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CASE REPORT

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MANAGEMENT OF A HOPELESS TEETH WITH

ENDO - PERIO LESION : SALVAGING A MOLAR

Dr.Ramnath Elangovan, Dr.Ramakrishnan Theyagarajan, Dr.Mejalla Muthiah Amala Dhas,

Dr.Sathish Kumar Krishnamurthy

Department of Periodontics,

Adhiparasakthi Dental College and Hospital,

Melmaruvathur, Kanchipuram 603319.Tamil Nadu , India.

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ABSTRACT

Website: jidam.idamadras.com

Pulpo-periodontal lesion is one of the most complicated

condition to be treated as it needs more accurate diagnostic

skills and precise treatment plans. The major challenge in

the treatment of the pulpo-periodontal lesion is to treat the

endodontic infection along with the regeneration of the

lost periodontal structures associated with the lesion. The

prognosis of the tooth depends upon the extension of the

periodontal structure loss around the tooth. Root canal therapy

and guided tissue regeneration technique with bone grafts

Address for correspondence:

and collagen membranes serve as a best mode of treatment

for pulpo -periodontal lesions. This case report describes the

salvaging of a hopeless teeth with an Endo-Perio lesion by an

Dr. E. Ramnath,

interdisciplinary approach.

Department of Periodontics,

KEYWORDS: Endo-Perio lesion; Guided Tissue

Adhiparasakthi Dental College

Regeneration; Bone graft, Collagen Membrane.

and Hospital, Melmaruvathur,

Kanchipuram 603319.

e-mail : ramubds2@gmail.com

Received

: 05.08.2019

Accepted

: 03.09.2019

Published

: 27.09.2019

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Ramnath et al : Management of a Hopeless teeth with Endo-perio lesion

INTRODUCTION:

gingiva in relation to 16. Initial probing depth of

about 15 mm was elicited (Fig 1) and tooth exhibited

Periodontal tissue destruction can be caused

Grade II mobility. The tooth (16) was tender on

by many etiological factors. The infection causing

percussion and was grossly decayed. IOPA of 16

periodontal tissue destruction may have their origin

showed dental caries approximating the pulp chamber

either from the pulpal tissues through the apical

of 16, widening of the periodontal ligament space

foramen or from the periodontal structures. The

was seen in 16 and bone loss involving the furcation

combined involvement of both pulpal and periodontal

and apical third of the mesio buccal, distobuccal

lesion is termed as Endo-Perio lesion. Based on the

and palatal roots of 16 (Fig 2). Based on the clinical

involvement of the tissue structures, it is classified

and radiological evidence it was diagnosed as a true

as primary endodontic lesion, primary endodontic

combined lesion. Initial treatment plan was extraction

lesion with secondary periodontal involvement,

of 16. Since the patient was not willing for extraction

primary periodontic lesion, primary periodontal

alternative plan was made. Patient underwent initial

lesion with secondary endodontic involvement and

Phase I therapy of scaling and root planing. Patient

true combined lesion.1 In true combined lesion, both

was put under antibiotic therapy of Amoxycillin

infections develop independently and progress until

500mg and Metronidazole 400mg thrice daily for

they join together. Dental pulp and periodontium have

five days and NSAID pain killer Aceclofenac 100mg

a very close relation as they are of ectomesenchymal

twice daily for three days.

origin. The relationship between the pulpal and

periodontal infections was first described by Simring

After 7 days, intra-oral examination showed

and Goldberg in 1964 and they account for about more

reduction of swelling in size. The tooth (16) was

than half of the tooth mortality.2 The destruction of

tested for vitality with Electric Pulp tester (EPT)

the periodontal apparatus is caused by the necrosis

which showed no response indicating the tooth was

of pulp through the apical foramen and sometimes

non-vital. Hence root canal therapy was planned

through the accessory canals which are located at

16. Access opening was done, canals were

different levels of root.3 When the destruction of

located,cleaning and shaping done and Calcium

the periodontal tissues progresses into periodontal

hydroxide intracanal medication was placed. Patient

pocket formation, the chances of reversal of the

was recalled after 1 week and obturation was done

endodontic lesion with time gets reduced. The main

in 16 ( Fig 3). Patient was recalled after 4 weeks for

goal of treatment is not only maintaining the natural

review

dentition but also to restore the lost periodontal

structures. Preservation of the natural tooth should

be the ultimate goal of periodontal therapy. The

endo-perio lesion is usually treated with root canal

therapy depending on the vitality of the affected tooth

followed by Guided Tissue Regeneration using bone

grafts and collagen membranes. This case report

describes the salvation of a hopeless teeth with an

endo- perio lesion by interdisciplinary approach.

Fig 1 : Swelling in relation to 16 and Initial probing

depth of about 15mm.

CASE REPORT:

A 16-year old male patient reported to the

Department of Periodontics with the chief complaint

of painful swollen gums in the upper right back

tooth region for past 5 days. Patient had no medical

history. Past dental history revealed that the patient

had undergone treatment for the same twice before

6 months. On intra-oral examination a swelling

Fig 2 : IOPA of 16 showing dental caries and bone

measuring about 3 x 3 mm was seen in the attached

loss involving the furcation of 16.

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Ramnath et al : Management of a Hopeless teeth with Endo-perio lesion

Fig 3 : IOPA showing root canal treated 16.

Fig 5: Full thickness mucoperiosteal flap reflected,

SURGICAL PROCEDURE:

degranulation done showing osseous defect.

After 4 weeks the patient was asymptomatic.

Grade II mobility had completely reduced and the

tooth became clinically firm. The probing depth

remained to be 15 mm and had a Grade II furcation

involvement of about 12mm which was measured

using Naber’s probe (Fig 4). Hence a localised flap

surgery was planned after explaining the procedure

to the patient and obtaining consent from the parents.

The surgical site was isolated and anaesthetised

using

2% lignocaine hydrochloride

(1:2,00,000

Fig 6 : Bone graft (Osseograft) placement in the

adrenaline). Crevicular, Interdental incisions were

osseous defect of 16.

placed in relation to 15, 16 and 17. Two vertical

incisions were placed in relation to 15 and 17 with a

wider base to enhance the blood supply to the flap. A

full thickness mucoperiosteal flap was reflected and

granulation tissue was removed (Fig 5). The osseous

defect was filled with Osseograft (Xenograft) (Fig

6). Healiguide collagen membrane was placed over

the bone graft (Fig 7). The flap was approximated

using single independent sling suture and the

vertical releasing incisions were approximated using

horizontal matrix suture using 3-0 silk suture (Fig 8).

Fig 7 : Collagen membrane (Healiguide) placed

Periodontal dressing was place over the surgical site

over the bone graft.

(Fig 9)

Fig 8 : Flap approximated using independent sling

and horizontal mattress sutures (3-0 silk).

Fig 4 : Furcation involvement of about 12mm using

Naber’sprobe.

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JIDAM/Volume:6/Issue:3/Pages 105 - 109/July-September 2019

Ramnath et al : Management of a Hopeless teeth with Endo-perio lesion

Fig 9 : Periodontal dressing placed over the

surgical site.

Fig 12 : Post-operative IOPA showing bone

POSTOPERATIVE INSTRUCTIONS:

formation around 16 region.

Analgesics were prescribed twice daily for

DISCUSSION:

three days for post-operative pain management.

0.2% chlorhexidine digluconate was also prescribed

The successful outcome of the endo-perio

to be used twice daily for 3 weeks. The patient was

lesion management solely depends on the precised

asked not to brush at the surgical site for 2 weeks.

diagnosis. The larger the periodontal defect

more it affects the outcome of the treatment. The

RESULT:

diagnostic tools for endo-perio lesion includes visual

examination, palpation, percussion, tooth mobility,

After 7 days of surgery, periodontal dressing

Intra-oral radiographs and pulp testing.⁴ Both

and sutures were removed, healing was satisfactory.

endodontic and periodontal infections are caused by

Patient was again assessed for healing at 3 months

mixed anaerobic microorganisms. But the pathways

(Fig 10) The Intraoral Periapical Radiograph at the

of infection are still a controversy. The two major

time period of

3 months showed excellent bone

pathways through which the infection spreads are

formation (Fig 12), there was a reduction in pocket

anatomic pathway and nonphysiologic pathways.⁵

depth to 3mm (Fig 11). The tooth became clinically

The Anatomic pathways includes the connection of

stable and functional.

pulp and periodontium through the apical foramen.

There are also other multitude of connections other

than the apical foramen which includes furcation,

collateral, lateral, secondary, accessory, intercanal

and reticular canals.⁶Other than the apical foramen

and the lateral canals there is a third mode of spread

of infection to the periodontium through the dentinal

tubules. The spread of bacteria through the tubules is

very limited as the radius of the dentinal tubules is

diminished about 5-40% by the odontoblastic process,

collagenous fibers and the sheet like lamina limitans

Fig 10 : Post-operative view at 1 month.

that are present in the dentinal tubules. The other

pathways include the spread of infections through the

perforations of root structures caused during access

to the pulp chamber or due to improper manipulation

of endodontic instruments. Vertical root fractures

constitutes the second group of artificial pathways

that paves way for the communication of the pulp

and the periodontal structures. Vertical root fractures

is caused in both vital and non-vital tooth by trauma.

Fracture may continue to the coronal aspect of the

tooth in vital tooth called as cracked tooth syndrome

Fig 11 : Reduction of pocket depth to 3mm.

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Ramnath et al : Management of a Hopeless teeth with Endo-perio lesion

(Cameron 1964)⁷. In endodontically treated tooth it is

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FINANCIAL SUPPORT AND

SPONSORSHIP:

Nil

CONFLICTS OF INTEREST:

There are no conflicts of interest.

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