Mastering the Diagnosis of Endodontic-Periodontal Lesions
Endodontic-periodontal lesions can be complex to diagnose due to overlapping symptoms. Identifying the primary cause — whether endodontic, periodontal, or a combined origin — is essential for selecting the appropriate therapy and ensuring the best possible prognosis.
Determining the exact cause of an endodontic-periodontal lesion can be challenging due to overlapping signs and symptoms. Accurate diagnosis is essential for successful treatment, making it critical to identify the primary etiology before beginning therapy.
In 1972, Simon et al1 classified endodontic-periodontal lesions as:
- Primary endodontic lesions
- Primary endodontic lesions with secondary periodontal involvement
- Primary periodontal lesions
- Primary periodontal lesions with secondary endodontic involvement
- True combined lesions
PRIMARY PERIODONTAL LESION
The etiology of a primary periodontal lesion is radicular biofilm and calculus. In these types of lesions, periodontal pockets tend to be wider and more generalized, and calculus is typically visualized on the root. However, unless the periodontal pocket has reached the apex, the pulps of these teeth will almost always remain vital.2,3 If pulp sensibility testing confirms the pulp is vital, then only periodontal therapy is needed and the success rate depends upon the periodontal treatment.1
PRIMARY PERIODONTAL LESION WITH SECONDARY ENDODONTIC INVOLVEMENT
A primary periodontal lesion with secondary endodontic involvement arises when a periodontal pocket reaches the apex of the tooth, and the pulp becomes necrotic.2,3 The etiology of these lesions can either be from advanced periodontal disease or congenital defects, such as a longitudinal groove or invagination on a tooth root (Figures 1A through 1D). When present, these types of deep grooves or invaginations can act as a route for bacteria to reach the apex. When pulp sensibility testing confirms a diagnosis of pulpal necrosis, root canal treatment should be performed. However, because the primary etiology is periodontal in origin, the tooth will also require periodontal therapy. As before, the prognosis hinges on the success of the periodontal therapy.1
CONCLUSIONS
An accurate diagnosis of endodontic-periodontal lesions can be confusing because these lesions can present with similar signs and symptoms. If a tooth has not been previously treated, and the pulp tests necrotic, root canal treatment should be performed, and no periodontal treatment is needed. If the pulp tests vital, then only periodontal treatment is indicated. However, in teeth with primary endodontic lesions with secondary periodontal lesions, primary periodontal lesions with secondary endodontic involvement, or true combined lesions, both endodontic and periodontal therapy are required. Because the therapeutic success rate of these combined lesions is ultimately determined by the periodontal treatment, it is recommended that a consultation be scheduled with a periodontist prior to initiation of any endodontic treatment.
REFERENCES
- Simon JHS, Glick DH, Frank AL. The relationship of endodontic-periodontic lesions. J Periodontol. 1972;43:202–208.
- Langeland K, Rodrigues H, Dowden W. Periodontal disease, bacteria, and pulpal histopathology. Oral Surg Oral Med Oral Pathol. 1974;37:257–270.
- Ricucci D, Siqueira JF, Rocas IN. Pulp response to periodontal disease: Novel observations help clarify the process of tissue breakdown and infection. J Endod. 2021;47:740–754.
This information originally appeared in Dunlap CA, Lundergan WP, Dunlap BC. Diagnosis of endodontic-periodontal lesions. Decisions in Dentistry. 2023;9(2):42-45.
