Jr.of Orofac. Scie.

1(1)2009

Journal of
OROFACIAL SCIENCES

Case Report
Endodontic Treatment In The Management Of Endodontic-Periodontic Lesions - A Case Report
K. Balakoti Reddy a*, Nagesh. Bollaa, Indira Priyadarshinia
a
Department of Conservative Dentistry & Endodontics, SIBAR Institute of Dental Sciences, Guntur, India.

ARTICLE INFO ABSTRACT

Article History : Occasionally periradicular lesions of endodontic origin may be radiographically
Received : 8 July 2009 indistinguishable from periodontal disease. Infected pulpal tissue and microbial
Received in revised form : 7 August 2009 by-products may move through accessory and furcal canals and cause loss of
Accepted : 28 August 2009 attachment in those areas. Accurate diagnosis may be particularly difficult when a
sinus tract originating from the endodontic lesion drains along the periodontal
Key Words : ligament space, giving the appearance of periodontal disease. Thorough diagnostic
Endo-Perio Lesion testing to confirm pulp necrosis or periodontal disease becomes critical when
Differential Diagnosis attempting to diagnose the specific disease entity accurately and then deliver suitable
Periodontal Disease treatment. This article describes the management of a patient presenting with a
combined endo-perio problem that was apparently treated adequately. However,
successful healing was obtained after thorough disinfection and sealing of the root
canal system.
©2009 SIDS.All Rights Reserved

INTRODUCTION : producing inflammation that is indistinguishable from

Endodontic periodontic relationship was first
described by Simring and Goldberg in 1964.Its the
spread of inflammation and infection from one
component to the other. 1 Pulpal and Periodontal
problems are responsible for more than 50% of tooth
mortality.2,3 The relationship between the pulp tooth and
the attachment apparatus of a tooth has been widely
documented (Simon et al, 1972; Paul B, Hutter JW,
1997; American Association of Endodontists newsletter,
2001). Most of the time periodontal inflammation due
to pulp space toxins occur in the apical region and thus
can readily be distinguished from a periodontal pocket.
However, occasionally necrotic infected tissue by-
products move through accessory or furcal canals,
* Corresponding author : Dr. K. Balakoti Reddy Professor,
Department Of Conservative Dentistry & Endodontics,
SIBAR Institute of Dental Sciences, Takkellapadu,
Guntur - 522 509.
periodontal disease9. The amount of tissue destruction
is directly correlated with the total microbial content in
the root canal system (Bystrom et al, 1987) and to the
length of time these tissues are exposed to the infecting
organism (Korzen et al, 1974). Differential diagnosis is
particularly difficult when a sinus tract originating from
the endodontic lesion may drain along the periodontal
ligament, giving the appearance of periodontal
breakdown (Simring M, Goldberg M, 1964; Seltzer et
al, 1967). Yamasaki et al (1994) have reported that
periradicular lesions may initially expand horizontally
through cancellous bone and then proceed
vertically.Analyzing a series of retrospective studies,
Blomlof et al (1993) concluded that endodontic
infection promotes periodontal pocket formation and
should be regarded as a risk factor in periodontitis
progression.4 Therefore, a primary endodontic lesion
draining through the attachment apparatus should be
treated initially by endodontic therapy (Zehnder M,
Hasselgren G, 2002)5. This must be confirmed by
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 Jr.of Orofac. Scie. 1(1)2009
accurate diagnostic tests to confirm pulp necrosis and
diagnostic probing (usually a precipitous drop in probe
depth is detected around a tooth) (Harrington, 1979).
CASE REPORT :
A 45 year old male patient was referred to the
Department of Conservative Dentistry & Endodontics
with a chief complaint of discomfort in mandibular right
first molar. He was known diabetic and was under
medication. On intra oral examination the tooth was
heavily restored and the tooth was tender on vertical
percussion with no mobility and there was a sudden drop
of periodontal probe indicating a deep periodontal
pocket of 10mm. The tooth was found to be not
responding to pulp testing. On radiographic examination
the tooth was heavily restored involving enamel, dentine
& pulp with periapical radiolucency. There was evidence
of bone loss on the distal root and the furcation area
(Fig 1). Thus a diagnosis of primary endodontic lesion
was established. Local anesthesia was given by inferior
alveolar nerve block of lidocaine 2% with epinephrine
1:100 000 (Lidocadren; Teva Ltd, Jerusalem, Israel) and
medium thickness rubber dam of 6x6 inches (Hygienic;
Coltene Whaledent) was placed. Access was achieved
using a round diamond bur (ISO 801001016, Komet,
and Lemgo, Switzerland). The pulp chamber was opened
& the canal was located. Working length determined
electronically using Dentaport ZX Apex locator (J.
Morita Mfg. Corp.japan) & confirmed radiographically
(Fig.2) as 21mm (Fig 2). Cleaning and shaping was
initiated using the crown-down technique with Gates-
Glidden drills (Dentsply-Maillefer, Ballaigues,
Switzerland) numbers 2-5 at the cervical and middle-
thirds of the root canals. The manual instrument size
15 was used to apical patency. The canal was negotiated
to the working length, as indicated by an apex locator
(Root ZX, J.Morita MFG Corp, Kyoto, Japan), with a
stainless steel size 15 hand file. Apical preparation was
performed by using ProFile (Tulsa Dental Products,
Tulsa, USA). The master apical file was size #30 for all
the root canals. Interappointment dressing of calcium
hydroxide was given. In the second appointment, as the
subjective symptoms were relived all canals were filled
with gutta-percha and AH26 sealer (Fig. 3) and the
opening cavity was sealed with Fuji IX (GC Corp.,
Tokyo, Japan). The post operative follow up after 6
months revealed no signs of pathosis with a pocket depth
of 3-4mm & radiographic evaluation showed radiopacity
at the distal root & furcation area that indicated
favourable healing and bone formation. (Fig:4).
Fig 1: Pre operative Fig 2: Working length
radiograph radiograph
Fig 3: Post obturation Fig 4: Post operative radiograph
radiograph after six months
DISCUSSION :
The periodontium and the pulpal have embryonic,
anatomic and functional interrelationship. They are
ectomesenchymal in origin, from which the cells
proliferate to form the dental papilla and follicle,
which are the precursors of the periodontium and the
pulp respectively. The embryonic development gives
rise to anatomical connections which remain
throughout the life of the tooth.6 As the tooth matures
and the root is formed, three main avenues for exchange
of infectious elements and other irritants between the
two compartments are created by (1) dentinal tubules,
(2) lateral and accessory canals, and (3) the apical
foramen.7
Classification of perio-endo lesions6
There are four types of perio-endo lesions and they
are classified due to their pathogenesis.
1. Endodontic lesions -an inflammatory process in the
periodontal tissues resulting from noxious agents
present in the root canal system of the tooth.
2. Periodontal lesions - an inflammatory process in the
pulpal tissues resulting from accumulation of dental
plaque on the external root surfaces.
3. True-combined lesions -both an endodontic and
periodontal lesion developing independently and
progressing concurrently which meet and merge at
a point along the root surface.
4. Iatrogenic lesions - Usually endodontic lesions
produced as a result of treatment modalities.6
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 Jr.of Orofac. Scie. 1(1)2009
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 often is the first clue in determining the
etiology of such a problem. Radiographic and clinical
evaluation can further clarify the nature of the problem.
In the preponderance of endodontic lesions, microflora
is the etiologic vector that dictates the clinical course of
the disease and therefore the treatment plan (Zehnder
M, Hasselgren G, 2002). On occasion, a sinus tract
originating from diseased apical tissues may drain
alongside the periodontal ligament, giving the
appearance of a periodontal pocket. After ruling out
fracture as the etiology, careful examination with a
periodontal probe should be done, not only at the site
of the lesion but also in the rest of the mouth. In addition,
a negative response to thermal challenge and lack of
mobility of the tooth may indicate that the lesion is
purely of endodontic origin. Thus root canal therapy
should be performed and periodontal therapy avoided,
or at least delayed, until one or two months after the
root canal has been performed (Blomlof et al, 1993),
and then only if the attachment apparatus does not seem
to be improving. Follow-up examination is crucial when
attempting to evaluate the prognosis of the treated tooth.
For primary endodontic lesions conventional endodontic
therapy alone will resolve the lesion. A review 4-6 months
post-operatively should show healing of the periodontal
pocket and bony repair. Surgical endodontic therapy has
been shown to be unnecessary even in the presence of
large periradicular radiolucencies and periodontal
abscesses. Invasive periodontal procedures should be
avoided as this may cause further injury to the
attachment - possibly delaying healing. If primary
endodontic lesions persist despite extensive endodontic
treatment it should arouse suspicions of an incorrect
diagnosis. The lesion may have secondary periodontal
involvement or be a true-combined lesion, the treatment
for which is outlined later. Primary endodontic lesions
with secondary periodontal involvement will not
completely resolve with endodontic treatment alone.
Root/re-root canal treatment is instituted immediately
and the cleaned and shaped root canal filled with calcium
hydroxide paste. As it is bactericidal, anti-inflammatory
and proteolytic it inhibits resorption and favours repair.
It also inhibits periodontal contamination of
instrumented canals via patent channels connecting the
pulp and periodontium before periodontal treatment
removes the contaminants. The canals are eventually
filled with a conventional obturation when
there is clinical evidence of improvement.
Conclusion:
In combined endodontic-periodontic lesions, it is
generally wise to treat the Endodontic component first,
because in many cases this will lead to complete
resolution of the problem. We can conclude that
endodontic lesions with involvement of the attachment
apparatus can be successfully healed by performing
adequate root canal treatment with great emphasis on
disinfection of the root canal system. Understanding the
mechanisms of bone destruction in these types of lesions
is of great importance when trying to achieve successful
healing.
References :
1) Simring M, Goldberg M. The pulp pocket approach:
retrograde periodontitis. J periodontal 1964:35:22-48.
2) Bender IB. Factors influencing radiographic appearance of
bony lesions. J Endod 8; 161-170,1982.
3) Chen SY,Wang HI,Clickman GN. The influence of
endodontic treatment upon periodontal wound healing. J Clin
periodontal24; 449-456,1997.
4) Blomlof L (1993) Relationship between periapical and
periodontal status. J Clin Periodontol 20: 117-23.
5) Jorge Vera, Martin Trope, Frederic Barnett and Kenneth S
Serota Endodontic Practice May 2006.
6) Mhairi R. Walker. The pathogenesis and treatment of endo-
perio lesions. CPD dentistry 2001: 2 (3): 9-95.
7) Ilan Roststein & James H. Simon .The endo-perio lesion: a
critical appraisal of the disease condition. Endodontic Topics
2006, 13, 34–56.
8) P. Carrotte F. Endodontics: Part 9 Calcium hydroxide, root
resorption, endo-perio lesions. British Dental Journal Volume
197 no. 12 December 25, 2004.
9) Gunnar Bernholtz. Interactions between pulpal and Periodontal
disease conditions: introduction. Endodontic Topics 2006,
13, 1–2.
10)Pradeep S. Anand,Nandakumar. Management of Periodontitis
Associated with Endodontically Involved Teeth: A Case Series.
The Journal of Contemporary Dental Practice, Volume 6, No.
2, May 15, 2005.
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