Endo-Perio Lesion / Endodontic - Periodontic Lesion

What are Endo-Perio Lesions?

Introduction

Endodontic - Periodontic Lesions are the simultaneous existence of pulpal problems and inflammatory periodontal disease, which affects the diagnosis and treatment planning and affects the sequence of care to be performed

Classification of Endo-Perio Lesions

A) Simon's Classification

1. Primary Endodontic Lesion
2. Primary Endodontic Lesion with Secondary Periodontal Involvement
3. Primary Periodontal Lesion
4. Primary Periodontal Lesion with Secondary Endodontic Involvement
5. True Combined Lesion
6. Concomitant Endodontic and Periodontal Lesion (Added by Belk and Guttman)

B) Oliet and Pollock's Classification (Based on Treatment Protocol)

1. Lesions that require Endodontic treatment procedures only
2. Lesions that require Periodontal treatment procedures only
3. Lesions that requires Combined Endodontic and Periodontic treatment procedures

Pulpoperiodontal Pathways

Pathways of Communication between Pulp and Periodontal tissue

1. Apical foramen
2. Dentinal tubules
3. Lateral canals
4. Periodontal ligament
5. Alveolar bone
6. Palatogingival groove
7. Neural pathways
8. Vasculolymphatic drainage pathways
9. Pathological communications due to fractures and perforations

Predisposing Factors of Endo-Perio Lesion

A) Atypical Anatomical Factors:

1. Malalignment of tooth leading to food impaction and occlusal trauma
2. Multirooted tooth - additional or fused roots
3. Additional root canals
4. Large lateral or accessory canals in coronal and middle section of roots

B) Trauma: Trauma to a tooth can originate from accidental blow, cavity preparation, restorative procedures, orthodontic treatments, tooth separation, malocclusion and detrimental habits

1. Crown farcture, root fracture or root displacement resulting in irreversible pulpitis, necrosis or periapical disease
2. Involvement of pulp and disturbance of the periodontal membrane, with the resultant sinus tract draining through periradicular tissue and exiting through the gingival crevice
3. Trauma along with gingival inflammation leads to deep periodontal pockets
4. Trauma in case of multirooted teeth leads to furcation involvement
5. Due to trauma possible cellular changes seen in the pulp or periodontium leading to internal or external bone resorption associated with root perforation

C) Iatrogenic Factors

1. Perforation into the furcation of multirooted teeth during root canal treatment
2. Root perforation during biomechanical preparation
3. Perforation in apical part of curved root during instrumentation

D) Systemic Factors - Systemic Diseases

Primary Endodontic Lesion

1. Etiology of Primary Endodontic Lesion
   • Dental Caries
   • Restorative procedures
   • Traumatic injuries
2. Clinical Features of Primary Endodontic Lesion
   • Pain
   • Tenderness to palpation and percussion
   • Sinus tract if present can be traced to the apex of the involved tooth
   • Abnormal response to vitality testing
3. Treatment plan - Endodontic therapy

Primary Endodontic Lesion with Secondary Periodontal Involvement

1. Etiology - Progression of Untreated or chronic primary Endodontic lesion
2. Clinical Feature
   • Plaque and calculus accumulating in the sulcus leading to pocket formation
   • Lowering of epithelial attachment
3. Treatment Plan - Endodontic treatment as primary line of therapy followed by Secondary Periodontal therapy

Primary Periodontal Lesion

1. Etiology - Plaque and Calculus
2. Clinical Feature
   • Horizontal or Angular bone loss
   • Tooth Mobility
   • Normal response to pulp vitality testing
3. Treatment Plan - Periodontal therapy

Primary Periodontal Lesion with Secondary Endodontic Involvement

1. Etiology - Periodontal disease progresses apically and involves pulp through apical foramen and lateral or accessory canal
2. Clinical Feature
   • Horizontal or Angular bone loss
   • Periodontal pocket formation
   • Tooth Mobility
   • Episodes of acute pulpal pain
3. Treatment Plan - Primary Endodontic treatment followed by long term Periodontal therapy

True Combined Lesion

1. Etiology - All endodontic and periodontal causes
2. Clinical Feature - Chronic lesion with gross pulpal and periodontal destruction
3. Treatment Plan - Endodontic therapy followed by Radisection or Hemisection

Concomitant Endodontic and Periodontal Lesion

1. Etiology - Distinct etiological factors of endodontic and periodontal disease which do not influence each other
2. Clinical Feature- Independent clinical features of both Pulpal and Periodontal Diseases
3. Treatment Plan - Both Pulpal and Periodontal diseases are treated independently