Management of the endodontic-periodontal lesion

Abstract

Endodontic-periodontal lesions (EPLs) develop due to the various pathways that allow microbial migration between these two compartments. The authors review the historical and current research on the aetiology, diagnostic pathways, prognostic factors and management strategies for EPLs, emphasising a multidisciplinary approach to managing EPLs. This paper aims to guide clinicians in managing these challenging cases with a combination of endodontic and periodontal therapies.

Fig. 1

Main EPL classification systems. Image created in BioRender rule below

Fig. 2

Case of a localised periodontal defect with a buccal sinus affecting tooth 23. a) The PA showed suboptimal obturation of tooth 23, but no frank apical pathology. b) Due to the localised distal probing depth and pattern of bone loss, a root fracture was suspected. Surgical exploration was undertaken and a broad circumferential defect was found circling the mid-third of the root. c, d) The root was stained, but no fracture was visualised. Guided tissue regeneration was undertaken. At one year, the sinus had resolved and the probing depths were ≤4 mm. e, f) Although the initial healing appears positive, the patient was warned of possible future failure given a root fracture was still suspect; although, one was not identified

Fig. 3

a, b, c) A J-shaped radiolucency, seen in the left image around the mesial root of tooth 46, typically indicates vertical root fracture (VRF). VRF may also present as a halo-shaped radiolucency around the root and involve the furcation of multirooted teeth (right image). Root fractures are often not directly detectable on CBCT imaging due to insufficient voxel size, non-axial cleavage planes and beam hardening artefacts due to restorative materials, such as metal posts (seen as white streaks and black bands in the middle image). It should be noted that a root groove may mimic a VRF radiographically (Fig. 4)

Fig. 4

a, b) PA and sagittal slice CBCT showing J-shaped radiolucency associated with the distal root of tooth 46. The distal root in fact had a root groove, rather than a VRF

Fig. 5

a, b) Pre-op PA of tooth 12 with persistent localised periodontal pocket. Bone loss extends to just below the end of the post. A CBCT was not performed on the basis that substantial scatter would prevent accurate visualisation of any fractures. Surgical exploration was opted for instead, where a root fracture was identified. Additionally, for post-crown restorations, a history of repeated debonding should raise a high suspicion of a root fracture

Fig. 6

Diagnostic pathway for teeth with endodontic periodontal lesions. Created in BioRender. Moyes, D. (2024) BioRender.com/r60j931

Fig. 7

Flowchart illustrating decision-making processes for various management options

Fig. 8

a) Tooth 32 presents with a localised deep periodontal pocket and vertical bone loss extending to, but not encompassing, the apex. A positive response to Endofrost was elicited but suppuration was consistently present. The true status of the pulp is questionable. b) Tooth 31 presented with bone loss to the apex and deep buccal and lingual probing depths. In contrast, both centrals were consistently positive to cold testing and so a decision needs to be made on whether to instigate RCT in this scenario

Fig. 9

Case of localised periodontitis in a young patient, including an EPL affecting tooth 43. Initial presentation of tooth 43 with deep periodontal probing depths >6 mm affecting buccal lingual and distal aspects of the tooth combined with diffuse apical pathology combined with marginal bone loss. a, b) The tooth was also over-erupted but not mobile. c, d) RCT was undertaken over two visits, with recontouring of the crown to improve appearance. Targeted subgingival PMPR was undertaken immediately after completion of the RCT. e, f) At six-month review, probing depths had reduced to 4 mm with resolution of the inflammation, no bleeding on probing and radiographic bone fill seen. The tooth was placed into a maintenance phase

Fig. 10

Persistent EPL case following RCT on tooth 21 (apex managed with MTA apexification). a, b) Deep buccal, mesial and palatal probing depths with associated vertical bone loss to the apex were present at baseline. c, d) Following surgical exposure, the granulation tissue was removed and an apicectomy was conducted as the lesion was assumed to be of endodontic origin. d, e) A small perforation was noted as well, which was repaired with a bioceramic putty (Total Fill BC putty). The defect was a contained two-walled defect with a narrow radiographic defect angle <20 ° and so deemed amendable to guided tissue regeneration. f) The defect was filled with a bovine-derived xenograft and collagen membrane (BioOss Collagen and BioGuide). g, h) The immediate post-operative appearance and at one-month review showing resolution of the inflammation with some recession. Due to the increased mobility post-operatively, a splint was placed which was subsequently changed to a lab-made, 0.4 mm, round wire splint, placed palatally for aesthetic reasons

Fig. 11

a, b, c) Localised periodontitis case with associated EPL on tooth 26. The distal root shows recession as well as inflammatory root resorption and there is as a degree III furcation lesion. c, d) This case was not amendable to regenerative surgery. In this case, RCT was conducted, followed by resection of the distal root. e) Floss was used to pass a Coepak periodontal dressing through the furcation to try and maintain the space and facilitate regular plaque removal from the furcation area. f) At one month, the furcation is open, but there is still some inflammation present and ongoing supportive care will be needed. This case will likely be classed as survival rather than success