Other periodontal conditions

Necrotising periodontitis is characterised by marginal gingival ulceration with loss of the interdental papillae and a grey sloughing on the surface of the ulcers (see figure: Necrotising ulcerative gingivitis). It is distinguished from necrotising gingivitis by the presence of bone loss around affected teeth. It can be accompanied by a characteristic halitosis and is usually painful³⁹ (for more information, see Necrotising gingivitis and periodontitis). 

Necrotising ulcerative gingivitis

Image shows the right buccal view of a patient with necrotising ulcerative gingivitis illustrating blunting of the interdental papillae and sloughing of the gingival tissues.

Periodontitis as a direct manifestation of systemic disease encompasses numerous systemic disorders and certain medications which can affect the periodontal attachment apparatus and cause loss of periodontal attachment and alveolar bone.⁴⁰ For the purposes of diagnosis, it is recommended to follow the classification of the primary disease according to the respective International Statistical Classification of Diseases and Related Health Problems (ICD) codes.¹⁷

Endodontic-periodontal (endo-perio) lesions occur as a result of a pathologic communication between the pulpal and periodontal tissues (see figure: Endo-perio lesion). 

Endo-perio lesion

A periapical radiograph taken using the long cone paralleling technique shows tooth 36 with a endo-perio lesion involving both root apices and the furcation, mild horizontal bone loss of less than 10% of root length and a mesially impacted 38.

Several classifications of endodontic-periodontal lesions exist. Risk factors for the development of endo-perio lesions are advanced periodontitis, trauma and iatrogenic events (e.g. root perforation). In all cases, both endodontic and periodontal treatment will be required. In an attempt to link the lesion present to the prognosis of the tooth (with those teeth with root damage having a poorer prognosis than those where the lesion was primarily periodontal), the 2018 Classification of Periodontal Diseases assigned a diagnosis on the basis of whether root damage was present and whether the patient has a diagnosis of periodontitis (see table: Classification of endodontic-periodontal lesions).³⁹ 

Classification of endodontic-periodontal lesions³⁹

Endo-perio lesions may occur in an acute or a chronic form and are characterised by deep periodontal pockets and/or negative/altered response to pulp sensibility tests.⁴¹ There may be evidence of damage to the root surface. Other signs and symptoms may include history of trauma or root canal treatment, spontaneous pain or pain on palpation/percussion, pus, tooth mobility, sinus tract/fistula, and crown and/or gingival colour alterations. Radiographic investigation is required to determine if there is root damage (e.g. root perforation or fracture) and also to determine the site and extent of periodontal bone loss. The prognosis of the involved tooth is dependent on several factors (for more information, see Combined endodontic-periodontal lesions).

Periodontal abscesses are lesions associated with localised accumulation of non-draining pus within the gingival wall of the periodontal pocket associated with rapid tissue destruction.⁴¹ Signs and symptoms include localised pain and swelling, bleeding and/or suppuration on probing, deep periodontal pocket and increased tooth mobility (for more information, see Periodontal abscess).