|Year : 2022 | Volume
| Issue : 2 | Page : 195-203
Diagnostic and therapeutic approaches to endodontic-periodontal lesions: A survey among dental surgeons in Ouagadougou, Burkina Faso
Wendpoulomdé Aimé Désiré Kabore1, Jocelyne Valérie Wendkouni Garé2, Célestin Koama1
1 Department of Conservative Dentistry and Endodontics, Training and Research Unit in Health Sciences, Joseph KI-ZERBO University, 03 BP 7021, Ouagadougou 03, Burkina Faso
2 Department of Public Health, Training and Research Unit in Health Sciences, Joseph KI-ZERBO University, 03 BP 7021, Ouagadougou 03, Burkina Faso
|Date of Submission||11-Aug-2021|
|Date of Decision||27-Sep-2021|
|Date of Acceptance||05-Oct-2021|
|Date of Web Publication||20-Apr-2022|
Dr. Wendpoulomdé Aimé Désiré Kabore
Department of Conservative Dentistry and Endodontics, Training and Research Unit in Health Sciences, Joseph KI-ZERBO University, 03 BP 7021 Ouagadougou 03
Source of Support: None, Conflict of Interest: None
Introduction: Endodontic-periodontal lesions (EPLs) continue to be a challenge for clinicians in terms of diagnosis, therapy, and prognosis. The objective of this study was to evaluate the diagnostic, therapeutic, and prognostic approaches to EPLs by dental surgeons in Burkina Faso.
Materials and Methods: This was a cross-sectional study with a descriptive purpose. The study population consisted of dental surgeons practicing in the city of Ouagadougou. The data were collected using a self-administered questionnaire and analyzed with R Commander version 3.6.0 software.
Results: Fifty practitioners participated in the survey. The level of knowledge of the diagnosis was above average for 70% of the practitioners surveyed, while 98% of the practitioners had an above-average level of knowledge regarding therapeutic and prognostic approaches to EPLs. The overall level of awareness of EPL management was average to good for 85.5% of the practitioners. Having a postgraduate degree was significantly associated with the overall level of knowledge (P = 0.01).
Conclusion: The overall theoretical knowledge of dental surgeons regarding EPLs appears to be good. Nevertheless, there are deficiencies in the knowledge of diagnostic parameters. This could result in failures in terms of how this pathology is managed.
Keywords: Dental surgeons of Burkina Faso, diagnosis, endodontic-periodontal lesions, knowledge, treatment
|How to cite this article:|
Kabore WA, Garé JV, Koama C. Diagnostic and therapeutic approaches to endodontic-periodontal lesions: A survey among dental surgeons in Ouagadougou, Burkina Faso. Saudi Endod J 2022;12:195-203
|How to cite this URL:|
Kabore WA, Garé JV, Koama C. Diagnostic and therapeutic approaches to endodontic-periodontal lesions: A survey among dental surgeons in Ouagadougou, Burkina Faso. Saudi Endod J [serial online] 2022 [cited 2022 May 18];12:195-203. Available from: https://www.saudiendodj.com/text.asp?2022/12/2/195/343552
| Introduction|| |
The periodontium and the endodontia are tissues that have an anatomical and physiological interrelationship, whereby the diseases of one entity can spread within the other and vice versa.,, When this spread is effective, it gives rise to an endodontic-periodontal lesion (EPL), which is a process involving interaction of pathologies of the pulp and the periodontium. This association was first described by Cahn in the beginning of the 20th century. Since then, a number of investigations have reported that pulpal and periodontal problems are responsible for more than 50% of pulp necrosis., The therapeutic decision for this pathology and the prognosis of a favorable outcome depend largely on the identification of its origin. A judiciously conducted diagnostic approach allows determination of an endodontic, periodontal, or combined origin., This type of lesion is a widely debated topic in the literature, and there are several classifications for periodontal-endodontic lesions. However, they still present a challenge for clinicians in terms of diagnosis, therapy, and prognosis. Although in most cases the manifestations of periodontal and endodontic diseases are clearly distinct, there are situations where the clinical and the radiographic manifestations can lead to a degree of confusion. This makes the final diagnosis uncertain and can consequently result in the wrong treatment choice and ultimately tooth extraction. The topic of EPLs is relevant to all areas of dentistry, and a multidisciplinary approach is important in the diagnosis and management of these lesions in order to optimize the chances of successful treatment. Burkina Faso, which is a sub-Saharan African country, has very few dental surgery doctors (general practitioners of dentistry) who mostly practice in the capital city Ouagadougou. These dental surgery doctors must have a 12-semester university training leading to a practicing doctorate in dentistry and registration with the National Order of Dental Surgeons of Burkina. The objective of this study was, therefore, to carry out an evaluation of the diagnostic, therapeutic, and prognostic approaches to EPLs by dental surgery doctors in Burkina Faso, whether or not they are specialists in order to devise recommendations to improve the management of this pathology.
| Materials and Methods|| |
The Research Ethics Committee of the Regional Health Directorate of the Centre approved the study (protocol N° 2018-0082/MS/SG/RCEN/DRSC). Participation in the study was voluntary once the objectives of the study had been presented to the subjects. Anonymity and confidentiality of the data were respected. No identifying data were entered into the data processing and analysis. All of the study participants were provided with information regarding the subject after the questionnaire had been administered.
Study design and setting
This was a descriptive cross-sectional study conducted in dental practices in Ouagadougou, from January 15 to March 25, 2019. Ouagadougou is the capital city of Burkina Faso and it is the largest city in the country with the majority of dental surgeons. These practitioners are spread across the public and private health sectors.
Study population, sample size, and sampling procedure
All dental surgeons who registered with the National Order of Dental Surgeons of Burkina Faso for the year 2018 and practicing in the city of Ouagadougou were the source population. The dental surgeons present at the time of the survey were included in the study, regardless of gender or sector of activity. Dental surgeons who were unwilling to provide consent were not included in the study.
According to the information of the National Order of Dental Surgeons of Burkina Faso, oral health care is provided by 92 dental surgeons, 61 of whom are deployed in the city of Ouagadougou. The sampling was exhaustive. We systematically took into account all the dental surgeons who fulfilled the conditions of the study. The selection of participants consisted of a census of all dentists.
Data were collected using a self-administered questionnaire. The questionnaire was pretested among 10 practitioners from the second largest city of the country and who were hence not part of the main study. Once validated, the survey form was sent to all dentists who could be reached in their practices. Some forms were completed immediately, although the time constraints due to the schedule of some practitioners required scheduling another appointment to collect the completed questionnaires.
The questionnaire comprised three sections with 18 multiple-choice questions [Appendice 1] and [Appendice 2].
- Six questions regarding sociodemographic and professional data allowed collection of variables such as age, gender, professional experience, or the number of years in practice, formal postgraduate training, the nature of continuing education, and the practice sector
- Six questions regarding knowledge of the diagnostic approach to EPLs. The variables in question were endodontic-periodontal communication pathways, clinical and functional signs, characteristics for assessing mixed or true EPLs, pathologies of relevance to EPLs, types of radiographs performed, and characteristic radiographic signs
- Six questions regarding knowledge of the therapeutic and the prognostic approaches to EPLs constituting the decision criteria whether or not to preserve a tooth affected by EPLs, the modalities of management of the different clinical forms, criteria determining the success rate of management, and the postoperative follow-up schedule.
The data were compiled using EPIDATA software and then transferred to R Command software version 3.6.0 (Vienna, Austria) for analysis. To identify the level of awareness of EPLs, scores were generated based on the various items addressed in the questionnaire [Appendice 1] and [Appendice 2]. The partial diagnostic knowledge score and the partial diagnostic treatment score were defined as the sum of the points obtained for the answers to the questions regarding the diagnostic and the therapeutic variables, respectively. The overall knowledge score represented the sum of the partial diagnostic knowledge score and the partial diagnostic treatment score. The expected values of the partial diagnostic knowledge score, the partial therapeutic knowledge score, and the overall knowledge score were 19, 11, and 30, respectively [Appendix 3]. The scores thus obtained allowed us to classify the respondents into three possible categories:
- Good knowledge: Practitioners who obtained a score of more than 70%
- Average knowledge: Practitioners with a score between 50% and 70%
- Poor knowledge: Practitioners who obtained a score of less than 50%.
A detailed description of the sociodemographic and the occupational characteristics, as well as the main variables relating to knowledge of EPLs, was carried out. A comparison of the different occupational profiles in terms of awareness of EPLs was carried out using Chi-square tests or Fisher's exact test when necessary. The significance threshold was set at P < 0.05, with a 95% confidence interval.
| Results|| |
Characteristics of the practitioners
Out of a total of 55 dental surgeons contacted for the study, 50 agreed to participate, thus amounting to a participation rate of 90.9%. Sixty-six percent of the sample consisted of men. The public practice subsector accounted for 60% of the dental surgeons. The average time in dentistry practice was 16.02 years ± 10.53, with extremes ranging from 0 to 46 years. In terms of continuing education, 98% of the practitioners had attended conferences, postgraduate teaching, and seminars, and 21 (42%) of the practitioners had obtained a postgraduate university diploma (PUD). These 21 practitioners had one or more postgraduate degrees. Fourteen of them had a higher studies certificate (oral biology, joint dental prosthetics, removable dental prosthetics, periodontology, oral surgery, oral medicine, pedodontics, endodontics, preventive dentistry, forensic odontology, maxillofacial prosthetics, and biochemistry), 11 had an interuniversity degree (implantology, orthodontics, oral pathology, medical pedagogy, infectiology, and clinical periodontology), and 5 had a master's degree (public health, biology, and dental sciences) [Table 1].
|Table 1: Sociodemographic and professional profiles of the dental surgeons|
Click here to view
Diagnostic approaches to endodontic-periodontal lesions
For the practitioners who were interviewed, the endoperiodontal communication channels were the apical foramen (88%) [Table 2]. The clinical and the functional signs retained by the practitioners were pulp necrosis, swelling, or abscess (94%); pain (90%); negative pulp vitality test (94%); and dental mobility with deep periodontal pocket (84%). The type of probing selected to characterize mixed EPLs periodontal pocket was circumferential (punctiform and arciform) as a “V” probing (46%) [Table 3]. The practitioners made a differential diagnosis of EPL based on a crack or a root fracture (82%) and retropulpitis (a secondary pulpitis caused by a periodontal lesion) (60%). The reference radiographic examination involved a simple retroalveolar (90%) assessment or with a gutta-percha point inserted into the periodontal pocket or fistula (62%). Eighty percent of the practitioners claimed that the loss of lamina dura in continuity with the apical foramen was the main radiographic sign associated with EPLs.
|Table 2: Intertissue transmission pathways for endodonticperiodontal lesions according to the practitioners (n=50)|
Click here to view
|Table 3: Signs of endodontic-periodontal lesion and the type of assessment for a mixed lesion according to the practitioners (n=50)|
Click here to view
Therapeutic and prognostic approaches
The criteria used for therapeutic decision-making (e.g., whether or not to preserve the tooth) were the degree of tooth damage (98%) and the patient's motivation (80%). In case of a lesion of endodontic origin, endodontic treatment combined with periodontal monitoring was the therapeutic option recommended by 78% of the practitioners. Endodontic treatment alone was also recommended by 24%. For the management of periodontal EPLs, 88% of the practitioners recommended periodontal treatment associated with pulp vitality monitoring. Faced with a mixed lesion, nearly all of the practitioners interviewed recommended an endodontic treatment combined with a periodontal treatment. The accuracy of the diagnosis (80%), the speed of the management (70%), and the patient's motivation (68%) were selected as the main criteria for the outcome of treatment. Being able to manage risk factors (46%) was also considered to be an element that could influence the success of treatment. The strict deadline for postoperative control in the event of EPLs was set at 3 months (46%) or 6 months (34%).
Knowledge and socioprofessional profile
Knowledge of the diagnosis was above average for 70% of the practitioners surveyed, while 98% of the practitioners had an above-average level of knowledge regarding the therapeutic and prognostic approaches to EPLs. The overall level of awareness of EPL management was average to good for 85.5% of the practitioners. Postgraduate education was significantly associated with the overall level of knowledge of the diagnostic, therapeutic, and prognostic approaches to EPL (P = 0.01). Among the dental surgeons who had a good knowledge of the therapeutic and the prognostic approaches, 72.2% had a PUD. No significant association was found between the level of knowledge of the diagnostic, therapeutic, and prognostic approaches and other sociooccupational variables [Table 4].
|Table 4: Overall knowledge of the management of endodontic-periodontal lesions according to the sociodemographic and the professional profiles of the practitioners (n=50)|
Click here to view
| Discussion|| |
This study pertains to a major public health issue in Burkina Faso. It took place in the city of Ouagadougou and involved 50 practitioners. Although this number of participants may seem insufficient, it is representative of the entire profession because the majority of dental surgeons in the country are in Ouagadougou. The data were collected by self-administration of the questionnaire by the respondents. The questions can be construed in various ways, leading to different interpretations. However, the wording of the questions was made as clear as possible in order to reduce this difference.
Sixty-six percent of the sample consisted of male practitioners. Similar findings were reported in the work of Kaboré et al. and Ndiaye et al., but not the study of Wagle et al. in Nepal, which reported a female predominance. The same observation for professional seniority was made by Kouame et al. in Abidjan. In addition, of the fifty practitioners surveyed, 42% had received at least postdoctoral training. These results confirm that dental surgeons in Ouagadougou have EPL experience and that they may have basic knowledge regarding EPLs. The main routes of endoperiodontal communication were well known to the dental surgeons who were interviewed. Indeed, periodontal tissues and endodontic tissues establish an interrelationship via physiological or pathological communication pathways. Clinical and functional signs that can accompany EPLs include pain, dental mobility with deep periodontal pocket, a negative or altered pulp response to vitality tests, dental abscess, gingival recession, dental dyschromia, and food impaction in case of an interproximal periodontal pocket. In this study, the knowledge of the practitioners of signs comprised mobility, pulp necrosis, swelling, or abscess and pain. This also reflects a lack of knowledge of the clinical and functional signs of EPLs. Indeed, although they are inconsistent, dyschromia resulting from pulp necrosis and food impaction may be associated with EPLs. Periodontal probing is of primary importance in the diagnosis of EPLs. Depending on the origin of the EPL, a characteristic probing is associated with the periodontal pocket. For mixed lesions, the type of associated probing is a circumferential as a “V”one. The study showed that the nature of mixed lesion probing is not well known by practitioners. Difficulties in differential diagnosis were also noted among the respondents. The differential diagnosis of EPL of periodontal origin is established by root cracks and fractures as well as by dental anatomical abnormalities. Although the precise clinical and radiographic diagnostic features of vertical root fractures are uncertain, such fractures can be associated with pain, fistulized abscess, and a punctiform periodontal pocket., This inadequacy in the establishment of a differential diagnosis can be a cause of misdiagnosis that can lead to an erroneous treatment choice. Regarding the type of radiography performed for the diagnosis of EPL, diagnostic periapical X-ray with a gutta-percha point inserted into the periodontal pocket or ostium of the fistula was recommended by 62% of the dental surgeons. The practitioners who were interviewed, therefore, have a very solid knowledge of the additional radiographic examination. According to Al-Bayata et al., this technique can help practitioners identify the source of inflammation and differentiate between lesions of endodontic versus periodontal origin. The clinical decision regarding preservation or extraction of the tooth can be a real challenge for dental surgeons. A wrong decision can lead to an irreversible treatment such as extraction. In this study, the criteria used for decision-making regarding the therapy to be implemented were the degree of impairment of the tooth and the patient's motivation. Recent works have shown that the patient's motivation is a key aspect in therapeutic decision-making., This motivation is based on the patient's perspective regarding the expected esthetic outcomes of the treatment, the longevity, the duration, and the costs associated with the various treatment options.
When faced with an EPL of endodontic origin, 24% of the practitioners surveyed indicated that they would perform endodontic treatment alone. Indeed, in the acute stage, periodontal lesions most often present as a periodontal pocket with five bony walls externalizing a purulent exudate in the gingival-dental groove., These can heal spontaneously as a result of endodontic treatment.,,, However, in the chronic stage, there is an accumulation of plaque at the level of the ostium of the fistula, resulting in a localized periodontal defect. At this stage, the majority of the practitioners (i.e., 78%) favor endodontic treatment with periodontal monitoring. Indeed, numerous observations have indicated this approach., In the case of an EPL of periodontal origin, evidence of endodontic involvement is a controversial issue in the literature. A pulp vitality test in this case is positive. Nevertheless, many recent clinical studies recommend endodontic treatment followed by periodontal treatment.,,, The majority of the dental surgeons surveyed (88%) suggested a periodontal treatment with pulp vitality monitoring. For a mixed lesion, all of the dental surgeons interviewed recommended endodontic and periodontal treatment. Indeed, this type of lesion has the particularity of presenting periodontal involvement associated with pulp necrosis. Its management, therefore, requires endodontic treatment followed by an initial periodontal treatment and/or a surgical treatment.
A re-evaluation of treatments is necessary in order to assess the results obtained and to decide on a possible additional treatment. Follow-up is, therefore, a key step in the treatment. Parolia et al. argue that waiting at least 3 months after the initial treatments is required to achieve objective results.
From an overall perspective, the present study showed that the level of knowledge varied according to the different approaches and according to the socioprofessional profile of the practitioners. Indeed, the level of knowledge of the diagnosis was above average for 70% of the practitioners surveyed, while 98% of the practitioners had an above-average level of knowledge of the therapeutic and the prognostic approaches to EPL. The choice of treatment is as important as an accurate diagnosis and it goes a long way in determining the outcome of the management of EPLs. The success of the treatment depends on the diagnostic accuracy and a judicious choice of the type of treatment. The overall knowledge of the diagnostic and therapeutic approaches is, therefore, the key to the success of EPL treatments. The level of knowledge of the diagnostic, therapeutic, and prognostic approaches to EPLs was significantly higher among practitioners with a postgraduate degree. These variations show that a suitable EPL treatment requires in-depth knowledge in several areas of dentistry to ensure the best chance of providing optimal treatment.
This study was limited to an assessment of the knowledge of dental surgeons. Following this work, clinical studies to assess the success of the treatments implemented should be considered. However, the most important thing would be first to set up a continuing education module on EPLs.
| Conclusion|| |
Endodontic-periodontal diseases often present great challenges to the clinician in terms of their diagnosis, management, and prognosis. The diagnosis must be rigorously performed. Periodontal probing associated with pulp vitality tests and radiography is needed whenever possible. This study revealed the degree of knowledge of dental surgeons in the city of Ouagadougou regarding the diagnostic, therapeutic, and prognostic approaches to EPLs. The general level of knowledge appeared to be good. Understanding the disease process through cause-and-effect relationships between the pulp and supporting periodontal tissues generally leads to successful treatment outcomes.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| Appendices|| |
| References|| |
Kuoch P, Bonte E. Endoperiodontal lesions and Chicago's new classification of periodontal and peri-implant diseases and conditions. J Contemp Dent Pract 2020;21:798-802.
Suchetha A, Salman K, Sapna N, Apoorva S, Darshan B, Bhat D. Endo-perio lesion: A case report. Int J Appl Dent Sci 2017;3:113-6.
Sirming M, Golberg M. The pulpal pocket approach: Retrograde periodontitis. J Periodontol 1964;35:22-48.
American Association of Endodontists. Glossary of Endodontic Terms. 10th
ed. Chicago, IL: American Association of Endodontists; 2020. p. 1-48.
Cahn LR. The pathology of pulps found in pyorrhetic teeth. Dent Items Int 1927;49:598-617.
Jakovljevic A, Knezevic A, Karalic D, Soldatovic I, Popovic B, Milasin J, et al.
Pro-inflammatory cytokine levels in human apical periodontitis: Correlation with clinical and histological findings. Aust Endod J 2015;41:72-7.
Signoretti FG, Gomes BP, Montagner F, Jacinto RC. Investigation of cultivable bacteria isolated from longstanding retreatment-resistant lesions of teeth with apical periodontitis. J Endod 2013;39:1240-4.
Verma PK, Srivastava R. Interdisciplinary approach for the management of bilateral periodontal: Endodontic defects. Saudi Endod J 2017;7:186-9. [Full text]
Lin S, Tillinger G, Zuckerman O. Endodontic-periodontic bifurcation lesions: A novel treatment option. J Contemp Dent Pract 2008;9:107-14.
Tsesis I, Nemcovsky CE, Nissan J, Rosen E, editors. Lesions of endodontic periodontal origin. In: Endodontic-Periodontal Lesions. Switzerland: Springer, Cham; 2019. Available from: https://doi.org/10.1007/978-3-030-10725-3_1
Rotstein I, Simon JH. Diagnosis, prognosis and decision-making in the treatment of combined periodontal-endodontic lesions. Periodontol 2000 2004;34:165-203.
Kaboré WA, Chevalier V, Gnagne-Koffi Y, Ouédraogo CD, Ndiaye D, Faye B. A survey of endodontic practices among dentists in Burkina Faso. J Contemp Dent Pract 2017;18:641-6.
Ndiaye D, Bane K, Niang O, Seck A, Kabore WA. Frequency and management of non-carious cervical lesions: Survey of Burkinabe dental surgeons. Rev Col Odontostomatol Afr Chir Maxillofac 2015;22:5-10.
Wagle M, Acharya G, Basnet P, Trovik T. Knowledge about preventive dentistry versus self-reported competence in proventive oral healthcare: A study among Nepalese dentists. Oral Health 2017;17:1-7.
Kouame KA, Kone T, Pesson D. Choice of imprint materials in daily practice: Survey of dental surgeons in the city of Abidjan. Rev Col Odontostomatol Afr Chir Maxillofac 2014;21:24-30.
Parolia A, Gait TC, Porto IC, Mala K. Endodontic-periodontal lesion: A dilemma from 19th
century. J Interdiscip Dent 2013;3:2-11.
Khan RN, Kumar A, Chadgal S, Jan SM. Endo-perio interrelationship – An overview. Int J Inf Res Rev 2017;4:3895-8.
Stephane S, Pierre M. Some considerations on endoparodontal lesions. Dent Floss 2009;39:30-4.
Liao WC, Tsai YL, Wang CY, Chang MC, Huang WL, Lin HJ, et al.
Clinical and radiographic characteristics of vertical root fractures in endodontically and nonendodontically treated teeth. J Endod 2017;43:687-93.
PradeepKumar AR, Shemesh H, Jothilatha S, Vijayabharathi R, Jayalakshmi S, Kishen A. Diagnosis of vertical root fractures in restored endodontically treated teeth: A time-dependent retrospective cohort study. J Endod 2016;42:1175-80.
Popescu SM, Diaconu OA, Scrieciu M, Marinescu IR, Drăghici EC, Truşcă AG, et al.
Root fractures: Epidemiological, clinical and radiographic aspects. Rom J Morphol Embryol 2017;58:501-6.
AL-Bayata F, Baharudin N, Mahmood N, Hidayat M. Gutta Percha tracing: A reliable technique in diagnosing periodontic-endodontic lesion. J Int Dent Med Res 2018;11:1086-90.
Azarpazhooh A, Dao T, Ungar WJ, Da Costa J, Figueiredo R, Krahn M, et al.
Patients' values related to treatment options for teeth with apical periodontitis. J Endod 2016;42:365-70.
Azarpazhooh A, Dao T, Ungar WJ, Chaudry F, Figueiredo R, Krahn M, et al.
Clinical decision making for a tooth with apical periodontitis: The patients' preferred level of participation. J Endod 2014;40:784-9.
Yasmina O, Collignon AM, Bouter D. Perio-endo lesions: Therapeutic approach. J Oral Implantol Periodontal 2013;32:1-13.
Vishwas JR, Shaikh SY, Tambe VH, Ali FM, Mustafa M. Management of endodontic-periodontic lesion of a maxillary lateral incisor with palatoradicular groove. Saudi Endod J 2014;4:83-6. [Full text]
Alquthami H, Alquthami A, Alghofili A, Alrushoud SS. Healing of an endodontic-periodontal lesion caused by trauma. A case report. Saudi Endod J 2020;10:279-82. [Full text]
Johnson BR. Management of endodontic-periodontic lesions. In: Nares S, editors. Advances in Periodontal Surgery. Switzerland: Springer, Cham; 2020. Available from: https://doi.org/10.1007/978-3-030-12310-9_15
. [Last accessed 2021 Mar 12].
Rosen E, Tsesis I, Nemcovsky CE, Nissan J, editors. Etiology and classification of endodontic-periodontal lesion. In: Endodontic-Periodontal Lesions. Switzerland: Springer, Cham; 2019. Available from: https://doi.org/10.1007/978-3-030-10725-3_2
. [Last accessed 2021 Mar 15].
Sistla KP, Raghava KV, Narayan SJ, Yadalam U, Bose A, Roy PP. Endo-perio continuum: A review from cause to cure. J Adv Clin Res Insights 2018;5:188-91.
Alquthami H, Almalik AM, Alzahrani FF, Badawi L. Successful management of teeth with different types of endodontic-periodontal lesions. Case Rep Dent 2018;2018:7084245.
American Academy of Periodontology. Guideline for periodontal therapy. J Periodontol 2001;72:1-8.
[Table 1], [Table 2], [Table 3], [Table 4]