J Clin Periodontol 2014; 41: 779–790 doi: 10.1111/jcpe.

12265

Systematic Review
Treatment of periodontal- Julia C. Schmidt†, Clemens Walter†,
Mauro Amato and Roland Weiger

endodontic lesions – a
Department of Periodontology,
Endodontology and Cariology, University of
Basel, Basel, Switzerland

systematic review †
Both authors contributed equally to this work.

Schmidt JC, Walter C, Amato M, Weiger R. Treatment of periodontal-endodontic

lesions – a systematic review. J Clin Periodontol 2014; 41: 779–790. doi: 10.1111/
jcpe.12265.

Abstract
Background: The treatment of periodontal-endodontic lesions is challenging due
to the involvement of both periodontal and endodontic tissues.
Objective: To evaluate the treatment options and outcomes of periodontal-
endodontic lesions.
Material and Methods: A systematic literature search was performed for articles
published by 12 May 2013 using electronic databases and hand search. Two
reviewers conducted the study selection, data collection and validity assessment.
The PRISMA criteria were applied. From 1087 titles identified by the search
strategy, five studies and 18 case reports were included.
Results: Clinical studies and case reports were published from the years 1981 to
2012. A pronounced heterogeneity exists among studies regarding applied treat-
ment protocols and quality of reporting. In all clinical studies, comprising 111
teeth, a non-surgical root canal treatment (RCT) was performed as initial treat-
ment step. Non-surgical and/or a surgical periodontal therapy was applied in
some studies without re-evaluation of the endodontic healing. Probing pocket
depth reductions were reported in all included studies, comprising the data from
Key words: periodontal surgery;
80 teeth at follow-up. periodontitis; pulp necrosis; root canal
Conclusions: A sequential treatment with root canal treatment as a first treatment treatment
step appears to be reasonable. An adequate time for tissue healing is suggested
prior to re-evaluation. Accepted for publication 21 April 2014

A communication between the peri- e.g. so-called periodontal-endodontic
odontium and the dental pulp exists lesions.
through different pathways inclu- An endodontic lesion may elicit an
ding the apical foramina, lateral and inflammatory response in the adja-
accessory canals or exposed dentinal cent periodontal tissue and thus can
tubules (Seltzer et al. 1963, Rotstein cause a retrograde periodontitis (Sim-
& Simon 2006). These anatomical ring & Goldberg 1964). A periodontal
structures enable the development lesion may provoke an extensive pulp
of diseases with concurrent periodon- pathosis (Langeland et al. 1974,
tal and pulpal tissue involvement, Bergenholtz & Lindhe 1978). In addi-
tion, periodontal and endodontic di-
Conflict of interest and source of seases can develop independently.
funding Teeth with a periodontal-endodontic
lesion feature an inflamed or necrotic
The authors declare that they have no pulp tissue and increased probing
conflicts of interest. No external fund- pocket depths leading to great vari-
ing was obtained for this review. ability of possible diagnostic findings,
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
e.g. altered response to pulp sensibi-
lity testing, multiple or singular incre-
ased periodontal probing depth, sinus
tract, pus, radiological J-shaped lesi-
on or infrabony defect (Harrington
1979, Abbott 1998). The retrospective
identification of the primary cause
of a periodontal-endodontic lesion,
however, is not possible in most
cases.
Several classification systems
were applied to describe these
lesions according to their pathogene-
sis or with respect to a suggested
therapy sequence (Simon et al. 1972,
Guldener 1975, Geurtsen et al. 1985,
Dietrich et al. 2002). However, the
779
780 Schmidt et al.
classification is still under an ongo-
ing scientific debate (Simon et al.
1972, Abbott & Salgado 2009). The
current classification of periodontal
diseases, even controversely discus-
sed, postulates the category “combi-
ned periodontal-endodontic lesion”
irrespective of the suspected patho-
genesis of the lesion (Armitage 1999,
Lang et al. 1999, Eickholz 2013).
The treatment of these lesions is
a challenge and treatment planning
needs to consider the involvement of
the periodontal and pulpal compart-
ment. A wide spectrum of different
therapeutic options and/or therapeu-
tic sequences including endodontic
and periodontal treatment with non-
surgical and/or surgical procedures
with or without local or systemic
antibiotics has been described in case
reports and clinical studies.
Review of Current Literature
Objective
The purposes of the present syste-
matic review were to identify the
treatment options and to evaluate
the therapy with respect to the out-
comes of combined periodontal-end-
odontic lesions in humans with
respect to tooth loss and probing
pocket depth (PPD) reduction.
The specific questions addressed in this
systematic review were:
In patients with combined periodon-
tal-endodontic lesions:
• Which treatments/treatment
sequences were applied?
• In case the treatment was per-
formed at different time points,
what was the time interval for
re-evaluation of the first treat-
ment step?
• Which rates of tooth loss occurred
after treatment?
•
Does treatment of combined peri-
odontal-endodontic lesions lead
to a PPD reduction?
Material and Methods
Protocols
The present systematic review consi-
ders the PRISMA (Preferred Repor-
ting Items for Systematic Review
and Meta-analyses) criteria (Liberati
et al. 2009, Moher et al. 2009) (Appen-
dix S1). The research questions were
adapted using the PICO (Patient,
Intervention, Comparison, Outcomes)
criteria (Miller & Forrest 2001).
Eligibility and ineligibility criteria
Publications were considered eligible
for inclusion in this systematic
review if they presented the follow-
ing parameters: (1) the presence of a
combined periodontal-endodontic
lesion defined as the co-existence of
a negative or altered pulp vitality
test and PPD ≥6 mm on at least one
tooth site in case reports or a mean
probing pocket depth ≥6 mm in
interventional studies and case series
and (2) a follow-up after treatment
of at least 6 months. No restrictions
in terms of type of publication, i.e.
case report, clinical study, review,
language and time point of publica-
tion were applied. Review articles
were screened for the presentation of
case reports within the review. A
publication considered ineligible for
inclusion was hierarchically catego-
rized (Appendix S4 and S5).
Outcome measures
The primary outcome measure was
tooth loss after treatment of com-
bined periodontal-endodontic lesions.
Changes in PPD, probing attachment
level (PAL), gingival recession (REC)
and radiographic findings were eval-
uated as secondary outcome vari-
ables.
Information sources
The electronic databases MEDLINE
by OVID and EMBASE and the
grey literature (www.opengrey.eu)
were searched for studies published
prior to May 12, 2013. A hand
search was performed on Journal of
Clinical Periodontology, Journal of
Periodontology, Journal of Endodon-
tics and International Endodontic
Journal from January 1990 to May
2013. Moreover, the references of
publications examined for inclusion
were thoroughly analysed to search
for additional publications.
Literature search
The search protocols in the different
databases were validated and created
as identical as possible (Appendix S2).
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Study selection
The combinations of search terms
resulted in a list of 1087 titles from
the electronic databases (Fig. 1).
Two of the authors (M. A. and J.
S.) screened the titles and abstracts
for compliance with the inclusion
criteria and selected 186 publications
for full text analysis. A third
reviewer (C. W.) reassessed both the
included and excluded studies.
Data collection process
Data items
The relevant data of included publi-
cations were collected in data extrac-
tion files.
Risk of bias in individual studies
The included studies were evaluated
by modified items from the Cochrane
Collaboration‘s Tool for assessing
risk of bias (Graziani et al. 2012)
(Appendix S3). Considering the ade-
quacy in the respective studies, the
items were graded and the percent-
age of positively graded items was
calculated (Graziani et al. 2012).
Summary measures
Most studies reported on mean PPD
with standard deviations at baseline
and at follow-up, but also individual
values or the range of individual val-
ues were presented.
Synthesis of results
Owing to the limited number of ran-
domized controlled clinical trials and
the significant heterogeneity in
reported treatment protocols, a pool-
ing of data or statistical meta-
analyses were not appropriate and
therefore not performed.
Results
Study selection
A total of 1087 titles from the elec-
tronic databases were identified
(Fig. 1). The titles and abstracts
were screened by two reviewers (ob-
served agreement = 90.16%, kappa =
0.773). The full texts of 186 publica-
tions (selected by at least one
reviewer) were further analysed. Full
text analysis led to exclusion of
further 171 studies (Appendix S4
and S5). Finally, 15 publications from
the electronic search satisfied the

Fig. 1. Selection process of the studies included (Moher et al. 2009).
inclusion criteria. Eight additional
publications were identified by screen-
ing the references of studies evaluated
for inclusion.
Description of characteristics, results, and
quality assessment
The analysis for clinical studies and
case reports was performed sepa-
rately. The characteristics of included
studies (Table 1) and case reports
(Table 2, Appendix S6) and the asses-
sment of risk of bias (Appendix S7)
are summarized in tables.
Summary of characteristics (PICO –
Population, Intervention/Comparison,
Outcomes)
Population – number and characteris-
tics of patients and tooth sites. The
mean age of patients in two of the
included publications amounted 44
and 51.2 years (Haueisen et al. 2000,
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Treatment of perio-endo lesions
Li et al. 2012). The patients‘ age in
two other publications ranged from
25 to 53 years (Hassan et al. 1986,
Sun & Liu 2009), whereas it was not
available in one case series (Ratka-
Kr€uger et al. 2000). The proportion
of females and males was provided
in two publications including each
18 males and 12 females (Sun & Liu
2009, Li et al. 2012). Two studies
stated exclusion criteria in terms of
the presence of systemic diseases,
increased mobility of teeth, tobacco
use, pregnancy and the use of antibi-
otics during the observation period
(Hassan et al. 1986, Li et al. 2012).
Three case series did not assign any
exclusion criteria (Haueisen et al.
2000, Ratka-Kr€ uger et al. 2000, Sun
& Liu 2009).
The included publications investi-
gated each between 10 and 37 teeth.
Overall, the treatment of combined
periodontal-endodontic lesions was
781
analysed in 111 teeth. Most publica-
tions examined various tooth types
including both single- and multi-
rooted teeth (Ratka-Kr€ uger et al.
2000, Sun & Liu 2009, Li et al.
2012). A total of 68 molars, 22
bicuspids, 20 incisors and one unspe-
cified tooth were analysed. Two case
series stated the proportion of upper
and lower teeth with a large majority
of teeth in the mandibula (Haueisen
et al. 2000, Ratka-Kr€uger et al. 2000).
The mean PPD at baseline ranged
from 6.01  0.31 mm to 14.29 
1.76 mm (Hassan et al. 1986, Li et al.
2012). The individual PPD values
ranged from 9 to 17 mm (Hassan
et al. 1986, Haueisen et al. 2000).
Clinical symptoms in terms of pain,
thermal sensitivity, gingival swelling,
pus discharge from gingival margin,
increased mobility and sensitivity to
percussion were occasionally reported
(Haueisen et al. 2000, Ratka-Kr€ uger
et al. 2000, Sun & Liu 2009, Li et al.
2012). The appearance of a sinus tract
was reported in some patients
(Haueisen et al. 2000, Ratka-Kr€ uger
et al. 2000). In two case series, all
included teeth demonstrated either a
caries profunda treatment combined
with a filling or a crown restoration
(Haueisen et al. 2000, Ratka-Kr€ uger
et al. 2000). The presence of a
restoration or a carious lesion was
not reported in the remaining
publications.
The radiographic findings were
described as periapical, lateral and/or
inter-radicular radiolucencies (Hauei-
sen et al. 2000, Ratka-Kr€ uger et al.
2000, Li et al. 2012). Moreover,
Ratka-Kr€ uger et al. (2000) specified
the pattern of bone loss on radio-
graphs as local and narrow, extending
to the apex and frequently without
any approximal bone loss.
In patients with combined periodon-
tal-endodontic lesions:
Which treatments/treatment sequences
were applied? Different treatments of
combined periodontal-endodontic
lesions, including periodontal and
endodontic approaches with non-
surgical and surgical methods were
performed. In all publications, a non-
surgical root canal treatment was
performed as initial treatment step.
A two-staged RCT with a temporary
intracanal medication was applied in
two case series. After re-evaluation
no further endodontic or periodontal
 782

Table 1. Characteristics of included studies

First Study design Number of Tooth type Clinical Radiographic Additional Treatment Follow-up † Calculated PPD at follow-up Additional outcomes Number Confounding
author teeth and (n) manifestations manifestations diagnosis sequence tooth loss of factors
(year of patients, age, (n) (n) (n) (n) drop-outs considered
publication) gender, (patients)
Schmidt et al.

exclusion and
criteria reasons

Hassan Prospective 14 teeth Maxillary  Mean PPD – – SRP + Occl – (2 w) – +6 mo 2 6.125  4.076 mm Mean attachment 2, NFD Tooth type,
et al. case series 14 patients and 14.29  RCT1 (GP, (mean  SD) gain age,
(1986) 25–40 yrs mandibular 1.76 mm (range LC) + PS (RBF, In 10 patients: 3.2– 8.16  2.9 mm systemic
Exclusion incisors (14) 12–17 mm) D) + root 5.2 mm (range) In 10 patients: diseases
criteria:  No vitality demineralization In 2 patients: 14.2 mm attachment gain
systemic (citric acid) –15.3 mm (range) 7.9–11 mm
(14)
diseases, in 2 patients:
teeth attachment gain
excessively 2.8 mm–1.7 mm
mobile/ Radiographic signs of
requiring partially bone fill,
splinting continuity of
lamina dura
Haueisen Retrospective 10 teeth Mandibular  Narrow PPD Periradicular (mesial Fistula (4) RCT1 – (CD, 3 w) – +6 mo 0 2–4 mm (range) No inflammation, no 0 Tooth type,
et al. case series 51.2 yrs molars (10) 9–12 mm (10) and/or distal) and RCT2 (GP, S, LC) FI, no increased age
(2000) (mean)  Pain (1) interradicular mobility, no

 Pus discharge radiolucency (10) sensitivity to

from gingival percussion,

radiographic signs
margin (3)
of complete bone
 FI (7)
repair (2) or
 Mobility grade I
advanced bone
(2), grade II (2)
repair (8)
 No vitality (7),
+ 12 mo 0 2–4 mm (range) Radiographic signs of 0
unclear response
complete bone
to pulp test (3) repair (except two
 Sensitivity to second molars with
percussion (2) horizontal bone
 Cp treatment loss of 1–2 mm)
and filling (2),
crown or partial
crown (8)

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Table 1. (continued)
First Study design Number of Tooth type Clinical Radiographic Additional Treatment Follow-up † Calculated PPD at follow-up Additional outcomes Number Confounding
author teeth and (n) manifestations manifestations diagnosis sequence tooth loss of factors
(year of patients, age, (n) (n) (n) (n) drop-outs considered
publication) gender, (patients)
exclusion and
criteria reasons

Ratka-Kr€
uger Retrospective 20 teeth Mandibular  Mean PPD Local narrow bone Fistula RCT1 – (CD, within +6 mo 5 3.1 mm (mean) No FI in 10 of 15 5, NFD Tooth type
et al. case series molars (15), 11.3 mm loss to apex, 2 mo) – RCT2 molars,
(2000) maxillary  Swelling and/or interradicular and/ (GP, S, LC) radiographic signs
molars (4), pus discharge or periapical of improvement up
other from gingival radiolucency to complete
tooth (1) without regeneration in
margin
interproximal bone most teeth
 FI (18)
loss in molars, +12 mo 11 2.2 mm (mean) No FI in 6 of 9 11, NFD
 No vitality or
periapical molars,
unclear response
radiolucency (>0.5 radiographic signs
to pulp test (20)
of root length) with of improvement up
 Sensitivity to per-
widened to complete
cussion some- periodontal regeneration in
times unclear ligament space most teeth
 Cp treatment
and filling (9),
crown or partial

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
crown (11)

Sun & Liu Prospective 37 teeth Bicuspids Teeth with 6 mo Bone loss – RCT1 – (1 w) – +6 mo 8 2.83  0.149 mm* Mean CAL 8, NFD Tooth type,
(2009) case series 30 patients (13), molars follow-up (n = 29) Occl + SRP – (4 w) 6.79  0.182 mm* age,
28–53 yrs (24)  Mean PPD – PS (MWF, BGa, Mean mobility experience of
18 male, 6.62  0.230 mm D, AB amox/ 1.38  0.092* therapist
12 female Mean CAL metro) +12 mo 18 2.42  0.233 mm* Mean CAL 18, NFD

8.76  0.209 mm 6.58  0.268 mm*
Mean mobility
 Mean mobility
1.26  0.104*
1.66  0. 134
Teeth with 12 mo
follow-up (n = 19)
 Mean PPD
6.74  0.285 mm
 Mean CAL
8.79  0.282 mm
 Mean mobility
1.68  0.172
 Pain
 Swelling
 No vitality (37)
Treatment of perio-endo lesions
783
 Table 1. (continued)
784

First Study design Number of Tooth type Clinical Radiographic Additional Treatment Follow-up † Calculated PPD at follow-up Additional outcomes Number Confounding
author teeth and (n) manifestations manifestations diagnosis sequence tooth loss of factors
(year of patients, age, (n) (n) (n) (n) drop-outs considered
publication) gender, (patients)
exclusion and
criteria reasons

Li et al. Prospective 30 teeth Test: Control: Periapical, lateral – Control: +3 mo 0 Control: Control: 0 Tooth type,
Schmidt et al.

(2012) randomized 30 patients anterior  Mean PPD and/or RCT1 (RF, S,  5.43  0.26 mm  Mean CAL age,
controlled 44 yrs (mean) teeth (2), 6.04  0.37 mm interradicular LC) + SRP (mean  SD) 1.15  0.21 - smoking,
trial 18 male, bicuspids (5),  Mean CAL radiolucency Test: Test: mm systemic
12 female molars (8) 1.60  0.19 mm Control: RCT1 (RF, diode  4.77  0.25 m- Mean mBI diseases,

Exclusion criteria: Control: anterior  Mean mBI 1.86  Mean PAI laser irradiationb, m** 0.80 experience
systemic teeth (4), 3.27 S, LC) + SRP of therapist
Test: (mean  SD) Test:
diseases, bicuspids (4), Test: (diode laser
 Mean PPD  Mean CAL
c
smoking, molars (7)  Mean PAI irradiation )
6.01  0.31 mm 1.06  0.19 -
pregnancy, 3.20
 Mean CAL mm
antibiotic intake
1.57  0.20 mm  Mean mBI
during
0.67
observation  Mean mBI 1.93
period
 Increased mobil-
ity

 No vitality (30) +6 mo 0 Control: Control: 0

 5.64  0.33 mm  Mean CAL

(mean  SD) 1.01  0.14 -
Test: mm
 4.34  0.23 m-  Mean mBI
m** (mean  0.60
SD)  Mean PAI
3.00
Test:
 Mean CAL
0.67  0.12 -
mm**
 Mean mBI
0.13**
 Mean PAI
2.47

a
xenograft; b1,5 W, continuous wave, one application (15 s); c1 W, continuous wave, one application daily (15 s) for 5 days; AB, systemic antibiotics; amox, amoxicillin; BG, bone graft;
CAL, clinical attachment loss; CD, calcium hydroxide dressing; Cp, caries profunda; D, periodontal dressing; FI, furcation involvement; GP, gutta percha; LC, lateral condensation; M,
membrane; mBI, modified bleeding index; metro, metronidazole; mo, months; MWF, modified Widman flap; NFD, not further described; Occl, occlusal adjustment; PAI, periapical index;
PPD, probing pocket depth; PS, periodontal surgery; RCT, root canal treatment; RBF, reverse bevel flap; RF, rotary files; S, sealer; SRP, scaling and root planing; w, weeks; yrs, years.
*p < 0.05 (difference between baseline and outcome).
**p < 0.05 (difference between control and test group); the wording used in the table was adapted from the publications included.
†
Time related to last treatment step.

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Table 2. Characteristics of included case reports
First author Gender Age Perio* Smoking Tooth PPD (mm) Clinical Radiographic Additional Treatment sequence Follow-up PPD (mm) Additional
(year of type at manifestations manifestations diagnosis (mo)‡ at outcomes
publication) baseline† follow-up–

Moucachen M 50 NR NR 38 12 NV, Per A, L – Extraction – – –

et al. (1981)
Geurtsen et al. F 17 NR NR 46 13 NV, R A, L, IR, – Extraction – – –
(1985) wPLS
Stamas & M 64 NR NR 26 7 NV, Pu, M0, A, L, IR – RCT1 + RCT2 12 2–3 BF
Johnson R
(1994)
Haueisen et al. M 59 NR NR 36 12 UV, Pu, Per, A, L – RCT1 + RCT2 18 2 BF
(1999) R
Haueisen et al. M 56 NR NR 46 12 UV, Pu, Per, A, L, IR – RCT1 + RCT2 12 2–3 BF
(1999) R
Ratka-Kr€ uger M 56 NR NR 47 12 NV, Pu, S, R, A, L, IR Ab, Fis RCT1 + RCT2 6 3 BF
et al. (1999) FI
Wood et al. M 62 NR NR 46 11 NV, Pa, Per, A, L, IR – RCT1 + RCT2 + SRP 6 3 No FI
(2003) C, R, FI
Zubery & F 23 AgP NR 22 10 NV, Pa, S, M2 A, L Ab RCT1 + SRP 21 2 BF, M0-1
Machtei (3 months) SRP
(1993)
Zucchelli F 39 P NR 12 12 UV, M3, Rec, A, L Fis RCT1 + SRP + Spl 36 3 BF, M0
(2007) infraBDh (4 months) PS (EMD,

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
BGa, ABf)
Zehnder (2001) M 28 AgP NR 15 8 NV, Pu, Pa, L Fis RCT1 + SRP + RCT2 + 6 5 BF, M1,
Per, M3 RCT3 (4 months) AttG
PS 3 mm
Kresic (1994) M 70 NR NR 43 11 NV, R A, L – RCT1 + SRP 22 4 BF, nPLS
(6 months) PS
Zubery & F 23 AgP NR 11 10 NV, Pa, S, A, L Fis RCT1 + SRP 12 2 BF, M0-1
Machtei M2, bBLh (3 months) SRP -
(1993) (9 months) – PS + ES
Walter et al. M 53 ChP HS 32 8i NV, R, Feh, A, L – RCT1 + RCT2 18 4 BF
(2008) infraBDh (14 months) PS
(BGa, Mb, ABf)
Danesh-Meyer M 40 NR NR 36 12 NV, Pu, R, L – RCT1 + PS (BGc, 6 2 BF, AttG
(1999) FIh, infraBDh Md, ABf) + RCT2– 8 mm
(4 months) RCT3
Haueisen & F 62 NR NR 46 12 NV, Pu, Pa, A, L, IR – RCT1 + PS (Res) + Spl 12 1 BF, M1
Heidemann Per, S, M2,
(2002) R, FIh
John et al. F 58 NR NR 21 14 NV, M2, L – RCT1 + Spl + PS 9 4 BF, M1
(2004) infraBDh (EMD, BGa, ABf)
Yavuz et al. M 25 NR NR 22 7 NV, S, bBLh, A, L, AccR Fis RCT1 + RCT2 + PS 12 3–4 BF
(2008) infraBDh (Res, BGe, ABf)
Treatment of perio-endo lesions

Ghezzi et al. M 38 NR NR 21 9 NV, Pu, L – RCT1 + SRP + PS 24 3 BF

(2012) infraBDh, (BGa,e, Mb, ABf)
bBLh
785
786 Schmidt et al.

therapy was deemed to be necessary

HS, heavy smoker; infraBD, infrabony defect; IR, interradicular radiolucency; L, lateral radiolucency; M, male; Me, membrane; M, mobility (grade 0–3); nPLS, normal periodontal ligament
BOP, bleeding on probing; C, caries; ChP, chronic periodontitis; EMD, enamel matrix derivates; ES, endodontic surgery; F, female; Fe, fenestration; Fis, fistula; FI, furcation involvement;

space; NR, not reported; NS, non-smoker; NV, negative vitality test response; P, periodontitis (not further specified); Pa, pain; Per, positive percussion test; PS, periodontal surgery; Pu, pus;
xenograft; bbioabsorbable; calloplast; dnon-resorbable; eautograft; fsystemic application; glocal application; hintra-operative finding; idata from patients record; jallograft; A, apical radiolu-
cency; Ab, abscess; AB, antibiotics; AccR, accessory root; AgP, aggressive periodontitis; AttG, attachment gain; bBL, buccal bone loss; BF, radiographic signs of bone fill; BG, bone graft;

R, restoration; RCT, root canal treatment; Rec, recession; Res, root resection; S, swelling; Spl, splint; SRP, scaling and root planing; UV, unclear or delayed vitality test response; wPLS,
Additional
outcomes

BF, M0
BF, no
in these case series (Haueisen et al.

BOP

widened periodontal ligament space; + time between various treatment steps <3 months; for more details see Appendix S6. –PPD corresponding to the highest reported PPD at baseline.
2000, Ratka-Kr€ uger et al. 2000). The
remaining publications combined an
endodontic with a periodontal treat-
PPD (mm)

follow-up–
ment. Li et al. (2012) selected a non-
at surgical approach by combining a

2
root canal treatment with the root
debridement of involved teeth with
(test group) or without (control
Follow-up

group) diode laser irradiation. The

(mo)‡

10

12
laser was applied both during RCT
and after initial periodontal treat-
ment in a mode aiming in bacterial
reduction. Two publications added
Treatment sequence

periodontal surgery to a conven-

(12 months) PS
RCT1 + SRP + PS

tional non-surgical periodontal and

(BGe, Md, ABf,g)

(BGj, Mb, ABf,g)

endodontic treatment. Hassan et al.

(BGc) + ES

(1986) applied citric acid as condi-

RCT1 + PS

tioning agent to the root surfaces

within an open flap debridement.
Sun & Liu (2009) used a xenogenous
bone graft material and adjuvant
Additional

systemic antibiotics in addition to

diagnosis

surgery.
–

In case the treatment was performed

at different time points, what was the
manifestations
Radiographic

time interval for re-evaluation of the

first treatment step? In two retro-
spective case series non-surgical
A, L

endodontic treatment was performed

A

as a first treatment step and the deci-

manifestations

sion for any further therapy was left

NV, M2, R,

open and performed 6 months after

Clinical

Rec, FIh,
infraBDh

NV, M2

re-evaluation of the healing after

RCT (Haueisen et al. 2000, Ratka-
For calculation purposes, only the highest and clearly defined PPD was taken.

Kr€ uger et al. 2000). In both case

series, in all re-evaluated patients, no
PPD (mm)

baseline†

further therapy was deemed neces-

10
at

sary since the initial RCT was classi-

9

fied as successful according to

clinical and radiographic criteria. In
Tooth

the remaining publications, a com-

type

16

12

bined treatment was initially planned

using a research plan and applied
Gender Age Perio* Smoking

without further decision making

NR
NS

within the healing process.

Which rates of tooth loss occurred

NR

NR

after treatment? No tooth loss was

Time related to last treatment step.

reported in either publications. The

*General periodontal conditions.

reported drop-out rate was two out

50

19

of 14 (Hassan et al. 1986), 11 out of

20 (Ratka-Kr€ uger et al. 2000) and
18 out of 37 (Sun & Liu 2009). No
F

F
Table 2. (continued)

drop-outs were reported in the

remaining two publications. As rea-
Oh et al. (2009)

sons were not provided, patients

First author

Politis et al.
publication)

who dropped out were assumed to

may have lost their treated teeth and
(year of

(1986)

considered as “worst case” for the

calculation of tooth loss (Spriet &
a

†
‡

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Dupin-Spriet 1993, Myers 2000). Of
the 111 treated teeth for 80 teeth an
outcome was reported, leading to
the assumption of 31 teeth may have
been lost during follow-up, repre-
senting a tooth loss rate within the
range of 0 to 27.9%.
Does treatment of combined periodon-
tal-endodontic lesions lead to a PPD
reduction? Probing pocket depth
reductions in terms of a decreased
mean PPD or a smaller PPD range
occurred from baseline to follow-up
in all included publications for the
teeth at follow-up. Data are reported
after 6 months in all included publi-
cations. Three case series provided
additional data after 12 months
(Haueisen et al. 2000, Ratka-Kr€ uger
et al. 2000, Sun & Liu 2009).
The PPD after a follow-up of
6 months decreased from a mean
PPD of 14.29  1.76 to 6.125 
4.076 mm (Hassan et al. 1986). The
individual values of the PPD ranged
from 3.2 mm to 15.3 mm (Hassan
et al. 1986).
In a randomized controlled trial,
Li et al. (2012) reported a signifi-
cantly different PPD reduction after
a follow-up of 6 months from a
mean PPD of 6.04  0.37 to 5.64 
0.33 mm in the control group and
from a mean PPD of 6.01  0.31 to
4.34  0.23 mm in the test group.
The PPD decreased from a
mean PPD of 11.3 mm to 3.1 mm
after 6 months and to 2.2 mm after
12 months (Ratka-Kr€ uger et al.
2000). After a follow-up of 6 months,
the reported PPD range of 9 to
12 mm at baseline declined to 2 to
4 mm with no further changes up to
12 months (Haueisen et al. 2000).
A statistically significant reduc-
tion of the PPD after 6 months, i.e.
from a mean PPD 6.62  0.230 to
2.83  0.149 mm and after 12 months,
i.e. from mean PPD of 6.74  0.285
to 2.42  0.233 mm was noted by
Sun & Liu (2009).
Discussion
Herein, we conducted a systematic
review to evaluate the best available
external evidence regarding the treat-
ment options and outcomes of peri-
odontal-endodontic lesions. A total of
five studies, i.e. one randomized con-
trolled clinical trial, two prospective
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Treatment of perio-endo lesions
and two retrospective case series, and
18 case reports were included from a
systematic literature search. Due to
an assumed scarcity of clinical studies,
the initial purpose of this systematic
review was to evaluate case reports
supposed to be the best external evi-
dence on this subject. As intervention-
al studies and case series, however,
were also found fulfilling the inclusion
criteria (Fig. 1), the data were pre-
sented separately for clinical studies
(Table 1) and case reports (Table 2,
Appendix S6) according to the sus-
pected hierarchy of best available
external evidence.
A plethora of classifications for
lesions with periodontal and end-
odontic tissue involvement has been
proposed. Several authors suggested
the differentiation between the pri-
mary cause(s) of the lesion, i.e. of
periodontal or endodontic origin
(Simon et al. 1972, Guldener 1975,
Geurtsen et al. 1985). However, the
correct identification of the disease
onset is frequently impeded and
remains of speculative nature in
many cases, due to an incomplete
dental history or critical results of a
pulp sensibility test, in particular in
multi-rooted teeth. According to
recent suggestions (Armitage 1999,
Lang et al. 1999, Abbott & Salgado
2009), in this systematic review, only
publications that described a well
defined feature of periodontal-
endodontic lesions, i.e. teeth with a
negative or an unclear response to a
pulp sensibility test and an increased
probing pocket depth, were consid-
ered (Appendix S4 and S5). Interest-
ingly, three studies included neither
used a classification system nor
determined the disease onset proba-
bly reflecting the difficulties and limi-
tations in differential diagnosis
(Hassan et al. 1986, Sun & Liu 2009,
Li et al. 2012).
The publications in this syste-
matic review were published within a
time frame from 1981 to 2012. As
one finding from this review, non-
surgical RCT as a sole treatment
approach was performed by some
early publications whereas guided
tissue regeneration (GTR) proce-
dures were more frequently applied
in recent publications (Stamas &
Johnson 1994, Ghezzi et al. 2012).
Time point of publication needs to
be considered as a relevant parame-
ter within a review, because dental
787
treatment options and/or materials
have changed dramatically over time
(Hassan et al. 1986, Li et al. 2012,
Rodriguez et al. 2013), probably
leading to difficulties in comparison
among the studies.
Although the English language is
commonly accepted as the language
of scientific research, relevant exter-
nal evidence could also arise from
studies in languages other than Eng-
lish (Morrison et al. 2012), in parti-
cular from members of the BRIC
countries (Brazil, Russia, India,
China) or findings from the early
days of scientific periodontology
(Schmidt et al. 2013). In addition, it
was suggested that positive research
findings are more likely to be pub-
lished in an international English-lan-
guage journal whereas negative
results may be rather reported in a
non English-language journal (Egger
et al. 2003). The influence of lan-
guage restrictions on the outcome of
systematic reviews is uncertain in
particular fields of medicine (Morri-
son et al. 2012). The exclusion of non
English-language studies from a sys-
tematic review, however, may lead to
a language bias. The literature search
of the present systematic review was
performed without any language
restrictions. Two original studies in
Chinese language have been trans-
lated. They fulfilled the inclusion cri-
teria and were included comprising
67 teeth out of 111 analysed teeth
(Sun & Liu 2009, Li et al. 2012).
Treatment planning includes the
consideration of diagnostic and prog-
nostic factors deemed to influence
the treatment outcome of periodon-
tal-endodontic lesions (Lang & To-
netti 2003, Kwok & Caton 2007).
However, in addition to mode of
endodontic and/or periodontal treat-
ment, potential confounding factors,
e.g. patient‘s age, gender, tooth type,
smoking, periodontal history and
chronicity of lesions, were inconsis-
tently considered in the included
publications resulting in a high risk
of bias (Appendix S7). Further
research analysing the impact of
these factors on the pathogenesis and
the outcome of therapy of periodon-
tal-endodontic lesions is required.
No tooth loss was reported except
for two case reports. In case series
and case reports, success and/or sur-
vival rates may be subject to a publi-
cation bias as a treatment success
788 Schmidt et al.
may be more likely to be published.
Therefore, treatment failures could
be underrepresented. Several drop-
outs occurred in three included publi-
cations (Hassan et al. 1986, Ratka-
Kr€uger et al. 2000, Sun & Liu 2009).
Such drop-out rates pose a threat to
validity of any study (Walter et al.
2012a). In general, there are different
possibilities to handle drop-outs
including the so-called “worst case”
analysis. As reasons for drop-outs
were not provided, this method was
applied in the present review and
patients who dropped were assumed
to may have lost their treated teeth
(Myers 2000, Sutherland 2001, Wang
et al. 2004). The tooth loss rate ran-
ged from 0 to 27.9% resulting in a
survival rate of 72.1 to 100%. The
survival rate may be affected by the
eligibility criteria, including the PPD
range, applied in the randomized
controlled clinical trial and in the
case series. For example, the exclu-
sion of hypermobile and multi-rooted
teeth seems to be of prognostic rele-
vance and may have implications on
the treatment outcome (Hassan et al.
1986). The herein reported survival
rate is within the previously noted
range of survival rates. Schacher
et al. found a survival rate of 61%
after at least 5 years to retain teeth
with treated periodontal-endodontic
lesions (Schacher et al. 2007). In
addition, a prospective clinical trial
reported a favourable outcome of
77.5% in apicomarginal defects
including periodontal-endodontic
lesions (Kim et al. 2008). In contrast
to the reported tooth loss and/or sur-
vival rate, the PPD reduction repre-
sents an alternative study end point,
possibly representing a success rate
from a strictly periodontal point of
view. A PPD reduction was achieved
in nearly all re-evaluated teeth, but
there may be remaining deep probing
depths (Hassan et al. 1986, Li et al.
2012). However, the PPD of the
included teeth differed remarkably
between the clinical studies (Hassan
et al. 1986, Li et al. 2012). Keeping
in mind, that a narrow localized deep
PPD may represent a draining sinus
tract of endodontic origin that healed
after root canal treatment (Weiger
et al. 1995, Abbott & Salgado 2009).
The data from clinical studies and
case reports were analysed separately
with respect to the suspected hierar-
chy of external evidence (Hujoel
2008). In general, the evidence levels
refer to the study design suggesting
randomized controlled clinical trials
as higher available external evidence
compared to other study designs
(Hujoel 2008). For this reason, some
authors feel there is a lack of direct
evidence in case an (meta-analysis of)
RCT‘s is missing (Walter et al.
2012b, Schmidt et al. 2013, Walter &
Friedmann 2013). In randomized
controlled clinical trials, patients
need to be assigned to a predefined
protocol. This design may exclude
the opportunity of alteration of a
treatment plan, which may be indi-
cated after evaluation of the tissue
response after root canal treatment.
Healing of lesions of endodontic ori-
gin depends on many modifying fac-
tors and may occur within a large
time frame (European Society of
Endodontology 2006, Ricucci et al.
2009, Walter et al. 2008). Prospective
case series or cohort studies permit
modifications of the treatment plan
and sequence with respect to indivi-
dual healing responses and findings
at different time points. A (prospec-
tive) case series seems to be more
reasonable to evaluate the treatment
of periodontal-endodontic lesions at
the current stage of knowledge. Four
case series and 18 case reports were
included in this review. In two case
series and four case reports including
five teeth, a non-surgical endodontic
treatment was performed as initial
treatment and the decision for fur-
ther procedures were based on the
tissue response at re-evaluation (Sta-
mas & Johnson 1994, Haueisen et al.
1999, 2000, Ratka-Kr€ uger et al.
1999, 2000, Walter et al. 2008). The
remaining publications predefined
the treatment sequence, i.e. a com-
bined treatment consisting of non-
surgical endodontic therapy with a
non-surgical and/or a surgical peri-
odontal therapy. Periodontal surgery
consisted of an open flap debride-
ment alone or in combination with
regenerative or resective procedures.
Incomplete tissue healing after
evaluation of the first treatment step
may lead to the decision of further
procedures (Dietrich et al. 2003).
Healing of periapical lesions may take
up to 4 years (European Society of
Endodontology 2006) or longer (Ric-
ucci et al. 2009). This process may be
modified by several hereditary, envi-
ronmental and behavioural risk fac-
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
tors, e.g. a smoking habit (Walter
et al. 2008, 2012b, Rodriguez et al.
2013). Similarly, the improvement of
periodontal conditions subsequent to
scaling and root planing may take
several months, with the deeper the
initial PPD the longer the time for
PPD reduction (Badersten et al.
1984). An observation time of at least
6 to 12 months before re-evaluation
of the first treatment step was sug-
gested by Zehnder (Zehnder 2001).
The publications included in this
review reported a follow-up time
between six and 12 months. However,
with respect to the individual range of
the time required for periodontal tis-
sue healing and the absence of radio-
graphic changes in early stages of
healing, the interpretation of treat-
ment results after six to 12 months
seems to be associated with some bias
(Hirsch et al. 1989, Jansson et al.
1997, Kim et al. 2008). The results
from included studies and case series
may need to be regarded as short-
term outcomes. Follow-up examina-
tions after an observation period of
several years would be desirable
although challenging.
With respect to the uncertain
treatment outcome of periodontal-
endodontic lesions and the successful
outcome of less invasive treatment
approaches (Stamas & Johnson
1994, Haueisen et al. 1999, 2000,
Ratka-Kr€ uger et al. 1999, 2000), the
concept of a sequential treatment
with re-evaluation at different treat-
ment stages may also be supported
from an economic point of view.
Financial costs and time efforts
increase dramatically with more
invasive treatment approaches (Wal-
ter et al. 2012c). On the other hand
patient-centred outcomes, including
quality of life, treatment time and
costs, are of increasing importance
within clinical trials to ensure an
appropriate allocation of resources
(Br€agger 2005, Walter et al. 2012c).
Conclusions and Clinical Relevance
Taken together, this review may pro-
vide some evidence for root canal
treatment as a first treatment step
for the treatment of combined peri-
odontal-endodontic lesions with
increased PPD and a negative
response of pulp sensibility testing.
A reasonable time for healing of the
endodontic lesion after root canal
 Treatment of perio-endo lesions 789

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Principal findings: In this systematic
review, a successful outcome in
terms of probing pocket depth
reduction of exclusive non-surgical
endodontic therapy was identified
for teeth with a negative response to
pulp sensibility testing combined
with increased probing pocket depth.
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Supporting Information
Additional Supporting Information
may be found in the online version
of this article:
Appendix S1. PRISMA 2009 check-
list.
Appendix S2. Electronic search strat-
egy for the databases MEDLINE
and EMBASE.
Appendix S3. Scores for assessment of
methodological and reporting quality.
Appendix S4. Studies and case series
excluded based on full text analysis,
and reason for exclusion.
Appendix S5. Case reports and reviews
based on full text analysis, and reason
for exclusion.
Appendix S6. Characteristics of
included case reports in detail.
Appendix S7. Quality assessment of
included studies.
Address:
Clemens Walter
Dept. of Periodontology, Endodontology and
Cariology
University of Basel
Hebelstrasse 3, CH-4056 Basel
Switzerland
E-mail: clemens.walter@unibas.ch
Practical implications: The findings
from this systematic review may
support an initial root canal treat-
ment for the treatment of this kind
of periodontal-endodontic lesions.
A reasonable time in advance of
consideration of further procedures
is suggested.