Journal of Conservative Dentistry
Home About us Editorial Board Instructions Submission Subscribe Advertise Contact e-Alerts Login 
Users Online: 686
Print this page  Email this page Bookmark this page Small font sizeDefault font sizeIncrease font size

Table of Contents   
Year : 2018  |  Volume : 21  |  Issue : 4  |  Page : 413-418
The effect of endodontic treatment using different intracanal medicaments on periodontal attachment level in concurrent endodontic-periodontal lesions: A randomized controlled trial

1 Senior Consultant Endodontist, HS Dental Institute Private Limited, Gurgaon, India
2 Department of Conservative Dentistry and Endodontics, Postgraduate Institute of Dental Sciences, Rohtak, Haryana, India
3 Department of Periodontics, Postgraduate Institute of Dental Sciences, Rohtak, Haryana, India

Click here for correspondence address and email

Date of Submission07-Dec-2017
Date of Decision15-Jan-2018
Date of Acceptance21-May-2018
Date of Web Publication27-Jul-2018


Aim: The aim of this study is to evaluate the effect of different intracanal medicaments used during endodontic treatment on periodontal attachment level in concurrent endodontic-periodontal lesions without communication.
Materials and Methods: Seventy-five teeth with combined endodontic-periodontal lesions were randomly assigned to 3 groups: Test Group I (calcium hydroxide [Ca(OH)2]), Test Group II (2% chlorhexidine + Ca(OH)2), and control group (no intracanal medicament). Root canal treatment (RCT) was performed using standard methodology. Teeth of test groups were medicated with respective medicaments for 10 days before obturation. Scaling and root planning was done 1 month after completion of RCT in all the groups. Clinical measurements, including probing depth (PD), clinical attachment level (CAL), and bleeding on probing (BOP) were recorded at baseline, 1, 3, and 6 months. Radiographic parameters, including periapical index (PAI) score and alveolar bone level, were measured at baseline and 6 months.
Statistical Analysis: Data were analyzed using Friedman test, Kruskal–Wallis, and Wilcoxon signed-rank test.
Results: Significant improvement in PD, CAL, %BOP, and PAI score (P < 0.05) was found in all the three groups from baseline to 6 months. However, there was no significant intergroup difference. No significant difference was observed from baseline to 6 months in marginal bone level within the three groups.
Conclusion: Endodontic treatment before periodontal therapy results in attachment gain. Intracanal medicaments may not affect the healing of concurrent endodontic-periodontal lesions without communication.

Keywords: Calcium hydroxide; chlorhexidine; clinical attachment level; endodontic-periodontal lesions

How to cite this article:
Bansal S, Tewari S, Tewari S, Sangwan P. The effect of endodontic treatment using different intracanal medicaments on periodontal attachment level in concurrent endodontic-periodontal lesions: A randomized controlled trial. J Conserv Dent 2018;21:413-8

How to cite this URL:
Bansal S, Tewari S, Tewari S, Sangwan P. The effect of endodontic treatment using different intracanal medicaments on periodontal attachment level in concurrent endodontic-periodontal lesions: A randomized controlled trial. J Conserv Dent [serial online] 2018 [cited 2022 May 25];21:413-8. Available from:

   Introduction Top

Endodontic-periodontal lesions usually present many diagnostic as well as management challenges to clinicians. Concurrent endodontic-periodontal diseases, which do not merge, apply to teeth, in which periapical and periodontal lesions are separate.[1] Teeth with such lesions have an infected pulp space coupled with apical periodontitis and marginal periodontitis with pocket formation. These relatively uncommon lesions have been scarcely reported in literature with no incidence data.

The contribution made by endodontic and periodontal component in concurrent endodontic-periodontal lesions is not always clear, and the completion of endodontic treatment before periodontal therapy in such lesions has been advocated to accelerate rapid healing of endodontic infection.[2] This treatment protocol is largely based on some review articles,[1],[2],[3] few case reports [4],[5] and clinical trials.[6]

As the root tissues are in close approximation to the periodontal structures, root canal space could serve as a reservoir for the therapeutic release of intracanal medicaments to the root dentinal tissue as well as external surface.[7],[8] The ability of hydroxyl ions to diffuse through exposed dentinal tubules and raise the pH at the external root surface following intracanal Ca(OH)2 medication has been demonstrated in in vitro studies.[9],[10] Intracanal placement of Ca(OH)2 medicament showed improvement in clinical periodontal parameters after performing endodontic treatment in concurrent endodontic-periodontal lesions.[4],[5] During the last few years, chlorhexidine (CHX) has received much attention as a potential root canal irrigant and intracanal medicament. Although the use of combined Ca(OH)2 and CHX as an intracanal medicament is not tested in well-controlled clinical trials, preliminary research suggests that this might serve as a rational combination with antimicrobial activity equal or somewhat superior to either of the ingredients used alone.[11],[12],[13],[14],[15]

Although few retrospective studies have observed positive correlation between endodontic infection and chronic periodontitis,[16],[17] only one prospective cohort study has so far demonstrated the effect of endodontic treatment using calcium hydroxide (Ca[OH]2) as intracanal medicament on the periodontal healing in concurrent endodontic-periodontal lesions.[6] Till date, no randomized controlled trial has evaluated the effect of intracanal medicaments on the healing of concurrent endodontic-periodontal lesions.

The purpose of the present randomized controlled clinical trial was, therefore, to evaluate the influence of different intracanal medicaments used during endodontic treatment on the periodontal attachment level in concurrent endodontic-periodontal lesions.

   Materials and Methods Top

Study population and experimental design

The present study was conducted as a randomized controlled, parallel-design, double-blind clinical trial. The review board of institution approved the study plan and it was conducted in accordance with the principles outlined in the Helsinki's Declaration on experimentation involving human subjects. Written informed consent was obtained from all patients.

Seventy-five teeth in 75 patients (37 males and 38 females) aged 28–65 years, meeting inclusion criteria were treated at the Department of Conservative Dentistry and Endodontics. Eligibility criteria included a negative response to vitality tests with radiographic evidence of periapical radiolucency and probing depth ≥5 mm coupled with generalized chronic periodontitis.

Patients who were having root-filled tooth, unrestorable tooth, perforated/fractured roots, history of periodontal therapy with in previous 6 months, inflammatory root resorption, Grade 3 mobile teeth, serious medical illness, requirement for antibiotic prophylaxis before dental care, and concurrent endodontic-periodontal lesion with communication were excluded from this study.

Sample size calculation

The sample size was determined with 80% power and a 5% level of statistical significance using the basic formula: M = 2 × [z(1−α/2)+ z(1−β)]2/Δ2. The sample size calculation determined that 16 patients per treatment arm would provide 80% power to detect a true difference of 1.0 mm between test and control using probing depth (PD) reduction in pockets >5 mm as the primary outcome variable, assuming that the common standard deviation is 1.0 mm. Accordingly, a sample of 25 patients per arm (75 in total) were to be recruited to compensate for possible dropout during the study period.

After baseline measurements, supragingival scaling with ultrasonic scaler was done and oral hygiene instructions were provided. Root canal treatment (RCT) was carried out by an endodontist following a standardized treatment protocol. Canals were enlarged three times larger than the initial binding file followed by step back and irrigated with 10 ml NaOCl (1%) using a 30-gauge NaviTip FX (Ultradent Products Inc, South Jordan, UT, USA). Smear layer was removed by irrigating with 5.0 mL 17% EDTA (Roth International Ltd, Chicago, IL, USA) for 1 min followed by 5.0 mL 1% NaOCl, and the final irrigant being 5 ml of distilled water. Canals were then thoroughly dried with paper points. Following this protocol, all the teeth were randomly allocated to the following three groups:

  • Test Group I – Ca(OH)2 paste (Pulpdent TempCanal, Pulpdent Corporation, Watertown, USA)
  • Test Group II – Paste made by mixing Ca(OH)2 powder (Roth International Ltd, Chicago, IL, USA) and 2% CHX liquid (Balas Dental Products, Chicago, IL, USA)
  • Control Group – No intracanal medicament.


A graduate student who was unaware of the study protocol made the envelopes having the name of the intracanal medicaments. The endodontist performing the RCT picked a sealed envelope from a pack after biomechanical preparation to determine which intracanal dressing to use. Finally, 25 teeth were allocated to each treatment group.

The intracanal medications were applied with lentulo spiral and access cavities were temporarily sealed with a minimum of 4 mm of IRM (Dentsply Caulk, Milford, DE, USA). After 10 days, intracanal medicament was removed and root canals were obturated by lateral compaction technique. If there were persisting deepest pocket depths ≥5 mm after 1 month, subgingival scaling and root planing under local anesthesia were performed.

Evaluation parameters

Baseline parameters were recorded before the initiation of endodontic treatment by another investigator (periodontist) (ST). Clinical attachment level (CAL), probing depth (PD), and bleeding on probing (BOP) were noted at 6 sites per tooth (mesiobuccal, midbuccal, distobuccal, mesiolingual, mid-lingual and distolingual sites of the tooth) using a calibrated 15 -mm periodontal probe (PCPUNC, HuFriedy, Chicago, IL, USA).

The periapical status was assessed using the periapical index (PAI) score [18] and the level of alveolar bone at the proximal root surface was measured with the ImageJ ® software (1.34 s; US National Institutes of Health, Bethesda, MD, USA). Using the software, a parallel straight line to the root surface was drawn over the digital image to measure the distance between cementoenamel junction and the most coronal bone level, at which the width of the periodontal ligament space was considered normal at both mesial and distal surfaces of the tooth. Alveolar bone level and the PAI score were assessed at baseline and at 6-month follow-up.

Follow-up schedule

Periodontal parameters were recorded at 1, 3, and 6 months after endodontic intervention (1 month after completion of endodontic treatment and supragingival scaling; 2 months after completion of scaling and root planning (SRP); and 5 months after SRP, respectively).

Statistical analysis

Intragroup analysis was done by applying Friedman test and Wilcoxon signed-rank test. Kruskal–Wallis test was done to determine intergroup differences.

   Results Top

A total of 75 teeth were included in the study (40 incisors and 35 molars). Recall rate was 95% at 1 month, 84% at 3 months, and 76% at 6 months [Figure 1]. Demographic characteristics for each treatment group are listed in [Table 1].
Figure 1: Consolidated standards of reporting trials flow chart

Click here to view
Table 1: Demographic characteristics and evaluation of radiographic assessment of marginal bone level and periapical index score of each group

Click here to view

Of the measurements taken at 6 aspects of each involved tooth, the maximum measurement recorded for PD and CAL was included for statistical analysis. Friedman test revealed statistically significant PD reduction, CAL gain, and reduction in % BOP within the three groups from baseline to 1, 3, and 6 months (P< 0.001) [Table 2]. No significant difference was observed from baseline to 6 months in marginal bone level within the three groups (P > 0.05) [Table 1]. Kruskal–Wallis test revealed no statistically significant difference among Control, Ca(OH)2, and 2% CHX+Ca(OH)2 groups in terms of mean PD reduction (P = 0.146), mean CAL gain (P = 0.435), and mean % BOP (P = 0.352) at 1 month, at 3-month (PD: P = 0.146, CAL: P = 0.3, %BOP: P = 0.933) as well as at 6-month time interval (PD: P = 0.714, CAL: P = 0.689, %BOP: P = 0.935) [Table 2] and in marginal bone level either at baseline or at 6-month period (mesial, P = 0.751; distal, P = 0.714) [Table 1].
Table 2: Comparison of periodontal parameters mean±standard deviation of control, calcium hydroxide, and 2% chlorhexidine + calcium hydroxide group at baseline, 1, 3, and 6 months

Click here to view

All the three groups exhibited a statistically significant decrease in PAI score between the baseline examination and 6-month evaluation (group I: P = 0.001, group II: P = 0.002, group III: P = 0.001). There was no statistically significant difference between groups at either the baseline examination (P = 0.823) or at 6-month (P = 0.659) [Table 1]. No adverse effects were observed clinically in the three groups during the entire course of the study.

   Discussion Top

Management of concomitant endodontic-periodontal lesion requires both endodontic treatment and periodontal therapy. Completion of endodontic treatment before periodontal intervention has been advocated since the presence of bacteria in the root canal system may affect the outcome of the periodontal treatment and to allow healing of pocket due to the endodontic component.[1],[2],[3],[4],[5],[6]

This study evaluated the periodontal healing following RCT in concurrent endodontic-periodontal lesions using Ca(OH)2 and 2% CHX+Ca(OH)2 paste as intracanal medicament, in comparison with the control group (without medicament) and observed statistically significant reduction in pocket depth and bleeding sites with gain in attachment level in all the groups up to 6-month of follow-ups. These results are in accordance with the study conducted by Vakalis et al.[6] which showed improved clinical periodontal parameters and gain in alveolar bone level in a majority of cases after performing RCT before periodontal treatment in endodontic-periodontal lesions. RCT removes infection in pulp space and prevents the remaining microbial irritants from entering periodontal space by sealing channels of communication between the pulp space and periodontal tissues. As cases selected for the study had necrotic tooth with periapical pathology, keeping a periodontal control group without performing endodontic treatment would be against the ethics of standard patient care. Therefore, periodontal control group was not included in our study.

Recently, antibacterial efficacy of different intracanal medicaments has been reported on the external root surface. Gomes et al.[7] observed that 2% CHX showed the maximum zone of inhibition against Porphyromonas gingivalis, Enterococcus faecalis, Actinomyces viscosus, and Candida albicans followed by a combination of Ca(OH)2 and CHX and the least with Ca(OH)2 alone. Silva et al.[8] found that Ca(OH)2 and saline solution did not show bacterial growth inhibition, whereas CHX and tetracycline depicted zones of inhibition in 70% and 40% of specimens, respectively. Raheja et al.[19] have documented that CHX may be used as an effective intracanal medicament for promoting periodontal healing in concomitant endodontic-periodontal lesions after surgical periodontal therapy.

Similar periodontal healing in the medicament and nonmedicament group in our study could be attributed to thorough cleaning and shaping and good obturation and proper periodontal debridement. It seems that no additional benefit is attained with the use of intracanal medicament and once an optimum reduction in intracanal bacteria is achieved following RCT, healing gets expedited. The nonsignificant effect of intracanal medicaments on periodontal healing in the present clinical trial could also be attributed to minimal or no passage of Ca(OH)2/Ca(OH)2+CHX to external root surface. While many replantation studies have reported a beneficial effect of Ca(OH)2 on external root resorption, these studies were performed on extracted teeth and pH was measured after preparation of cavities on external root surface.[20],[21],[22],[23]

Duration of Ca(OH)2 intracanal dressing varies from 1 to 3 weeks. Gomes et al.[7] and Silva et al.[8] Used intracanal medicament for 2 days and 2 h in their in vitro studies, respectively. Saif et al.[24] recorded that the pH on external root surface following intracanal Ca(OH)2 dropped from 8.5 to 7 within 7 days with maximum pH remaining up to 3 days. However, further studies are required to evaluate periodontal healing after long-term intracanal Ca(OH)2 medication. Incorporation of different commonly applied intracanal medicaments in long-term studies may help in better understanding of their effects on periodontal healing. It would also be interesting to observe the effect of intracanal medications on periodontal attachment gain after surgical periodontal therapy.

   Conclusion Top

Within the limits of this study, we can conclude that treatment of endodontic-periodontal lesions by performing endodontic treatment before periodontal therapy results in significant improvement in the periodontal parameters. However, short-term Ca(OH)2 and 2% CHX+Ca(OH)2 paste intracanal medicament therapy may not have a significant effect on the periodontal healing.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Abbott PV, Salgado JC. Strategies for the endodontic management of concurrent endodontic and periodontal diseases. Aust Dent J 2009;54 Suppl 1:S70-85.  Back to cited text no. 1
Zehnder M, Gold SI, Hasselgren G. Pathologic interactions in pulpal and periodontal tissues. J Clin Periodontol 2002;29:663-71.  Back to cited text no. 2
Sunitha V R, Emmadi P, Namasivayam A, Thyegarajan R, Rajaraman V. The periodontal – Endodontic continuum: A review. J Conserv Dent 2008;11:54-62.  Back to cited text no. 3
Walter C, Krastl G, Weiger R. Step-wise treatment of two periodontal-endodontic lesions in a heavy smoker. Int Endod J 2008;41:1015-23.  Back to cited text no. 4
Abbott P. Endodontic management of combined endodontic-periodontal lesions. J N Z Soc Periodontol 1998;83:15-28.  Back to cited text no. 5
Vakalis SV, Whitworth JM, Ellwood RP, Preshaw PM. A pilot study of treatment of periodontal-endodontic lesions. Int Dent J 2005;55:313-8.  Back to cited text no. 6
Gomes BP, Montagner F, Berber VB, Zaia AA, Ferraz CC, de Almeida JF, et al. Antimicrobial action of intracanal medicaments on the external root surface. J Dent 2009;37:76-81.  Back to cited text no. 7
Silva MR, Chambrone L, Bombana AC, Lima LA. Early antimicrobial activity of intracanal medications on the external root surface of periodontally compromised teeth. Quintessence Int 2010;41:427-31.  Back to cited text no. 8
Tronstad L, Andreasen JO, Hasselgren G, Kristerson L, Riis I. PH changes in dental tissues after root canal filling with calcium hydroxide. J Endod 1981;7:17-21.  Back to cited text no. 9
Nerwich A, Figdor D, Messer HH. PH changes in root dentin over a 4-week period following root canal dressing with calcium hydroxide. J Endod 1993;19:302-6.  Back to cited text no. 10
Siqueira JF Jr., Paiva SS, Rôças IN. Reduction in the cultivable bacterial populations in infected root canals by a chlorhexidine-based antimicrobial protocol. J Endod 2007;33:541-7.  Back to cited text no. 11
Gomes BP, Vianna ME, Sena NT, Zaia AA, Ferraz CC, de Souza Filho FJ, et al. In vitro evaluation of the antimicrobial activity of calcium hydroxide combined with chlorhexidine gel used as intracanal medicament. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:544-50.  Back to cited text no. 12
Patil S, Dodwad PK, Patil AC, Singh B. Evaluation of antimicrobial efficacy of calcium hydroxide paste, chlorhexidine gel, and a combination of both as intracanal medicament: An in vivo comparative study. J Conserv Dent 2013;16:65-70.  Back to cited text no. 13
[PUBMED]  [Full text]  
Vaghela DJ, Kandaswamy D, Venkateshbabu N, Jamini N, Ganesh A. Disinfection of dentinal tubules with two different formulations of calcium hydroxide as compared to 2% chlorhexidine: As intracanal medicaments against Enterococcus faecalis and Candida albicans: An in vitro study. J Conserv Dent 2011;14:182-6.  Back to cited text no. 14
[PUBMED]  [Full text]  
Eswar K, Venkateshbabu N, Rajeswari K, Kandaswamy D. Dentinal tubule disinfection with 2% chlorhexidine, garlic extract, and calcium hydroxide against Enterococcus faecalis by using real-time polymerase chain reaction:In vitro study. J Conserv Dent 2013;16:194-8.  Back to cited text no. 15
[PUBMED]  [Full text]  
Jansson LE, Ehnevid H, Lindskog SF, Blomlöf LB. Radiographic attachment in periodontitis-prone teeth with endodontic infection. J Periodontol 1993;64:947-53.  Back to cited text no. 16
Ehnevid H, Jansson LE, Lindskog SF, Blomlöf LB. Periodontal healing in relation to radiographic attachment and endodontic infection. J Periodontol 1993;64:1199-204.  Back to cited text no. 17
Orstavik D, Kerekes K, Eriksen HM. The periapical index: A scoring system for radiographic assessment of apical periodontitis. Endod Dent Traumatol 1986;2:20-34.  Back to cited text no. 18
Raheja J, Tewari S, Tewari S, Duhan J. Evaluation of efficacy of chlorhexidine intracanal medicament on the periodontal healing of concomitant endodontic-periodontal lesions without communication: An interventional study. J Periodontol 2014;85:1019-26.  Back to cited text no. 19
Esberard RM, Carnes DL Jr., Del Rio CE. PH changes at the surface of root dentin when using root canal sealers containing calcium hydroxide. J Endod 1996;22:399-401.  Back to cited text no. 20
Miñana M, Carnes DL Jr., Walker WA 3rd. PH changes at the surface of root dentin after intracanal dressing with calcium oxide and calcium hydroxide. J Endod 2001;27:43-5.  Back to cited text no. 21
Chamberlain TM, Kirkpatrick TC, Rutledge RE. PH changes in external root surface cavities after calcium hydroxide is placed at 1, 3 and 5 mm short of the radiographic apex. Dent Traumatol 2009;25:470-4.  Back to cited text no. 22
Heward S, Sedgley CM. Effects of intracanal mineral trioxide aggregate and calcium hydroxide during four weeks on pH changes in simulated root surface resorption defects: An in vitro study using matched pairs of human teeth. J Endod 2011;37:40-4.  Back to cited text no. 23
Saif S, Carey CM, Tordik PA, McClanahan SB. Effect of irrigants and cementum injury on diffusion of hydroxyl ions through the dentinal tubules. J Endod 2008;34:50-2.  Back to cited text no. 24

Correspondence Address:
Dr. Shweta Bansal
HS Dental Institute Private Limited, Sector 14, Gurgaon, Haryana
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JCD.JCD_337_17

Rights and Permissions


  [Figure 1]

  [Table 1], [Table 2]

This article has been cited by
1 Efficacy of minimally invasive therapy and laser therapy in the comprehensive treatment of endoperiodontal lesions
Nurgul Zh. Zholdassova, Ainur Amanzholkyzy, Azamat I. Kaikan, Yerik S. Isbulatov, Albina M. Nurtileuova
Polish Annals of Medicine. 2021;
[Pubmed] | [DOI]
2 Healing of endodontic periodontal lesion after non-surgical treatment
E. Hidoussi, H. Sarraj, N. Zokkar, W. Batbout, N. Douki, L. Bhouri
Ceská stomatologie/Praktické zubní lékarství. 2020; 120(2): 50
[Pubmed] | [DOI]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  

    Materials and Me...
    Article Figures
    Article Tables

 Article Access Statistics
    PDF Downloaded234    
    Comments [Add]    
    Cited by others 2    

Recommend this journal