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 Table of Contents  
Year : 2016  |  Volume : 1  |  Issue : 2  |  Page : 27-30

Comprehensive treatment of endo-perio lesion: A case report

1 Assitant Professor, Department of Periodontics and Community Dental Sciences (PCS), King Khalid University, College of Dentistry, Abha, Saudi Arabia
2 Associate Professor, Department of Periodontics and Community Dental Sciences (PCS), King Khalid University, College of Dentistry, Abha, Saudi Arabia

Date of Web Publication8-Aug-2020

Correspondence Address:
BDS, MDS Shahabe Saquib
Department of Periodontics and Community Dental Sciences, College of Dentistry, King Khalid University, Abha
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1658-743X.291742

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Pulpal infection may cause a tissue destructive process that proceeds from the apical region of a tooth toward the gingival margin. The term “retrograde periodontitis” was suggested in order to differentiate this from marginal periodontitis in which the infection spreads from the gingival margin toward the root apex. Proper diagnosis of the various disorders affecting the periodontium and the pulp is important to exclude unnecessary and even detrimental treatment. This is a clinical case report of an endodontic–periodontic lesion in relation to lower centrals and left lateral incisor. Root canal treatment has been done with the respected teeth six months ago, but the lesion showed no sign of healing. Radiographic examination revealed peri-radicular radiolucency in relation to 31, 41, and 42. Periodontal flap surgery was performed with apicectomy and the defect was filled with bone graft. Patient reviewed for one year which showed uneventful healing and no recurrence of the lesion.

Keywords: Endo-Perio lesion, Regenerative surgery, Endodontic therapy

How to cite this article:
Saquib S, AlQahtani N, Javali MA. Comprehensive treatment of endo-perio lesion: A case report. King Khalid Univ J Health Scii 2016;1:27-30

How to cite this URL:
Saquib S, AlQahtani N, Javali MA. Comprehensive treatment of endo-perio lesion: A case report. King Khalid Univ J Health Scii [serial online] 2016 [cited 2021 Jan 18];1:27-30. Available from: https://www.kkujhs.org/text.asp?2016/1/2/27/291742

  Introduction Top

Pulp and periodontal problems are responsible for more than 50% of tooth mortality. Cahn (1927) was one of the first investigators to state that periodontal disease had an influence on the pulpal tissue. The pathways for the spread of infection between pulpal and periodontal tissues have been discussed extensively with wide controversy.[1],[2] Pulpal infections can drain through the periodontal ligament space and give an appearance of periodontal destruction, termed as retrograde periodontitis. Periodontal infection can cause pulpal necrosis by extending onto the pulp chamber through apical foramen, termed as retrograde pulpitis. Infection through similarly, both pulpal and periodontal infections can exists at the same time in the same tooth, termed combined lesions, where the treatment depends on the degree of involvement of the tissues. It was found that pathogenic microorganisms of periodontal lesion and root canal of tooth with endo- perio lesion is almost the same and consist of anaerobic microorganisms.[3]

The most conventional and widely used classification for endo-perio lesions was given by Simon et al. (1972), separating lesions involving both periodontal and pulpal tissues into the following groups:[4]

  1. Primary endodontic lesions
  2. Primary endodontic lesions with secondary periodontal involvement
  3. Primary periodontal lesions
  4. Primary periodontal lesions with secondary endodontic involvement
  5. True combined lesions

In general, when primary disease of one tissue, i.e. pulp or periodontium, is present and secondary disease is just starting, always treat the primary disease.[5],[6],[7] In endo-perio lesion it is recommended to treat endodontic lesion followed by treatment of periodontal lesion. Most of the time if the lesion is primarily endodontic it heals after successful endodontic therapy.

Periodontal status is main factor for prognosis of tooth with endo-perio lesion, because in some case periodontal intervention is required to treat and regenerate the damaged periodontal structure. Regenerative periodontal surgery provides more predictable result for the regeneration of lost periodontal structures. Recently various bone graft materials are available in the market which has good predictability for regeneration of lost periodontal structure.[8],[9] Demineralized freeze dried bone allograft is one of the materials which has predictable bone regeneration property in periodontal defect.[10]

  Case Report Top

A 32 year old female patient reported to the Out Patient Department of the Dental Institute, complaining of mobility and pus discharge from the lower anterior region. She also complains of intermittent throbbing pain which was aggravated on biting and during night time. Patient gave a history of trauma with lower incisor two years ago in road traffic accident.

Clinical examination:

Intra-oral examination revealed healthy gingival condition around the complaint region [Figure 1]. Periodontal examination revealed pocket of 9 mm on the labial aspect of 41 which was extending beyond muco-gingival junction. Attached gingival and alveolar mucosa in lower labial region was tender on palpation, suggesting of underlying pathology. The respected tooth had grade I mobility, which was not interfering with function. Vitality test was done with 31, 41 and 42. All the examined teeth showed negative vitality test.
Figure 1: Preoperative clinical view and IOPA of the lower anterior region

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Radiographic examination:

Revealed peri-radicular radiolucency in relation to 31, 41, and 42 [Figure 1]. The lesion was extending from 31 to 42. The radiolucency was suggestive of periapical pathology.


Patient has been explained about the treatment procedure and informed consent was obtained from the patient. Depending on the result of vitality test all the non-vital teeth were advised root canal treatment. After completion of root canal treatment regular follow-up of the peri-apical pathology was recorded. Radiograph taken at the regular interval revealed no significant healing of the peri-radicular area. The patient was still complaining of pain and discomfort in that region.

After six months of follow up periodontal surgical intervention was advised to the patient to treat the periapical pathology. Fifteen days after phase one therapy patient was scheduled for the regenerative periodontal surgery.

Subsequently periodontal flap was reflected by using crevicular and releasing incision. Complete scaling root planing and degranulation was done to visualize the anatomy of the defect [Figure 2]. The defect was oval shape and 1x1.2x0.8cm in size. The labial aspect of root with respect to 41 was completely denuded of bone; bone was present on the lingual and lateral aspects of the root. Close observation of apex revealed over extended gutta-percha point with 41. Over-obturated gutta-percha was removed by using high speed rotating bur. Apicectomy was performed with 41 by using high speed rotating bur. Retrograde filling was performed with the use of Glass Inomer Cement [Figure 2]. In the next step the osseous defect was filled by Demineralized freeze dried bone allograft [TATA Memorial HospitalTissue Bank] [Figure 2]. Flap was sutured back by using interrupted direct loop suture. Postoperative instruction and antibiotic was given to the patient.
Figure 2: Complete degranulation, retrograde filling and bone graft placed in the defect

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Patient was recalled after 7 days for suture removal and then reviewed every month for one year. Patient showed uneventful healing and no recurrence up to the end of one year of follow-up period [Figure 3]. Radiographic evaluation at the end of one year showed evidence of bone regeneration in the peri- radicular area [Figure 3].
Figure 3: Postperative clinical view and IOPA of the lower anterior region at the end of one year

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  Discussion Top

The pathways for the spread of bacteria between pulpal and periodontal tissues have been discussed with controversy.[11] Pulpal infection can drain through the periodontal ligament space and give an appearance of periodontal destruction, termed retrograde periodontitis. While treating an endo-perio case it is very important to set a diagnosis before commencing the treatment because treatment plan will change according to the nature and class of the disease. Following table will surely help the clinician in diagnosis of the lesion [Table 1]. Periodontal status is important for prognosis of tooth with endo-perio lesion, because comprehensivet reatment of endo-perio lesions should consist of two stages: infection elimination from the root canal and regeneration of the lost periodontium.[3]
Table 1: Difference between pulpal and periodontal lesion

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The presented case was a primary endodontic lesion with secondary involvement of periodontal tissue. The patient gave history of trauma two years ago with mobility and mildthrobbing pain with 41 since six months. The treatment was done on the basis of evidence that apicectomy of the offending tooth,[12] and DFDBA placement in the defect helps in regeneration of the lost periodontal tissue.[1314] One year clinical follow up of the patient showed uneventful healing and no recurrence. Radiographic evaluation at the end of one year showed evidence of bone regeneration in the peri-radicular area.

Libin et al (1975) were the first to report the use of cortical and cancellous DFDBA in humans. Demineralization of an allograft exposes bone morphogenetic proteins within the bone matrix. These proteins induce a cascade of events leading to cellular differentiation and the formation of bone through osteoinduction.[1314] Histological studies in humans performed by Bowers et al. revealed the formation of new attachment apparatus in intra-bony defects grafted with DFDBA. DFDBA for dental use usually have graft material in various particle sizes, and the range from 250 to 750 mm is the most frequently available.[1516] Meta-analysis performed by Trombelli et al. showed better result with respect to gain in clinical attachment and reduction in probing depth when open flap debridement is compared with the bone allograft.[17] Recent studies have shown thata combination of Platelet Rich Fibrin (PRF) with DFDBA demonstrated better results with respect to regeneration of periodontal intrabony defect.[1819]

  Conclusion Top

The endodontic periodontal lesion often presents a diagnostic and treatment dilemma. Those teeth that appear to have a periodontal problem of endodontic origin have an excellent prognosis. In some cases, only endodontic therapy or periodontal treatment alone is indicated. In other cases, a combined approach is required. If the prognosis is questionable or poor even with good periodontal and endodontic treatment, extraction of the affected tooth may be indicated. The treatment rendered and the subsequent success or failure of that treatment is directly dependent on making an accurate diagnosis of the lesion.

  References Top

Jansson L, Ehnevid H, Blomlof L, et al. Endodontic pathogens in periodontal disease augmentation. J Clin Periodontal. 1995;22:598-602.  Back to cited text no. 1
Jansson L, Ehnevid H, Lindskog S, et al. The influence of endodontic infection on progression of marginal bone loss in periodontitis. J Clin Periodontal. 1995;22:729-73.  Back to cited text no. 2
Grudianov AI, Makeeva MK, Piatgorskaia NV. Modern concepts of etiology, pathogenesis and treatment approaches to endo-perio lesions. Vestn Ross Akad Med Nauk. 2013;8:34-6.  Back to cited text no. 3
Simon J H, Glick D H, and Frank A L. The relationship of endodontic- periodontic lesions. J Periodontal. 1972;43:202-8.  Back to cited text no. 4
Richard E W, Mahmoud T. Principles and Practice of Endodontics. 3rd Edition Philadelphia W B Saunders Company. 2002:467-84.  Back to cited text no. 5
Rotstein I, Simon JH. Diagnosis, prognosis and decision-making in the treatment of combined periodontal endodontic lesions. Periodontol 2000. 2004;34:165-203.  Back to cited text no. 6
Harrington GW, Steiner DR, Ammons WE. The periodontal-endodontic controversy. Periodontol 2000. 2002;30:123-30.  Back to cited text no. 7
Varughese V, Mahendra J, Thomas AR, Ambalavanan N.Resection and Regeneration - A Novel Approach in Treating a Perio-endo Lesion.J Clin Diagn Res. 2015;9:08-10  Back to cited text no. 8
Kambale S, Aspalli N, Munavalli A, Ajgaonkar N, Babannavar R.A sequential approach in treatment of endo-perio lesion a case report.J Clin Diagn Res. 2014;8:22-4.  Back to cited text no. 9
MeIIonig J. Decalcified freeze dried bone allografts as an implant material in human periodontal defects. J Pertodontics Restorative Dent.1984;4:4055.  Back to cited text no. 10
Jansson L, Ehnevid H, lindskog S, et al. Relationship between periapical and periodontal status. A clinical retrospective study. J Clin Periodontol. 1993;20:17- 23.  Back to cited text no. 11
Quality guidelines for endodontic treatment: consensus report of the European Society of Endodontology. Int Endod J. 2006;39:921-30.  Back to cited text no. 12
Mellonig J T. Autogenous and allogeneic bone grafts in periodontal therapy. Crit Rev Oral Biol Med. 1992;3:333–52.  Back to cited text no. 13
Nasr HF, Aichelmann-Reidy ME, Yukna RA. Bone and bone substitutes. Periodontol 2000. 1999;19:74–86.  Back to cited text no. 14
Bowers G M, Chadroff B, Carnevale. Histologic evaluation of new attachmentapparatus formation in humans. Part III. J Periodontol. 1989;60:683.  Back to cited text no. 15
Bowers GM, Chadroff B, Carnevale R, et al. Histologic evaluation of new attachment apparatus formation in humans. Part II. J Periodontol. 1989;60:675–82.  Back to cited text no. 16
Trombelli L, Heitz-Mayfield LJ, Needleman I, et al. A systematic review of graft materials and biological agents for periodontal intraosseous defects. J Clin Periodontol. 2002;29:117–35.  Back to cited text no. 17
Chhaya B, Vipin B. Evaluation of efficacy of autologous platelet-rich fibrin with demineralized-freeze dried bone allograft in the treatment of periodontal intrabony defects. J Indian Soc Periodontol. 2013; 17: 361-6.  Back to cited text no. 18
Nesligül N, Timuçin B,Yavuz F. The use of platelet-rich fibrin (PRF) and PRF-mixed particulated autogenous bone graft in the treatment of bone defects: An experimental and histomorphometrical study. Dent Res J. 2015; 12: 418–24.  Back to cited text no. 19


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]


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