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References

Singh P. Endo-perio dilemma: a brief review. Dent Res J. 2011; 8:39-47
Philipsen HP, Reichart PA. Calcifying epithelial odontogenic tumour: biological profile based on 181 cases from the literature. Oral Oncol. 2000; 36:17-26
Simring M, Goldberg M. The pulpal pocket approach: retrograde periodontitis. J Periodontol. 1964; 35:22-48
Rotstein I, Simon JH. Diagnosis, prognosis and decision-making in the treatment of combined periodontal-endodontic lesions. Periodontology 2000. 2004; 34:165-203
Simon JH, Glick DH, Frank AL. The relationship of endodontic-periodontic lesions. J Periodontol. 1972; 43:202-208

An unusual presentation of a periodontal-endodontic lesion

From Volume 46, Issue 8, September 2019 | Pages 738-740

Authors

Olivia Johnson King

BSc(Hons), BDS(Hons), MFDS RCS(Edin)

Dental Core Trainee in Oral Surgery

Articles by Olivia Johnson King

Email Olivia Johnson King

Clare Steel

BDS (Manc), MFDS RCS (Edin), M Oral Surg RCS (Eng), PGCert MedEd (Newc)

Specialty Registrar in Oral Surgery, Eastman Dental Hospital, 256 Gray's Inn Road, London WC1X 8LD

Articles by Clare Steel

Abstract

Periodontal-endodontic (perio-endo) lesions involve pulpal and periodontal disease in the same tooth and are seen routinely by dental practitioners. An unusual presentation of a perio-endo lesion in the lower left mandible is demonstrated. It caused significant buccal expansion and perforation of the lingual plate, and was provisionally diagnosed as a malignancy.

CPD/Clinical Relevance: This case has highlighted the need for clinicians to be aware of the unusual way that periodontal-endodontic lesions may present both clinically and radiographically.

Article

Periodontal-endodontic (perio-endo) lesions involve the association of pulpal and periodontal disease within the same tooth. These lesions can cause a diagnostic dilemma for clinicians and it is important for the correct diagnosis to be made to ensure appropriate treatment is carried out. Aetiological factors include bacteria, viruses and fungi. Other factors, including trauma, root resorption, perforations and dental malformations, can play a role in the progression of perio-endo lesions.1

Malignancy of the oral cavity can present as ulceration or a raised lesion with or without induration, non-healing sockets, loose teeth, swelling, pain/numbness and lymphadenopathy, amongst many other symptoms.

The case of an unusual predicted malignancy, confirmed as a perio-endo lesion associated with lower left first and second molars, is demonstrated. The case highlights the need for practitioners to be aware of atypical appearances of such lesions.

Case report

A 77-year-old man was referred to the oral surgery department regarding an unusual peri-radicular lesion associated with the lower left first and second molars. There was no pain associated with the lower left quadrant but he was aware of a swelling in this region with altered sensation. On clinical examination, the lower left first molar was grade I mobile and the lower left second molar was grade II mobile. Buccal and lingual expansion was noted on palpation.

An orthopantogram (OPG) and cone beam computed tomograph (CBCT) were taken. Radiographic imaging (Figure 1) showed a large apical radiolucency with multiple radio-opacities in the region of the lower left first and second molars. There was extensive resorption of the distal root of the lower left first molar and mesial root of the lower left second molar. The lesion had also caused perforation of the lingual plate and significant buccal expansion as indicated in the CBCT (Figures 2 and 3). The inferior alveolar nerve canal was within the radiolucent lesion.

Figure 1. Orthopantogram showing a radiolucent lesion in the left mandible associated with the lower left first and second molars. There are radio-opaque islands evident within the lesion.
Figure 2. Sagittal view of CBCT left mandible demonstrating resorption of the mesial root of the lower left second molar and distal root of the lower left first molar.
Figure 3. Axial view of CBCT left mandible demonstrating perforation of the lingual plate.

The provisional diagnoses for a lesion of this clinical and radiographic appearance were:

  • Calcifying epithelial odontogenic tumour (CEOT) – this is a rare benign tumour and represents approximately 1–2% of all odontogenic tumours.2 It usually presents in the premolar or molar region of the mandible and can cause expansion of surrounding bone. In the early stages, these lesions are radiolucent but, as they develop, multiple radio-opacities become evident within the lesion.
  • Malignant neoplasm – malignant tumours of mandibular bone are rare and their radiolucency and radiodensity can vary, depending on the degree of destruction. These tumours can cause resorption of teeth and destruction of buccal and lingual cortical plates.

    • Perforation of the lingual plate can sometimes be an indication of malignancy. Owing to the suspected malignant nature, an urgent biopsy was requested.

    With regards to treatment, the decision was made to section the bridge distal to the lower left canine and extract the lower left first and second molars. The lesion apical to the lower left first and second molars underwent curettage and was sent for histo-pathological analysis. During the procedure, this area bled extensively (Figures 4 and 5). The histo-pathological analysis results revealed the following:

  • Lower left first molar region – features are those of necrotic cellular debris and inflamed periodontal mucosa, in keeping with an endo-periodontal disease process.
  • Lower left second molar region – features are those of inflamed mucosa and epithelial downgrowth, in keeping with an endo-periodontal disease process.
    • Figure 4. Immediate post-operative view of the lower left first molar after extraction. There is evidence of patchy resorption on the mesial root surface.
    Figure 5. Immediate post-operative view of the lower left first molar. There were hard deposits firmly attached to the distal root surface.

    The histo-pathologist was asked to re-analyse the hard deposits on the distal root of the lower left first molar. It was hypothesized that these could be subgingival calculus deposits that had developed over an extended time. Following further analysis, the histo-pathologist explained that these deposits showed dense necrotic matter.

    Discussion

    Simring and Goldberg first discovered the association between the pulp and periodontium in 1964.3

    There are three routes that have been linked in the development and progression of perio-endo lesions:4

  • Dentinal tubules;
  • Lateral and accessory canals;
  • Apical foramen.

    • The above pathways are anatomical methods for spread of bacteria between the pulp and periodontal tissues. There are many ways in which perio-endo lesions can be classified. One of the most widely used classifications was described by Simon, Glick and Frank, which is summarized in Table 1.5


    Primary Endodontic An inflammatory process in the root canal system results in inflammation of the periodontal tissues.
    Primary Endodontic with Secondary Periodontal Involvement Occurs when dental plaque forms in a sinus tract causing progression of periodontitis.
    Primary Periodontal An accumulation of plaque and bacteria on the external root surface causing an inflammatory process in the pulpal tissues. The pulp is usually vital.
    Primary Periodontal with Secondary Endodontic Involvement Occurs when periodontal disease causes simultaneous pulpal necrosis as the disease progresses apically.
    True Combined Periodontal and endodontic lesions develop independently and simultaneously meeting at a point along the root surface.

    To the authors' knowledge, there are no reported cases of perio-endo lesions presenting in this manner. This case has highlighted the need for clinicians to be aware of the unusual way these lesions may present on a radiograph.

    In this case, there was root resorption and deposition of calcified material on the root surfaces. The authors are aware that the pathogenesis of the perio-endo lesions can cause resorption of the outer layer of cementum and believe the root resorption that occurred in this case was infective in nature and likely contributed to the development and progression of the perio-endo lesion.

    Periapical lesions have the ability to perforate cortical bone and cause swelling of the overlying mucosa. In this case, there was extensive buccal expansion and perforation of the lingual plate. It was hypothesized that the persistent presence of pathology in the region caused buccal and lingual expansion and perforation over time. The patient was reviewed at four weeks after the dental extractions and curettage of underlying bone. The surgical site was found to be healing normally with no signs of infection (Figure 6). This patient will be kept under regular review in the department.

    Figure 6. Post-operative orthopantogram taken 4 weeks following extraction of the lower left first and second molars and curettage of underlying bone.