Anda di halaman 1dari 10

[Downloaded free from on Monday, March 17, 2014, IP: 202.62.16.

238]  ||  Click here to download free Android application for this journal

Invited Review Endo‑perio lesion: A dilemma from 19th until

21st century
Abhishek Parolia, Toh Choo Gait1, Isabel C. C.M. Porto2, Kundabala Mala3
Faculty of Dentistry, Divison of Oral Clinical Sciences, 1School of Dentistry, International Medical University, Kuala
Lumpur, Malaysia, 2Department of Restorative Dentistry, Cesmac University Center, Maceió, Alagoas, Brazil,
Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Manipal University,
Mangalore, Karnataka, India

Address for correspondence: Dr. Abhishek Parolia, E‑mail:

The interrelationship between endodontic and periodontal diseases has been a subject of speculation, confusion and controversy
for many years. Pulpal and periodontal problems are responsible for more than 50% of tooth mortality today. An endo‑perio
lesion can have a varied pathogenesis which ranges from quite simple to relatively complex one. These lesions often present
challenges to the clinician as far as diagnosis and prognosis of the involved teeth are concerned. It is very essential to make a
correct diagnosis so that the appropriate treatment can be provided. To make a correct diagnosis the clinician should have a
thorough understanding and scientific knowledge of these lesions and may need to perform restorative, endoontic or periodontal
therapy, either singly or in combination to treat them. Therefore, this presentation will highlight the diagnostic, clinical guidelines
and decision‑making in the treatment of these lesions from an Endodontist’s point of view to achieve the best outcome.


• Perio‑endo lesions are very complex in nature and can have a varied pathogenesis.
• Treatment decision‑making and prognosis depend primarily on the diagnosis of the specific endodontic and/or periodontal diseases.
• To have the best prognosis, clinician should refer the case to various areas of specialization, to perform restorative,
endodontic or periodontal therapy, either singly or in combination. Therefore, to achieve the best outcome for these
lesions, a multi‑disciplinary approach should be involved.

Key words: Diagnosis, endo‑perio lesions, management

INTRODUCTION today.[1] They present challenges to the clinician as

far as diagnosis and prognosis of the involved teeth

T he pulp‑periodontal interrelationship is a
unique one and can consider them as a
single continuous system or as one biologic unit in
are concerned. It is very essential to make a correct
diagnosis so that the appropriate treatment can be
provided. The relationship between the periodontium
which there are so many paths of communication. and the pulp was first discovered by Simring and
The interrelationship of these structures influences Goldberg in 1964.[1] Since then, the term ‘perio‑endo
each other during health, function and disease. lesion’ has been used to describe lesions due to
They can get affected individually or combined; inflammatory products found in varying degrees in
when both systems are involved they are called true both periodontium and pulpal tissues.
endo‑perio lesions. Endodontic‑periodontal problems
are responsible for more than 50% of tooth mortality The pulp and periodontium have embryonic, anatomic
and functional interrelationship. There are various
pathways for the exchange of infectious elements
Access this article online
and irritants from the pulp to periodontium or vice
Quick Response Code:
versa, leading to the development of endodontic periodontal lesions.[2,3]

Pathways of developmental origin (anatomical

10.4103/2229-5194.120514 pathways):
• Apical foramen, accessory canals/lateral canals

2 Journal of Interdisciplinary Dentistry / Jan-Apr 2013 / Vol-3 / Issue-1

[Downloaded free from on Monday, March 17, 2014, IP:]  ||  Click here to download free Android application for this journal

Parolia, et al.: Endo ‑ perio

• Congenital absence of cementum exposing dentinal of microorganisms, duration of the disease and the host
tubules defense mechanism. Similarly, the reverse of the effect
• Developmental grooves of a necrotic pulp on the periodontal ligament, has been
referred to as retrograde pulpitis.[5]
Pathways of pathological origin:
• Empty spaces on root created by Sharpey’s fibers Over the past century, the dental literature has
• Root fracture following trauma consistently reflected a controversy related to the effect
• Idiopathic root resorption ‑ internal and external of periodontal disease on the dental pulp. It has been
• Loss of cementum due to external irritants. found that the pulp has a quite sophisticated vasculature
system with a network of capillary beds, precapillary
Pathways of iatrogenic origin: sphincters and arteriovenous shunts, which provides a
• Exposure of dentinal tubules following root planning significant capacity for the pulp to survive. From clinical
• Accidental lateral root perforation during endodontic observations, it is rare to find a virgin tooth (no decay,
procedures restorations, fracture, perforation) with evidence of
• Root fractures during endodontic procedures. periapical pathosis for which cause for the pulp becoming
necrotic cannot be determined. Many studies have
The main etiological factors for endo‑perio lesions are demonstrated that periodontal disease or sequelae of
living (bacteria, fungi and viruses) and nonliving pathogens. periodontal treatment does not affect the pulp.[6‑8] On
Along with these, many contributing factors such as trauma, the other hand, studies have suggested that the effect
root resorptions, perforations, and dental malformations of periodontal disease on the pulp is atrophic and
also play an important role in the development and degenerative in nature including a decrease in number of
progression of such lesions[4,5] [Figure 1]. The condition of pulp cells, an increase in dystrophic calcifications, fibrosis,
the pulp is an important factor in susceptibility to microbial as well as a direct inflammatory affect.[9‑11] Therefore,
invasion. A vital pulp is very resistant to microbial invasion. periodontal disease and periodontal treatments should
Penetration of the surface of a healthy pulp by oral bacteria be regarded as potential causes of pulpitis and pulpal
is relatively slow or may be blocked entirely. In contrast, necrosis’. [12] However, It has been advocated that
a necrotic pulp is rapidly invaded and colonized by periodontal disease has no effect on the pulp, unless it
bacteria. When the pulp becomes necrotic, inflammatory extends all the way to the tooth apex, the dental pulp is
byproducts of pulpal origin may leach out through these capable of surviving significant insults and that the effect
pathways and initiate/trigger an inflammatory vascular of periodontal disease as well as periodontal treatment
response in the periodontium, cause destruction of on the dental pulp is negligible.[13]
periodontal tissue fibers, resorption of adjacent alveolar
bone and cementum. Nature and extent of periodontal Though there are many conflicting studies abound,
destruction depends on various factors such as virulence Harrington et al.[14] mentioned another parameter which

Figure 1: Etiological and contributing factors in endo‑perio lesions

Journal of Interdisciplinary Dentistry / Jan-Apr 2013 / Vol-3 / Issue-1 3

[Downloaded free from on Monday, March 17, 2014, IP:]  ||  Click here to download free Android application for this journal

Parolia, et al.: Endo ‑ perio

may influence our clinical impressions related to the the other. Recently, von Arx and Cochran[22] proposed a
dental pulp, and indeed many of our misinterpretations, clinical treatment classification of perio‑endo‑furcation
from early histological observations. They explained the lesions based on the role of membrane application in
importance of adequate fixation of pulp tissue as it has endodontic surgery. Singh[23] classified endo‑perio lesions
always been, and continues to be, a challenge, and artifacts based on the pathogenesis and added the term iatrogenic
resulting from inadequate fixation continue to be described lesions, usually endodontic lesions produced as a result
as evidence of pathosis. They recommended careful of treatment modalities. There are many classifications for
reviewing of the papers published prior to 1975, as well as endo‑perio lesions, but for differential diagnostic purposes,
some written since if their descriptions of perceived pulp the so‑called ‘endo‑perio lesions’ are best classified as
pathosis are in fact simply histological artifacts. endodontic, periodontal, or a combined disease.[24] These
lesions can also be classified by treatment depending
Historically the effect of periodontal disease on the dental on whether endodontic, periodontal, or combined
pulp has been a source of discussion but recently the
treatment modalities are needed. All these classifications
effect of pulpal necrosis on the initiation and progression
are mainly based on the theoretic pathways explaining
of marginal bone loss has been discussed.[13] The potential
how these radiographic lesions are formed. Therefore, by
effect of a tooth with a necrotic pulp or a tooth with
comprehensive understanding of the pathogenesis and
previous root canal treatment has been taken into account
investigations, the clinician can make a sound diagnosis,
as a risk factor in the initiation, progression of periodontal
formulate an appropriate treatment plan and assess the
disease, and the resolution of periodontal pockets.
prognosis of these lesions.
Many studies have stated that a pulpless tooth with a
periapical lesion promotes the initiation of periodontal
pocket formation, progression of periodontal disease, DIAGNOSIS
and interferes with healing of a periodontal lesion after
periodontal treatment.[15‑17] It has also been found that Nomenclature distinguishes between lesions caused by
the periapical trauma may occur by over instrumentation periodontal pathogens, as seen in chronic periodontitis,
during shaping and cleaning of the root canal, extrusion and lesions of the apical periodontal tissues associated with
of irrigants, sealer and gutta percha points that may endodontic pathology. When the location is distinct and the
hinder new bone, cementum and connective tissue repair. lesion is discrete, the two are easy to differentiate. When
Therefore, precautions should be taken when periodontal they simultaneously affect the marginal and apical areas of
therapy has to be followed by endodontic treatment. the periodontium, thus making it essential to ascertain their
true cause through differential diagnosis.[25] If a patient has
been monitored over a period of time diagnosis of primary
endodontic disease and primary periodontal disease
usually can be easily done; once the lesions progress
to their final stage, they usually give similar clinical and
The first classification of endodontic‑periodontal lesions
radiographic appearance and the differential diagnosis
based on pathology of origin was proposed by Simon
becomes more challenging. For example, a similar in
et al.[18] as follows:
clinical and radiographic features will be seen with both, a
• Primary endodontic lesions
growing periapical lesion with secondary involvement of
• Primary periodontal lesions
• Primary endodontic lesions with secondary periodontal periodontal tissues and a longstanding periodontal lesion
involvement that has progressed to the apex.
• Primary periodontal lesions with secondary endodontic
It is easier to determine the origin of the lesion when a
pulp vitality test is positive because this will rule out an
• True combined lesions.
endodontic etiology. However, pulp tests may not be
Though Simon et al. have classified these lesions into always reliable. This consideration is particularly relevant
five types but actually three, four and five can be when challenges to pulpal status arise from periodontal
considered as combined lesions. There have been many diseases such as partial necrosis of a pulp in a multirooted
classifications suggested by several other authors such tooth due to long standing periodontal lesions. If pulpal
as “independent periodontal and endodontic lesions”[19] necrosis is associated with inflammatory involvement of
or “concomitant pulpal and periodontal lesions”[20,21] to the periodontal tissue, it presents a greater diagnostic
describe endo‑perio lesions. In contrast to combined problem. In this situation, the location of these pulpal
perio‑endo lesions, concomitant pulpal and periodontal lesions is most often at the apex of the tooth, but they may
lesions reflect the presence of two separate and distinct also occur at any site where lateral and furcal canals exit
disease states with different causative factors and with into the periodontium.[26] Therefore, accurate diagnosis can
no clinical evidence that one disease state has influenced be made by careful history taking, thorough oral hard and

4 Journal of Interdisciplinary Dentistry / Jan-Apr 2013 / Vol-3 / Issue-1

[Downloaded free from on Monday, March 17, 2014, IP:]  ||  Click here to download free Android application for this journal

Parolia, et al.: Endo ‑ perio

soft tissue examination, the use of pulp testing procedures The following steps help in diagnosing the exact lesion
and periodontal probing.[19] [Table 1].

Table 1: Diagnostic procedures used to identify the endo-perio lesion

Examination/tests Primary endodontic lesion Primary periodontal Primary endodontic Primary periodontal True combined
lesion secondary periodontal secondary lesionorconcomitant pulpal
endodontic and periodontal lesions
Visual (magnifying loupes Soft tissue‑presence of sinus Inflamed gingiva/gingival Plaque forms at the Presence of plaque, Plaque, calculus and
and operative microscope opening recession around multiple gingival margin of subgingival calculus periodontitis will be
can be effective) Tooth‑presence of decay/ teeth the sinus tract and and swelling around present in varying degrees
large restoration/fractured Accumulation of plaque leads to inflammation multiple teeth Swelling around single or
restoration or tooth/ and subgibgival calculus of marginal gingiva Presence of pus, multiple teeth
erosions/abrasions/cracks/ around multiple teeth exudate exudate Presence of pus, exudate
discolorations/poor RCT Intact teeth Root perforation/ Presence of
fracture/misplaced localized/
Presence of swelling
post generalized gingival
indicating periodontal
abscess recession and
exposure of root
Pain Sharp Usually dull ache Usually sharp shooting Usually dull ache Dull ache usually
Sharp only in acute Dull ache in chronic Sharp only in acute Only in acute conditions it
condition conditions periodontal abscess is severe
Palpation (a positive It does not indicate whether Pain on palpation Pain on palpation Pain on palpation Pain on palpation
response to palpation may the inflammatory process is
indicate active periradicular of endodontic or periodontal
inflammatory process) origin
Percussion (it indicates the Normally tender on The sensitivity of the Tender on percussion Tender on Tender on percussion
presence of a periradicular percussion proprioceptive fibers in percussion
inflammation that may be an inflamed periodontal
either from pulpal or PDL ligament will help identify
origin) the location of the pain
Mobility (tooth mobility is Fractured roots and recently Localized to generalized Localized mobility Generalized mobility Generalized mobility with
directly proportional to the traumatized teeth often mobility of teeth higher grade of mobility
integrity of the attachment present high mobility related to the involved
apparatus or to the extent tooth
of inflammation in the PDL
Pulp vitality using cold test, A lingering The pulp is vital and Pulp vitality tests Pulp vitality may Usually negative because
electric test, blood flow response‑irreversible pulpitis responsive to testing negative be positive in of non‑vital pulp. Vitality
tests, and cavity test (an No response‑necrotic multirooted teeth tests may give a positive
abnormal response may pulp (non‑vital) response in multirooted
indicate degenerative teeth
changes in the pulp)
Pocket probing A deep narrow solitary Multiple wide and deep Presence of Presence of multiple Probing reveals the typical
pocket in the absence of pockets solitary wide wide and deep conical periodontal type of
periodontal disease may pocket [Figure 2a‑d] periodontal pockets probing with the exception
indicate the presence of a but if periodontal that at the base of the
lesion of endodontic origin or lesion is due to periodontal lesion, the
a vertical root fracture fracture of root then probe will abruptly drop
solitary deep narrow further down the lateral
pocket (mainly root surface and may even
localized) extend to the apex of the
Sinus tracing (by inserting A radiograph with gutta Sinus tract mainly at the Sinus tract mainly at Sinus tract mainly at Difficult to trace out the
a semi rigid radiopaque percha points to apex or lateral aspect of the root the apex or furcation the lateral aspect of origin of the lesion, if a
material into the sinus tract furcation area in molars area the root sinus tract is present, it
until resistance is met) may be necessary to raise
a flap to determine the
etiology of the lesion
Radiographs Presence of deep carious Vertical bone loss and Presence of deep Angular bone loss in The radiographic
lesions/extensive or defective more generalized than carious lesions/ multiple teeth with a appearance of combined
restorations/previous poor to lesions of endodontic extensive or defective wide base coronally endodontic–periodontal
root canal treatment/possible origin restorations/previous and narrow at the disease may be similar to
mishaps/root fractures/root Bone loss wider coronally poor root canal apex of the root that of a vertically fractured
resorption with peripical treatment/diminution tooth
radiolucency of the pulp canal space/
Often, the initial phases of possible mishaps/root
periradicular bone resorption fractures [Figure 3a and
from endodontic origin is b]/root resorption with a
confined only to cancellous wide base radiolucency
bone. Therefore it cannot be around the apex of the
detected unless the cortical root [Figure 4a‑e]
bone is also affected
Cracked tooth testing using Painful response to the No symptoms Painful response to the No symptoms Painful response to the
transillumination wedging patient at the time of patient at the time of patient at the time of
staining chewing, especially on chewing, especially chewing, especially
releasing the biting pressure on releasing the biting on releasing the biting
pressure pressure
RCT= Root canal therapy, PDL= Periodontal ligament

Journal of Interdisciplinary Dentistry / Jan-Apr 2013 / Vol-3 / Issue-1 5

[Downloaded free from on Monday, March 17, 2014, IP:]  ||  Click here to download free Android application for this journal

Parolia, et al.: Endo ‑ perio

TREATMENT AND PROGNOSIS OF Primary endodontic lesions

ENDO‑PERIO LESIONS Primary endodontic diseases usually heal following root
canal therapy. The outcome of endodontic treatment is
Treatment decision‑making and prognosis depend primarily influenced by the presence of microorganisms within the
on the diagnosis of the specific endodontic and/or periodontal root canal system. Good prognosis is to be expected if
disease [Table 2]. The main factors to consider are pulp vitality treatment is carried out properly with a focus on infection
and the type and extent of the periodontal defect. control. The sinus tract extending into the gingival sulcus

Table 2: Treatment map of endodontic-periodontal lesions

















6 Journal of Interdisciplinary Dentistry / Jan-Apr 2013 / Vol-3 / Issue-1

[Downloaded free from on Monday, March 17, 2014, IP:]  ||  Click here to download free Android application for this journal

Parolia, et al.: Endo ‑ perio

or furcation area disappears at an early stage once the as primary endodontic lesions. Primary periodontal
affected pulp has been removed and the root canals lesions should be treated by hygiene phase therapy
well cleaned, shaped, and obturated. In case of tooth in the first instance. Subsequently, poor restorations
with large periapical lesion, orthograde endodontic and developmental grooves that are involved in the
therapy has been advised instead of surgical endodontic lesion must be removed. Periodontal surgery should be
therapy.[27,28] Placement of intra‑canal medicaments such performed after the completion of hygiene phase therapy
as calcium hydroxide has found to be very effective in if deemed necessary. Since, the presence of an intact
the healing of large periapical lesion. Calcium hydroxide cementum layer is important for the protection of the
works in many ways, [29] chemically it damages the pulp and vigorous surgical periodontal procedures may
microbial cytoplasmic membrane by the direct action remove cementum and expose dentinal tubules, which in
of hydroxyl ions, suppresses enzyme activity, disrupts turn transport irritants, thereby cause pulpal inflammation
the cellular metabolism and inhibits deoxyribonucleic and necrosis of the dental pulp. Therefore, clinicians should
acid (DNA) replication by splitting DNA. Physically it acts take precautions during periodontal therapy and avoid the
as a physical barrier that fills the space within the canal use of irritating chemicals, minimize the use of ultrasonics
and prevents the ingress of bacteria into the root canal and rotary scaling instruments when <2 mm of dentin
system. It also kills the remaining micro‑organisms by thickness remaining. Judicious use of periodontal surgical
withholding substrates for growth and limiting space for intervention is advantageous to treat this lesions.[35]
multiplication. Biologically it encourages the periapical
hard tissue healing around teeth with infected canals, Primary endodontic with secondary
inhibits root resorption and stimulates periapical healing periodontal lesions [Figure 2]
after trauma.[30‑34]
The treatment and prognosis of the tooth with these
lesions are different from those of teeth involved with
Primary periodontal lesions
only primary endodontic disease. The prognosis for
Primary periodontal disease should only be treated by treatment of primary endodontic disease with secondary
periodontal therapy. In this case, the prognosis depends periodontal involvement depends primarily on the
on the severity of the periodontal disease, efficacy of severity of periodontal involvement. Tooth with these
periodontal therapy and patient response; however, lesions should first be treated with endodontic and
prognosis of primary periodontal lesions is not as favorable simple hygiene phase therapy. In this case, multi‑visit
endodontics should be practiced and the placement of
intracanal medicament was found to be very useful in
reducing inflammation and favoring repair.[36] Treatment
results should be evaluated in 2‑3 months and only then
further periodontal treatment should be considered. This
sequence of treatment allows sufficient time for initial

a b

c d
Figure 2: Primary endodontic lesion with secondary periodontal
involvement.  (a) Clinical picture showing maxillary right first molar
with the presence of palatal swelling with 7mm deep periodontal b
pocket mimicking primary periodontal lesion. (b) Radiograph showing Figure 3: Primary endodontic secondary periodontal lesion. (a) Intraoral
presence of deep coronal restoration and mesial caries approaching periapical radiograph showing root canal treated maxillary left first
the pulp with periapical radiolucency, confirming primary endodontic premolar with radiolucency along the root. Clinically, a deep narrow
lesion. (c) Radiograph showing completion of root canal therapy in pocket was found on the mesial aspect of the root suggesting the
maxillary molar with periapical healing. (d) Clinical picture showing presence of vertical root fracture. (b) Clinical view of the extracted tooth
complete resolution of periodontal pocket showing two fractured fragments of the tooth

Journal of Interdisciplinary Dentistry / Jan-Apr 2013 / Vol-3 / Issue-1 7

[Downloaded free from on Monday, March 17, 2014, IP:]  ||  Click here to download free Android application for this journal

Parolia, et al.: Endo ‑ perio

a b

c d e
Figure 4: Patient complained of pus discharge from gums in between central incisors. Patient gave a history mild impact trauma on mandibular
anterior 10 years ago. (a) Clinical picture showing the presence of sinus opening in between central incisors. (b) Radiograph of mandibular
anterior teeth showing the presence of large radiolucency in between central incisors with a wide base at the apex suggesting primary endodontic
lesion (both centrals did not respond to vitality tests). (c) Radiograph showing initiation of root canal therapy and placement of calcium hydroxide
as an intracanal medicament. (d) Radiograph showing completion of root canal treatment. (e) Radiograph showing healing after 1 year

tissue healing and better assessment of the periodontal It has been recognized that the success of the treatment
condition. [37,38] It also reduces the potential risk of depends mainly on immediate sealing of the perforation
introducing bacteria and their byproducts during the initial and appropriate infection control. Several materials such as
phase of periodontal healing. In this regard, it has been mineral trioxide aggregate, reinforced zinc oxide‑eugenol
suggested that aggressive removal of the periodontal cementglass ionomer cements and Vitremer have been
ligament and underlying cementum during interim recommended to seal root perforations. [40‑42] Root
endodontic therapy may adversely affect periodontal fractures may also present as primary endodontic lesions
healing, therefore, should be avoided.[39] But in cases with secondary periodontal involvement. These typically
where healing with only endodontic therapy does not occur on root‑treated teeth, often with post and crowns.
occur then both endodontic and periodontal treatments Treatment depends on the tooth type, extent, duration
should be carried out since with endodontic treatment and location of fracture, for example, single rooted tooth
alone, only part of the lesion may heal up to the level with lesions caused by vertical root fracture has a hopeless
of the secondary periodontal lesion. If the endodontic prognosis and should be extracted[43] while molars can
treatment is adequate, the prognosis depends on the be treated by root resection or hemisection.[44] However,
severity of the marginal periodontal damage and the many case reports are described in literature where many
efficacy of periodontal treatment. Primary endodontic innovative techniques to treat and retain anterior teeth
lesions with secondary periodontal involvement may have been attempted with varying success. Clinician
also occur as a result of iatrogenic damage such as root have either removed the fractured segment or attempted
perforation or fracture during root canal treatment or to bond the root using a biocompatible material.[45‑48]
placement of pins or posts. Root perforations are treated Therefore, before considering any complex or extensive
according to their aetiology. The outcome of the treatment restructure treatment, the desirability for retention of
of root perforations depends on the size, location, time of the tooth root should be carefully weighed up against
diagnosis and treatment, degree of periodontal damage as extraction and replacement with a denture, bridge or
well as the sealing ability and biocompatibility of the sealer. implant.

8 Journal of Interdisciplinary Dentistry / Jan-Apr 2013 / Vol-3 / Issue-1

[Downloaded free from on Monday, March 17, 2014, IP:]  ||  Click here to download free Android application for this journal

Parolia, et al.: Endo ‑ perio

Primary periodontal secondary endodontic and healing categories.[57] The pre‑surgical assessment
lesion and true combined lesions includes establishing and verifying the non‑vital status
of the pulp, the extent and severity of the periodontal
Primary periodontal disease with secondary endodontic destruction, and therapeutic prognosis of the planned
involvement and true combined endodontic‑periodontal regenerative procedure. Once the therapeutic prognosis
diseases require both endodontic and periodontal of the periodontal regenerative procedure is determined
regenerative procedures. The success rate of the to be favorable, then endodontic therapy should be
endodontic‑periodontal combined lesion without a provided. Root canal therapy helps to reduce the mobility
concomitant regenerative procedure has been reported of the involved tooth therefore, after a successful root
to a range from 27% to 37%. [49] Combined lesions canal therapy; tooth mobility should be further assessed to
can be classified into three types, first, tooth with two determine the necessity for splinting. Cortellini et al.[58,59]
separate lesions, one endodontic usually periapical and have recommended splinting of the mobile tooth before
one periodontal with no communication, second, teeth GTR procedure. The intra‑surgical assessment should
with a single lesion that involves both endodontic and include morphology of the periodontal defect, defect
periodontal pathoses and third, teeth with endodontic type, material of choice to fill the defect and augment
and periodontal lesions that were once separate but healing, control of patient’s oral hygiene, and wound
now communicate. True‑combined lesions should be stabilization.[60,61] Furthermore, long term follow up
treated initially as primary endodontic lesions with is mandatory for these lesions. However, advanced
secondary periodontal involvement. Prior to surgery, diagnostic tests like cone beam computer tomography to
palliative periodontal therapy should be completed and check the conditions of the hard tissues, pulse oximetry
root canal treatment carried out. The prognosis of true for evaluate the true vitality, polymerase chain reaction
combined lesion is often poor or even hopeless, especially to identify the specific microbes may add value in proper
when periodontal lesions are chronic and extensive. diagnosis. Cases should be well discussed to achieve
The prognosis of combined diseases mainly rests with good prognosis.
the ef ficacy of periodontal therapy. [5] Though, root
amputation, hemisection or bicuspidization may allow the
root configurations to be changed sufficiently for a part CONCLUSION
of the root structure to be saved, however, the operator
need to consider various factors before root resection A perio‑endo lesion can have a varied pathogenesis which
such as tooth function, root filling, anatomy, restorability, ranges from quite simple to relatively complex one. To
bone support around the healthy root and patient’s make a correct diagnosis the clinician should have a
compliance. A tooth that requires a root to be resected thorough understanding and scientific knowledge of these
always needs root canal treatment; therefore, the surgery lesions. Despite the segmentation of dentistry into the
must be planned with care, particularly with respect various areas of specialization, a clinician needs to perform
to the timing of the root treatment. Ideally, the tooth restorative, endodontic or periodontal therapy, either
should be root filled prior to surgery.[36] The prognosis singly or in combination. Therefore, to achieve the best
of an affected tooth can also be improved by increasing outcome for these lesions, a multi‑disciplinary approach
bony support, which can be achieved by bone grafting should be involved.
and guided tissue regeneration (GTR). These advanced
treatment options are based on responses to conventional
periodontal and endodontic treatment over an extended REFERENCES
time period. These regenerative procedures with the aid
1. Simring M, Goldberg M. The pulpal pocket approach: Retrograde
of the microscope, in the treatment of combined lesions
periodontitis. J Periodontol 1964;35:22‑48.
have been found to have a success rate of 77.5%.[50] 2. Mjör IA, Nordahl I. The density and branching of dentinal tubules
GTR therapy was first introduced in 1980’s since then in human teeth. Arch Oral Biol 1996;41:401‑12.
both human and animal studies have demonstrated 3. Zehnder M, Gold SI, Hasselgren G. Pathologic interactions in pulpal
various degrees of regeneration of bone and attachment and periodontal tissues. J Clin Periodontol 2002;29:663‑71.
apparatus.[51,52] GTR therapy has also been implemented 4. Sunitha VR, Emmadi P, Namasivayam A, Thyegarajan R, Rajaraman
V. The periodontal‑endodontic continuum: A review. J Conserv Dent
in the endodontic surgeries as a concomitant treatment 2008;11:54‑62.
during the management of the endodontic‑periodontal 5. Rotstein I, Simon JH. Diagnosis, prognosis and decision‑making
lesions.[53‑56] The decisions and treatment strategy for in the treatment of combined periodontal‑endodontic lesions.
the application of the regenerative procedures are Periodontol 2000 2004;34:165‑203.
made at various levels such as pre‑surgical, post‑root 6. Jaoui L, Machtou P, Ouhayoun JP. Long‑term evaluation of
endodontic and periodontal treatment. Int Endod J 1995;28:249‑54.
canal treatment, intra‑surgical, and post‑surgical. Factors
7. Torabinejad M, Kiger RD. A histologic evaluation of dental pulp
influencing treatment outcome should also be considered tissue of a patient with periodontal disease. Oral Surg Oral Med
at each level under patient‑specific, defect‑specific, Oral Pathol 1985;59:198‑200.

Journal of Interdisciplinary Dentistry / Jan-Apr 2013 / Vol-3 / Issue-1 9

[Downloaded free from on Monday, March 17, 2014, IP:]  ||  Click here to download free Android application for this journal

Parolia, et al.: Endo ‑ perio

8. Bergenholtz G, Nyman S. Endodontic complications following J Endod 2003;29:565‑6.

periodontal and prosthetic treatment of patients with advanced 33. Evanov C, Liewehr F, Buxton TB, Joyce AP. Antibacterial efficacy of
periodontal disease. J Periodontol 1984;55:63‑8. calcium hydroxide and chlorhexidine gluconate irrigants at 37°C
9. Langeland K, Rodrigues H, Dowden W. Periodontal disease, and 46°C. J Endod 2004;30:653‑7.
bacteria, and pulpal histopathology. Oral Surg Oral Med Oral Pathol 34. Khan AA, Sun X, Hargreaves KM. Effect of calcium hydroxide
1974;37:257‑70. on proinflammatory cytokines and neuropeptides. J Endod
10. Mandi FA. Histological study of the pulp changes caused by 2008;34:1360‑3.
periodontal disease. J Br Endod Soc 1972;6:80‑2. 35. Mhairi RW. The pathogenesis and treatment of endo‑perio lesions.
11. Petka K. The 14 warning signs. Endod Prac 2001;4:8‑26. CPD Dent 2001;2:77‑104.
12. Wang HL, Glickman GN. Endodontic and periodontic 36. Carrotte P. Endodontics: Part 9. Calcium hydroxide, root resorption,
interrelationships. In: Cohen S, Burns RC, editors. Pathways of the endo‑perio lesions. Br Dent J 2004;197:735‑43.
Pulp. 8th ed. St Louis: C. V. Mosby; 2002. p. 651‑64. 37. Paul BF, Hutter JW. The endodontic‑periodontal continuum revisited:
13. Czarnecki RT, Schilder H. A histological evaluation of the human New insights into etiology, diagnosis and treatment. J Am Dent
pulp in teeth with varying degrees of periodontal disease. J Endod Assoc 1997;128:1541‑8.
1979;5:242‑53. 38. Chapple IL, Lumley PJ. The periodontal‑endodontic interface. Dent
14. Harrington GW, Steiner DR, Ammons WF. The periodontal- Update 1999;26:331‑6, 338, 340.
endodontic controversy. Periodontol 2000 2002;30:123‑30. 39. Blomlöf L, Lindskog S, Hammarström L. Influence of pulpal
15. Jansson L, Ehnevid H, Lindskog S, Blomlöf L. Relationship between treatments on cell and tissue reactions in the marginal periodontium.
periapical and periodontal status. A clinical retrospective study. J Periodontol 1988;59:577‑83.
J Clin Periodontol 1993;20:117‑23. 40. Parir okh M, Torabinejad M. Mineral trioxide aggr egate:
16. Jansson LE, Ehnevid H, Lindskog SF, Blomlöf LB. Radiographic A comprehensive literature review – Part III: Clinical applications,
attachment in periodontitis‑prone teeth with endodontic infection. drawbacks, and mechanism of action. J Endod 2010;36:400‑13.
J Periodontol 1993;64:947‑53. 41. Tsatsas DV, Meliou HA, Kerezoudis NP. Sealing effectiveness
17. Jansson L, Ehnevid H, Lindskog S, Blomlöf L. The influence of of materials used in furcation perforation in vitro. Int Dent J
endodontic infection on progression of marginal bone loss in 2005;55:133‑41.
periodontitis. J Clin Periodontol 1995;22:729‑34. 42. Weldon JK Jr, Pashley DH, Loushine RJ, Weller RN, Kimbrough WF.
18. S i m o n J H , G l i c k D H , F r a n k A L . T h e r e l a t i o n s h i p o f Sealing ability of mineral trioxide aggregate and super‑EBA when
endodontic‑periodontic lesions. J Periodontol 1972;43:202‑8. used as furcation repair materials: A longitudinal study. J Endod
19. H a r r i n g t o n G W, S t e i n e r D R . P e r i o d o n t a l ‑ e n d o d o n t i c 2002;28:467‑70.
considerations. In: Walton RE, Torabinejad M, editors. Principles 43. Solomon C, Chalfin H, Kellert M, Weseley P. The endodontic‑periodontal
and Practice of Endodontics. 3rd ed. Philadelphia: Saunders Co.; lesion: A rational approach to treatment. J Am Dent Assoc
2002. 1995;126:473‑9.
20. Wang HL, Glickman GN. Endodotic and periodontic interelationships. 44. Moule AJ, Kahler B. Diagnosis and management of teeth with vertical
In: Cohen S, Burns RC, editors., Pathways of the Pulp. 8th ed. St. Louis: root fractures. Aust Dent J 1999;44:75‑87.
Mosby; 2002. p. 651‑64. 45. Tamse A, Fuss Z, Lustig J, Kaplavi J. An evaluation of endodontically
21. Ammons WF, Harrington GW. The periodontic‑endodontic treated vertically fractured teeth. J Endod 1999;25:506‑8.
continuum. In: Newman MG, Takei HH, Carranza FA, editors. 46. Unver S, Onay EO, Ungor M. Intentional re‑plantation of a vertically
Carranza’s Clinical Periodontology. 9 th ed. Philadelphia: W. B. fractured tooth repaired with an adhesive resin. Int Endod J
Saunders; 2002. p. 840‑50. 2011;44:1069‑78.
22. von Arx T, Cochran DL. Rationale for the application of the GTR 47. Özer SY, Ünlü G, Değer Y. Diagnosis and treatment of endodontically
principle using a barrier membrane in endodontic surgery: treated teeth with vertical root fracture: Three case reports with
A proposal of classification and literature review. Int J Periodontics two‑year follow‑up. J Endod 2011;37:97‑102.
Restorative Dent 2001;21:127‑39.
48. Hanada T, Quevedo CG, Okitsu M, Yoshioka T, Iwasaki N,
23. Singh P. Endo‑perio dilemma: A brief review. Dent Res J (Isfahan) Takahashi H, et al. Effects of new adhesive resin root canal filling
2011;8:39‑47. materials on vertical root fractures. Aust Endod J 2010;36:19‑23.
24. Rotstein I, Simon JH. The endo‑perio lesion: A critical appraisal of 49. Oh SL, Fouad AF, Park SH. Treatment strategy for guided tissue
the disease condition. Endod Top 2006;13:34‑56. regeneration in combined endodontic‑periodontal lesions: Case
25. Edoardo F. Endo‑Periodontal Lesions. London: Quintessence report and review. J Endod 2009;35:1331‑6.
Publishing; 2011. p. 1‑2. 50. Kim E, Song JS, Jung IY, Lee SJ, Kim S. Prospective clinical
26. Meng HX. Periodontic‑endodontic lesions. Ann Periodontol study evaluating endodontic microsurgery outcomes for cases
1999;4:84‑90. with lesions of endodontic origin compared with cases with
27. Stock CJ. Endodontics in practice. Diagnosis and treatment planning. lesions of combined periodontal‑endodontic origin. J Endod
Br Dent J 1985;158:163‑70. 2008;34:546‑51.
28. Whyman RA. Endodontic‑periodontic lesions. Part II: Management. 51. Nyman S, Gottlow J, Karring T, Lindhe J. The regenerative potential
N Z Dent J 1988;84:109‑11. of the periodontal ligament: An experimental study in the monkey.
29. Siqueira JF Jr, Lopes HP. Mechanisms of antimicrobial activity of J Clin Periodontol 1982;9:257‑65.
calcium hydroxide: A critical review. Int Endod J 1999;32:361‑9. 52. Nyman S, Lindhe J, Karring T, Rylander H. New attachment following
30. Fava LR, Saunders WP. Calcium hydroxide pastes: Classification and surgical treatment of human periodontal disease. J Clin Periodontol
clinical indications. Int Endod J 1999;32:257‑82. 1982;9:290‑6.
31. Rehman K, Saunders WP, Foye RH, Sharkey SW. Calcium ion 53. Taschieri S, Del Fabbro M, Testori T, Saita M, Weinstein R.
dif fusion from calcium hydroxide‑containing materials in Efficacy of guided tissue regeneration in the management of
endodontically‑treated teeth: An in vitro study. Int Endod J through‑and‑through lesions following surgical endodontics:
1996;29:271‑9. A pr eliminary study. Int J Periodontics Restorative Dent
32. Lin YH, Mickel AK, Chogle S. Effectiveness of selected materials 2008;28:265‑71.
against Enterococcus faecalis: Part 3. The antibacterial effect of 54. Britain SK, Arx TV, Schenk RK, Buser D, Nummikoski P, Cochran
calcium hydroxide and chlorhexidine on Enterococcus faecalis. DL. The use of guided tissue regeneration principles in endodontic

10 Journal of Interdisciplinary Dentistry / Jan-Apr 2013 / Vol-3 / Issue-1

[Downloaded free from on Monday, March 17, 2014, IP:]  ||  Click here to download free Android application for this journal

Parolia, et al.: Endo ‑ perio

surgery for induced chronic periodontic‑endodontic lesions: 59. Schulz A, Hilgers RD, Niedermeier W. The effect of splinting of teeth
A clinical, radiographic, and histologic evaluation. J Periodontol in combination with reconstructive periodontal surgery in humans.
2005;76:450‑60. Clin Oral Investig 2000;4:98‑105.
55. Kerezoudis NP, Siskos GJ, Tsatsas V. Bilateral buccal radicular groove 60. Tonetti MS, Prato GP, Cortellini P. Factors affecting the healing
in maxillary incisors: Case report. Int Endod J 2003;36:898‑906. response of intrabony defects following guided tissue regeneration
56. John V, Warner NA, Blanchard SB. Periodontal‑endodontic and access flap surgery. J Clin Periodontol 1996;23:548‑56.
interdisciplinary treatment: A case report. Compend Contin Educ 61. Trombelli L, Kim CK, Zimmerman GJ, Wikesjö UM. Retrospective
Dent 2004;25:601‑2,604. analysis of factors related to clinical outcome of guided tissue
57. Bashutski JD, Wang HL. Periodontal and endodontic regeneration. regeneration procedures in intrabony defects. J Clin Periodontol
J Endod 2009;35:321‑8. 1997;24:366‑71.
58. Cortellini P, Tonetti MS, Lang NP, Suvan JE, Zucchelli G,
Vangsted T, et al . The simplified papilla preservation flap How to cite this article: Parolia A, Gait TC, Porto IC, Mala K. Endo-perio
in the regenerative treatment of deep intrabony defects: lesion: A dilemma from 19th until 21st century. J Interdiscip Dentistry 2013;3:
Clinical outcomes and postoperative morbidity. J Periodontol 2-11.
Source of Support: Nil, Conflict of Interest: None declared.



The journal issue has a unique new feature for reaching to the journal’s website without typing a single letter. Each article on
its first page has a “Quick Response Code”. Using any mobile or other hand-held device with camera and GPRS/other internet
source, one can reach to the full text of that particular article on the journal’s website. Start a QR-code reading software (see
list of free applications from and point the camera to the QR-code printed in the journal. It will
automatically take you to the HTML full text of that article. One can also use a desktop or laptop with web camera for similar
functionality. See or for the free applications.

Journal of Interdisciplinary Dentistry / Jan-Apr 2013 / Vol-3 / Issue-1 11