DIAGNOSIS OF ENDODONTIC-PERIODONTAL

LESIONS
Diagnosis of the combined endodontic and periodontal lesions
is often multifaceted and exasperating. A growing periapical
lesion with secondary involvement of the periodontal tissue
may have the similar radiographic appearance as a chronic
periodontal lesion which has reached to the apex. An
endodontically treated tooth or a nonvital tooth associated
with periodontal lesion can pose greater diagnostic problem
as in such cases pulpal inflammation is frequently associated
with inflammation of periodontal tissue.
Thus, a careful history taking, visual examination,
diagnostic tests involving both pulpal and periodontal testing
and radiographic examination are needed to diagnose such
lesions.
Tooth with combined endodontic-periodontal lesions must
fulfill the following criteria:
Tooth involved should be nonvital.
There must be destruction of the periodontal attachment which
can be diagnosed by probing from gingival sulcus to either apex
of the tooth or to the level of involved lateral canal.
Both endodontic therapy and periodontal therapy are required
to resolve the lesion completely.

Chief Complaint of Patient

Patient may tell the pain indicating pulpal or periodontal

type. History of patient may reveal previous pulpal exposure
or any periodontal treatment.
It is generally seen that pulpal condition is usually acute
where as periodontal or secondary pulpal or combined
lesions are usually chronic in nature.

Associated Etiology

For pulpal disease, caries trauma or pulp exposure is common

etiology whereas for periodontal disease is associated with
plaque/calculus, history of bleeding gums or bad odor.

Clinical Tests
Different signs and symptoms can be assessed by visual
examination, palpation and percussion (Fig. 26.15). Presence
of carious tooth, recession, swelling of gingiva, plaque/
calculus or increased pocket depth may indicate endoperio
lesion (Fig. 26.16). Mobility testing tells the integrity of
attachment apparatus or extent of the inflammation in the
periodontal ligament.

Radiographs

Radiographs are of great help in diagnosing caries, extensive

restorations, pulp treatments if done, previous root canal
treatments, root form, root resorption, root fracture, stage
of root development, root canal obliteration, thickened
periodontal ligament space and any changes in the alveolar
bone (Fig. 26.17).

Pulp Vitality Tests

Any abnormal response of pulp may indicate degenerative
changes occurring in the pulp. Cases associated with nonvital
pulp have pulpal pathology whereas teeth associated
with vital pulp usually have periodontal disease. Commonly

used pulp vitality tests are cold test, electric test, blood flow
test and cavity test. Recent advances in the diagnosis include
the use of Laser Doppler Flowmetery, pulp oximetery and
magnetic resonance imaging.

Tracking Sinus or Fistula

Tracking the fistula may aid the clinician to differentiate
the source (Fig. 26.18). This guttapercha
is inserted slowly
through the sinus and IOPA X-ray is taken. Being radiopaque,
guttapercha
helps in determining the source of infection.

Pocket Probing
Pocket probing helps in knowing location and extent of the
pockets, depth of pocket and furcation involvement if any
(Fig. 26.19).

Microbiological Examination

Occasionally the micro biological analysis can provide an

important information regarding the main source of the
problem.

Distribution
Pulpal pathology is usually localized in nature whereas
periodontal condition is generalized.

Bone Loss
In pulpal disease, bone loss is generally localized, and
wider apically. It is not associated with vertical bone loss. In
periodontal disease, bone loss is generalized which is wider
coronally. It may be associated with vertical bone loss.

Pain
When pain is associated with pulpal pathology, it is usually
acute and sharp in nature and patient cannot identify the
offending tooth. Whereas pain associated with periodontal
pathology is dull in nature and patient can identify the
offending tooth (because of presence of proprioceptive nerve
fibers in the periodontal ligament).

Swelling
If swelling is seen on the apical region, it is usually associated
with pulpal disease. If it is seen around the margins or
lateral surface of teeth, swelling is usually associated with
periodontal disease.

Treatment and Prognosis

Treatment planning and prognosis depends mainly on
diagnosis of the specific endodontic and/or periodontal
disease. In teeth with combined endodontic-periodontal
lesions, the prognosis depends on extent of destruction
caused by the periodontal disease. If lesion is of endodontic
origin, an adequate endodontic treatment has good
prognosis. Thus in combined disease, prognosis depends on
efficacy of periodontal therapy.