4. Dr Bhaumik Nanavati Proof Approved

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J. Adv Oral Research CASE REPORT

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Journal of Advanced Oral Research, Vol 4; Issue 1: Jan - Apr2013 www.joaor.org

Endo periodontal lesion A case report

Bhaumik Nanavati* Neeta V Bhavsar

Jaydeepchandra Mali

*MDS, Senior Lecturer, Department of Peridontology, College of Dental Science and

Research Centre, Manipur, Ghuma Road, Ahmedabad, Gujarat, India. MDS, Professor &

Head, Department of Peridontology, Government Dental College, Ahmedabad, Gujarat,

India MDS, Senior Lecturer, Department Of Periodontology, Vaidik Dental College and

Research Center, Daman, India. Email:[email protected]

Abstract:

The pulp and periodontium haveembryonic, anatomic and functional inter-

relationships. The simultaneous existence of pulpal

problems and inflammatory periodontal diseasecan complicate diagnosis and treatment planning.This case report evaluates the efficacy ofdecalcified freeze dried bone allograft along with

bioabsorbable barrier membrane in themanagement of furcation defect associated with an

endo-perio lesion in a right mandibular first molar.A 36-year-old male patient with an endo-periolesion in the right mandibular first molar wasinitially treated with endodontic therapy.Following the endodontic treatment, the furcation

defect was treated using decalcified freeze driedbone allograft (DFDBA) along with guided tissueregeneration (GTR) membrane. At the end of 9months, there was a gain in the clinical attachmentlevel and reduction in probing depth. Radiographicevidence showed that there was a significant bonyfill.Keywords: DFDBA, GTR membrane, furcation,endo- perio.

Introduction:

The actual relationship between

periodontal and pulpal disease was first describedby Simring and Goldberg in 1964.1Since then, the

term endo-perio lesion has been used to describelesions due to inflammatory products found invarying degrees in both the periodontium and thepulpal tissues. The endodontium and periodontium

are

are closely related and diseases of one tissue maylead to the involvement of the other. Thedifferential diagnosis of endodontic and

periodontal diseases can sometimes be difficult but

it is of vital importance to make a correct diagnosisso that the appropriate treatment can be provided.Endodontic-periodontal lesions present challengesto the clinician as far as diagnosis and prognosis of

the involved teeth are concerned. Etiologic factorssuch as bacteria, fungi, and viruses as well as

various contributing factors such as trauma, rootresorptions, perforations, and dental malformationsplay an important role in the development andprogression of such lesions.

Furcation involvement presents one of the

major challenges in endodontic therapy withperiodontal involvement. Although the role ofpulpal pathology in the etiology of furcationinvolvement is still unclear, the high incidence ofmolar teeth with accessory canals supports such anassociation.

Various treatment modalities[2] have been

proposed for the treatment of furcationinvolvement alone including open flapdebridement, bio-modification of root surface andvarious regenerative procedures including GTRand bone grafts. Bone grafts having a property of

osteogenesis, osteoinduction and osteoconductionhave been used in the past.A new property of osteostimulation

[3] has

been reported in some recently available materials.This case report attempts to utilize a decalcifiedfreeze dried bone allograft with the property ofosteostimulation as bone replacement graft in thetreatment of a combined endo-perio lesion withfurcation involvement.

Relationship between pulp and periodontium:

Pulpal and periodontal problems areresponsible for more than 50% of tooth mortality.

The periodontium and pulp have embryonic,anatomic and functional interrelationship. The

Serial Listing: Print-ISSN (2320-2068)

Online-ISSN (2320-2076)

Formerly Known as Journal of Advanced Dental

Research

Bibliographic Listing: Indian National Medical

Library, Index Copernicus, EBSCO PublishingDatabase, Proquest, Open J-Gate.


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relationship between pulpal and periodontaldisease can be traced to embryologicaldevelopment, since the pulp and the periodontiumare derived from a common mesodermal source.

[4]

At the stage of tooth development, the developingtooth bud pinches off a portion of mesoderm thatbecomes pulp, while the remaining mesodermdevelops into the periodontium. Ectomesenchymalcells proliferate to form the dental papilla andfollicle, which are the precursors of theperiodontium and the pulp, respectively. Thisembryonic development may give rise to ananatomical connection between these two vitalstructures throughout the life of a tooth. Threemain pathways[4] have been implicated in thedevelopment of periodontal-endodontic lesions,namely:

1.

Dentinal tubules2. Lateral and accessory canals3. Apical foramen

Classification:The most commonly used classification was givenby Simon et al.

[5]

1. Primary endodontic lesion2. Primary periodontal lesion3. Primary endodontic lesion with secondary

periodontal involvement4. Primary periodontal lesion with secondary

endodontic involvement

5. True combined lesionCase report:A 36-year-old patient reported to the

Department of Periodontics, with a complaint ofpain in the lower right back tooth region associatedwith pus discharge since 1 month. On intraoralexamination, a periodontal abscesss was found to

be present in relation with 46 (figure 1). Aradiograph was taken and it showed widening ofperiodontal ligament space in relation with 46 andradiolucency in the furcation area (figure 3). Thehorizontal probing depth (HPD) with Naber's

probe and vertical probing depth (VPD) with theUNC-15 probe were measured which were foundto be 4 mm and 8 mm (figure 2), respectively. Thepatient was then referred to department ofconservative dentistry to check for tooth vitality.Electric pulp testing was done to check for toothvitality, which confirmed that the tooth wasnonvital.

Treatment planning was done taking intoconsideration that the tooth was nonvital withgrade II furcation involvement as well.

Endodontic treatment was taken up firstand the patient was followed up for 3 months. At

the end of third month, IOPA was taken with 46which showed that the furcation involvement stillprevailed. On clinical examination, it wasobserved that there was no change in the soft tissuemeasurements. Therefore, periodontal regenerativesurgery using DFDBA alogn with GTR membranewas planned for treatment of furcation defect(figure 4).

Figure.1 preoperative Radiograph

Figure.2 HPD of 4 mm with Naber's Probe

Figure.3 Radiograph showing grade II

furcation involvement


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Figure.4 Bone grafting with DFDBA along with

barrier membrane (GTR)

Figure.5 Postoperative after 9 months

Figure.6 Radiograph at 9 months showing bone

fill in furcation area.

Surgical procedure:

After taking care of asepsis andsterilization the surgery was planned. The areaselected for surgery was anesthetized using

xylocaine with adrenaline 1:200,000. A full

thickness flap was raised at the buccal aspect

following intracrevicular incision and verticalreleasing incision. A vertical releasing incisionwas placed extending into the alveolar mucosa notcloser than one tooth to the involved area, i.e. 46.Full thickness flap was raised till the base offurcation defect followed by split thickness flapbeyond the mucogingival junction. This was doneso as to facilitate the coronal positioning of flap,there by resulting in complete coverage of thedefect and the material used. After reflectionthorough degranulation and debridement was doneat the defect area using Gracey's curette # 13 and14. Also thorough scaling and root planning wascarried out on the exposed root surface area of thedefect.

Decalcified freeze dried bone allograftwith osteoconductive and osteostimulative

properties was placed and stabilized in thefurcation area with guided tissue regeneration

(GTR - PERIOCOL) membrane (figure 4).Primary soft tissue closure of the flap was donewith nonresorbable black silk (30) suture usinginterrupted suturing technique.

Post-operative instructions:

The patient was advised proper plaquecontrol and was prescribed 0.12% chlorhexidine

mouthwash for rinsing twice daily. The sutureswere removed 10 days after surgery and the patientwas advised to brush at the surgical site using a

postsurgical brush for 2 weeks. The patient wasalso advised to continue mouthwash for another 3

weeks.The patient was put on regular recall at 1,

3, 6 and 9 months. A DFDBA with GTRmembrane resulted in a substantial amount of bonefill in the furcation. After 9 months the probing

depth was found to be reduced by 3 mm. The post-operative radiograph shows bone fill in thefurcation defect as shown in (figure 6).

Discussion:

When a clinician cannot make a definitive

diagnosis in the case of an endo-perio lesion, itmay be prudent for him or her to initiate either ofthe treatment modalities and hope for repair.However, this could be overcome by properhistory taking and sequential treatment planning.When the etiology is purely endodontic, calciumhydroxide can be used as an intracanalmedicament. It is an excellent medicament ingeneral, because it is bactericidal, anti-inflammatory and proteolytic; it inhibits resorptionand it favors repair. It is especially effective inendodontic lesions with extensive periapicalpathology and pseudo pockets, because of its


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temporary obturating action which would inhibitperiodontal contamination of the instrumentedcanals via patent channels of communication. Thisregimen usually will resolve the pseudo pocketwithin a few weeks.

However, lesions which are not truecombined lesions, little or no improvement wouldbe seen with the periodontal perspective afterendodontic treatment, leaving a very poor andoften hopeless prognosis. But with the advent ofnew regenerative materials, however, successfulperiodontal treatment of such lesions has beenpossible.

In this report the pulp vitality test whichshowed the nonvital nature of the tooth was apivoting finding suggesting the primaryendodontic involvement. Generally, in a case of

combined endo-perio lesion, an adequateendodontic therapy would result in healing of the

endodontic component and the prognosis wouldfinally depend on the efficacy of periodontalrepair/regeneration initiated by either of thetreatment procedures. In this case, followingendodontic treatment the periodontal lesion did

reduce to an extent on radiographic evaluationafter 3 months but did not subside completely with

no change in the clinical parameters. Thisconfirmed a secondary periodontal involvementalong with primary endodontic component.

Periodontal regeneration has beenattempted with variety of grafting materials,

among which demineralized freeze dried boneallografts (DFDBA) apparently facilitatedregeneration in humans.

[6]Schallhorn and

McClain(1988)[7]

reported on improved clinicalresults in intrabony defects and degree II

furcations, following a combination therapyincluding barrier membranes plus DFDBA andcitric acid root conditioning. Guillemin etal.(1993)[8] compared the effect of DFDBA alonewith a combination of barrier materials and

DFDBA in intrabony defects with significantamount of CAL gains and bone fill at six months,but no differences was found between thetreatments. Anderreg et al. (1991)[9] compared theeffect of GTR treatment alone with GTR combinedwith DFDBA and found significant improvementin terms of horizontal probing attachment level inthe group of mandibular degree II furcation treatedwith combination therapy. Lekovic et al.(1990)

[10]

carried out the same study and found that thecombination therapy resulted in greater extent offurcation fill, indicating a possible added benefitfrom the use of grafting material in combination

with bioabsorbable barrier membranes for thetreatment of mandibular degree II furcation.

Conclusion:

The healing of an endodontic lesion ishighly predictable, but the repair or regeneration ofperiodontal tissues is questionable if associatedwith it. Endodontic therapy mostly should precedeperiodontal pocket elimination procedures in thecase of a primary endo and secondary periodontalinvolvement; however, endodontic therapy wouldresult only in resolution of the endodonticcomponent of involvement and would have a littleeffect on the periodontal lesion. Therefore athorough diagnostic examination usually willindicate the primary etiology and, thereby, directthe proper course of treatment plan as presented inthis case.

The results of this case report suggest thatdecalcified freeze dried bone allograft (DFDBA)

along with guided tissue regeneration (GTR)membrane resulted in a significant amount of bonefill and reduction in HPD.

References:

1. Simring M, Goldberg M. The pulpal pocketapproach: retrograde periodontitis. JPeriodontol. 1964;35:22-48.

2. Muller HP, Eger T. Furcation diagnosis. JClin Periodontol. 1999;26:485-98.

3. Libin BM, Ward HL: Decalcifiedlypophillized bone allografts for use in humanperiodontal defects. J Periodontal.

1975;46:51.4. Rotstein I, Simon JH. Diagnosis, prognosis

and decision making in the treatment ofcombined periodontal-endodontic lesions.Periodontol. 2000;2004(34):165-203.

5. Simon JH, Glick DH, Frank AL. Therelationship of endodontic- periodonticlesions. J Periodontol. 1972;43:202-8.

6. Ouhayoun J. Biomaterials used as bone graftsubstitutes. Proceedings of the 2

nd European

Workshop on Periodontology. Quintessencepublishing Co.ltd. 1996:313-58.

7. Schhallhorn and McClain. Combined osseouscomposite grafting, root conditioning andguided tissure regeneration. InternationalJournal Of Periodontics And RestorativeDentistry. 1988;4:9-31.

8. Guillemin M, Mellonig J. Healing inperiodontal defects treated with decalcifiedfreeze dried bone allograft in combinationwith e-PTFE membranes. Journal of ClinicalPeriodontology. 1993;20:528-36.


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9. Anderegg C. Mellonig J. Clinical evaluationof the use of decalcified freeze dried boneallograft with guided tissue regeneration inthe treatment of molar furcation area. Journalof Periodontology. 1991;62:264-8.

10.Lekovic V. Carranza F. Treatment of class IIfurcation defects using poroushydroxylapatite in conjuction with PTFEmembrane. Journal of Periodontology.1990;61:575-8.


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