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Case Report Combined endodontic - Periodontal lesion: A

clinical dilemma
Pushpendra Kumar Verma, Ruchi Srivastava1, K. K. Gupta1, Amitabh Srivastava1
Departments of Conservative Dentistry and Endodontics, 1Periodontology and Implantology, Sardar Patel
Postgraduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh, India

Address for correspondence: Dr. Pushpendra Kumar Verma, E-mail: pushpendrakgmc@gmail.com

ABSTRACT
Endodontic-periodontal combined lesion is a clinical dilemma because making a differential diagnosis and deciding a prognosis
are difficult. Lesions of the periodontal ligament and adjacent alveolar bone may originate from infections of the periodontium
or tissues of the dental pulp. Periradicular bone loss secondary to endodontic pathosis is typically seen in teeth with necrotic
pulps. The ultimate goal of periodontal therapy is not only to maintain the natural dentition, but also to restore lost periodontium.
Combined periodontal and endodontic diseases involve the periodontal attachment apparatus. The treatment of endodontic-
periodontal combined lesions requires both endodontic therapy and periodontal regenerative procedures. With advancements
in new techniques and materials different treatment choices are available, providing a superior prognosis. This article includes
case reports of combined endo-perio lesions which were first treated with conventional endodontic therapy and then followed
by periodontal surgery. This combined treatment resulted in a radiographical evidence of alveolar bone gain. This case report
demonstrates that proper diagnosis, followed by removal of etiological factors and utilizing the combined treatment modalities
will restore health and function to the teeth with severe attachment loss caused by an endo-perio lesion.

Key words: Combined endodontic-periodontal lesion, guided tissue regeneration, periradicular surgery

INTRODUCTION lesions may be obtained by endo-perio therapy.

However, when a significant loss of the periodontal

P reservation of the natural dentition is the

ultimate goal of dental therapy. In periodontics,
the goal is not only to maintain the natural dentition,
attachment apparatus and osseous structure occurs,
the long-term prognosis becomes poor.[2]

but also to restore lost periodontium. Lesions of the
periodontal ligament and adjacent alveolar bone
may originate from infections of the periodontium
or tissues of dental pulp.[1] Periradicular bone loss
secondary to endodontic pathosis is typically seen
in teeth with necrotic pulps. Combined periodontal
and endodontic diseases involve the periodontal
attachment apparatus. Pulpal necrosis may lead to
destruction of the attachment apparatus by extension
through the apical foramen or through accessory
canals that may be located at different levels on the
root surface. An acceptable treatment results, for
combined endodontal and periodontal (endo-perio)
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DOI:
10.4103/2229-5194.85034
Formulating a differential diagnosis among combined
lesions has been challenging. Therefore, diagnostic
steps should include thorough patient-reported
dental history, visual inspection for presence of sinus
tract and severe inflammation in association with large
restoration and anatomic anomalies such as palatal
grooves,[3] radiographical confirmation with tracing
the sinus track, results of clinical findings including
percussion and palpation, routine periodontal
assessment for presence of mobility or deep probing
depth, testing for coronal cracks and pulp vitality
testing.[4] These tests are customarily accepted as
being reliable in differentiating between pulpal and
periodontal disease.
This report presents a few cases in which no bone
remained around the facial and apical areas of
maxillary teeth, when a flap was raised. It was treated
first with conventional endodontic therapy combined
with periodontal regenerative procedures.

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Verma, et al.: Combined endodontic - Periodontal lesion - A clinical dilemma
CASE REPORTS
Case 1
A 34-year-old female pr esented to Department
of Periodontology and Implantology, Sardar Patel
Postgraduate Institute of Dental and Medical Sciences,
Lucknow, Uttar Pradesh, with a complaint of pus discharge
from maxillary central incisors. She was systemically
healthy and medical history was not contributory to this
dental problem. On clinical examination, probing depth
was 12 mm on mesial aspect of 11 [Figure 1] and 8 mm
on mesial of 21 [Figure 2]. Mobility was grade II in both
teeth. The buccal gingiva showed slight swelling and
clear signs of inflammation. The teeth did not respond to
percussion and palpation tests. It neither responded to the
electrical pulp test nor thermal tests. Periapical radiograph
showed a deep bony defect extending to root apex of 11,
21, in addition to the periapical radiolucency [Figure 3].
Initial diagnosis was pulp necrosis and asymptomatic
apical periodontitis, and the teeth were thought to have
primary endodontic involvement. However, the pattern
of periodontal bone loss, with a wide base, coupled
with generalized marginal periodontitis, suggested that
there was also primary periodontal involvement in this
case.[5] Therefore, considering the dental history, clinical
tests and radiographs, the diagnosis of this case was an
endodontic-periodontal combined lesion, according to
Simon classification 1972.[6]
First conventional root canal treatment was done, which
was followed by periodontal surgery after 2 days. After
local anesthesia, a mucoperiosteal papilla preservation flap
was raised from distal to 12 to distal to 23. After raising
the flap, severe osseous destruction was observed on
facial surface of 11, 21 [Figure 4]. The buccal and mesial
root surfaces and the apical area were root planed. The
teeth had periodontal attachment remaining on lingual
and distal surfaces. Transillumination revealed no apparent
cracks or fracture. After thorough root planing and
apical curettage, the large osseous defect was filled in a
presutured flap with alloplastic bone graft (Periobone-GTM,
Top-Notch Healthcare, Aluva, Kerala, India) covering the
root surface [Figure 5]. The flap was repositioned and
interrupted suturing was done with nonresorbable 3-0
silk suture material [Figure 6]. Antibiotics and analgesics
were prescribed for 1 week. Patient was monitored on
weekly schedule postoperatively, to ensure good oral
hygiene in the surgerized area [Figure 7]. Supportive
periodontal maintenance at 3 months was prescribed to
maintain periodontal health and to re-evaluate this area. At
1-yr recall, the teeth were asymptomatic with successful
healing, mobility was reduced to less than grade I and
probing depth was minimal. The radiograph after 1yr
follow-up, showed evidence of apparent bone fill with
resolution of the osseous defect [Figure 8].
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Case 2
A 42-year-old female presented to Department of
Conservative Dentistry and Endodontics, Sardar Patel
Postgraduate Institute of Dental and Medical Sciences,
Lucknow, Uttar Pradesh, with a complaint of discoloration
and pus discharge from right maxillary lateral incisor.
She had no contributory medical history. On clinical
examination, probing depth on distal aspect of the tooth
was 12mm [Figure 9], mobility was grade I. The buccal
gingiva showed sinus opening in relation to 12. The tooth
did not respond to percussion and palpation tests. The
tooth was non responsive to pulp vitality tests. Periapical
radiograph showed radiolucency to the root apex of
tooth 12 [Figure 10]. Therefore, considering the dental
history, clinical tests, and radiographs, the diagnosis was
combined endodontic-periodontal lesion, according to
Simon classification 1972.[6]
First conventional root canal treatment was done and after
2 days periodontal surgery was performed. After local
anesthesia, a mucoperiosteal flap was raised. After raising
the flap, severe 3-wall osseous destruction was observed
on distal surface of tooth 12 [Figure 11]. After thorough
root planing and apical curettage, the defect was filled
with alloplastic bone graft (Periobone-GTM, Top-Notch
Healthcare Products Pvt Ltd, Aluva, Kerala, India) and a
resorbable guided tissue regeneration (GTR) membrane
(Periocol-GTR TM, Eucare Pharmaceuticals, Chennai, India)
[Figures 12-15]. The flap was repositioned and interrupted
suturing was done with nonresorbable 3-0 silk suture
material. Postoperative evaluation was done same as in
previous case. At 1-yr recall, radiograph showed evidence
of apparent bone fill with resolution of the osseous defect
[Figure 16].
DISCUSSION
Endodontic-periodontal lesion is a clinical manifestation
of the pathologic/inflammatory intercommunication
between pulpal and periodontal tissues via open
structures such as apical foramina, lateral, accessory
canals, and dentinal tubules. [1] On the basis of the
pathologic origin, Simon et al. [6] classified endodontic-
periodontal lesions into primary endodontic lesions,
primary endodontic lesions with secondary periodontic
involvement, primary periodontic lesions, primary
periodontic lesions with secondary endodontic
involvement, or true combined lesions. Bone loss
secondary to pulpal pathosis is believed to result from
the spread of inflammatory irritants from the pulp to the
periodontal ligament.[7] The treatment of endodontic-
periodontal combined lesions requires both endodontic
therapy and periodontal regenerative procedure, as
discussed in this case report. The goal of periradicular
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Verma, et al.: Combined endodontic - Periodontal lesion - A clinical dilemma

Figure 1: Preoperative tooth 11, probing depth 12 mm Figure 2: Preoperative tooth 21, probing depth 8 mm

Figure 3: Preoperative I.O.P.A. X-ray after endodontic treatment Figure 4: Osseous defect upto apex

Figure 5: Bone graft Figure 6: Sutures placed

surgery is to remove all necrotic tissues from the
surgical site, to completely seal the entire root canal
system, and to facilitate the regeneration of hard and
soft tissues including the formation of a new attachment
apparatus.[8]
It is interesting to note that there was no radiographic or
clinical evidence of preexisting deep decay in either of
the teeth, and no cracks were evident. The most common
clinical/radiographic features of these endodontic-
periodontal lesions reported were the periapical

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Verma, et al.: Combined endodontic - Periodontal lesion - A clinical dilemma

Figure 7: Postoperative 2 week Figure 8: Follow-up 1 year

Figure 9: Preoperative sinus in tooth 12 Figure 10: Preoperative IOPA X-ray

Figure 11: Osseous defect upto apex Figure 12: Bone graft

radiolucency and deep pocket depths with a nonvital
pulp status.
Traditional approaches to treat periodontal and endodontic
defects include nonsurgical debridement of root surfaces
or root canals, as well as surgical approaches that provide
better access to clean the root surfaces and apical lesions
and to reshape the surrounding bone/root apex.
Bone loss caused by pulpal disease is reversible, whereas

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Verma, et al.: Combined endodontic - Periodontal lesion - A clinical dilemma
Figure 13: Guided tissue regeneration membrane
Figure 15: Post operative 2 week
advanced bone loss caused by periodontal disease is
usually irreversible.[9] The necessity of periodontal surgical
therapy most likely was because the periodontal bone loss
was more advanced and was less likely to resolve after
non surgical root canal therapy alone.[1]
Generally, partial apical root resection has been suggested
for all endodontic surgery caused by the multiple apical
canals to the pulp.[10] In this case report, root canal
debridement and removal of granulation tissue around
the root and apex was done, without subsequent root
resection and retrograde filling. However, periradicular
curettage was the sole procedure for the following reasons:
(a) periapical curettage is able to remove the granulation
tissue without root resection;[11] (b) there is no difference
in healing with curettage alone or curettage with root-end
resection more dentinal tubules may remain open after
root-end resection, allowing more contaminants to leak
out through the tubules.[12] However, in case-2, using the
GTR membrane technique, combined with bone graft,
the result was clinically successful after a 1yr follow-up
period. The role of bone graft in both the cases was for
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Figure 14: Sutures placed
Figure 16: Follow-up 1 year
space-making and also for inducing bone formation and
the attachment gain seen in these cases.
A long junctional epithelium formed over the dehisced
root surface has been suggested to be a contributing
factor for the poor therapeutic prognosis. The rationale for
using GTR barrier membranes in case 2 with bone grafting
materials is to encourage the growth of key surrounding
tissues, while excluding unwanted cell types such as
epithelial cells.[13] GTR therapy has been implemented in the
endodontic surgeries as a concomitant treatment during
the management of the endodontic-periodontal lesions.
However, from clinical and radiographic findings, the result
of this combined technique was quite impressive, resulting
in a significant reduction of probing depth and bone fill.
Selecting a defect that is amenable to regeneration is
also critical for achieving success. This is also true for an
endodontic defect. Some of the patient factors that might
contribute to positive outcome includes the good plaque
control, compliance, nonsmoking, anti-infective therapy
and systemic health.
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Verma, et al.: Combined endodontic - Periodontal lesion - A clinical dilemma
Other factors that might also negatively affect the healing
process include occlusal trauma, improper surgical
technique (such as excessive flap tension), early mechanical
disruption, and contamination during surgery. Wang and
Boyapati[14] suggested 4 factors, the so-called PASS principle,
that are critical for predictable bone regeneration: primary
wound closure, angiogenesis as a blood supply and source
of undifferentiated mesenchymal cells, space maintenance,
and stability of the wound. Space maintenance involves the
creation of space for periodontal tissues to grow into; which
was achieved in these cases with a bone graft.
CONCLUSION
Although traditional nonsurgical periodontal therapy and
regular endodontic therapy can be predictably used to
arrest mild to moderate defects, it might be inadequate
for the treatment of disease characterized by deep
pockets or wide circumferential apical defects. Currently,
regenerative techniques are widely available in terms of
their predictability to regenerate the lost tissue/bone in all
types of defects or for all situations. A careful preoperative
diagnosis, appropriate case selection and knowledge
of the factors that can negatively affect regeneration
outcomes can help to optimize successful regenerative
attempts. Treatment strategies used in this case report
suggests that combined endodontic-periodontal lesions
can be successfully managed with multiple regenerative
procedures.
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How to cite this article: Verma PK, Srivastava R, Gupta KK, Srivastava A.
Combined endodontic - Periodontal lesion: A clinical dilemma. J Interdiscip
Dentistry 2011;1:119-24.
Source of Support: Nil. Conflict of Interest: None declared.
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