Periodontology Diagnosis - Combined Periodontic-Endodontic Lesions

Periodontology or periodontics is the specialty of dentistry which studies the supporting structures of the teeth, in addition to diseases or conditions which impact these structures. The periodontium or supporting tissues, includes the gingiva or gums, alveolar bone, cementum, and the periodontal ligament. A periodontist is a dentist who specializes in the prevention, diagnosis and treatment of periodontal disease. They also specialize in dental implant placement.

While there have been decades of literature working to describe periodontal-endodontic (perio-endo) lesions, they continue to be a misunderstood disease. The anatomic connections which occur between the dental pulp and the periodontium offer a pathway for perio-endo communication. Each of these tissues are mesenchymal in their origin. Once they are mature, the stay connected through the following: apical foramina, lateral canals, exposed dentinal tubules, and developmental grooves. These pathways provide a method for pulpal disease to affect the periodontium. Likewise, the pathways act as an ingress for periodontal disease to negatively impact the pulp. Literature which has been published regarding periodontal-endodontic often varies in the terminology used, criteria for diagnosis, and strategies for managing the condition. These numerous variations, in addition to the clinical and radiographic commonalities between perio-endo lesions and other dentoalveolar pathoses, make the diagnosis a challenge. Combined periodontic-endodontic lesions are localized, restricted areas of bacterial infection which originates from the dental pulp, periodontal tissues surrounding the tooth, or both.

Cause

Combined periodontic-endodontic lesions take the form of an abscess and usually originate from two distinct locations which includes:

  • Endo-Perio: the infection from the tooth’s pulp can spread into the bone which immediately surrounds the tip, apex, or root of the tooth to form a periapical abscess. This infection, can then multiply coronally and communicate with the alveolar bone and the oral cavity as it spreads through the periodontal ligament.
  • Perio-Endo: the infection from a periodontal pocket can multiply through the accessory canals into the root canal of the affected tooth. The results in a pulpal inflammation. It is possible that the accessory canals are not be large enough to allow for bacterial penetration. The periodontal disease must reach the apex of the tooth in order to induce an endodontic lesion.

Fortunately, the prognosis, treatment and expected management of the condition do not depend on the source of the infection.

It is also possible for a combined lesion to occur as the result of a fractured tooth.

Treatment

Treatment typically involves conventional endodontic therapy which is followed by a conventional periodontal therapy. If the lesion is determined to be too severe for treatment, the effected tooth may need to be extracted.

Proper diagnosis allows for an effective and prompt treatment. In addition, perio-endo lesions may be readily treated.

The treatment for primary endodontic lesions often involves a non-surgical root canal therapy in addition to complete restorative care. In this cases, periodontal intervention is not required, and the outcome for the teeth is predictable. The success rates for non-surgical root canal therapy is up to 97%.

For many dental professionals, perio-endo diseases are challenging to diagnose. This is often more challenging due to the lack of consistent terminology used in academic literature. As with other related topics, the use of consistent terminology for a comprehensive and systematic approach in diagnosing and treating the condition can result in improved outcomes for the patient.