2024 Chinese Expert Consensus: Diagnosis and Treatment of Combined Periodontal - Endodontic Lesions
1. Introduction
Combined periodontal - endodontic lesions are complex oral conditions that involve both the periodontal tissues (gums, periodontal ligament, alveolar bone) and the dental pulp. These lesions can cause significant pain, discomfort, and potential tooth loss if not properly diagnosed and treated. The 2024 Chinese Expert Consensus aims to provide evidence - based guidelines for the accurate diagnosis and effective treatment of such lesions.
2. Classification
2.1 Primary endodontic lesion with secondary periodontal involvement
Pathogenesis: Pulpal infection spreads through the apical foramen to the periapical tissues. Over time, if left untreated, the inflammatory process can extend laterally into the periodontal ligament and alveolar bone, leading to periodontal - like lesions. For example, a long - standing pulpitis may progress to a periapical abscess, which can then erode the surrounding alveolar bone and involve the periodontal pocket.
Clinical features: Usually, the initial symptoms are related to pulpitis, such as severe toothache, sensitivity to hot and cold. As the lesion progresses, periodontal manifestations like deepening of the periodontal pocket, bleeding on probing, and alveolar bone loss in the apical area may occur. Radiographically, there is often a periapical radiolucency that may extend laterally along the root surface.
2.2 Primary periodontal lesion with secondary endodontic involvement
Pathogenesis: Severe periodontal disease with deep periodontal pockets can allow bacteria and their by - products to reach the pulp through accessory canals or the apical foramen. The periodontal inflammation can also cause a decrease in the blood supply to the pulp, leading to pulp necrosis. For instance, in advanced periodontitis, the bacteria - laden pocket epithelium can invade the pulp via lateral canals.
Clinical features: Initially, periodontal symptoms predominate, including bleeding gums, periodontal pocket formation, and tooth mobility. As the pulp becomes involved, symptoms of pulpitis or pulp necrosis, such as pain, may appear. Radiographs show significant periodontal bone loss, and sometimes, a radiolucency may be present at the apex or along the root associated with pulp involvement.
2.3 True combined lesion
Pathogenesis: In this case, both the periodontal and endodontic systems are simultaneously affected by independent but co - existing factors. For example, a tooth may have a carious lesion that exposes the pulp, and at the same time, the patient has poor oral hygiene, leading to periodontal disease. The two inflammatory processes then interact and exacerbate each other.
Clinical features: It presents with a combination of severe periodontal and endodontic symptoms. There are deep periodontal pockets, extensive alveolar bone loss, tooth mobility, as well as pulp - related pain, sensitivity, or signs of pulp necrosis. Radiographically, there is a complex pattern of periapical and periodontal radiolucencies that are difficult to distinguish as being solely from one origin.
3. Diagnosis
3.1 Clinical examination
Pulp vitality testing: Use methods such as thermal (hot and cold) tests and electrical pulp tests to assess the vitality of the pulp. A non - vital pulp indicates endodontic involvement. However, false - negative or false - positive results can occur, so it should be interpreted in combination with other findings.
Periodontal examination: Check for periodontal pocket depth, bleeding on probing, tooth mobility, and gingival recession. The presence of deep periodontal pockets and severe periodontal inflammation suggests periodontal disease.
Occlusal examination: Evaluate the occlusal relationship to determine if occlusal trauma is contributing to the lesion. Excessive occlusal forces can exacerbate both periodontal and endodontic problems.
3.2 Radiographic examination
Periapical radiographs: Provide a basic view of the periapical and periodontal regions. They can show the presence of periapical radiolucencies, alveolar bone loss, and the integrity of the root. However, they may have limitations in accurately assessing the extent of the lesion in three dimensions.
Cone - beam computed tomography (CBCT): Offers a more detailed three - dimensional view of the teeth and surrounding tissues. It can precisely show the location, size, and relationship between the endodontic and periodontal lesions, especially useful for complex cases. For example, it can clearly demonstrate the connection between a periapical lesion and a periodontal pocket through accessory canals.
3.3 Microbiological examination
Although not always routine, in some complex cases, microbiological analysis of the endodontic and periodontal samples can help identify the causative microorganisms. This can guide more targeted antibiotic therapy if necessary. For example, the presence of specific anaerobic bacteria such as Porphyromonas gingivalis in periodontal samples or Enterococcus faecalis in endodontic samples may influence treatment decisions.
4. Treatment
4.1 Treatment principles
Address both endodontic and periodontal problems: Since the two systems are interconnected in combined lesions, treatment should aim to eliminate infection from both the pulp and the periodontal tissues.
Individualized treatment: Consider the patient's overall health, the type and severity of the lesion, and the prognosis of the tooth when formulating a treatment plan.
4.2 Endodontic treatment
Root canal treatment: For endodontic - related problems, standard root canal treatment is usually the first step. This involves cleaning, shaping, and filling the root canals to eliminate pulp - related infection. In cases where the pulp is necrotic, thorough debridement of the root canal system is crucial. For example, using advanced rotary endodontic instruments and appropriate irrigation solutions like sodium hypochlorite to ensure complete removal of bacteria and necrotic tissue.
Apical surgery: In some cases where root canal treatment fails or when there are persistent periapical lesions, apical surgery may be required. This includes procedures such as apical resection, curettage of periapical granulomas or cysts, and apical retro - filling.
4.3 Periodontal treatment
Initial periodontal therapy: This includes oral hygiene instructions, scaling, and root planing to remove plaque and calculus from the tooth surface and root. These procedures help to reduce the periodontal infection and improve the periodontal environment.
Surgical periodontal treatment: For deep periodontal pockets that do not respond to initial therapy, periodontal surgical procedures such as flap surgery, guided tissue regeneration, or bone grafting may be necessary. These surgeries aim to reduce pocket depth, promote bone regeneration, and improve the attachment of periodontal tissues to the tooth.
4.4 Sequencing of treatment
For primary endodontic lesions with secondary periodontal involvement: Endodontic treatment is usually the first priority. After root canal treatment, the periodontal condition may improve spontaneously as the source of the primary infection is removed. However, if the periodontal lesion persists, additional periodontal treatment may be required.
For primary periodontal lesions with secondary endodontic involvement: Initial periodontal therapy should be carried out first. If the pulp remains vital after periodontal treatment, close monitoring is needed. If pulpitis or pulp necrosis develops, endodontic treatment should be initiated.
For true combined lesions: Both endodontic and periodontal treatments may need to be carried out simultaneously or in an alternating sequence, depending on the severity of each component. Close cooperation between endodontists and periodontists is essential.
4.5 Follow - up
Regular follow - up is crucial to assess the success of treatment. Patients should be recalled at specific intervals, usually 3, 6, and 12 months after treatment. At each follow - up, clinical examinations, including pulp vitality testing, periodontal probing, and assessment of tooth mobility, as well as radiographic examinations, are performed to evaluate the healing of the endodontic and periodontal tissues. If any signs of recurrence or treatment failure are detected, appropriate measures should be taken promptly.