Indian J Dent Res, 21(4), 2010 579

Address for correspondence:

Dr. Nina Shenoy
E-mail: thedentist1@usa.net
Received : 20-09-09
Review completed : 26-01-10
Accepted : 29-04-10
REVIEW ARTICLE
Endo-perio lesions: Diagnosis and clinical considerations
Nina Shenoy, Arvind Shenoy
ABSTRACT
The interrelationship between periodontal and endodontic disease has aroused confusion,
queries and controversy. Differentiating between periodontal and endodontic problems can be
difficult. A symptomatic tooth may have pain of periodontal and/or pulpal origin. The nature
of that pain is often the first clue in determining the etiology of such a problem. Radiographic
and clinical evaluation can help clarify the nature of the problem. In some cases, the influence
of pulpal pathology may create periodontal involvement. In others, periodontal pathology
may create pulpal pathology. This review article discusses the various clinical aspects to be
considered for accurately diagnosing and treating endoperio lesions.
Key words: Endo-perio lesions, periodontal, pulpal, diagnosis
Department of Periodontics,
A B Shetty Institute of Dental
Sciences, Mangalore, India
Primary endodontic lesions
Primary endodontic lesions with secondary periodontal
involvement
Primary periodontal lesions
Primary periodontal lesions with secondary endodontic
involvement
True combined lesions
Classifcation as recommended by the World Workshop
for Classifcation of Periodontal Diseases (1999)
PERIODONTITIS ASSOCIATED WITH
ENDODONTIC DISEASE
Endodonticperiodontal lesion
Periodontalendodontic lesion
Combined lesion
From the point of view of treating these cases effcaciously,
a better clinical classifcation was provided by Torabinejad
and Trope in 1996.
[5]
Based on the origin of the periodontal pocket
Endodontic origin
Periodontal origin
Combined endoperio lesions
Separate endodontic and periodontal lesions
Lesions with communication
Lesions with no communication
Pathways connecting endodontic and periodontal
tissues
There are two forms of possible pathways for bacteria and
their products connecting the two tissues: Anatomical and
Non-physiological
[6]
[Figure 1].
The relationship between the pulp and the periodontium
has been extensively studied; however, queries regarding the
diagnosis, prognosis and treatment are raised time and again.
The pathways for the spread of bacteria between pulpal and
periodontal tissues have been discussed with controversy.
[1-3]

Pulpal infection can drain through the periodontal ligament
space and give an appearance of periodontal destruction,
termed retrograde periodontitis. Similarly, 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. This article is an attempt to provide a rational
approach to the perioendo/endoperio question in order
to scientifically diagnose and treat these lesions with
predictable success.
The most conventional classifcation used for endodontic
periodontal lesions was given by Simon et al. (1972),
[4]

separating lesions involving both periodontal and pulpal
tissues into the following groups:
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DOI:
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580 Indian J Dent Res, 21(4), 2010
Clinical diagnosis and management of endo-perio lesions Shenoy and Shenoy
Anatomical pathways
The major connections between periodontal and pulpal
tissues are the apical foramina. In addition to these main
avenues of communication, there are a multitude of
branches connecting the main root canal system with the
periodontal ligament. In addition to the apical foramina and
accessory canals, there is a third possible route for bacteria
and their products, the dentinal tubules.
[6]
Non-physiological pathways
Iatrogenic root canal perforations: They are serious
complications during dental treatment and have a rather
poor prognosis. Perforations may be produced by powered
rotary instruments during the attempt to gain access to the
pulp or during preparation for a post. Improper manipulation
of endodontic instruments can also lead to a perforation of
the root.
[7]
Vertical root fractures: The second group of artificial
pathways between periodontal and pulpal tissues are vertical
root fractures. Vertical root fractures are caused by trauma
and have been reported to occur in both vital and non-vital
teeth. In vital teeth, vertical fractures can be continuations
of coronal fractures in the cracked tooth syndrome, or can
occur solely on root surfaces.
[8]
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. This condition
may mimic, clinically, the presence of a periodontal
abscess.
[9]
In reality, it is a sinus tract from pulpal origin
that opens through the periodontal ligament area. For
diagnosis purposes, it is imperative for the clinician to 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.
PRIMARY ENDODONTIC LESIONS WITH
SECONDARY PERIODONTAL INVOLVEMENT
The root canal system primarily becomes infected as a
result of dental caries,
[10]
traumatic injuries and coronal
microleakage.
[11]
Pulp infammation or necrosis may lead
to an infammatory response in the periodontal ligament at
the apical foramen or foramina or at the site of a lateral or
accessory canal. The resulting infammatory lesion can range
in extent from a minimal infammatory process confned
to the periodontal ligament to extensive destruction of the
periodontal ligament, tooth socket and surrounding bone.
Such a lesion may result in a localized or diffuse swelling
that may occasionally involve the gingival attachment. A
lesion related to pulpal necrosis may also result in a draining
sinus tract that drains through the alveolar mucosa or
attached gingiva, but may occasionally drain through the
gingival sulcus of the involved tooth or through the gingival
sulcus of an adjacent tooth. After adequate root canal
treatment, lesions resulting from pulpal necrosis resolve an
exceptionally high percentage of the time.
[12]
The integrity of the periodontium will be reestablished if
root canal treatment is done well. If a draining sinus tract
through the periodontal ligament is present before root
canal treatment, resolution of the defect that can be probed
is expected [Figures 24].
PRIMARY PERIODONTAL DISEASE
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 prognosis depends on the stage of periodontal
disease and the effcacy of periodontal treatment.
[13]
PRIMARY PERIODONTAL DISEASE 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. In single-rooted teeth,
the prognosis is usually poor. In molar teeth, the prognosis
may be better.
[12]
The pulp response to cementum and dentin removal and
exposure of patent dentinal tubules by periodontal root
planing will vary with the remaining dentin thickness.
Unless dentin removal is excessive, pulp response will
be negligible. 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.
Unless periodontal disease has progressed to involve the
tooth apex, the effect of periodontal disease on the pulp
appears to be negligible.
[6]
Prognosis for a tooth involved
with periodontal disease is determined by the outcome
expected from periodontal therapy.
[9,12,13]
TRUE COMBINED DISEASE
These lesions occur when an endodontically induced
periapical lesion exists at a tooth that is also affected by
marginal periodontitis.
[9,12-17]
The two lesions can either
Indian J Dent Res, 21(4), 2010 581
Clinical diagnosis and management of endo-perio lesions Shenoy and Shenoy
merge or exist separately. Merged lesions form by ongoing
marginal attachment loss or by exacerbations of apical
periodontitis. Teeth with vertical root fractures also belong
to this category and have been found to have radiolucencies
involving the periodontal ligament in 75% of the cases.
True combined endodonticperiodontal disease occurs less
frequently than other endodonticperiodontal problems.
The degree of attachment loss in this type of lesion is
invariably large and the prognosis isguarded. 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. Sometimes, supplementary
surgical procedures are required. In most cases, periapical
healing may be anticipated following successful endodontic
treatment. The periodontal tissues, however, may not
respond well to treatment and will depend on the severity
of the combined disease. The application of guided tissue
regeneration (GTR)
[1822]
in periapical surgery has seen an
increase in recent years based on favourable outcomes
reported in periodontal applications. GTR in combined
lesions has been described in numerous case reports, which
generally result in clinical improvement.
CLINICAL DIAGNOSTIC PROCEDURES
Visual examination
A thorough 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 infammation, ulcerations or sinus tracts.
Frequently, the presence of a sinus tract is associated with
a necrotic pulp.
Palpation
Palpation is performed by applying frm digital pressure
to the mucosa covering the roots and apices. With the
index fnger 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.
[23]
Percussion
Although this test does not disclose the condition of the pulp,
it indicates the presence of a periradicular infammation.
An abnormal positive response indicates infammation of
the periodontal ligament that may be either from pulpal
or periodontal origin. The sensitivity of the proprioceptive
fbers in an infamed periodontal ligament will help identify
the location of the pain. This test should be performed
gently, especially in highly sensitive teeth.
Mobility
Tooth mobility is directly proportional to the integrity of
the attachment apparatus or to the extent of infammation in
the periodontal ligament.
[13]
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.
Radiographs
Interpretation of discrete periapical or lateral lesions and
discrete periodontal lesions is of clinical importance in
suggesting the cause of the lesion and the proper diagnostic
procedures to follow to confirm the cause.
[24-26]
Often,
the initial phases of periradicular bone resorption from
endodontic origin are confned only to cancellous bone.
Therefore, it cannot be detected unless the cortical bone is
also affected. However, when there is radiographic evidence
that bone loss extends from the level of crestal bone to or
near the apex of the tooth, the radiograph is of little value
in determining the cause.
[20-22]
Fistula tracking
Endodontic or periodontal disease may sometimes develop a
fstulous sinus track. Infammatory exudates may often travel
through tissues and structures of minor resistance and open
anywhere on the oral mucosa or facial skin. Intraorally, the
opening is usually visible on the attached buccal gingiva
or in the vestibule. Fistula tracking is done by inserting
a semirigid radiopaque material into the sinus track until
resistance is met. Commonly used materials include gutta-
percha cones or pre-softened silver cones. A radiograph is
then taken, which reveals the course of the sinus tract and
the origin of the infammatory process
[12,13]
[Figures 5 and 6].
Pulp testing
The most commonly used pulp vitality tests are cold test,
electric test, blood fow tests and cavity test. The presence
or absence of vital tissue in a tooth with a single canal can
be determined with confdence with the current pulp-
testing procedures. The same degree of confdence cannot
be ascribed to positive pulp test responses in a tooth with
multiple canals.
[23,27]
PERIODONTAL PROBING
Acute or "blow-out" lesions
When a patient presents with a localized swelling that
involves the gingival sulcus, it may be diffcult to determine
whether the swelling is due to a periodontal abscess or an
abscess of endodontic origin.
[12,28]
The tooth must be non-
vital. The swelling is usually on the labial side of the tooth
but may occasionally be on the lingual side. As the sulcus
is probed, there is usually normal sulcus depth all the way
around the tooth until the area of the swelling is probed.
At the edge of the swelling the probe drops signifcantly
to a level near the apex of the tooth and the probing depth
remains the full width of the swelling. At the opposite edge
of the swelling, probing is once again within normal limits.
582 Indian J Dent Res, 21(4), 2010
Figure 4: Complete healing after 6 months Figure 5: Clinical view of draining sinus in relation to 44 and 45
Figure 6: Sinus tracing with gutta-percha cone showing origin of sinus
at apex of 44
The width of the detached gingiva can be as broad as the
entire buccal or lingual surface of the tooth. This swelling
can be characterized as having "blown-out"
[24]
the entire
attachment on that side. Endodontic treatment only is
indicated. As the result of endodontic management of the
swelling, complete periodontal reattachment occurs within
1 week in most cases.
TYPICAL PERIODONTAL LESIONS
In periodontal disease, bone loss always begins at the crestal
bone level and progresses apically. The typical lesion is
conical in contour. The probing may start from a sulcus
depth that is within normal limits, then gradually step
down a slope to the apical extent of the lesion and then
step up again on the other side to a sulcus depth within
normal limits. Occasionally, the clinical presentation of a
periodontal lesion will have the sloping contour of a conical
lesion on one side but a more precipitous, sharp drop-off
on the other. Such probing should be considered to be of
the "periodontal type" of probing. A periodontal lesion will
not resolve in response to root canal treatment even if the
associated tooth is pulpless. The prognosis for a tooth with
conical-shaped probing must be based on the prognosis for
resolving the periodontal lesion. If it can be demonstrated
that a tooth is pulpless and if the periodontal prognosis is
favorable, root canal treatment should be completed before
periodontal therapy. In summary, conical-shaped probing
indicates periodontal pathosis.
Healty Pulp
Necratic
Infected Pulp
Apical Foramen
Vertical Root
Fracture
Apical Foramen
Vertical Root
Fracture
Healty
Periodontium
Infected
Periodontium
Apical Foramen
Vertical Root
Fracture
Figure 1: Pathways for communication between endodontic and
periodontal tissues Figures 2 and 3: Primary endodontic lesion treated endodontically
2 3
Clinical diagnosis and management of endo-perio lesions Shenoy and Shenoy
Indian J Dent Res, 21(4), 2010 583
LESIONS WITH NARROW SINUS TRACT-TYPE
PROBING
An apparent periodontal lesion may or may not be detectable
radiographically. Clinically, a lesion may be probed for some
distance down the root surface of the involved tooth but the
defect is in fact a sinus tract. Typically, on probing the sulcus
depth within normal limits, with the exception of one very
narrow area that can be probed some distance down the
root surface of the tooth, in many cases it can be probed all
the way to the apex of the tooth. Usually, the break in the
attachment is only about 1 mm wide, and probing 1 mm
to either side of the lesion will be within normal limits. A
lesion that probes in this manner is in fact a sinus tract, and
the probing represents a typical sinus tract type of probing.
The tooth is non-vital. Customary root canal procedures are
indicated. There is usually no need for curettage or surgical
intervention. It is strictly a sinus tract similar to a sinus tract
exiting in the alveolar mucosa or attached gingiva. When
a sinus tract occurs over the lateral root surface of a tooth,
it will respond to root canal treatment like any other sinus
tract. Typically, the orifce into such a sinus tract will close
within 1 week after the cleaning and shaping appointment.
Clinical considerations
A deep periodontal defect should always be suspected
to harbor bacteria and should therefore be treated
endodontically. If the remaining dentition is periodontally
healthy and a vertical root fracture has been ruled out,
healing of the attachment apparatus can be expected after
endodontic treatment without any periodontal treatment.
Lesion characteristics
Table 1 lists the critical lesion characteristics that
significantly contribute to the diagnostic process. A
systematic evaluative process goes a long way in accurate
diagnosis and treatment planning.
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.
[12,13,15,16]
When secondary disease is established and chronic, both
primary and secondary diseases must be treated. By and
large, endodontic therapy precedes periodontal therapy.
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. The resolution of extensive destruction
following the treatment of chronic periodontitis is less
predictable. It is important to realize that it is clinically not
possible to determine the extent to which one or the other
of the two disorders (endodontic or periodontal) has affected
the supporting tissues. Therefore, the treatment strategy
must be frst 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. Thus, periodontal therapy, including deep scaling
with and without periodontal surgery, should be postponed
until the result of the endodontic treatment can be properly
evaluated.
Sequencing treatment for endo-perio lesions
In acute cases, it is of paramount importance to diagnose the
source of the pain and/or swelling and delineate it to be and
endodontic or periodontal. This problem should be treated
frst as a priority. Follow soon after with other treatment.
The debate on which treatment should be initiated frst has
vexed dentists for long.
Periodontal treatment
It is a known fact that root canal infection signifcantly
affects periodontal healing. Pocket depth reduction is
signifcantly lesser in the presence of canal infection.
[29,30]
There is more marginal epithelium over cemental defects if
the canals are infected. Removal of cementum will expose
dentinal tubules, which means that if there are bacteria
in the canal, it could promote infammatory resorption. It
may also expose periodontal tissues to toxic medicaments if
used in canal. This is not so critical in areas with recession.
Table 1: Lesion characteristics and diagnostic features of endo-perio lesions
Lesion Pain Swelling Periodontal pocketing Radiographic Vitality
Primary endodontic Moderate to severe Possible None unless sinus tract Possible periapical radiolucency Non-vital
Primary endodontic secondary
periodontic
Moderate to severe Likely Evident or sinus tract Radiolucency from apex to
sulcus, decreased crestal bone
height
Non-vital
Primary periodontic None to moderate Possible Moderate Decreased crestal bone height Vital
Primary periodonticsecondary
endodontic
None unless acute endo Possible Severe Bone loss approaching apex Vital
Combined pulpalperiodontal Moderate to severe Likely Severe, connects with
periapex
Bone loss extending to apex Non-vital
Clinical diagnosis and management of endo-perio lesions Shenoy and Shenoy
584 Indian J Dent Res, 21(4), 2010
Endodontic treatment
Early initiation of endodontic treatment ensures that the
cementum layer is kept intact until root canal infection is
eliminated. Because there would be no exposed dentine on
the root surface, there is reduced chance of root resorption
and improved periodontal healing. On the other hand, if the
root canal flling does not have a good seal then the flled
canals may be reinfected from periodontal bacteria.
The risk of infection is heightened if periodontal treatment
is delayed, especially when a combined lesion with
communication exists between the two sites. Sterility is
more likely while there is a medicated dressing like calcium
hydroxide in the canal. Hence, in some cases, it might
be prudent to delay the root flling until the periodontal
infection has been eliminated.
Treating both lesions concurrently
This would be required when both endodontic and
periodontal infection are present simultaneously. Combined
endoperio lesions that exist separately on the same tooth
(meaning that they are not physically merged) have recently
gained a lot of attention. The true combined endodontic and
periodontic lesion requires an accurate diagnosis. This is
often a diffcult diagnosis and therefore requires reevaluation
after either the periodontal or endodontic problems are
treated. In such cases, if there is no communication,
then complete the endodontic therapy frst and initiate
periodontal treatment soon after.
When lesions communicate, it makes sense to commence
endodontic treatment first and medicate canals until
prognosis is known.
Abott,
[31]
in a detailed analysis on treatment considerations,
recommends the following protocol.
Initial management
Remove existing restorations and caries
Chemomechanically prepare canals
Medicate canals (depends on symptoms)
Follow-up management
Change intracanal dressing after 34 weeks
Provide initial periodontal treatment
Review healing after 3 months
Reassess need for further periodontal treatment
If more periodontal treatment (e.g., surgery) is required,
Change intracanal medication again
If healing response is favourable,
Complete root canal flling
Longer-term management
Defer root flling until after
Need for periodontal surgery assessed
Surgery completed with satisfactory outcome
Overall prognosis has been assessed to be adequate
enough to justify further endodontic and restorative
treatment and their costs
CONCLUSION
Treatment of combined endodontic and periodontal lesions
does not differ from the treatment given when the two
disorders occur separately. The part of the lesion sustained
by the root canal infection can usually be expected to resolve
after proper endodontic treatment. The part of the lesion
caused by the plaque infection may also heal following
periodontal therapy, although little or no regeneration of
the attachment apparatus can be expected. This suggests
that the larger the part of the lesion caused by the root
canal infection, the more favourable the prognosis is for
regeneration of the attachment.
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Source of Support: Nil, Confict of Interest: None declared.
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Clinical diagnosis and management of endo-perio lesions Shenoy and Shenoy
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