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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 bet ween periodontal and endodont ic disease has aroused confusion, queries and
controversy. The actual relati onshi p between periodontal and pulpal disease was first described by Simring and
Gol dberg in 1964. Since then, the term "perioendo" lesion has been used to describe lesions att ri butable to
inf lammatory product s found in varying degrees in both the periodontium and the pulpal tissues. The pulp and
peri odontium have embryonic, anatomic and functional interrelationships. The simultaneous existence of
pul pal problems and infl ammatory periodontal di sease can obscure diagnosis and treatment planning. A perio'
endo l esion can have a diverse pathogenesis which ranges from quite simple to somewhat complex. Knowledge
of these disease processes is essential in coming to the correct diagnosis. This is achievable by careful hi story
taking, examination and the use of radiographs. The prognosis and treat'l1ent of each endodontic periodontal
disease type vari es. Primary periodontal disease with secondary endodontic involvement and true combined
endodontic'periodont al diseases require both endodontic and periodontal therapies. The prognosis of these
cases equally depends on the severity of periodontal disease and the response to periodontal treatment . Thi s
"-20Ies the operator to const r uct a suitable t reat ment plan where unnecessary, prolonged or even detrimental
.... : 's avoided.
lCeyword5: "erio Lesions, Periodontal, Pu Ipal, Diagnosis, Treatment
,, - :;oc -'c 0eriodontallesion t reatment is a chall enge to the cl inician and treatment often requ ires a combined
therapeutic effort.
The cl assificat ion of periodontal disorders by the American Academy of Periodontology, 1999', contains
'peri odontitis in connection with endodontallesions' (commonly referred to as perio-enda lesions) 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 t o 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 infl ammatory products
found in varying degrees in both the periodontium and the pulpal tissues. The dental pulp and periodontal
t issues are closely related . The pulp origi nates from the dental papilla while the periodontal ligament from the
dental foll 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 bet ween the t wo compartments
are created by
(1) Dentinal tubules,
(2) l ateral and accessory canals, and
(3) The apical foramen. When the pulp becomes inflamed/infected, it elicits an inflammatory response of the
periodontal ligament at the apical foramen and/or adjacent to openings of accessory canals.'Noxious elements
of pulpal origin, including 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, thi s has been evident by, f inding extensive bacterial colonisation of periodontal pocket s and
infected root canals time and again. s" .
Perio-endo lesions are often ini t ially not clinically visible or are accompanied by non-specific di scomfort, such as
sensitivity when biting. Sometimes this may lead to fistula formation or an abscess. The diagnosis of perio-endo
lesions often results from coincidental 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 lesi on
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 lesi on in a tooth with a necrotic pulp may drain coronally through the
periodontal ligament into the gingival sulcus. This condition may clinically mimic a peri odontal a bscess. Primary
endodontic lesions usually heal 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, shaped and obturated. If, after a period of time, a suppurati ng primary endodontic disease
remains untreated, it may then become secondarily involved with marginal periodontal breakdown. Plaque
forms at the gingival margin of the si nus tract and leads to marginal periodontitis. The t ooth subsequent ly
requires both endodontic and periodontal treatment. Primary endodontic lesions with secondary periodontal
involvement should first be treated with 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.
Endodonti c 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 with 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
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3mm. (Fi g: 4) A post- operative 10PA X-ray revealed decreased radiolucency and bone fill in the furcation area in
j ust one week after 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
possibl e 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- Requiri ng endodontic treatment only;
Type 2 - Requiring periodontal treatment only and;
Type 3 - Requiring combined endo-perio treatment. "
As a consequence of the shared root and anatomically 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 challenge to the cl inician for correct diagnosis and treatment planning.
The long-term prognosis after t reat ment of perio-endo lesions is determined by correct primary diagnosis and
careful endodontic treat ment, followed by periodontal treatment. It is imperative that both endodontic lesion
and periodonta Ilesion be addressed individually and sequentially.
CONCLUSION
In this case performing endodonti c- periodontal treatment of the tooth sequentially the lesion reduced and
subsided completely. Hence this case report demonstrates the nature of periodontal lesion as a secondary
involvement to an origina Ily endodontic lesi on involving the tooth. In th is case both endodontic and periodontal
treat ment s were carried out sequentially in the same appointment resulting in shorter chair side time,
eliminating the need for a second separate appointment for periodontal surgical procedures. Thus, t his li ne of

treatment may hold better prospect s of treating endodontic periodontal lesions in a shorter time.
BIBLI OGRAPHY
1. American Academy of Periodontology. International workshop for a classification of periodontal diseases
and conditions. Ann PeriodontoI1999;4:1-112.
2. The pulpal pocket approach: Retrograde Periodontitis. Simring M, Goldberg M . .J PeriodontoI1964:35:22-
48
3. The densi ty and branchi ng of dentinal t ubules in human teeth. Mjor lA, Nordahl !. Arch Oral 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-
43.
5. Kipioti A, Nakou M, Legakis N, Mitsis F. Microbiological fi ndings of infected root canals and adjacent
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