RestorativeDentistry Enhanced CPD DO C

Philippa Hoyle

Manoj Tank, Somayeh Modarres-Simmons and Claire Annabel Storey

Assessment and Management of

Endo-Periodontal Lesions
Abstract: Endo-periodontal lesions present a number of challenges for clinicians. These include understanding their underlying aetiology,
forming an accurate diagnosis and suitable prognosis and subsequently formulating an effective treatment strategy. This article aims
to provide a summary of the literature available in the areas highlighted above, with particular reference to the recent joint American
Academy of Periodontology and European Federation of Periodontology (AAP/EFP) world workshop for classification of periodontal and
peri-implant diseases.
CPD/Clinical Relevance: This paper outlines important aspects a clinician must consider, including anatomy, a systematic methodology
for assessment and introduction of the new classification of periodontal diseases in diagnosis. Prognosis and formulation of appropriate
management strategies are explored.
Dent Update 2019; 46: 930–941

The new classification of periodontal and symptomatic presentation to the clinic.1 categories:
peri-implant diseases has retained the In general dental practice, there  Primarily endodontic in nature − when
recognition of endo-periodontal lesions can be confusion unpicking the signs and triggered by a deep carious lesion which
(EPLs) as a separate disease classification, symptoms in patients presenting with an is driven bacterially or trauma to the tooth
due to the known pathophysiological EPL. Part of this uncertainty is deciphering allowing ingress of bacteria.
differences from periodontitis, especially whether the infection is endodontic or  Primarily periodontal in nature − when
in the acute form, which includes its rapid periodontal in origin. In all EPL cases, periodontal destruction has exposed the
onset and tissue destruction, as well as whether acute or chronic, there is a pulp canal orifices and retrograde bacterial
pathological communication between the ingress to the pulpal complex is possible.
Philippa Hoyle, BChD(Hons), MJDF periodontal and pulpal tissues, thereby  Combined perio-endo lesion − when
RCS(Eng), Specialty Registrar in resulting in more complex and challenging both processes occur concurrently.
Restorative Dentistry, Charles Clifford management. The anatomical variations in However, the recent joint
Dental Hospital, Sheffield (email: root canal morphology internally, including American Academy of Periodontology and
[email protected]), Manoj the presence of accessory and lateral European Federation of Periodontology
Tank, BDS(Brist), MJDF RCS(Eng), canals and intricacy of the periodontium (AAP/EFP) world workshop for classification
MClinDent(Perio), MPerio RCS(Edin), externally, provide challenging conditions of periodontal and peri-implant diseases
Specialist in Periodontics, Private for diagnosing and controlling bacterial advised that a classification system based
infections. EPLs significantly negatively upon disease history was unhelpful for
Practice, Surrey, Hampshire and Wiltshire,
affect the prognosis of a tooth and present assessing the current clinical condition of
Somayeh Modarres-Simmons, BDS(Lon),
challenges for management, involving the lesion,5 nor did it give insight in how
Dip Endo(Lon), MClinDent(Endo), MEndo
multiple treatment modalities.2 to approach the treatment of such lesions.
RCS(Edin), Specialist in Endodontics,
Prognosis is dependent upon The new classification for EPLs is presented
Private Practice, Surrey and Hampshire
an accurate diagnosis and this can be aided later in this paper and addresses these
and Claire Annabel Storey, BDS, MFDS,
by a good disease classification system. The shortcomings.
MSc(Rest Dent), MRes FDS RCS(Eng), first reported classification of EPL divided By exploring the anatomy and
Consultant in Restorative Dentistry, the condition into five subcategories,3 pathophysiology of the EPL, systematically
Charles Clifford Dental Hospital, Sheffield, however, subsequently this was adapted assessing such a lesion and diagnosing
Wellesley Road, Sheffield, S10 2SZ, UK. by Chapple and Lumley4 into the following based upon the new classification,
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was located in a periodontal pocket.14

Such lateral and accessory canals can act
as pathways through which bacteria and
toxic substances can be transported to the
periodontium and induce inflammation.
Clinically, teeth with furcation involvement
and moderate bone loss should be assessed
endodontically in case of infection via this
route.
It must be remembered that,
when a tooth has an apical abscess,
drainage may occur through the gingival
margin creating a communication, rather
than draining through a juxta-apical sinus
(Figure 1).

2. Periodontal effects on the pulpal tissues

Periodontal disease has a number
of anaerobic bacteria associated
Figure 1. Some of the potential pathways of communication between pulp and periodontium. with it including: Aggregatibacter
actinomycetemcomitans (Aa),
Porphyromonas gingivalis, Tannerella
forsythia, Treponema denticola, and
provides guidance to practitioners on their linked together with communication
Prevotella intermedia, amongst others.
appropriate management. possible via:9
The question of whether or not
 Apical foramen;
plaque-induced periodontal disease may
Anatomy and pathophysiology  Dentine tubules;
cause pulp tissue alteration is controversial.
 Lateral root canals;
Periodontal and endodontic diseases In recent years, observations have indicated
 Furcation root canals;
are both of bacterial origin. It is the that chronic periodontal disease induces
 Fracture lines within root structure;
formation of a biofilm (aggregation of or mediates pathological alterations in the
 Iatrogenic damage.
micro-organisms in an extracellular matrix tissue of dental pulp.17,18,19 Inflammatory
Lateral and accessory canals
attached to a solid surface) that increases cell infiltrate and tissue necrosis have been
form during root development, often due
the virulence of such bacteria. This is observed in the pulp adjacent to lateral
to a break in the root sheath caused by
mainly due to the synergy, chemotaxis and canals and apical foramina, associated with
the presence of periodontal vessels during
production of endotoxins within a biofilm. infected periodontal pockets or exposure
the calcification stage. After development,
The micro-organisms in EPLs are correlated to the oral cavity due to recession.9,20,21
they often become blocked or reduced in
with those involved in pulp and periodontal Secondary dentine formation in the root
size. Some may remain patent, serving as
disease, particularly protease-producing additional pathways for the neurovascular canal area has also been regarded as the
anaerobic bacteria. The flora, together supply of a tooth. result of pathologic pulp tissue reactions to
with their interaction with the tissues Accessory canals can be found periodontal disease.
and the potential synergistic impact, are all along the root and within the furcation, On the other hand, it has
summarized in the sections below. but the majority apically.10 De Deus found been considered that periodontal
that 27% of 1140 extracted teeth had disease, regardless of severity and plaque
1. Pulpal effects on the periodontium accessory canals, with molars most likely accumulation on root surfaces, does not
Endodontic lesions are thought to be to have them, followed by premolars, affect the dental pulp.22 Pathologic pulp
polymicrobial yet less complex than then incisors and canines.11 This has been tissue alterations in periodontally sound
periodontal lesions. Infected pulpal tissue corroborated by various authors, with furcal teeth occurred as often as periodontally
has evidence of prominent anaerobic canals present in 20−60% of molars,12 which infected teeth, and it was concluded that
species that are similar to those seen are more likely to be patent. the status of the periodontium does not
in periodontal lesions, for example, There is ample evidence exert any great influence on the pulp.23 No
Fusobacterium, Porphyromonas and indicating that infection of the pulp can correlation has been confirmed between
Prevotella species.6,7,8 There is a close communicate with the periodontium at the severity of periodontal disease and the
anatomical relationship between the locations other than the apex of the tooth.13 presence, or absence, of pulpal pathosis.24
root canal system and the periodontal In examining 100 teeth, Kirkham found The controversy is potentially
environment (Figure 1). The periodontal that 23 had one or two accessory canals attributable to the difficulty in accessing
tissues and the dental pulp are integrally and, in two of these, the accessory canal suitable control material, in which
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 RestorativeDentistry

Endodontic Disease Potential Communications Periodontal Disease

Polymicrobial Apical foramen Polymicrobal
Associated bacterial species: Dentine tubules Associated bacterial species:
 Fusobacterium species  Aggregatibacter actinomycetemcomitans
Lateral root canals
 Porphyromonas species (Aa)
 Prevotella species Furcation root canals  Porphyromonas gingivalis
 Tannerella forsythia
Fracture lines within root structure
 Treponema denticola
Root resorption  Prevotella intermedia
Iatrogenic damage
Table 1. Comparison of bacterial species and potential communications.

Endo-periodontal lesion with root damage Root fracture or cracking

Root canal or pulp chamber perforation

External root resorption

Endo-periodontal lesion without root EPL in a periodontitis patient Grade 1 – narrow deep periodontal pocket
damage in 1 tooth surface
Grade 2 – wide deep periodontal pocket in
1 tooth surface
Grade 3 – deep periodontal pockets in >1
tooth surface
EPL in a non-periodontitis patient Grade 1 – narrow deep periodontal pocket
in 1 tooth surface
Grade 2 – wide deep periodontal pocket in
1 tooth surface
Grade 3 – deep periodontal pockets in >1
tooth surface
Table 2. Classification of EPLs, adapted from Papapanou et al.1

pathological pulp tissue alterations 3. How joint lesions occur strategy and treatment sequencing.
unrelated to periodontal destruction can Endo-periodontal lesions are a result of Historically, there have been
be studied. communications between the pulpal and numerous attempts to classify EPLs, often
Patients who have been periodontal tissues through the routes concentrating on the pathogenesis of
treated and maintained for chronic described above, allowing transfer of the lesion, aiming to increase the efficacy
periodontal disease are likely to have microbial flora and by-products of the of treatment provided by attempting to
been subjected to multiple treatments, biofilm25 (Table 1). When two separate identify the primary source of infection.
some of which are now regarded as lesions meet on the same tooth a joint In reality, trying to identify the primary
historic, and it is not uncommon to lesion is created. The literature suggests aetiology of such lesions is challenging,
observe iatrogenic damage on exposed that, regardless of the lesion originating often impossible.
root surfaces from multiple root from the periodontal or endodontic tissues, The AAP/EFP world workshop
surface treatments. Handscalers (when or as a result of concomitant disease proposed a new classification system
sharp) remove more hard tissue and processes affecting the same tooth, the based upon current disease presentation
cementum than ultrasonic debridement bacteria involved are comparable.1,12 using the signs and symptoms available
or air polishing treatments, further which have a direct impact upon prognosis
compromising pulpal protection over Classification and management. This includes the
time by decreased dentine width and The classification of EPLs clinically informs assessment of the presence of fractures and
potentially more lateral canal exposure. the rationale behind the therapeutic perforations, whether it is a periodontitis
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Figure 2. Flowchart to demonstrate systematic approach to achieve diagnosis based on new classification.

patient, and the full extent of the Following this systematic detailed below and in Figure 2.
periodontal tissue destruction around the methodology to establish a diagnosis will The clinician is advised to take a
tooth in question. help provide clarity and consistency within detailed history to include:
Table 2 shows the new a clinician’s approach when determining  Localization of pain;
classification of EPLs, adapted from prognosis and subsequently managing the  Pain on biting and previous pain
Papapanou et al.1 The clinician must first EPL. experiences from the tooth;
determine whether the EPL is associated  Bitter/unpleasant taste due to
with damage to the root structure, suppuration/bleeding;
Clinical assessment of EPLs
iatrogenic or otherwise. Such lesions  Previous trauma to the tooth;
will usually have a poor prognosis and The clinical presentation of an EPL can  Previous endodontic treatment to the
a restorability assessment is prudent to differ considerably, depending upon the tooth;
decide whether the tooth can be preserved. aetiology behind the lesion. For example,  Any periodontal treatment history.
If there is no structural damage, in acute forms such as in recent trauma Extra-oral examination should assess for
clinicians must next determine whether or an iatrogenic event, the patient may signs of systemic infection, including:
they are dealing with a periodontitis patient present with abscess and associated pain. In  Fever or malaise;
or not. The lesion is then graded 1, 2 or contrast, chronic lesions may present as an  Facial swelling;
3, depending on the morphology of the asymptomatic EPL, which developed over  Lymphadenopathy.
periodontal pocket in the EPL. Figure 2 a longer period of time in a periodontitis Intra-oral examination should include:
shows a flowchart to help clinicians arrive patient.5  General screening for periodontitis;26
at a diagnosis based upon this classification The clinician’s assessment of an  Probing pocket depth around tooth in
system. EPL should include the following aspects question including judgement on whether
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 RestorativeDentistry

a narrow or wide pocket is present; degrees of bone loss may be evident. groups for a tooth with an EPL have been
 Buccal and oral soft tissue palpation and Lesions of primary endodontic and suggested.5 These are as follows:
presence of swellings, sinus tracts and/or periodontal origin are clinically and 1. Hopeless;
suppuration; radiographically very similar. 2. Poor;
 Mobility assessment; 3. Favourable.
 Percussion test; Sensibility testing There are a number of factors
 Presence of root grooves and furcations; The presence of a periodontal pocket that can affect the prognosis associated
 Signs of root fracture or perforations of reaching, or close to, the apex combined with such teeth. These factors include
the tooth structure; with a negative or altered response to the extent of the periodontal destruction
 Crown or gingival discoloration; sensibility testing have been identified around the tooth and the presence and
 Assessment of occlusion and as primary signs of EPLs within the new severity of any periodontal disease affecting
identification of occlusal trauma affecting classification.1,5 the rest of the dentition. EPLs arising from
the tooth (fremitus). Sensibility tests are surrogate iatrogenic or traumatic events are usually
Assessing for root structure tests for tooth vitality and may be able considered of hopeless prognosis.5
damage is particularly important, and is to differentiate between pulpal and There are a number of other
the first step in the diagnostic process as periodontal diseases. However, a false factors to consider when assessing
referred to above. The findings outlined by positive response might be elicited, with prognosis. These include the patient’s
Herrera et al indicate that the usual causes available tests particularly in cases of multi- healing response and the effectiveness
of root structural damage were because rooted teeth that may have partial pulp of the patient’s self-care and professional
of:5 necrosis. Similarly, a false negative response maintenance regimen. The success rate and
 Iatrogenic root, pulp or furcation may be elicited in teeth with significant longevity of a treatment and restorations
perforation (either during endodontic sclerosis of the pulpal environment or provided also impacts on the overall
instrumentation or post preparation); substantial in/direct restorations. In primary prognosis of a tooth with an EPL.
 Root fracture or cracking (either periodontal disease, the pulp is more likely For example, if iatrogenic
externally from trauma or due to post to be responsive to sensibility testing than damage such as a perforation is the primary
preparation, placement or removal); with primary endodontic disease. cause of the EPL, it is important to consider
 External root resorption (usually It is important to carry out that the presence of a perforation can
secondary to trauma) or internal root sensibility testing on teeth affected by reduce the success of non-surgical root
resorption communicating with the primary periodontal disease, particularly canal therapy by 54% on average. However,
periodontal ligament; when there are deep pockets and recession this is size and position dependent.27
 Pulp necrosis (due to trauma) draining affecting them, due to the risk of exposing
through the periodontal tissues. potential communications to the pulp. Management
Special tests should follow once a Anecdotally, altered and recommendations
provisional diagnosis is made. This should unreliable responses to sensibility testing
The main factors to be considered when
include: can occur around such teeth, presumably
planning the management for EPLs are the
 A periapical radiograph; due to the neurovascular system becoming
pulp vitality of the tooth affected, as well as
 Sensibility testing with thermal and bathed in inflammatory substances.
the type and the extent of the periodontal
electric tests to account for the sensitivity Where testing is inconclusive, it can be
defect.
and specificity of both tests. useful to provide a course of non-surgical
Occlusal trauma, such
This is detailed later in this periodontal treatment first and reassess the
as fremitus on lateral or protrusive
paper. tooth in question at review to make a final
movements, should be identified
decision on whether endodontic therapy is
and eliminated to reduce the risk of
required.
Aspects of the radiograph to assess exacerbating the already inflamed
Aspects of the radiograph to assess periodontium. Sometimes it is not possible
include: Prognosis to eliminate such forces fully and splinting
 General bone levels; The current diagnosis and classification of the tooth to the adjacent teeth is
 Presence of localized deeper bone loss system is also beneficial in assessing the indicated. Splinting of the teeth may also be
towards the apex (often referred to as prognosis of affected teeth, rather than indicated to carry out an accurate occlusal
‘J-shaped’), or within the root furcation(s); identifying the primary source of infection, adjustment, particularly if the tooth/teeth
 Deep caries or restoration; which is often difficult and does not affect are mobile. Splinting has a place within the
 Signs of fractures or perforations, either the management or prognosis of the tooth.5 treatment of such lesions, especially if it will
laterally or through the pulp chamber Clinicians need to be confident in assessing improve patient comfort and function.28
floor; prognosis of teeth as this informs the In primary endodontic disease
 Root resorption processes. decision whether to retain or extract the the pulp is often necrotic and infected;
Radiographically, depending tooth. clinically these lesions may appear
on the avenue of fistulation, different Three main prognostic concurrently with drainage from the
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gingival sulcus area/sinus and possible dependent upon the remaining clinical infections affecting his posterior teeth with
swelling in the buccal attached gingiva. signs and symptoms and the reassessed current pain from the UL6. He was a non-
When there is drainage the patient may be prognosis of the tooth, balanced against the smoker, medically fit and well and his oral
asymptomatic.29 tooth’s strategic importance. It is necessary hygiene was adequate. The clinical findings
If a lesion is diagnosed and to consider whether tooth removal and are summarized in Tables 3 and 4 and
treated as primary endodontic disease subsequent replacement would be more Figures 3 and 4.
due to lack of evidence of plaque-induced appropriate. Following the new classification,
periodontitis, and there is soft tissue healing The following case will this case would be classified as EPL without
on clinical probing and bony healing demonstrate use of the new classification root damage in a periodontitis patient
radiographically, a valid retrospective and processes highlighted above to come (Grade 3). The patient’s first phase of
diagnosis can be made. In the absence to a diagnosis and treatment strategy for treatment was a non-surgical phase that
of adequate healing, further periodontal successful management of an EPL. included:
treatment is indicated. 1. Oral hygiene education.
2. In this case, given the lateral periodontal
Case example abscess associated with the UL6 and the
Order of treatment
This case involves a 35-year-old male periodontal pocketing around the patient’s
Primary endodontic disease with secondary who presented with a history of recurrent other posterior teeth and that the tooth was
periodontal involvement should be first
treated endodontically, reviewed after three
months and only then should periodontal
therapy be considered. This sequence of Extra-oral Assessment Fever or malaise NAD
treatment allows sufficient time for initial
Facial swelling NAD
tissue healing and better assessment of the
periodontal condition. It also reduces the Lymphadenopathy NAD
potential risk of introducing bacteria and
General screening for Localized periodontitis –
their by-products during the initial healing
periodontitis Stage IV
phase. The periodontal healing can be
Grade C
adversely affected by aggressive removal
of the periodontal ligament and underlying Intra-oral Assessment Pocketing 10 mm wide pocketing
cementum during interim periodontal around distal UL6 (2 sites)
therapy. with bleeding on probing
Primary periodontal disease Periodontal pocketing
with secondary endodontic or a true associated with other
combined lesion requires both endodontic posterior teeth
and periodontal treatment. The success rate
Soft tissues Fluctuant swelling with
of the endo-periodontal lesions without a
associated sinus in the
concomitant regenerative procedure has
buccal aspect UL6
been reported to range from 27%−37%.30
This is significantly lower than the reported Mobility No mobility
success rate of 93% with conventional
orthograde root canal therapy.31 A long Percussion test NAD
junctional epithelium formation over the
dehisced root surface has been suggested Presence of root grooves/ F1 involvement UL6
to be a contributing factor for the poor furcations buccally
therapeutic prognosis.32 It has also been
Signs of root fracture/ NAD
demonstrated that intra-pulpal infection
perforation/root resorption
tends to promote epithelial down growth
along a denuded dentine surface. Crown or gingival NAD
It is accepted that non-surgical discoloration
management of EPLs should be undertaken
Sensibility testing (ethyl UL6 – positive
as a primary course of treatment. The
chloride and EPT)
response to the primary course of treatment
should be reviewed and a decision made Occlusal assessment NAD
as to whether the tooth would benefit from including identification of
a surgical approach following failure to occlusal trauma
achieve resolution.
Table 3. Summary of clinical findings for case example.
The surgical approach will be
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 RestorativeDentistry

General bone levels Localized bone loss around a

posterior teeth
Localized bony defects Specifically localized
deep vertical bone defect
extending to the apex of
the disto-buccal root UL6
Radiographic assessment
Deep caries/restorations Small occlusal restoration
Signs of fractures or NAD
perforations, either laterally
or through the pulp
chamber floor
Root resorption processes NAD
Table 4. Summary of radiographic findings of case example.

Figure 3. Pre-operative presentation – lateral Figure 5. Clinical presentation following non-

periodontal abscess buccal to UL6 visible. surgical phase of treatment. Figure 7. (a, b) Post-operative presentation
following surgical phase to resect the disto-
buccal root.

after one month, then post-treatment

records were taken after three months
to assess for healing and stabilization. It
was evident at this point that there was
considerable recession affecting the disto-
buccal root of the UL6 and that this tooth
was now not responsive to sensibility
testing. The rest of the dentition had
Figure 4. Pre-operative radiograph UL6. Figure 6. Post-operative radiograph following
stabilized.
non-surgical root canal treatment UL6.
Demonstrates composite plug in the disto-buccal
3. Non-surgical root canal treatment was
canal. then initiated on UL6, including a bulk fill
responding positively to sensibility testing composite plug in the disto-buccal canal
at first, it was considered that the EPL was to aid future surgical intervention. The
primarily periodontal in nature. The first anaesthetic, in order to drain the abscess occlusion was designed with no guidance
line treatment was therefore non-surgical via the periodontium and stabilize the other on the UL6.
periodontal therapy (NSPT), including periodontally involved sites. The patient Following the initial non-surgical
full mouth debridement under local attended an oral hygiene education review phase, the buccal swelling associated with
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