Navigating Endo-Perio Lesions: Simplified Solutions for Your Practise

Classification of Endo-Perio Lesions (by Simon et al.)¹

Type of LesionClinical Characteristics
Primary Endodontic Lesion
  • Usually presents as an ‘isolated’ periodontal problem with the affected tooth only
  • No generalised periodontal disease
  • History of pulpitis
  • A sinus tract originating from the apex is present in the sulcus
  • Pulp vitality test: Negative
Primary Periodontal Lesion
  • Patients present with generalised chronic periodontitis
  • Minimal or no pain
  • Pulp vitality test: Positive
Primary Endodontic Lesion with Secondary Periodontal Involvement
  • Presence of plaque and calculus in the way of the sinus tract
  • Pulp vitality test: Negative
Primary Periodontal Lesion with Secondary Endodontic Involvement
  • Pulp vitality test: Negative or altered (pulp can be necrotic or partially vital, especially in multi-rooted teeth)
True Combined Lesion
  • Features are similar to primary periodontal lesions
  • There may be some caries, trauma, fracture, wear defects, deep restoration, or a history of endodontic therapy
  • Pulp vitality test: Negative

Diagnosing Endo-Perio Lesions²

Clinical signs that will help you diagnose if the lesion is endodontal or periodontal in origin:

Clinical SignEndodontal LesionPeriodontal Lesion
Pulpal vitalityNon-vitalVital
Plaque / CalculusUnrelatedPrimary cause
InflammationAcuteChronic
Periapical lesionRadiolucentUsually not related
Vertical bone lossAbsentPresent
Junctional epitheliumNo apical migrationApical migration present
GingivaNormalRecession
Bone lossWider apicallyWider coronally

Determining a Suitable Treatment Plan Protocols²

Once you have identified the type of lesion, here’s a simple flow that will help you decide on a suitable treatment plan:

Step 1: Perform a pulp vitality test

Pulp StatusLikely Diagnosis
If the pulp is vitalYou may have a periodontal lesion in hand
If the pulp is non-vitalYou may be dealing with an endodontal lesion

 

Step 2: Check for pockets

Probing DepthLikely Origin of Lesion
If the probing depth is < 3 mmThe lesion may be endodontic in origin
If the probing depth is > 3 mmThe lesion may be periodontal in origin

Treatment Protocol for Endo-Perio Lesions²,³

  • Primary Endodontic Lesion
PrognosisRecommended Management
If the prognosis is goodPerform endodontic therapy, and restore and review the tooth over the next few weeks and months.
If the prognosis is poorExtract the tooth.
  • Primary Periodontal Lesion
PrognosisRecommended Management
If the prognosis is goodPerform non-surgical periodontal therapy and review. Some patients may require supportive periodontal therapy.
If the prognosis is poorExtract the tooth.
  • Combined Lesions

i) Primary endodontic with secondary periodontal lesion

  • Perform endodontic therapy, followed by simple hygiene phase → Monitor the tooth and evaluate after 2-3 months 

  • If needed, periodontal therapy can be performed

If the lesion is due to perforation→ Seal the perforation and keep under observation.

If there is a fracture → Manage it appropriately.

ii) Primary periodontal lesion with secondary endodontic lesion

  1. Endodontal therapy followed by palliative periodontal therapy. Evaluate after 2 to 3 months. 

  2. Check for periapical resolution.

  1. If periapical lesion is resolved→ The tooth may be grade 1 mobile and may require splinting.

  2. If the periapical lesion is not resolved → Treat for root damage, osseous defects and aberrant local morphology.

  1. In case of poor prognosis at any step, extraction is the best solution.

  2. In the case of pockets, treat them appropriately depending on pocket depth.

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References:

  1. Dunlap, C. A., DDS, Lundergan, W. P., DDS, Dunlap, B. C., & BS. (2023, June 30). Classification of endodontic-periodontal lesions. Decisions in Dentistry. https://decisionsindentistry.com/2023/07/classification-of-endodontic-periodontal-lesions/
  2. Keerthika R, Nivedhitha MS, Endodontic Periodontal Lesion Diagnosis and Treatment Decision Analysis, J Res. Med Dent Sci, 2021, 9 (2): 140-145. https://www.jrmds.in/articles/endodontic-periodontal-lesion-diagnosis-and-treatment-decision-analysis.pdf
  3. Ling Siew, K., Goh, V., Ling Goo, C., & Francis Corbet and Wai Keung Leung, E. (2019). The periodontal-endodontic relationship, what do we know? Periodontology and Dental Implantology. https://doi.org/10.5772/intechopen.78664

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