ENDO-PERIO LESIONS: SIMPLIFIED CLASSIFICATION

Fig. 1

Simon et al 1972 (8)

1. Primary Endodontic Lesions
2. Primary Endodontic Lesions With Secondary Periodontic Involvement
3. Primary Periodontic Lesions
4. Primary Periodontic Lesions With Secondary Endodontic Involvement
5. "True" Combined Lesions

Fig. 2

Foce Classification System for EPLs - 2022 (9)

Class 1 – Crown-down Plaque-induced Periodontal Lesions

• Start from the crown and propagate along the root apically to deep periradicular areas. 
• May lead to signs and symptoms mimicking pulp disease, with no pulp involvement 
• It requires only periodontal treatment or at a later stage it may involve the pulp tissues through lateral canals or the apical foramen that requires root canal treatment followed by periodontal treatment.

Class 2 – Down-crown Periodontal Lesions of Endodontic Origin

• Start from the apical foramen or patent accessory canals in an apico-coronal direction. Through the periodontal ligament. 
• Can cause periodontitis but will not lead to irreversible loss of the periodontal tissue attachment unless left untreated.

Class 3 – Combined Endo-perio Lesions 

• A plaque-generated pocket extending apically and merging with a periodontal lesion of endodontic origin that developed at the root apex. 

Fig. 3

Class 1 – Crown-down Plaque-induced Periodontal Lesions

periodontitis caused by bacterial plaque (biofilm) at the periodontal margin. it is identified at a more coronal level of the root. 

A clinical case of 45 female patient presented with pain related to the lower 1st molar on the left side. Upon radiographic examination, it was presented with crystal bone loss related to the distal root with presence of evident local factors beyond the CEJ. While clinically it was presented with grade II furcation involvement (Glickman’s classification) only on the buccal side. treatment was initiated 1st non surgically with phase I therapy and surgical treatment after two weeks with open debridement.  

Fig. 4

Large amount of local factors related to the furcation area and the distal root.

Fig. 5

Open debridement. 

Fig. 6

Suturing

Fig. 7

Class 2 – Down-crown Periodontal Lesions of Endodontic Origin 

pulpal infection deriving from pulp and propagating coronally along the root. It is found at/near the root apex or laterally through lateral canals.

A 49 year old female patient presented clinically with broken old amalgam restoration related to the lower 2nd molar on the left side. 

Upon clinical examination, it a fistulous tract through the gingival margin with probing depth of 7mm mid buccal point, 5mm mesially. 

Upon radiographic examination, it has periapical radiolucency related to the medial tooth. And large amalgam restoration coronally with amalgam pin near the distal pulp horn.

Treatment was initiated endodontically and post-endodontic restoration.

Fig. 8

Isolation and Access cavity Preparation.

Fig. 9

Radiographic sequence of root canal treatment.

Fig. 10

Post Endodontics restoration; Preparation and cementation of an overlay. 

Fig. 11

One month follow up; 2 mm PD buccal and 2 mm PD mesially. 

Complete Healing of EPL.

Fig. 12

Class 3 – Combined Endo-perio Lesions 

A plaque-generated pocket extending apically and merging with a periodontal lesion of endodontic origin that developed at the root apex. 

The pulpal disease is limited only to the root canal space and does not involve the periradicular tissues either radiographically (no widening in the PDL space) or clinically (no pain on palpation or percussion). It’s noted in patients with generalized marginal periodontitis.

A 40 female old patient presented with continuous pain related to the lower 1st molar on the right side. Clinical examination revealed class V decay on the mesial line angle buccally. Deep periodontal pocket mesially with deep PD of 6 mm. and Class I miller  Classification of recession. Radiographic examination revealed large class II amalgam restoration that is very close to the pulp on the distal side and large angular bone loss related to the mesial root. 

Treatment was done for both pulp and periodontal tissue.

Fig. 13

Phase I therapy first with EMS airflow for removal of local factors.

Fig. 14

Endodontic treatment; Amalgam removal, pre-endo build up and access cavity preparation.  

Fig. 15

Post Endodontic filling and restoration of the class V cavity. 

Fig. 16

Periodontal treatment; Minimally invasive technique.

One vertical incision preserving the interdental papillae.

Fig. 17

Flap reflection; 3 osseous walled defect.

Fig. 18

Connective tissue graft harvesting from the palate.

Fig. 19

CTG suturing with 7-0 prolene suture. 

Fig. 20

Alloplast Bone grafting.

Fig. 21

Suturing and post operative radiograph

Fig. 22

Herrera et al. proposed a new classification of EPLs into those without root damage or with root damage. 

EPLs without root damage primarily arise from bacterial infections in pulp and/or periodontal tissues.

EPLs with root damage arise from vertical tooth defect, perforation defect, or resorptive defects.

Fig. 23

Diagnosis of EPLs (11)

1. Radiographic Evaluation;
   In endodontic  disease,  bone  loss is localized and mostly in the apical  area.
   In  periodontal disease,  bone  resorption is more generalized  and  mostly at  the  crestal bone.
2. Pulp testing;
   In endodontic disease, the tooth is non-vital.
   In periodontal disease, the tooth is vital in most cases.
3. Palpation and percussion;
   - Applying firm digital pressure to the mucosa covering the roots and apices.This will detect the presence of periradicular abnormalities or ‘‘hot’’ zones that produce painful response.
   - An abnormal positive Percussion response indicated inflammation of the PDL that may be either from pulpal or periodontal origin.
4. Clinical signs; sinus or fistulas tract.
5. Tooth Mobility; Hypermobility is quite common in cases of primary endodontic involvement and should not be confused with true mobility caused by periodontal destruction.
6. Periodontal probing