The origin of a periodontal-endodontic lesion can be difficult to determine, and both types of defects usually require treatments. In combined periodontal-endodontic lesions and lesions of uncertain origin, therapy should always begin with endodontic treatment, since the influence of the endodontium on the periodontium is greater than vice versa. A specific protocol is needed for the management of endodontic-periodontal lesions, because the clinical picture shows inflammation of pulpal and periodontal tissues.
Different therapy concepts can be considered, depending on the severity of inflammation and the clinical situation. Healing processes can occur through regeneration and reconstitution of the original function or through regenerative processes with various materials. Regenerative techniques based on the local application of bone substitute materials are widely used. Furthermore, bone morphogenic proteins and commercially available enamel matrix derivatives (cEMD) have been described to support the regenerative process.
The clinical success of all these treatments depends mainly on the shape, localization, and extent of the original bony lesion. Lesions of endodontic origin seldom require surgical intervention. In periodontal-endodontic lesions particularly, there is usually an open wound area, for which special treatment concepts are needed. Kim et al could show that combined endodontic-periodontal lesions have poor prognoses, even if treatment is aided by a microscope.
A 60-year-old woman presented to her dentist. A radiograph showed a deep bony defect with an apical lesion at the distal root of the mandibular right first molar. Four weeks after root canal treatment, the patient was referred with pain to the Department of Operative Dentistry, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany. The radiograph showed a deep intraosseous defect on the distal root of this tooth and approximately 2 mm of extruded gutta-percha (Fig 1b). The clinical picture presented a distal probing depth (PD) of 12 mm (Fig 1c) and bleeding.
A mucoperiosteal flap procedure was performed to access the area between the mandibular right second premolar and the right second molar (Fig 1d). The extruded gutta-percha was removed. cEMD (Emdogain, Straumann) was applied to the root surface, and the flap was repositioned (Fig 1e). Radiographs taken 10 and 24 months after surgery showed good periradicular regeneration (Figs 1f and 1g). A reduction of PD to 5 mm and of furcation involvement to 1 mm was observed (Fig 1h).
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