The challenge of endo-periodontal lesions in diabetic patients

The management of endo-periodontal lesions (EPL) requires a precise understanding of the anatomical and microbial communications between the pulp and the periodontium. In this context, diabetes acts as a major systemic modifier: persistent hyperglycemia intensifies oxidative stress, alters the immune response, and compromises the predictability of bone healing. While the literature establishes a clear link between poor metabolic control and an increased prevalence of periapical lesions or endodontic treatment failures, practitioners still lack a unified protocol integrating these systemic variables into local diagnosis.

The objective of this structured narrative review, analyzing data published between 2016 and 2025, is to synthesize the evidence linking diabetes, glycated hemoglobin (HbA1c), and the therapeutic outcomes of LEP. The authors aim to transform these heterogeneous data into a clinical practice framework guided by HbA1c, thereby facilitating decision-making in the dental practice.

The central question of the study focuses on the ability of glycemic control to inform diagnosis, prognosis, and treatment sequencing. The hypothesis is based on the need for metabolic risk stratification to adapt the intensity of periodontal interventions, prioritize endodontic infection control, and secure decisions for elective or regenerative surgery based on patient stability.

Methodology: a structured synthesis of evidence

This study takes the form of a structured narrative review, integrating a clinical framework developed by experts. The objective is to translate heterogeneous literature into a practical decision-making model for the management of endo-periodontal lesions in diabetic patients.

The documentary corpus was selected over the period spanning from January 2016 to December 2025. The synthesis is based on the following types of sources:

• Consensus reports and clinical practice guidelines.
• Systematic reviews, meta-analyses and umbrella reviews.
• Randomized, non-randomized, and observational clinical studies.
• Mechanistic studies or contemporary narrative reviews of direct relevance.

Les auteurs ont exclu les rapports de cas cliniques, les expérimentations animales ainsi que les études in vitro n’ayant pas de lien direct avec l’élaboration du cadre clinique. La méthode d’analyse privilégie une intégration thématique des données plutôt qu’une approche purement statistique.

In this protocol, the glycated hemoglobin (HbA1c) level is used as a prognostic and planning variable, without substituting for pulp vitality tests or periodontal probing. This framework specifically aims to improve diagnostic precision, optimize therapeutic sequencing, define the surgical schedule, and refine risk communication with the patient.

Analysis of results and clinical impact

This narrative review, synthesizing data published between 2016 and 2025, confirms that persistent hyperglycemia is not merely a peripheral risk factor, but a direct modulator of therapeutic success. The results highlight a clear correlation between elevated HbA1c levels and an increased prevalence of radiolucent periapical lesions, as well as a higher risk of losing endodontically treated teeth. Clinically, this means that the predictability of tissue healing is compromised by oxidative stress and the accumulation of advanced glycation end products (AGEs) characteristic of the diabetic patient.

The strength of this study lies in the proposal of an HbA1c-stratified decision-making framework. Unlike conventional approaches, the authors advocate for a strict hierarchy: the control of endodontic infection (necrosis, active intracanal infection) remains the absolute priority, while elective or regenerative periodontology interventions must be systematically deferred in cases of poor metabolic control until medical stabilisation is achieved.

The limitations of this work stem from the heterogeneous nature of the sources (systematic reviews, observational studies, and consensus reports), precluding any calculation of overall effect size by meta-analysis. Nevertheless, the study validates the fact that periodontal treatment is safe and can induce a modest reduction in HbA1c, particularly in patients whose initial glycemic control is most deficient.

Study summary

This narrative review (2016-2025) demonstrates that diabetes significantly increases the prevalence of radiolucent periapical lesions and reduces the retention rate of endodontically treated teeth. While periodontal treatment allows for a modest reduction in HbA1c, persistent hyperglycemia systematically degrades the predictability of tissue healing and the local immune response.

In concrete terms, for the practitioner:

• Prioritise treatment: In the presence of an endo-periodontal lesion with necrosis, systematically eliminate the intracanalar infection before initiating complex periodontal therapies.
• Postpone surgery: Defer any elective surgery or periodontal regeneration procedure in patients with poorly controlled diabetes until metabolic stabilization validated by HbA1c is achieved.
• Adjust follow-up: Use the HbA1c level as a risk indicator to modulate the frequency of radiographic checks, as healing is slower and less predictable in diabetic patients.

Study Lexicon: Diabetes and Endo-Periodontal Lesions

Endo-periodontal lesions (EPL): Clinical entities where the dental pulp and supporting tissues communicate via the apical foramen, lateral canals, or tubules. In the context of diabetes, these pathways become channels for the exacerbation of inflammation.

HbA1c (Glycated hemoglobin): A true metabolic "referee" for the practitioner. This measurement estimates glycemic exposure over 8 to 12 weeks and dictates the therapeutic schedule: it allows deciding whether to engage in regenerative surgery or if the patient must be stabilized beforehand.

AGEs (Advanced Glycation End-products): Molecules resulting from persistent hyperglycemia that accumulate in the tissues. They activate inflammatory signals via specific receptors, directly disrupting collagen metabolism and periapical bone repair.

Oxidative stress: Biological imbalance intensified by hyperglycemia. It plays a key role in immune dysfunction and dysbiotic biofilm activity, thereby reducing the predictability of healing after endodontic treatment.

2017 World Workshop Classification: A reference framework distinguishing endo-periodontal lesions according to the presence or absence of root damage (fractures, perforations). This distinction is vital as it immediately guides the prognosis and the feasibility of regenerative treatment.

Periapical radiolucency: Radiological image indicating bone destruction. The study notes that in diabetic patients, these lesions are more frequent on teeth already endodontically treated, a sign of an altered immune response and delayed healing.

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