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Table of Contents
Year : 2022  |  Volume : 9  |  Issue : 3  |  Page : 86-89

Endo–perio lesions: A dilemma

1 Associate Professor, Department of Periodontology, Government Dental College, Raipur, Chhattisgarh, India
2 Professor and HOD, Department of Periodontology, Government Dental College, Raipur, Chhattisgarh, India
3 Post Graduate Student, Department of Periodontology, Government Dental College, Raipur, Chhattisgarh, India
4 Lecturer, Department of Conservative Dentistry and Endodontics, Government Dental College, Raipur, Chhattisgarh, India

Date of Submission26-Aug-2022
Date of Acceptance03-Sep-2022
Date of Web Publication28-Sep-2022

Correspondence Address:
Dr. Shirish Kujur
Associate Professor, Department of Periodontology, Government Dental College, Raipur, Chhattisgarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpcdr.ijpcdr_20_22

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Endo–perio lesions are a common finding in dental practice. Progression of an endodontic lesion, if allowed leads to periodontal involvement or vice versa. This is a case series of two cases of the endodontic lesion with periodontal involvement that has been treated by performing root canal treatment followed by flap surgery. The tooth was first endodontically treated that was followed by periodontal treatment. Six months postoperatively, there was a significant gain in clinical attachment level. Radiographically, there was a significant amount of bone fill observed.

Keywords: Bone graft, endo–perio lesion, furcation involvement, root canal treatment

How to cite this article:
Kujur S, Gupta V, Sreeraj V S, Ratre S, Soni V. Endo–perio lesions: A dilemma. Int J Prev Clin Dent Res 2022;9:86-9

How to cite this URL:
Kujur S, Gupta V, Sreeraj V S, Ratre S, Soni V. Endo–perio lesions: A dilemma. Int J Prev Clin Dent Res [serial online] 2022 [cited 2023 Jan 29];9:86-9. Available from: https://www.ijpcdr.org/text.asp?2022/9/3/86/357309

  Introduction Top

Endo–perio lesions are a challenging condition for dental professionals regarding the diagnosis and treatment for the same. Simring and Goldberg described the relation between pulpal and periodontal disease in 1964 Simring and Goldberg.[1] Bacterial infection is the main cause for pulpal and periodontal disease. Cross infection between the root canal and the periodontal ligament can occur through the following pathways: Anatomical (apical foramen, lateral and accessory canals, dentinal tubules, and palatogingival grooves) nonphysiological pathways (iatrogenic root canal perforations and vertical root fractures) Zehnder et al.[2] Periodontal destruction is the loss of bone from the coronal-to-apical direction, whereas endodontic infection is from the apical-to-coronal direction. Periodontic–endodontic lesions are complex in nature and have varied pathogenesis. Treatment, decision-making, and prognosis depend primarily on the diagnosis of the specific disease. To have the best prognosis, the clinician must refer the case to various areas of specialization, to perform restorative and endodontic and periodontal therapy either singly or in combination.[3] Pulpal infection leads to an inflammatory response to the periodontal structures; however, the periodontal infection leading to pulpal inflammation is still under discussion and there are conflicting opinions regarding the same Seltzer et al.[4]

Furcation involvement presents one of the major challenges in endodontic therapy with periodontal involvement. Although the role of pulpal pathology in the etiology of furcation involvement is still unclear, the high incidence of molar teeth with accessory canals supports such an association.

Various treatment modalities have been proposed for the treatment of furcation involvement alone including open flap debridement, biomodification of the root surface, and various regenerative procedures including guided tissue regeneration and bone grafts.[5] Bone grafts having a property of osteogenesis, osteoinduction, and osteoconduction have been used in the past.

The main factors to take into account for decision-making regarding the treatment are the pulp vitality and type and extent of the periodontal defect.


The most commonly used classification was given by Simon, Glick, and Frank in 1972, which includes:[6]

  1. Primary endodontic lesion
  2. Primary periodontal lesion
  3. Primary endodontic lesion with secondary periodontal involvement
  4. Primary periodontal lesion with secondary endodontic involvement
  5. Truly combined lesion.

  Case Report Top

Case 1

A 35-year-old male patient came to the department of periodontology with the complaint of pricking pain in the upper front tooth region for 1 month. Localized tenderness on percussion in relation to the maxillary left central incisor was present [Figure 1]a. A radiograph was taken and it showed extruded gutta-percha cone in relation to 21 and the presence of bone loss mesial and distal to 21 [Figure 1]b. The mesial bone defect was vertical bone defect extending up to the junction of the apical and middle one-third of the root.
Figure 1: Case 1 - (a) Preoperative probing, (b) Preoperative IOPA, (c) Full-thickness flap raised, (d) Debridement and bone tunneling done to remove gutta-percha, (e) Bone graft placed, (f) Surgical area sutured, (g) Immediate postoperative. IOPA: Intraoral periapical

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Routine blood examination was done for the patient and phase I therapy was performed. After a phase I therapy, flap debridement was planned.

During the surgical procedure, local anesthesia given and full-thickness mucoperiosteal flap was raised [Figure 1]c. The bony defect was exposed. After reflection, thorough degranulation and debridement were done at the defect area using Gracey curette # 1 and 2. Furthermore, thorough scaling and root planning were carried out on the exposed root surface area of the defect. After thorough debridement to remove tunneling of bone was performed to get access to the root apex. After exposing the apical portion, gutta-percha cone was removed [Figure 1]d. Bone graft was used to fill the bony defects [Figure 1]e. Finally, suturing was done to close the flap [Figure 1]f, [Figure 1]g.

Case 2

A 26-year-old male patient came to the department of periodontology with the complaint of pain and pus discharge from the lower right back region. On examination, deep pocket of 7 mm was present distal to 46 [Figure 2]b. There was pus discharge and bleeding on probing. The oral hygiene of the patient was fair. Intraoral periapical was taken and it showed vertical bony defect extending to the apical one-third of the root of 46 distally. Furcation involvement was present in radiograph [Figure 2]a.
Figure 2: Case 2 - (a) Preoperative radiograph, (b) Preoperative probing depth, (c) Endodontic treatment completed, (d) Full-thickness flap raised, (e) Bone graft placed in bony defect, (f) Surgical site sutured, (g) Postoperative probing at 6 months

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Routine blood examination was done for the patient and phase I therapy was performed, and then regenerative osseous surgery was planned after root canal treatment [Figure 2]c.

During the surgical procedure, local anesthesia was given and full-thickness mucoperiosteal flap was raised [Figure 2]d. Bony defect was exposed. After reflection, thorough degranulation and debridement were done at the defect area using Gracey curette #11 and12 #13 and14. Bone graft was placed to fill the bony defect [Figure 2]e. Surgical site suture with 3–0 silk suture [Figure 2]f. After 6 months, the patient was recalled and reevaluated. Probing pocket depth was reduced to 4 mm, and there was no pus discharge and bleeding on probing [Figure 2]g.

  Discussion Top

The diagnosis and prognosis of the tooth having endo–perio lesions present a challenge to the clinicians. Correct diagnosis is important to determine the treatment and long-term prognosis. However, treating a complex endodontic periodontal lesion is still one of the most common challenges in today's clinical practice. The simultaneous existence of endodontium and periodontium tissue destruction can complicate the diagnosis and subsequently affect the prognosis of the involved teeth.[7]

The possible influence of endodontic treatment on the healing response of furcation defects is related to the accessory canals and permeable areas of dentin and cementum. Accessory canals in the whole furcation area of molars are found in 30%–60% of molars and predispose this area to be a zone of intense communication between pulpal and periodontal tissues (Lowman et al.,1973).[8] These canals are mostly observed in the furcation area of mandibular molars Gutmann.[9]

Treatment of endo–perio lesion requires both endodontic treatment and periodontal regenerative treatment. The treatment strategy is to first focus on debridement and disinfection of the root canal system followed by an observation period. The goal of periodontal surgery is to remove all necrotic tissues from the surgical site and facilitate the regeneration of hard and soft tissue along with the formation of new attachment apparatus.

In the reported cases, the established diagnosis in case 1 was primary endodontic with secondary periodontal lesion and case 2 was primary periodontal with secondary endodontic lesion. Endodontic therapy was done and followed by periodontal surgery. In both cases, the bony defect was present and there was a furcation involvement in the second case. The results post 6 months have shown a significant amount of bone fill in the bony defect areas and in furcation involvement region also.

Similarly, in a case series published by Hacer Aksel in 2014, one case with primary endodontic and secondary periodontal lesions was reported. Endodontic treatment was administered followed by periodontal surgery after 3 months.[10] One-year follow-up of the patient revealed resolution of the symptoms and improved clinical and radiographic findings.

  Conclusion Top

The healing of an endodontic lesion is highly predictable, but the repair or regeneration of periodontal tissues is questionable if associated with it. Endodontic therapy mostly should precede periodontal pocket elimination procedures in the case of a primary endo and secondary periodontal involvement; however, endodontic therapy would result only in the resolution of the endodontic component of involvement and would have a little effect on the periodontal lesion. Therefore, a thorough diagnostic examination usually will indicate the primary etiology and thereby direct the proper course of treatment plan as presented in this case.

This case demonstrates that proper diagnosis, followed by removal of etiological factors and osseous grafting, will restore health and function to a tooth with severe attachment loss caused by a perio–endo lesion.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Simring M, Goldberg M. The pulpal pocket approach: Retrograde periodontitis. J Periodontol 1964;35:22-48  Back to cited text no. 1
Zehnder M, Gold SI, Hasselgren G. Pathologic interactions in pulpal and periodontal tissues. J Clin Periodontol 2002;29:663-71.  Back to cited text no. 2
Parolia A, Gait TC, Porto IC, Mala K. Endo-perio lesion: A dilemma from 19 th until 21 st century. Journal of Interdisciplinary Dentistry. 2013 Jan 1;3(1):2.  Back to cited text no. 3
Seltzer S, Bender IB, Ziontz M. The interrelationship of pulp and periodontal disease. Oral Surg Oral Med Oral Pathol 1963;16:1474-90.  Back to cited text no. 4
Müller HP, Eger T. Furcation diagnosis. J Clin Periodontol 1999;26:485-98.  Back to cited text no. 5
Simon JH, Glick DH, Frank AL. The relationship of endodontic-Periodontic lesions. J Periodontol. 1972;43:202-8  Back to cited text no. 6
Harrington GW, Steiner DR, Ammons WF. The periodontal-endodontic controversy. Periodontol 2000 2002;30:123-30.  Back to cited text no. 7
Lowman JV, Burke RS, Pelleu GB. Patent accessory canals: Incidence in molar furcation region. Oral Surg Oral Med Oral Pathol 1973;36:580-4.  Back to cited text no. 8
Gutmann JL. Prevalence, location, and patency of accessory canals in the furcation region of permanent molars. J Periodontol 1978;49:21-6.6  Back to cited text no. 9
Aksel H, Serper A. A case series associated with different kinds of endo-perio lesions. J Clin Exp Dent 2014;6:e91-5.  Back to cited text no. 10


  [Figure 1], [Figure 2]


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