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Endo-Perio Lesions - The Commonest and Least Identified Dental Problems

Published on Apr 09, 2021   -  4 min read

Abstract

Endo-perio lesions are characterized by the presentation of pulpal and periodontal problems in a specific tooth. To know more about its symptoms, types, and treatment options, please read the article.

Contents

Introduction:

Dental problems are often manifested with pain and mobility. These lesions appear majorly in the form of pain only due to pulpal infection, while sometimes there is a combined lesion with pain, mobility, and pus. These problems are difficult to determine since the symptoms appear different in different individuals. All these dental diseases are classified into one category as endo-perio lesions. Microbial infections do play a major role in the progression of these diseases. Individuals are often asymptomatic and may report later after the progressive stage. Even complications can also be there. Hence, every effort must be made to identify these diseases with the best treatment options and excellent results.

Oral diseases are inclined to two main sites:

  1. Endodontium - Endodontium includes the pulp chamber and pulp canals.
  2. Periodontium - Periodontium includes periodontal ligament, cementum, alveolar bone, and gingiva.

The two main dental diseases, caries and periodontitis, affect both these structures. Both endontium and periodontium are interrelated, meaning infection in one can spread and involve another tissue. These diseases affecting independently or in a relative manner are collectively called endo-perio lesions.

What Are the Common Symptoms of Endo-Perio Lesions?

They mostly appear in the form of pain and mobility. Sometimes there is a large amount of bone loss also (most probably vertical). Usually, pus is not found, but concurrent infection can cause a chronic abscess. Microbial infections are also evident with a large amount of occurrence of both facultative gram-negative streptococci and spirochaetes. Also, there can be a progression of viruses and fungi. There can be necrosis also inside the pulp chamber, which can initiate an inflammatory response. The process starts from the periodontal ligament and passes through apical foramen and accessory canals. After that, it results in rapid and widespread destruction of periodontium, which results in infection in the form of either a radiolucent lesion (apex) or may invade the furcations.

How Are Endo-Perio Lesions Classified?

For simplicity, these lesions can be classified into five main categories:

1) Primary Endo (Involving Endodontium only) and secondary perio (Periodontium later).

2) Primary Perio (involving Periodontium only) and secondary Endo (Endodontium later).

3) Only Endodontium involvement with no periodontium involvement.

4) Periodontium only with no Endodontic involvement and last is Inter-relative (Involving both with progression from either side).

5) True Combined lesion where periodontal and endodontic lesions develop independently and join together.

Currently, the term peri-radicular is used for the clinical classification of these diseases. The treatment options also vary according to the involvement of the lesions. The success of treatment strategies in the case of pure endodontic lesions and combined endo-perio lesions depends upon endodontic therapy. However, the healing process depends upon periodontal therapy.

How to Diagnose Endo-Perio Lesions?

Individuals have different symptoms at different stages. The onset and duration of symptoms depend upon the type of progression of the disease. Usually, Endodontic lesions are characterized by severe pain and deep radiolucent lesions. Apical foramen act as nidus (focus of infection) in endodontic infections. These can be accompanied by fractures [at both apical (lowermost portion) and coronal (uppermost portion)] and avulsion (tooth coming out of the socket). An avulsion is characterized by excessive mobility (grade-3) and necrosis (in some cases).

There are chances that bone loss could also be present with alveolar deformity. Periapical abscess (pus in the endodontium) can also be there in pure endodontic lesions. However, since both endodontium and periodontium are inter-connected, dental infections can enter periodontium also. In that case, there can be starting of bone loss and light pain on lateral percussion.

In the case of pure periodontal lesions, there is either periodontal (in association with pocket) or gingival pus (involving gingiva). Gingival pus rarely causes any big periodontal defects, but periodontal pus in the form of chronic lesions can pave the way for large intrabony (within the radius of alveolar bone) or infrabony (below the crest of alveolar bone) defects.

Primary periodontal lesions may also manifest as sudden mobility (grade 2 or 3) or class 3 or 4 gingival recession. Mobile teeth are very difficult to manage because of extreme pain and poor bony support. Class 3 or 4 gingival recession can make tooth root prone to caries causing secondary endodontic lesion. Even furcation can also be involved. Usually, grade 3 and 4 furcations are prone to cause secondary endodontic lesions. These lesions are the root cause of angular (vertical) bone defects and tooth mortality.

What Are the Available Treatment Options for Endo-Perio Lesions?

Treatment options are according to the involvement of lesions.

Primary endodontic lesions are treated by root canal treatment (RCT). Sometimes apicectomy (surgical removal) is done to remove the diseased root in advance cases or in failure of RCT. Fractures and grade 2 and 3 mobility are treated with a combination of splinting and RCT. Splinting reduces the mobilization, and RCT decreases the pain.

In case of bone loss, both allografts and autografts are used. Even ridge augmentation (for treatment of alveolar bone deformities) are accomplished by papilla preservation flaps and autogenous grafts. The purpose of these grafts is to induce osteogenesis (new bone formation) and osteoinduction (induce bone formation). Titanium mesh is also integrated to stimulate the process. Recession (class 3 and 4) is treated with both rotational and autogenous soft tissue grafts. The purpose of these soft tissue grafts is to stop the recession and prevent its recurrence. Both gingival and Periapical abscesses are treated by incision and drainage. But periodontal abscess, in case of chronic formation, may require flap surgery for drainage.

Furcations are treated according to their grades. Grade I and II do not involve endodontium, but grade 3 and 4 requires extensive treatment. Grade 3 is treated with resection (involving removal of diseased root in upper molars), while hemisection (removal of one complete root with a crown portion also) is done in lower molars.

What Are the Possible Complications of Endo-Perio Lesions?

These lesions may have some deleterious effects. Furcation and recession involvement usually leads to extraction of the involved tooth if not treated early, while abscesses can lead to extraction of multiple teeth due to sudden mobility and advanced bone loss in advanced cases. There can be chances of cyst formation also which remained undiagnosed for a long time. So these lesions require special focus.

Conclusion:

Endo-perio lesions are combined lesions having a different appearance in different individuals. They require special attention. Hence, both clinicians and patients should be aware of their complications, and they must be treated in a systemic manner.

 

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Last reviewed at:
09 Apr 2021  -  4 min read

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