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Endo-Perio Lesion: INDIAN DENTAL ASSOCIATION

WEST DELHI

An Interdisciplinary Approach To Solve The Dilemma Of Which Came First

-The Chicken Or The Egg?

Dr. Harpreet Singh Grover, Dr. Shailly Luthra, Dr. ShrutiMaroo •

ABSTRACT

The interrelationship between periodonta l and endodontic disease has aroused confusion, queries and

controversy. The actual re lationship between periodontal and pu lpal disease was first described by Simring and

Goldberg in 1964. Since then, the term "perio·endo" lesion has been used to describe lesions attri butable to

inf lammatory product s found in va rying degrees in both the periodontium and the pulpal tissues. The pulp and

periodontium have embryon ic, anatomic and functional inter·relationsh ips. The simu ltaneous existence of

pulpal problems and infl ammatory periodonta l disease can obscure diagnosis and treatment planning. A perio'

endo lesion can have a diverse pathogenesis which ranges from qu ite simple to somewhat complex. Knowledge

of these disease processes is essentia l in coming to the correct diagnosis. This is achievable by ca reful histo ry

taking, examination and the use of radiographs. Th e prognosis and treat'l1ent of each endodontic· periodontal

disease type varies. Prim ary periodontal disease w ith secondary endodontic involvement and tru e combined

endodontic'periodontal diseases requ ire both en dodontic and periodonta l therapies. The prognosis of these

cases equally depends on the severity of periodontal disease and the response to pe riodonta l treatment. This

"-20Ies the operator to const ruct a suitable t reat ment plan w here unnecessary, prolonged or even detrimental

:",£=:.~ .... : 's avoided.

lCeyword5: ;; ~d "erio Lesions, Periodontal, Pu Ipal, Diagnosis, Treatment

,,- :;oc -'c 0eriodontallesion t reatment is a ch allenge to the cl inician and treatment often requ ires a combined

therapeutic effort.

The classification of periodontal disorders by the American Academy of Periodontology, 1999', co ntains

'periodontitis in connection with endodontallesions' (commonly referred to as perio-end a lesion s) as one ofthe

total of eight disorder groups. This is comprehended to mean pathological disorders that can be determined,

cl inically or through the use of radiographs, to be common to both t he periodontium and the endodontium of a

tooth.

JIDA West Delhi· Dec. 2012

The relationship between periodontal and pulpal disease was fi rst described by simring and Goldberg in

1964-'since then, the term, 'perio-endo lesion' has been used to describe lesions due to inflammatory products

found in varying degrees in both the periodontium and the pulpal tissues. The dental pulp and periodontal

t issues are closely related . The pu lp originates from the dental papilla while the periodontal ligament from the

denta l fo ll icle and is separated by Hertwig's epithelial root sheet As the toot h matures and the root is formed,

three main apertures for exchange of infectious elements and other irri tants between the two compartments

are created by

(1) Dentinal tubules,

(2) l ateral and accessory canals, and

(3) The apica l foramen. When the pulp becomes inflamed/infected, it elicits an inflammatory response of the

pe riodonta l ligament at the apical foramen and/or adjacent to openings of accessory canals.'Noxious elements

of pulpal origin, includ ing inflammatory mediators and bacterial byproducts, may leach out through the apex,

lateral and accessory canals, as wel l as the dentinal tubules, triggering an inflammatory response in the

periodontium including a n early expression of antigen presentation.'

Periodontal and endodontal bacterial disorders are anaerobic mixed infections. In general as well as in

part icular cases, this has been evident by, f ind ing extensive bacterial colonisation of periodonta l pocket s and

infected root canals time and again. s" .

Perio-endo lesions are often ini t ially not clin ica lly visible or are accompanied by non-specific discomfort, such as

sensitivity when biting. Sometimes this may lead to fistula formation or an abscess. The diagnosis of perio-endo

lesions often results from coincidenta l findings, e.g. due to conspicuous radiograph results and in particular due

to significantly increased exploratory depths at one particular aspect of a tooth .•

The most commonly used classification was given by Simon, Glick and Frank in 1972" According to this

classification, perio-endo lesions can be classified into:

1. Primary endodontic lesion

2. Primary periodontal lesion

3. Pri mary endodontic lesion with secondary periodontal involvement

4. Primary periodontal lesion with secondary endodontic involvement

5. True combined lesion

An acute exacerbation of a chronic apical lesion in a tooth with a necrotic pulp may drain coronally through the

periodontal ligament into the gingiva l sulcus. This condition may clinically mimic a peri odonta l a bscess. Primary

endodontic lesions usua lly hea l following root canal treatment. The sin us tract extending into the gingival sulcus

orfurcation area disappears at an early stage once the affected pulp has been removed and the root canals have

been well cleaned, sh aped and obturated. If, after a period of time, a suppurating primary endodontic disease

remains untreated, it may then become secondarily involved with marginal periodontal breakdown. Plaque

forms at the gingival margin of the sinus tract and leads to marginal periodontitis. The t ooth subsequent ly

requires both endodontic and periodonta l treatment. Primary endodontic lesions with secondary periodonta l

involvement should first be treated w ith endodontic therapy followed by periodontal therapy. "'This reduces the

JIDA West Delhi- Dec. 2012

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potential risk of introducing bacteria and their by-products duri ng the initial healing phase." If the endodontic

. treatment is adequate, the prognosis depends on the severity of the marginal periodontal damage and the

efficacy of the periodontal treatment. Wi t h endodontic treatment alone, only part of the lesion wil l heal to the

level ofthe secondary periodontal lesion.

While scaling and root planing remain the initial t reatment modalities in periodontal therapy, subgingival

curettage can be used as an adjunct along with routine endodontic treatment for treatment of this malady.

CASE REPORT

A 34-year-old female patient reported to the outpatient Department of SGT Dental College, Hospital and

Research Institute, Gurgaon with the chief complaint of pain for the last f ifteen days and a swelling since two

days in the lower right back region of the jaw. Patient did not give any relevant medical history and there were no

underlying systemic conditions .

On intraoral examination, revealed grossly carious 45 along with an intraoral swelling present in relation with 45.

A radiograph was taken. 10PA also showed widening of periodontal ligament space in relation wi th the mesial

root and radiolucency in the furcation area. (Fig 1)

(Fig 1) (Fig 2)

The horizontal probing depth (HPD) with Naber's probe and vertical probing depth (VPD) with the UNC-15 probe

were measured which were found to be 6 mm and 7 mm, respectively.

Endodontic treatment was taken up first under Local Anesthesia using Xylocaine with Adrenaline 1:200,000.

Access cavities were prepared.Cleaning and shaping of the canals was done w ith 5.25% sodium hypochlorite

irrigation and a single sitting Root Canal Treatment was completed and a temporary dressing was placed (Fig 2).

(Fig 3) (Fig 4) (FigS)

This was followed by Subgingival scafing along with subgingival curettage being performed in the same sitting.

(Fig 3) The patient was prescribed Ofloxacilin+ Ornidazole SOOmg B.D. for S days along with Ibuprofen 400 mg

B.D for 5 days .she was advised proper plaque control, using 0.2% chlorhexidine mouthwash twice daily for t wo

weeks. One week post operatively there was complete resolution of the abscess and a reduced probing dept h or

JIDA West Delhi- Dec. 2012 • -

3mm. (Fig:4) A post- operative 10PA X-ray revea led decreased radio lucency and bone fill in the furcation area in

just one week afte r the combined perio-endo treatment.(Fig: 5)

DISCUSSION :

Endo-perio lesions can persist if not treated properly. To obtain excellent results patient's case history with al l

possible routes, an accurate diagnosis and correct treatment plan are necessary:Based on treatment plan,

Grossman (1988) classified endo-perio lesions into 3 types:

• Type 1- Requ iring endodontic treatment only;

Type 2 - Requiring periodontal treatment only and;

Type 3 - Requiring combin ed endo-perio treatment. "

As a consequence of the shared root and anatomica lly predetermined connect ion paths between the

periodontium and the endodontium, a bacterial infection originating in one of these tissues may transfer to the

other. Endo-Perio lesion always poses a cha llenge to the cl inician for correct diagnosis and treatment planning.

The long-term prognosis after t reatment of perio-endo lesions is determined by correct primary diagnosis and

careful endodontic treatment, followed by periodontal treatment. It is imperative that both endodontic lesion

and periodonta Ilesion be addressed individually and sequentially.

CONCLUSION

In this case performing endodontic- pe riodontal treatment of the tooth sequentially the lesion reduced and

subsided com pletely. Hence this case report demonstrates the nature of periodontal lesion as a secondary

involvement to an origina Ily endodontic lesion involving the tooth. In th is case both endodontic and periodonta l

treat ments were carried out sequentially in the same appointment resulting in shorter chair side time,

eliminating the need for a second separate appointment for periodontal surgica l procedures. Thus, t his li ne of •

treatment may hold better prospect s of treating endodontic periodontal lesions in a shorter time.

BIBLIOGRAPHY

1. American Academy of Periodontology. International workshop for a classification of periodontal diseases

and co nd itions. Ann PeriodontoI1999;4:1-112.

2. Th e pulpal pocket approach: Retrograde Periodontitis . Simring M, Goldberg M . .J PeriodontoI1964:35:22-

48

3. The density and branching of dentinal t ubu les in human teeth. Mjor lA, Nordahl !. Arch Ora l Bioi 1996:41:

401- 412.

4. Shetty A, Ramachandra BK, Shubhashini NS, Anjali K, Niharika J. Diode Laser Assisted Management of

Endo-perio Lesion in Maxilla ry incisor using LANAP: A Case Report. International Dentistry SA 2010;12: 38-

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5. Kipioti A, Nakou M, Legakis N, Mitsis F. M icrobiologica l find ings of infected root cana ls and adjacent

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