IP International Journal of Periodontology and Implantology 2019;4(4):147–151

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IP International Journal of Periodontology and Implantology

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Case Report
Endo perio lesions- A synergistic approach

Shruthi Raveendran1 , Shruthi S1 , Parichaya Batra1 , Shirish A Magadum2 ,

Sanjeela Guru1 , Nisha K.J1, *
1 Dept. of Periodontics, Vydehi Institute of Dental Sciences and Research Centre, Bangalore, Karnataka, India
2 Dept. of Conservative Dentistry, Vydehi Institute of Dental science and Research Centre, Bangalore, Karnataka, India

ARTICLE INFO ABSTRACT

Article history: The interrelationship between endodontic and periodontal diseases has been a subject of speculation,
Received 07/12/2019 confusion and controversy for many years. Pulpal and periodontal problems are responsible for more
Accepted 25/12/2019 than 50% of tooth mortality today. A symptomatic tooth may have pain of periodontal and/or pulpal origin.
Available online 07-01-2020 The nature of that pain is often the first clue in determining the etiology of such a problem. A thorough
understanding of the disease history and the patient’s signs and symptoms, complete examination with full
investigation, and the use of a systematic step-by-step approach in the management of such challenging
Keywords:
endodontic-periodontal lesions with regular recall visits helps to achieve complete success in the treatment.
Endoperio
Novabone © 2019 Published by Innovative Publication. This is an open access article under the CC BY-NC-ND
Regeneration license (https://creativecommons.org/licenses/by/4.0/)

1. Introduction the periodontal ligament

(b) Primary endodontic lesion with secondary peri-
The three structures the tooth, the pulp and the periodontium
odontal involvement
supporting it forms a single biologic unit hence influencing
2. Primary periodontal lesion
each other during health, function and disease. This close
3. Primary periodontal lesion with secondary endodontic
inter relationship could result in concomitant lesions leading
involvement
to the periodontal endodontic (perio endo) infections which
4. Combined endodontic periodontal lesion
has always been a challenge for the dental professionals to
5. Iatrogenic periodontal lesion
diagnose and manage. But it is of vital importance to make
a correct diagnosis so that appropriate treatment plan can be
provided. This classification has increased the understanding of
The ectomesenchymal origin of both the pulp and the origin and its disease process which is important
periodontal tissues gives rise to anatomical connections, for establishing the correct diagnosis and treatment with
which remain throughout life. 1 The relationship between the predictable success. The success rate of treating the
periodontium and pulp was first discovered by Simring and endoperio lesions without a regenerative procedure ranges
Goldberg in 1964. 2 between 27- 37% which is very low. 4
In 2014, Al- Fouzan suggested a new endodontic Inspite of the treatment of endo perio lesions being
periodontal interrelationship classification, based on the a multidisciplinary approach many times the periodontal
primary disease and its secondary effect. 3 aspect of the treatment plan is neglected due to various
reasons making the endodontic therapy alone a failure.
1. Retrograde periodontal disease Hence in this case series we are aiming to discuss the endo
(a) Primary endodontic lesion with drainage through perio cases treated with an endodontic treatment followed
* Corresponding author. by a regenerative periodontal therapy /resective periodontal
E-mail address: drnishakj2016@gmail.com (Nisha K.J). therapy with a follow up of up to 12 months.

https://doi.org/10.18231/j.ijpi.2019.031
2581-9836/© 2019 Innovative Publication, All rights reserved. 147
148 Raveendran et al. / IP International Journal of Periodontology and Implantology 2019;4(4):147–151

2. Case Series debrided and root planning was done using Hu-Friedy
Gracey curettes. Distal portion of the tooth was resected
All the patients discussed below reported to the Department
using a carbide bur, and the resected portion was extracted.
of Periodontics Vydehi Dental College and Hospital,
Flap was sutured using 3-0 silk suture followed by
Bangalore.
periodontal dressing.
6 months follow up showed uneventful healing and
2.1. Case 1 absence of mobility. Hence, prosthetic rehabilitation was
A male patient aged 45 years old reported with a done after 6 months (Figure 2).
chief complaint of pain in lower left back tooth region
since a month. Clinical examination revealed the 2.3. Case 3
presence of periodontal probing depth of 6, 7, and
5 mm on mesiobuccal, mid buccal and disto buccal A 37 year old female patient reported with a chief complaint
regions respectively and the presence of grade II furcation of pain and swelling in upper front tooth region since
involvement in relation to 36. Tooth was non carious and 15days. On clinical examination diffuse palatal swelling
showed negative response towards thermal and electric pulp with normal probing depth and grade I mobility was
test. Intra oral periapical radiograph showed the presence present. It also revealed the presence of trauma from
of an ill-defined radiolucency in the furcation area and occlusion. Tooth showed negative response towards electric
an angular defect on the distal root surface extending up pulp testing. IOPAR showed well defined radiolucency
to middle third of the root. Hence the treatment plan in the periapical region of 21,22 suggestive of periapical
included endodontic therapy first followed by periodontal cyst requiring an apicectomy procedure. Hence after the
regenerative therapy. completion of endodontic therapy the patient was scheduled
After successful endodontic treatment patient was posted for apicectomy.
for regenerative periodontal surgery. After administration Endodontic therapy was done followed by which patient
of 2% local anaesthesia with 1:200000 adrenaline, using 15 was taken up for apicoectomy. 2% local anaesthesia
no blade crevicular incision was given starting from distal with 1:200000 adrenaline was administered, sub marginal
line angle of 34 to mesial line angle of 37. Full thickness incision was made using a 15 no blade, full thickness
mucoperiosteal flap was reflected, defect was debrided and mucoperiosteal flap was reflected extending beyond the
root planning was done using Hu-Friedy Gracey curettes, periapical region, using stainless steel bur window opening
pre suturing was done followed by placement of Novabone was done at the apex of the root and the cyst was
putty in the defect region and flap was sutured using 3- exposed followed by enucleation of the cyst. The root
0 silk suture followed by periodontal dressing and post- end was resected followed by burnishing of the apical
operative instructions were given. 12 months follow up end. Presuturing was done. Platelet rich fibrin was placed
of the patient showed complete resolution of the pain, in bony defect and guided tissue regeneration membrane
reduction of probing pocket depth to 4mm and IOPAR (Healiguide) was used to cover the defect. Flap was sutured
showed significant bone fill in the furcation area and around using 3-0 silk suture and periodontal dressing was given.
the tooth.(Figure 1) Patient reported for suture removal after 10 days. Healing
was satisfactory. 12 months revaluation of IOPAR showed a
2.2. Case 2 decrease in radiolucency in the periapical region and clinical
revaluation showed the absence of tooth mobility. (Figure 3)
A 32-year-old female patient reported with a chief
complaint of pain in lower left back tooth region since 6 2.4. Case 4
months. On clinical examination 13mm probing depth was
noted on distobuccal surface of 36 with grade I mobility. A 35year old female patient reported with a chief complaint
Tooth was non responsive to thermal and electric pulp of pain and pus exudation from upper front tooth region
testing. IOPAR showed complete radiolucency in distal root since a month. On clinical examination there was normal
surface extending up to apical third of the root. Based on the probing depth with pus exudation from gingival sulcus irt
clinical and radiographic investigations the treatment plan 21. Further examination revealed the presence of trauma
included an endodontic therapy followed by periodontal from occlusion. 21 showed negative response to pulp
root resective therapy. vitality. Radiographic investigation showed a short root
After the successful endodontic therapy, the patient was length. The prognosis was explained to the patient followed
scheduled for root resective surgery. After administration of by all the treatment options. Since she insisted on retaining
2% local anaesthesia with 1:200000 adrenaline, crevicular the tooth, we went ahead with endodontic therapy followed
incisions were made using a 15 no blade starting from by periodontal regenerative therapy.
mesial line angle of 35 to distal line angle of 37. Full After initial phase I therapy, endodontic therapy was
thickness mucoperiosteal flap was reflected, defect was carried out followed by periodontal flap surgery under
 Raveendran et al. / IP International Journal of Periodontology and Implantology 2019;4(4):147–151 149

Fig. 1: Case 1

Fig. 2: Case 2

local anaesthesia. Crevicular incision were given and full 3. Discussion

thickness mucoperiosteal flap was reflected. Fenestration
was noted at root apex and alveolar ridge defect in 11 The successful treatment of end operio lesions always poses
region. Gutta percha was burnished at root apex and a major challenge. The key to success in treating these cases
the fenestration area was closed using a GTR membrane. highly depends on thorough case history and clinical and
The alveolar defect was restored with Perioglas bone graft necessary radiographic investigations to determine the cause
followed by placement of Periocol GTR. Flap was sutured and reach an exact diagnosis of the case. In addition, the
and periodontal dressing was given. ability of the clinician to categorize the lesion makes the
treatment strategy clearer and more precise.
In the present case series several successful endodontic
and periodontal cases were presented with different
Post-operative revaluation showed the presence of grade treatment modalities.
I mobility. To stabilize the tooth splinting was done and In all the reported cases we have first tried to achieve
patient was put on maintenance therapy. Post 12months re- clean root canal system by which we have eliminated pain
evaluation showed the resolution of clinical symptoms and and which would help in gaining periapical seal. Different
reduction of mobility and the patient was given a permanent regenerative materials like Novabone putty, Platelet Rich
prosthesis (Figure 4). fibrin, Perioglas and Perio Col GTR membrane were used.
150 Raveendran et al. / IP International Journal of Periodontology and Implantology 2019;4(4):147–151

Fig. 3: Case 3

Fig. 4: Case 4

The first two cases presented fell into the category glycol as an additive and glycerine as the binder. It has
of Primary periodontal lesion with secondary endodontic dual action of osteoconduction and osteostimulation. 5 It
involvement. And the next two were the cases where the enhances the bone regeneration capacity by accelerating the
traumatic occlusion was the causative factor. Ideally the resorption rate of the graft material. And in this case, it has
treatment plan in the last two cases should have included successfully showed a regeneration in the furcation area and
an orthodontic correction but as the patient was not willing around the tooth.
to go for the orthodontic treatment and the prognosis for the
same was questionable, we went ahead with an endodontic In the second case as the distal root irt 36 was devoid of
treatment followed by periodontal treatment. bone completely we could not go for a more conservative
approach hence root resective periodontal therapy was the
In the first case we used Novabone putty as the choice of treatment. Root resection can successfully treat
regenerative material which has a bimodal particle specific furcation defects that cannot be solved by other sur-
distribution of calcium phosphosilicate with polyethylene gical and non- surgical approaches. 6 Complications are not
 Raveendran et al. / IP International Journal of Periodontology and Implantology 2019;4(4):147–151 151

rare with these procedures but are usually unavoidable when 6. Conflict of interest
specific endodontic, surgical and restorative guidelines are
None.
followed. In the present case patient was successfully
treated and the missing half of the tooth was prosthetically
restored after 6 months. References
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The above all mentioned cases were treated with a Author biography
multidisciplinary approach with expertise from endodontics
and prosthodontics involved. In all the cases we were Shruthi Raveendran PG Student
able to identify the repair and regeneration of the lost bone
thereby increasing the longevity of teeth in turn improving Shruthi S Reader
its prognosis.
Parichaya Batra Senior Lecturer
4. Conclusion
Shirish A Magadum PG Student
The ultimate goal of any dental treatment is the preservation
and restoration of the function of natural tooth. And Sanjeela Guru Reader
the treatment of any endo perio lesions always needs a
Nisha K.J Head of Department
multidisciplinary approach. Hence the synergistic approach
towards a condition can definitely increase the longitivity of
tooth.
Cite this article: Raveendran S, Shruthi S , Batra P, A Magadum S,
Guru S, Nisha K.J . Endo perio lesions- A synergistic approach. Int J
5. Source of funding Periodontol Implantol 2019;4(4):147-151.

None.