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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 10  |  Issue : 2  |  Page : 105-109

Successful endodontic management of endo-perio lesions with different treatment modalities: Case series


Department of Conservative Dentistry and Endodontics, D A Pandu Memorial RV Dental College and Hospitals, Bengaluru, Karnataka, India

Date of Web Publication9-Jul-2019

Correspondence Address:
Dr. Vijetha Vishwanath
Department of Conservative Dentistry and Endodontics, D A Pandu Memorial RV Dental College and Hospitals, J. P. Nagar, 1st Phase, Bengaluru - 560 078, Karnataka
India
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DOI: 10.4103/srmjrds.srmjrds_16_19

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  Abstract 

Diagnosis and management of endo-perio lesions differ from those lesions of single causative factor. These present signs and symptoms, which cannot be easily attributed or accounted for, require more detailed examination and definitive treatment plan. The outcomes are not readily predictable as of lesions of single origin. Distinguishing the primary etiological factor and overlapping secondary clinical features require thorough knowledge and understanding of the pathology, anatomy, and microbiology with respect to the teeth involved. The primary and secondary etiological factors can have numerous variations and hence makes arriving at a definitive treatment plan complex. However systematic examination combined with relevant investigations always provides a correct direction toward optimum treatment plan. This article presents four cases of endo-perio lesions and their successful management by different treatment modalities.

Keywords: Different treatment modalities, endo-perio lesions, furcal involvement, hemisection, nonsurgical root canal treatment, restorative rehabilitation


How to cite this article:
Vishwanath V, Rao H M, Keshava Prasad B S, Shashikala K. Successful endodontic management of endo-perio lesions with different treatment modalities: Case series. SRM J Res Dent Sci 2019;10:105-9

How to cite this URL:
Vishwanath V, Rao H M, Keshava Prasad B S, Shashikala K. Successful endodontic management of endo-perio lesions with different treatment modalities: Case series. SRM J Res Dent Sci [serial online] 2019 [cited 2019 Sep 16];10:105-9. Available from: http://www.srmjrds.in/text.asp?2019/10/2/105/262377


  Introduction Top


The human periodontium and dental pulp are closely connected by their proximity and by the presence of apical and lateral radicular foramina, which permit the passage of pathogens between these two distinct anatomical areas.[1] The actual relationship between periodontal and pulpal diseases was first described by Simring and Goldberg in 1964.[2] The expression endo-perio lesion was devised to better describe the etiopathogenesis in such cases and includes the following:

  • Lesions that result from apical to coronal migration of endodontic pathogens and their toxins with or without fistula or sinus tract at the gingival margins depending on the nature of infection
  • Originating from a marginal lesion which has subsequently affected more apical periodontal areas. The pulp and the periodontium are distinct from one another and are anatomically connected through the foramina
  • Resulting from a combination of the above, in which case the differential diagnosis must attribute each portion of the lesion to its cause.[1]


Periodontal disease causes a destruction of the bone in a coronal-to-apical direction while direction of the endodontic lesions is from apex to coronal.[3] Diagnosis of combined lesions are hence difficult and may not be able to distinguish the definitive source of origin of the presenting lesion. It is an established fact and evidenced based that pulpal and periodontal lesions are primarily due to microbial infection. Hence, both the disease processes could originate as separate entities and may overlap during the progress of the same. Diagnosis is complicated by the fact that these diseases are too frequently viewed as independent entities.[4]

Classification

    1. Simon et al. 1972[5]
    2. Primary endodontic lesions
    3. Primary endodontic lesions with secondary periodontal involvement
    4. Primary periodontal lesions
    5. Primary periodontal lesions with secondary endodontic involvement
    6. True combined lesions.


  1. Walton et al. in 1996,[6] based on the origin of the periodontal pocket:
    1. Endodontic origin
    2. Periodontal origin
    3. Combined endo-perio lesion
    4. Separate endodontic and periodontal lesions
    5. Lesions with communication
    6. Lesions with no communication.


  2. World workshop for classification of periodontal diseases (1999)[7] and periodontitis associated with endodontic disease:
    1. Endodontic-periodontal lesion
    2. Periodontal-endodontic lesion
    3. Combined lesion.



  Case Reports Top


Case 1

Examination

A 45-year-old female patient reported with a chief complaint of pain in the right lower back tooth region in the last 3 weeks. Medical history revealed that the patient was a diabetic and on medication for 5 years. Intraoral examination revealed a deep carious lesion in 46, which tested positive to percussions. The buccal gingiva showed mild swelling with sinus tract opening. The tooth did not respond to pulp tests and 45 was found missing. On periodontal examination, there was a deep periodontal pocket in relation to 46 and Grade II mobility. General oral hygiene was not satisfactory.

Investigation

Radiographic examination revealed a radiolucent area involving enamel, dentin, and pulp suggesting of deep occlusal caries [Figure 1]a. Furcation radiolucency was seen. Distal surface of distal root had nearly 90% bone loss. The tooth was mesially drifted slightly. Electric pulp testing (Parkell Electronics Division, Farmingdale, NY) was done to check for pulp status, which confirmed that the tooth was nonvital.
Figure 1: (a) Preoperative intraoral periapical radiographs. (b) Working length. (c) Master cone. (d) Obturation. (e) Three-month recall. (f) Six-month recall. (g) Twelve-month recall showing progressive healing of the bone around the distal root

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Diagnosis

Based on the finding, diagnosis was made as an endo-perio lesion of primary endodontic with secondary periodontal involvement.

Treatment planning

Based on the strategic importance of the tooth, the patient was willing for an endodontic treatment. The tooth was relieved from occlusion. Endodontic treatment was completed in three visits under rubber dam isolation, in a span of 2 weeks with interappointment calcium hydroxide intracanal dressings. When the localized swelling resolved and the tooth was asymptomatic, treatment was completed [Figure 1]b, [Figure 1]c, [Figure 1]d and access restoration was done. It should be noted that no periodontal intervention was carried out, and it was reserved for a later stage if necessary. Postendodontic restoration with metal crown was completed after 3 months. The follow-up examination showed healthy gingival status, absence of tooth mobility, and progressive hard tissue repair in the periapical and furcal areas of tooth 46 as seen in the radiograph [Figure 1]d, [Figure 1]e, [Figure 1]f, [Figure 1]g.

Case 2

Examination

A 33-year-old female patient reported with a chief complaint of pain, food lodgment, and mobile tooth in the left lower back tooth region for 1 year. The patient gives a history of visiting a private clinic for the treatment of the same and was advised extraction. Medical history was noncontributory. Intraoral examination revealed deep dental caries in 36 which showed a positive response to percussion. On periodontal examination, deep periodontal pocket was noted in relation to 36 and Grade III mobility. General oral hygiene was satisfactory.

Investigation

Radiographic examination revealed furcal radiolucency and bone loss [Figure 2]a. Electric pulp testing (Parkell Electronics Division, Farmingdale, NY) and thermal testing were done for pulp status, which confirmed that the tooth was nonvital.
Figure 2: (a) Preoperative radiograph. (b) Working length. (c) Postobturation. (d) Three-month recall. (e) Six-month recall. (f) Twelve-month recall showing progressive periapical healing

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Diagnosis

Based on the finding, diagnosis was made as an endo-perio lesion of primary endodontic with secondary periodontal involvement.

Treatment planning

The tooth was relieved from occlusion. Endodontic treatment was completed in four visits under rubber dam isolation, in a span of 4 weeks with interappointment calcium hydroxide intracanal dressings [Figure 2]b and [Figure 2]c. Access restoration was done with alloy-reinforced glass ionomer at the fourth appointment. Postendodontic restoration with crown was delayed for nearly 6 months, where the mobility had decreased greatly, to avoid occlusal contacts and to provide stress-free conditions for healing of the bone. No periodontal intervention was carried out. The follow-up examination showed healthy gingival status, absence of tooth mobility, and progressive hard tissue repair in the periapical and furcal areas of tooth 36 as seen in the radiograph [Figure 2]d, [Figure 2]e, [Figure 2]f.

Case 3

Examination

A 54-year-old female patient reported with a chief complaint of food lodgment in the right lower back tooth region in the past 2 months. Medical history and dental history were noncontributory. Intraoral examination revealed sound tooth structure of 46 but tested positive to percussion. On periodontal examination, deep periodontal pocket was noted in relation to 46 and Grade II mobility. General oral hygiene was satisfactory.

Investigation

Radiographic examination revealed furcal radiolucency with severe bone loss up to the apical third on the distal root. Electric pulp testing (Parkell Electronics Division, Farmingdale, NY) and thermal testing were done for pulp status, which confirmed that the tooth was nonvital.

Diagnosis

Based on the finding, diagnosis was made as an endo-perio lesion of primary periodontal with secondary endodontic involvement.

Treatment planning

The tooth was relieved from occlusion. Endodontic treatment was completed in two visits under rubber dam isolation, in a span of 2 weeks with interappointment calcium hydroxide intracanal dressing [Figure 3]a. After completion of root canal treatment, the patient was referred for periodontal intervention [Figure 3]b and [Figure 3]c. One-month and 6-month recall [Figure 3]d and [Figure 3]e showed clinical improvement in the tooth and the patient is being followed up.
Figure 3: (a) Working length. (b) Master cone. (c) Obturation. (d) Three-month recall. (e) Six-month recall

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Case 4

Examination

A 23-year-old male patient reported with a chief complaint of pain in the left lower back tooth region in the last 3 months. Medical history and dental history were noncontributory. Intraoral examination revealed grossly destructed tooth structure of 36, which tested positive to percussions. On periodontal examination, deep periodontal pocket was noted in relation to 36. General oral hygiene was satisfactory.

Investigation

Radiographic examination revealed a radiolucent area involving enamel, dentin, and pulp suggesting of deep occlusal caries [Figure 4]a. Furcation radiolucency was seen. Electric pulp testing (Parkell Electronics Division, Farmingdale, NY) was done to check for tooth vitality, which showed a delayed response.
Figure 4: (a) Preoperative intraoral periapical radiographs. (b) Working length. (c) Master cone. (d) Clinical photograph showing grossly destructed distal crown structure. (e) Radiograph showing furcal bone loss and root canal treatment of the mesial roots. (f) Access restoration with alloy reinforced glass ionomer. (g) Radiograph showing access restoration. (h) Sectioning of the tooth. (i) Extracted distal root stump. (j) Atraumatic extraction of the distal half of the tooth followed by suturing. (k) Intraoral periapical radiographs immediate postoperative to confirm the absence of any fractured tooth fragment. (l) Fixed prosthesis. (m) Follow-up 12 months postoperative

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Treatment

As the patient was young and was willing to retain the tooth, it was planned for endodontic treatment of the salvageable part of the tooth and hemisection of the other part. Root canal procedure was carried out only for the mesial root under rubber dam isolation [Figure 4]b and [Figure 4]c. The obturating material was sheared off at the level of orifice [Figure 4]d and [Figure 4]e, access restoration was done with alloy-reinforced glass ionomer [Figure 4]f and [Figure 4]g, and buccolingual vertical cut was given with a long shank tapered fissure carbide bur till the furcation was reached for hemisecting the distal root and crown [Figure 4]h. The distal half was extracted atraumatically [Figure 4]i, and the socket was gently irrigated and debrided. Buccal and lingual flaps were approximated and sutured back in position [Figure 4]j. Confirmatory radiograph was taken to rule out any residual tooth or root fragment [Figure 4]k. Occlusal reduction was done for retained half of the tooth, which allowed the surgical site to heal with no occlusal stresses. After the complete healing of socket, the remaining tooth was checked for its structural integrity to serve as an abutment for postendodontic restoration and restore the edentulous space. A fixed partial denture was cemented to restore functional harmony [Figure 4]l. The 12-month follow up [Figure 4]m showed good healing and normal function.


  Discussion Top


The pulp and periodontium share common features of embryonic, anatomic, and functional characteristics. Simultaneous existence of pulpal and periodontal diseases can complicate diagnosis and treatment planning. This further affects the sequence of care to be performed and its long-term prognosis.[2] However, there is not much clinical difficulty in the diagnosis of primary endodontic disease and primary periodontal disease. Vitality test is the first and the most essential step for proper diagnosis. Although the vitality test cannot provide the histological status of the dental pulp, their ability to register pulp vitality is quite satisfied. The ability of vitality tests to detect nonsensitive reaction represented that a necrotic pulp was reported as 89% with the cold test and 88% with the electrical test.[8]

Chronic inflammatory reaction of the infected root canal can sometimes extend into the gingival sulcus and drains through the sinus tracts. The periodontal manifestations tend to resolve soon after endodontic treatment if there are no local periodontal factors or any defective features in coronal or radicular anatomy of teeth as confirmed by cases 1 and 2 in this study. Usually, any further intervention is always performed after a minimum observation period of 3 months. Conversely, there has been a debate in the literature about the impact of the endodontic treatment on the healing potential of the periodontium. Some studies have been reported that endodontic treatment may cause an inhibitory effect on periodontal wound healing while some of them have demonstrated no significant effects. The possible influence of endodontic treatment on the healing response of furcation defects is related to the accessory canals and permeable areas of dentin and cementum.[3]

An attempt to completely debride the root canal system followed by hermetic fluid-tight three-dimensional seal with obturating materials usually results in uneventful healing of primary endodontic lesions along with closure of the sinus tract if any. This also results in normal periodontal architecture in about 4–6 months along with signs of osseous repair of even large periapical rarefactions without any surgical intervention. Hence any invasive procedure, either endodontic or periodontal, should be avoided as this may cause further injury to the attachment, possibly delaying healing.[9]

Viable options to be considered for extensively carious and periodontally weak multirooted teeth before extraction are hemisection and bicuspidization. Hemisection involves root canal treatment of the remaining roots followed by a fixed prosthesis to maintain the occlusal balance. It not only preserves the tooth but also reduces the financial burden, psychological trauma, and occlusal dysfunction. As in case 4, good prognosis was observed with proper occlusion, absence of mobility, and healthy periodontal condition up to 1 year of follow-up.


  Conclusion Top


The management of endo-perio lesions is not unidirectional but includes various treatment options which will result in optimum resolution of the disease process. The clinician should be aware of the underlying biological and etiopathological factors for successful treatment outcome of such cases. In addition to conventional treatment procedures, other therapeutic modalities using advanced techniques and materials such as regenerative procedures, root resection, and hemisections should be considered as per clinical situation which will result in a favorable long-time prognosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Foce E. Endo-Periodontal Lesions. London: Quintessence Publishing; 2011;3-5.  Back to cited text no. 1
    
2.
Simring M, Goldberg M. The pulpal pocket approach: Retrograde periodontitis. J Periodontol 1964;35:22-48.  Back to cited text no. 2
    
3.
Aksel H, Serper A. A case series associated with different kinds of endo-perio lesions. J Clin Exp Dent 2014;6:e91-5.  Back to cited text no. 3
    
4.
Al-Fouzan KS. A new classification of endodontic-periodontal lesions. Int J Dent 2014;2014:919173.  Back to cited text no. 4
    
5.
Simon JH, Glick DH, Frank AL. The relationship of endodontic-periodontic lesions. J Periodontol 1972;43:202-8.  Back to cited text no. 5
    
6.
Walton RE, Torabinejad M, Trop M. Endodontic and periodontal interrelationships. In: Walton RE, Torabinejad M, editors. Principles and Practice of Endodontics. Philadelphia: W. B. Saunders; 1996.  Back to cited text no. 6
    
7.
Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol 1999;4:1-6.  Back to cited text no. 7
    
8.
Petersson K, Söderström C, Kiani-Anaraki M, Lévy G. Evaluation of the ability of thermal and electrical tests to register pulp vitality. Endod Dent Traumatol 1999;15:127-31.  Back to cited text no. 8
    
9.
Singh P. Endo-perio dilemma: A brief review. Dent Res J (Isfahan) 2011;8:39-47.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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