ABSTRACT
Background:
Endo-perio lesions are challenging to manage in diabetic patients due to impaired healing and infection risk. This study compared long-term outcomes of nonsurgical and surgical treatments for these lesions.
Methods:
We analyzed 187 diabetic patients with endo-perio lesions. 92 received nonsurgical treatment (root canal treatment ± scaling and root planing) and 95 underwent surgery (apicoectomy ± guided tissue regeneration). The primary outcome was tooth retention (Kaplan–Meier analysis). Secondary outcomes included lesion resolution, probing depth reduction, clinical attachment level gain, and patient-reported pain/discomfort.
Results:
At 10 years, tooth retention was 82% (nonsurgical) and 75% (surgical) (P = 0.32). Both groups improved significantly (P < 0.05), but surgery yielded greater probing depth reduction and clinical attachment gain (P < 0.01). Surgical patients initially reported more discomfort, but pain levels were similar at 6 and 12 months.
Conclusions:
Both approaches showed comparable long-term tooth retention. Surgical treatment enhanced periodontal healing but caused more initial discomfort.
KEYWORDS: Diabetes mellitus, endo-perio lesion, nonsurgical treatment, surgical treatment, tooth retention
INTRODUCTION
Endo-perio lesions, a complex interplay of pulpal and periodontal disease,[1,2] are particularly challenging in diabetic patients.[3] Diabetes compromises healing, immune response, and increases infection susceptibility,[4] impacting lesion prognosis.[5,6] Impaired vascularity and leukocyte function hinder tissue repair and infection control,[7] while the higher prevalence of periodontal disease in diabetics further complicates matters.[8,9] This necessitates a comprehensive approach to treatment planning.[10]
Nonsurgical management typically involves root canal treatment and scaling/root planing, aiming for conservative healing. Surgical intervention, including apicoectomy and guided tissue regeneration, addresses residual infection and promotes periodontal regeneration.
Although research exists on treating endo-perio lesions, long-term data specific to diabetic patients is limited. This study compared long-term outcomes of nonsurgical versus surgical treatments, focusing on tooth retention, to inform treatment planning for this population.
MATERIALS AND METHODS
This retrospective cohort study analyzed records of diabetic patients (type 1 or 2) with endo-perio lesions from [June 2014] to [Dec 2014]. Inclusion criteria were: confirmed diabetes diagnosis, radiographic/clinical evidence of endo-perio lesions, and minimum 10-year follow-up. Patients with recent periodontal/endodontic treatment, systemic conditions (other than diabetes) affecting periodontal health, or incomplete records were excluded.
Treatment groups
Non-surgical: Root canal treatment ± scaling and root planing.
Surgical: Apicoectomy ± guided tissue regeneration.
Outcome measures
Primary: Tooth retention at 10 years.
Secondary: Lesion resolution (radiographic), probing depth reduction, clinical attachment level gain, and patient-reported pain/discomfort (VAS) at baseline, six, and 12 months.
Data were analyzed using IBM SPSS, V. 25. Descriptive statistics summarized patient characteristics. Kaplan–Meier analysis compared tooth retention. Independent t-tests, Mann–Whitney U tests, and Chi-square tests compared variables, with P < 0.05 considered significant.
RESULTS
187 patients (mean age 54.2 ± 12.8 years) were included (92 nonsurgical, 95 surgical). Baseline characteristics are shown in Table 1.
Table 1.
Baseline characteristics
| Nonsurgical | Surgical | P | |
|---|---|---|---|
| Age (years) | 53.8±13.2 | 54.6±12.5 | 0.65 |
| Gender (M/F) | 48/44 | 52/43 | 0.71 |
| Diabetes Type (1/2) | 12/80 | 15/80 | 0.58 |
| HbA1c (%) | 7.8±1.5 | 7.9±1.4 | 0.72 |
| Smoking (Y/N) | 22/70 | 25/70 | 0.63 |
10-year tooth retention was 82% (nonsurgical) and 75% (surgical) (P = 0.32).
Table 2 shows secondary outcomes. Both groups improved significantly (P < 0.05), but surgery showed greater PD reduction and CAL gain (P < 0.01).
Table 2.
Secondary outcomes at 10 years
| Outcome | Non-surgical | Surgical | P |
|---|---|---|---|
| Lesion Resolution (%) | 88% | 92% | 0.38 |
| PD Reduction (mm) | 3.1±1.5 | 4.2±1.8 | <0.01 |
| CAL Gain (mm) | 2.9±1.3 | 3.8±1.6 | <0.01 |
Table 3 shows patient-reported outcomes. Surgical patients had higher initial discomfort (P < 0.01), but pain was similar at 6 and 12 months.
Table 3.
Patient-reported outcomes (VAS)
| Time | Nonsurgical | Surgical | P |
|---|---|---|---|
| Baseline | 3.2±1.8 | 4.8±2.1 | <0.01 |
| 6 Months | 1.5±1.2 | 1.8±1.4 | 0.25 |
| 12 Months | 0.8±0.9 | 1.1±1.0 | 0.18 |
DISCUSSION
This study found comparable long-term tooth retention with both non-surgical and surgical treatments for endo-perio lesions in diabetic patients. The high retention rates (82% and 75%) suggest that both approaches are viable with proper case selection and execution. This aligns with Kim et al. (2015),[1] who reported similar findings in a general population, indicating diabetes might not significantly alter the long-term prognosis with appropriate treatment.
Our study’s strengths include the large sample size, well-defined criteria, and long follow-up. However, limitations include its retrospective nature and lack of standardized treatment protocols. Unexpectedly, surgical treatment resulted in significantly better periodontal healing (Probing depth [PD] reduction and Clinical attachment level [CAL] gain), potentially due to better access and the use of guided tissue regeneration.
The objective of this research was to evaluate and analyze the long-term results of dental implants and how diabetic patients may compare in terms of quality of life and tooth structure. Our findings support surgery for periodontal healing in combination with tooth retention. This is an important contribution to the existing long-term data concerning the diabetic population, for which there is a lack of such data.
These results are preliminary, and further studies on the control of diabetes during the treatment period and on various surgical methods are warranted. Such analysis, together with cost-effectiveness and patient preferences, will make it possible to elucidate meaningful outcomes for this particular group of patients.
CONCLUSION
Both non-surgical and surgical approaches showed comparable long-term tooth retention in managing endo-perio lesions in diabetic patients. Surgical treatment resulted in superior periodontal healing but with greater initial discomfort. Treatment choice should be individualized based on patient factors, lesion characteristics, and clinician expertise.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
REFERENCES
- 1.Adam M. ‘Combined endo-perio lesions’ - What is the best treatment? Evid Based Dent. 2021;22:158–159. doi: 10.1038/s41432-021-0230-y. doi: 10.1038/s41432-021-0230-y. Erratum in: Evid Based Dent 2022;23:5. doi: 10.1038/s41432-022-0234-2. [DOI] [PubMed] [Google Scholar]
- 2.Jivoinovici R, Suciu I, Dimitriu B, Perlea P, Bartok R, Malita M, Ionescu C. Endo-periodontal lesion--endodontic approach. J Med Life. 2014;7:542–4. Erratum in: J Med Life 2014;7:627. [PMC free article] [PubMed] [Google Scholar]
- 3.Grudianov AI, Makeeva MK, Piatgorskaia NV. [Modern concepts of etiology, pathogenesis and treatment approaches to endo-perio lesions. Vestn Ross Akad Med Nauk. 2013:34–6. [PubMed] [Google Scholar]
- 4.Alshawwa H, Wang JF, Liu M, Sun SF. Successful management of a tooth with endodontic-periodontal lesion:A case report. World J Clin Cases. 2020;8:5049–6. doi: 10.12998/wjcc.v8.i20.5049. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Tewari S, Sharma G, Tewari S, Mittal S, Bansal S. Effect of immediate periodontal surgical treatment on periodontal healing in combined endodontic-periodontal lesions with communication-A randomized clinical trial. J Oral Biol Craniofac Res. 2018;8:105–12. doi: 10.1016/j.jobcr.2018.04.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Adcock JE, Bright D. Surgical intervention of complex endo-perio lesions. Tex Dent J. 2007;124:736–43. [PubMed] [Google Scholar]
- 7.Sharma R, Hegde V, Siddharth M, Hegde R, Manchanda G, Agarwal P. Endodontic-periodontal microsurgery for combined endodontic-periodontal lesions:An overview. J Conserv Dent. 2014;17:510–6. doi: 10.4103/0972-0707.144571. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Khojaste M, Navabi S, Shiezadeh F. Treatment of a hopeless tooth with combined endodontic-periodontal lesion using guided tissue regeneration:A case report with one year follow-up. Iran Endod J. 2022;17:212–5. doi: 10.22037/iej.v17i4.38667. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Nagaveni NB, Kumari KN, Poornima P, Reddy V. Management of an endo-perio lesion in an immature tooth using autologous platelet-rich fibrin:A case report. J Indian Soc Pedod Prev Dent. 2015;33:69–73. doi: 10.4103/0970-4388.149013. [DOI] [PubMed] [Google Scholar]
- 10.Fajrianti H, Karimah F, Dewi SK, Ratih DN, Devitaningtyas N, Karina VM, et al. Regenerative Surgical Management of an Endodontic Periodontic Lesion of the Mandibular Molar Combined With External Inflammation Root Resorption. Case Rep Dent. 2024;2024:1048933. doi: 10.1155/2024/1048933. [DOI] [PMC free article] [PubMed] [Google Scholar]