J Periodontol • May 2010
Case Report
Periodontal-Endodontic Lesion of a Three-Rooted Maxillary
Premolar: Report of a Case
Steven B. Blanchard,* Amjad Almasri,† and Jonathon L. Gray*
Background: A 43-year-old African American male
initially presented for a dental evaluation of a recur-
rent swelling on the buccal aspect of tooth #12. His
medical history was unremarkable except for a 20–
pack year history of smoking. He was eventually di-
agnosed as having a necrotic pulp #12, and received
root canal treatment. The patient’s problem was unre-
solved, and he was subsequently referred for a peri-
odontal evaluation with a presumptive diagnosis of
a periodontal abscess.
Methods: A flap was reflected from teeth #11
through #15. A buccal furcation invasion was discov-
ered on #12. Shortly thereafter, three distinct roots
with three grade III furcation invasions were located.
The tooth was deemed untreatable, and was ex-
tracted. The thin buccal plate of the extraction socket
was preserved using freeze-dried bone allograft to fa-
cilitate future prosthodontic replacement.
Results: Healing was uneventful. Periodontal open
flap debridement surgery was provided for the re-
mainder of the mouth, and the patient was placed
on a 3-month recall program.
Conclusions: Periodontitis associated with end-
odontic lesions are among the most daunting
diagnostic and therapeutic challenges faced by peri-
odontists. This is particularly true for maxillary pre-
molars with multiple roots. The tooth in this case,
once periodontally involved, had a very poor progno-
sis. The prognosis was further compromised by the
pulpal involvement. Therapy consisted of extraction
of the tooth to relieve the patient’s discomfort and
treating the adjacent teeth with periodontal open
flap debridement surgery. A review of the literature
pertinent to the diagnosis and management of peri-
odontal-endodontic lesions is also presented. J Peri-
odontol 2010;81:783-788.
KEY WORDS
Case report; diagnosis; endodontic; furcation defect;
periodontal lesion; prognosis.
* Department of Periodontics and Allied Dental Programs, Indiana University
School of Dentistry, Indianapolis, IN.
† Private practice, San Antonio, TX.
P
atients occasionally present with lesions affect-
ing the periodontium that are a diagnostic
challenge including lesions affecting both the
periodontium and periapical regions. Defects in-
volving both pulpal and periodontal disease have
caused confusion and controversy in dentistry.1-3
Pulpal inflammation and infections that extend into
the periodontal space may present with signs con-
sistent with those of periodontitis. Likewise, de-
structive periodontitis that extends to the periapical
regions may lead to pulpal pathoses and symptoms
not typically found with periodontitis. Proper di-
agnosis and treatment can usually be made from a
careful inspection of the lesion in conjunction with
radiographic evaluation, pulpal vitality testing, and a
comprehensive clinical examination. However, ab-
errations in normal tooth or root anatomy may com-
plicate formulation of a proper diagnosis and lead to
treatment failure. Retrospective studies reveal the
relatively poor prognosis for maxillary first premo-
lars.4,5 The purpose of this article is to present a case
of a three-rooted maxillary first premolar that was
referred for periodontal treatment of a buccal swell-
ing that failed to resolve following endodontic
therapy, and to review the literature pertinent to the
diagnosis and management of periodontal-endodon-
tic lesions.
CASE PRESENTATION
A 43-year-old African American male presented to
Indiana University School of Dentistry, Indianapolis,
Indiana, complaining of recurrent episodes of pain as-
sociated with tooth #12 in March 2002. His medical
history was unremarkable except for a 20–pack year
history of cigarette smoking. His previous dental his-
tory included a diagnosis of chronic periodontitis and
was treated non-surgically in the Predoctoral Clinic in
October 1998; this treatment was repeated in 2000. In
February 2002, the patient presented with a draining
sinus tract associated with tooth #12. Clinical exam-
ination revealed that tooth #12 had a necrotic pulp,
the patient was referred to the Predoctoral Endodontic
doi: 10.1902/jop.2010.090418
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Periodontal-Endodontic Lesion of Three-Rooted Premolar Volume 81 • Number 5

Clinic for treatment, and root canal therapy was com-

pleted in March 2002. One month later, the patient
began orthodontic treatment (private practice). In
March 2004, he was referred to the Graduate End-
odontics Clinic for evaluation of a soft tissue swelling
on the buccal aspect of tooth #12. The radio-
graph (Fig. 1) revealed a radiolucency midway down
the root. Because of deep probing depths around the
tooth and purulence, the patient was referred to the
Graduate Periodontics Clinic with a presumptive diag-
nosis of a periodontal abscess in tooth #12.
The patient was asymptomatic and his temperature
was normal. There were no palpable lymph nodes, nor
was there any exudate present. Probing depths of 6 to
9 mm were found around tooth #12 with mild-moder-
Figure 1.
ate chronic periodontitis affecting teeth #13 through Initial radiograph showing radiolucency halfway down the roots of
#15. Vitality testing was negative, as would be ex- tooth #12 that turned out to be a furcation invasion.
pected of a tooth that had received root canal therapy.
No evidence of a root fracture was seen at the evalu-
ation appointment. A decision was made to reflect
a flap to treat a presumed periodontal abscess or frac-
tured root.
After obtaining informed written consent, buccal
and palatal mucoperiosteal flaps were reflected to
gain access to teeth #11 through #15 to treat tooth
#12 and other periodontal problems in that sextant
(Fig. 2). It was immediately apparent that tooth #12
had three roots, of which only two had received root
canal treatment. All furcation invasions were Glick-
man grade III. Because of the anatomy of the defect
and the long root trunk on tooth #12, it was deter-
mined that the prognosis was hopeless and the tooth
was extracted. The extracted tooth and the socket are
Figure 2.
shown in Figures 3 and 4. Because of the thin buccal Surgical view of buccal and mesio-buccal furcation. Note the tip of
wall of the socket, the site was grafted with a freeze- the periodontal probe in the mesio-buccal furcation.
dried bone allograft to preserve socket dimensions.
Furthermore, it was determined that there might be
an early furcation invasion on the buccal aspect of morphology.8 Numerous studies have reported
tooth #13, but that it had a favorable prognosis. No that the prevalence of three roots in maxillary first
furcation invasion was detected on the distal aspect premolars varies from 0% to 9.2% depending on the
of tooth #13 despite the interproximal bone loss in population studied.8-24 If one combines all the data
this area. Surgical periodontal therapy consisting of available from these 17 studies, three-rooted premo-
open flap debridement with apical flap positioning lars have a reported mean prevalence of 1.8% (67 out
was completed on the other teeth in the sextant, of 3,668 total teeth examined) (Table 1).
and healing was uneventful. A post-treatment radio- Three-rooted premolars may be detected on peri-
graph of the extracted tooth revealed that the palatal apical or bitewing radiographs but may go undetected
root had been unfilled. with these traditional radiographic images. Changing
the radiographic horizontal angulation may allow bet-
DISCUSSION ter visualization of the root anatomy if multiple roots
Undetected and untreated root canal spaces are are suspected. Several authors have offered clues
a leading cause of endodontic failure.6,7 Maxillary first to aid in the diagnosis of multiple roots in maxillary
premolars are among the most difficult teeth to treat premolar teeth. A study by Sieraski et al.25 found
endodontically because of variations in the number that three roots were usually present on maxillary
of roots, the number of canals, variations in direction premolars if the radiographic mid-root mesio-distal
of the roots, longitudinal concavities of the roots, and dimension equaled or exceeded the mesio-distal
difficulties of using radiographs to visualize the apical width of the crown. An abrupt straightening or loss

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J Periodontol • May 2010
Figure 3.
Extracted tooth #12.
Figure 4.
Extraction socket. Note thin buccal and palatal plates necessitating
socket preservation.
of a radiolucent root canal space may also be indica-
tive of an extra canal in the same root or in other, sep-
arate roots.26 A third root may also be present if
radiographic images of maxillary premolars repeat-
edly show indistinct root morphology with resultant
questioning of the exact shape of the roots.27 This
case not only had an undiagnosed and unfilled root
canal space, but also was severely compromised
by diminished periodontal attachment as a result of
chronic periodontitis.
Periodontitis associated with endodontic lesions
are among the most daunting diagnostic and thera-
peutic challenges faced by periodontists. There have
been several systems developed for classification
of combined pulpal and periodontal problems, but
the classification devised by Simon et al.2 is still
Blanchard, Almasri, Gray
commonly used to describe these lesions. Their clas-
sification system distinguishes pulpal-periodontal
problems into five categories: 1) primary endodontic
lesions, 2) primary endodontic lesions with secondary
periodontal involvement, 3) primary periodontal le-
sions, 4) primary periodontal lesions with secondary
endodontic involvement, and 5) ‘‘true’’ combined
lesions. Rossman1 has described the clinical pre-
sentations and treatment options for these lesions,
discussed next.
Primary endodontic lesions are essentially those
lesions associated with a non-vital pulp where the
inflammatory process extends along the periodontal
ligament and drains through the gingival sulcus (sinus
tract). They present as an isolated periodontal lesion
or those involving furcation invasions of a multirooted
tooth with normal interproximal bone levels. There is
minimal plaque and calculus associated with these
lesions. Radiographic appearance may be relatively
normal or appear as isolated bone loss around the af-
fected tooth. Probing depths are normal around the
remaining teeth and probing around the affected
tooth may be associated with an isolated deep prob-
ing depth in the area of the sinus tract. Pulpal vitality
testing reveals a non-vital tooth and the treatment
modality involves endodontic therapy of the affected
tooth. With successful debridement and obturation of
the root canal space, the sinus tract along the root
heals uneventfully, and no further treatment is indi-
cated.
If the primary endodontic lesion persists for an ex-
tended period, plaque may migrate along the sinus
tract with secondary periodontal breakdown. These
lesions present clinically as those of primary end-
odontic origin except that plaque and calculus are de-
tected in the periodontal pocket. Pulpal vitality tests
are again negative and treatment consists of end-
odontic therapy and initial conservative non-surgical
therapy to eliminate the associate plaque and calcu-
lus. Root planing should not be done until completion
of the endodontic therapy to avoid removal of viable
connective tissue attachment to the root that would
heal by reattachment following endodontic obtura-
tion. The prognosis for the endodontic component is
excellent and the prognosis of the secondary peri-
odontal component is based on the severity of the
residual periodontal defect.
Primary periodontal lesions that extend to the apex
of the teeth can sometimes mimic endodontic prob-
lems. However, the pattern of attachment loss from
chronic periodontitis tends to be generalized and
a pattern of widespread bone loss is noted on most
teeth. Unlike the previously discussed primarily end-
odontic lesions, the pulps of primary periodontal
lesions remain vital and no endodontic therapy is in-
dicated unless the pulpal status degenerates. Pain is
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Table 1.
Published Studies on Prevalence of Three Roots in Maxillary First Premolars

Sample Size Three Three

Authors Year Population (# teeth) Roots (#) Roots (%)

Barrett9 1925 USA 32 0 0

Okamura10 1927 Japan 312 0 0

11
Mueller 1933 USA 130 0 0
Pucci and Reig12 1945 Uruguay 165 4 2.4
13
Barone, Pagano, and Cagnoli 1955 Uruguay 100 2 2
Bernaba, Madiera, and Hetem14 1965 Brazil 200 4 2
15
Carns and Skidmore 1973 USA 100 6 6

De Deus16 1975 Brazil 108 4 3.5

17
Vertucci and Gegauff 1979 USA 400 16 4
Walker18 1987 China 100 0 0
19
Sánchez-Mercant and Mangarelli-Vence 1989 Uruguay 32 1 3.1
Woelfel and Scheid20 1990 USA 200 2 1
8
Pécora et al. 1991 Brazil 240 6 2.5

Loh21 1998 Singapore 957 0 0

22
Kartal, Ozcxelik, and Cimilli 1998 Turkey 300 4 1.3
Chaparro et al.23 1999 Spain 150 5 3.3
24
Lipski et al. 2004 Poland 142 13 9.2

Total: 3,668 Total: 67 Overall prevalence

(%): 1.80

typically absent from most periodontal lesions, even
those in advanced stages of disease, unless a peri-
odontal abscess develops. The prognosis is entirely
dependent upon the response to periodontal therapy
but teeth with bone loss approaching the apices of
teeth have a predictably poor prognosis.
Primary periodontal lesions with secondary end-
odontic involvement are those where periodontal
inflammation and bone loss leads to a retrograde in-
fection of the pulp. The teeth may be painful due to
the extension of the infective process to the pulp. Un-
like the solitary lesions of primary endodontic origin
with secondary periodontal involvement, the pattern
of bone loss from these lesions tends to be general-
ized. These lesions may also be caused by extension
of periodontal infection into the pulp through lateral
canals or accessory canals, which are often located
in the apical third of the root and in the furcation re-
gions of multirooted teeth.28,29 Pulpal testing reveals
that the teeth are non-vital, but the results may be
mixed, especially in multirooted teeth. Endodontic
therapy and periodontal therapy are indicated in these
lesions and the prognosis is largely dependent upon
the periodontal prognosis. However, the prognosis
for teeth with bone loss approaching or extending to
the apices of teeth is generally poor.
True combined lesions present real diagnostic
challenges and may be difficult to differentiate be-
tween lesions that have a primary periodontal etiology
with secondary endodontic involvement both clini-
cally and radiographically. The true combined lesions
are those with simultaneous pathosis of both the pe-
riodontium and pulp occurring independently of each
other. Vertical root fractures on an imposed chronic
periodontitis may initiate a combined lesion.30 In
the combined lesion, pulp testing is negative and there
is evidence of generalized periodontal bone loss. Ex-
amination should include testing for the possibility of
a vertical root fracture. Treatment of the true com-
bined lesion involves both periodontal and endodontic

786
J Periodontol • May 2010
therapy, frequently of a complex nature.31 With the
unpredictable nature of the treatment of these lesions,
extraction and implant replacement are often the
treatment of choice today.
It may be difficult to ascertain if the case presented
here was a true combined lesion. At the time of peri-
odontal surgery, there was extensive loss of facial
bone with grade III periodontal furcation invasions
noted at all three furcations. Previous periodontal
chartings and radiographs from the patient’s chart
revealed a history of 2 to 4 mm of generalized at-
tachment loss associated with chronic periodontitis
before presenting with the symptomatic swelling on
tooth #12, which resulted in extraction. Because the
palatal canal had not been debrided or obturated
when endodontic treatment was initially completed,
it is possible that chronic inflammation from the end-
odontic lesion may have led to destruction of bone in
the furcation and facial regions, which then commu-
nicated with the ongoing chronic periodontitis. Ex-
tensive bone loss in the furcation regions combined
with a long root trunk for this tooth rendered a hopeless
periodontal prognosis in this case, regardless of the
actual diagnosis (periodontitis associated with end-
odontic lesions/combined periodontal-endodontic le-
sion tooth #1232). Had the diagnosis of a three-rooted
premolar been made at time of endodontic therapy 2
years prior, complete debridement and obturation of
the root canal spaces would have resolved the end-
odontic component and may have prevented the ex-
tensive alveolar bone destruction noted and the tooth
may have had favorable periodontal prognosis. In ret-
rospect, the atypical root morphology on the radio-
graphic images and the persistent swelling following
endodontic therapy should have alerted the treating
clinicians to suspect other etiologies for this particular
clinical case.
CONCLUSIONS
We present a case of a previously undiagnosed
three-rooted maxillary first premolar. Previous end-
odontic therapy of tooth #12 failed to treat all three
root canals, and at the time of periodontal referral
because of recurrent buccal swellings 2 years later,
the patient presented with extensive furcation inva-
sion revealed following flap reflection. The tooth
was deemed periodontally hopeless and extracted.
The problems associated with making a diagnosis
and effectively treating three-rooted premolar teeth
were discussed along with a review of periodontal-
endodontic lesions. This case emphasizes the
importance of a thorough clinical radiographic
examination prior to initiation of therapy. A proper
diagnosis of lesions affected by both periodontal
and pulpal disease is essential for the successful
treatment of these complex lesions.
Blanchard, Almasri, Gray
ACKNOWLEDGMENT
The authors report no conflicts of interest related to
this case report.
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Correspondence: Dr. Steven B. Blanchard, Indiana Uni-
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W. Michigan St., Indianapolis, IN 46202. Fax: 317/274-
1363; e-mail: stblanch@iupui.edu.
Submitted July 21, 2009; accepted for publication
December 18, 2009.