relation to 12. The tooth did not respond to percussion and palpation tests. The tooth was non responsive to pulp vitality tests. Periapical radiograph showed radiolucency to the root apex of tooth 12 [Figure 10]. Therefore, considering the dental history, clinical tests, and radiographs, the diagnosis was combined endodontic-periodontal lesion, according to Simon classification 1972. 
First conventional root canal treatment was done and after 2 days periodontal surgery was performed. After local anesthesia, a mucoperiosteal flap was raised. After raising the flap, severe 3-wall osseous destruction was observed on distal surface of tooth 12 [Figure 11]. After thorough root planing and apical curettage, the defect was filled with alloplastic bone graft (Periobone-G TM , Top-Notch Healthcare Products Pvt Ltd, Aluva, Kerala, India) and a resorbable guided tissue regeneration (GTR) membrane (Periocol-GTR TM , Eucare Pharmaceuticals, Chennai, India) [Figure 12],[Figure 13],[Figure 14],[Figure 15]. The flap was repositioned and interrupted suturing was done with nonresorbable 3-0 silk suture material. Postoperative evaluation was done same as in previous case. At 1-yr recall, radiograph showed evidence of apparent bone fill with resolution of the osseous defect [Figure 16].
| Discussion|| |
Endodontic-periodontal lesion is a clinical manifestation of the pathologic/inflammatory intercommunication between pulpal and periodontal tissues via open structures such as apical foramina, lateral, accessory canals, and dentinal tubules.  On the basis of the pathologic origin, Simon et al.  classified endodontic-periodontal lesions into primary endodontic lesions, primary endodontic lesions with secondary periodontic involvement, primary periodontic lesions, primary periodontic lesions with secondary endodontic involvement, or true combined lesions. Bone loss secondary to pulpal pathosis is believed to result from the spread of inflammatory irritants from the pulp to the periodontal ligament.  The treatment of endodontic-periodontal combined lesions requires both endodontic therapy and periodontal regenerative procedure, as discussed in this case report. The goal of periradicular surgery is to remove all necrotic tissues from the surgical site, to completely seal the entire root canal system, and to facilitate the regeneration of hard and soft tissues including the formation of a new attachment apparatus. 
It is interesting to note that there was no radiographic or clinical evidence of preexisting deep decay in either of the teeth, and no cracks were evident. The most common clinical/radiographic features of these endodontic-periodontal lesions reported were the periapical radiolucency and deep pocket depths with a nonvital pulp status.
Traditional approaches to treat periodontal and endodontic defects include nonsurgical debridement of root surfaces or root canals, as well as surgical approaches that provide better access to clean the root surfaces and apical lesions and to reshape the surrounding bone/root apex.
Bone loss caused by pulpal disease is reversible, whereas advanced bone loss caused by periodontal disease is usually irreversible.  The necessity of periodontal surgical therapy most likely was because the periodontal bone loss was more advanced and was less likely to resolve after non surgical root canal therapy alone. 
Generally, partial apical root resection has been suggested for all endodontic surgery caused by the multiple apical canals to the pulp.  In this case report, root canal debridement and removal of granulation tissue around the root and apex was done, without subsequent root resection and retrograde filling. However, periradicular curettage was the sole procedure for the following reasons: (a) periapical curettage is able to remove the granulation tissue without root resection;  (b) there is no difference in healing with curettage alone or curettage with root-end resection more dentinal tubules may remain open after root-end resection, allowing more contaminants to leak out through the tubules.  However, in case-2, using the GTR membrane technique, combined with bone graft, the result was clinically successful after a 1yr follow-up period. The role of bone graft in both the cases was for space-making and also for inducing bone formation and the attachment gain seen in these cases.
A long junctional epithelium formed over the dehisced root surface has been suggested to be a contributing factor for the poor therapeutic prognosis. The rationale for using GTR barrier membranes in case 2 with bone grafting materials is to encourage the growth of key surrounding tissues, while excluding unwanted cell types such as epithelial cells.  GTR therapy has been implemented in the endodontic surgeries as a concomitant treatment during the management of the endodontic-periodontal lesions.
However, from clinical and radiographic findings, the result of this combined technique was quite impressive, resulting in a significant reduction of probing depth and bone fill. Selecting a defect that is amenable to regeneration is also critical for achieving success. This is also true for an endodontic defect. Some of the patient factors that might contribute to positive outcome includes the good plaque control, compliance, nonsmoking, anti-infective therapy and systemic health.
Other factors that might also negatively affect the healing process include occlusal trauma, improper surgical technique (such as excessive flap tension), early mechanical disruption, and contamination during surgery. Wang and Boyapati  suggested 4 factors, the so-called PASS principle, that are critical for predictable bone regeneration: primary wound closure, angiogenesis as a blood supply and source of undifferentiated mesenchymal cells, space maintenance, and stability of the wound. Space maintenance involves the creation of space for periodontal tissues to grow into; which was achieved in these cases with a bone graft.
| Conclusion|| |
Although traditional nonsurgical periodontal therapy and regular endodontic therapy can be predictably used to arrest mild to moderate defects, it might be inadequate for the treatment of disease characterized by deep pockets or wide circumferential apical defects. Currently, regenerative techniques are widely available in terms of their predictability to regenerate the lost tissue/bone in all types of defects or for all situations. A careful preoperative diagnosis, appropriate case selection and knowledge of the factors that can negatively affect regeneration outcomes can help to optimize successful regenerative attempts. Treatment strategies used in this case report suggests that combined endodontic-periodontal lesions can be successfully managed with multiple regenerative procedures.
| References|| |
|1.||Meng HX. Periodontic-endodontic lesions. Ann Periodontol 1999;4:84-90. |
|2.||Skoglund A, Persson G. A follow-up study of apicoectomized teeth with -up total loss of buccal bone plate. Oral Surg Oral Med Oral Patho11985;59:78-81. |
|3.||Schwartz SA, Koch MA, Deas DE, Powell CA. Combined endodontic-periodontic treatment of a palatal groove: A case report. J Endod 2006;32:573-8. |
|4.||Peters DD, Baumgartner JC, Lorton L. Adult pulpal diagnosis: I-evaluation of the positive and negative responses to cold and electrical pulp tests. J Endod 1994;20:506-11. |
|5.||Rotstein I, Simon JH. Diagnosis, prognosis and decision-making in the treatment of combined periodontal-endodontic lesions. Periodontol 2000 2004;34:165-203. |
|6.||Simon JH, Glick DH, Frank AL. The relationship of endodontic-periodontic lesions. J Periodontol 1972;43:202-8. |
|7.||Barkhordar RN, Stewart GG. The potential of periodontal pocket formation with untreated accessory root canals. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1990;70:769-72. |
|8.||Karabucak B, Setzer FC. Conventional and surgical retreatment of complex periradicular lesions with periodontal involvement. J Endod 2009;35:1310-5. |
|9.||Law AS, Beaumont RH. Resolution of furcation bone loss associated with vital pulp tissue after nonsurgical root canal treatment of three-rooted mandibular molars: A case report of identical twins. J Endod 2004;30:444-7. |
|10.||Bashutski JD, Wang HL. Periodontal and endodontic regeneration. J Endod 2009;35:321-8. |
|11.||Zehnder M, Gold SI, Hasselgren G. Pathologic interactions in pulpal and periodontal tissues. J Clinic Periodontol 2002;29:663-71. |
|12.||Gilheang PA, Figdor D, Tyas MJ. Apical dentin permeability and microleakage associated with root end resection and retrograde filling. J Endod 1994;20:22-6. |
|13.||Oh SL, Fouad AF, Park SH. Treatment strategy for guided tissue regeneration in combined endodontic-periodontal lesions: Case report and review. J Endod 2009;35:1331-6. |
|14.||Wang HL, Boyapati L. ''PASS'' principles for predictable bone regeneration. Implant Dent 2006;15:8-17. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16]