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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 7  |  Issue : 3  |  Page : 186-189

Interdisciplinary approach for the management of bilateral periodontal: Endodontic defects


1 Department of Conservative Dentistry and Endodontics, Saraswati Dental College, Lucknow, Uttar Pradesh, India
2 Department of Periodontology, Saraswati Dental College, Lucknow, Uttar Pradesh, India

Date of Web Publication21-Aug-2017

Correspondence Address:
Ruchi Srivastava
Department of Periodontology, Saraswati Dental College, Lucknow - 227 105, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1658-5984.213477

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  Abstract 

Bone destruction is one of the factors responsible for tooth loss. Bone loss caused by pulpal disease is reversible whereas advanced bone loss caused by periodontal disease is usually irreversible. Preservation of a tooth with advanced bone loss is possible with careful restorative and surgical management. The main aim of regenerative therapy is the formation of a new attachment apparatus, including bone. This case report describes the management of bilateral perio-endodontic lesions in maxillary region, with a combination of endodontic therapy and periodontal regenerative technique.

Keywords: Bone graft, demineralized freeze-dried bone allograft, endo-perio lesions, periodontal regeneration


How to cite this article:
Verma PK, Srivastava R. Interdisciplinary approach for the management of bilateral periodontal: Endodontic defects. Saudi Endod J 2017;7:186-9

How to cite this URL:
Verma PK, Srivastava R. Interdisciplinary approach for the management of bilateral periodontal: Endodontic defects. Saudi Endod J [serial online] 2017 [cited 2017 Nov 22];7:186-9. Available from: http://www.saudiendodj.com/text.asp?2017/7/3/186/213477


  Introduction Top


The relationship between the pulp and periodontium has been extensively studied, but differentiating between periodontal and endodontic problems can still be difficult. A symptomatic tooth may have pain of periodontal and/or pulpal origin. In some cases, influence of pulpal pathology may create periodontal involvement, whereas in others, periodontal pathology may create pulpal pathology.[1] The ultimate goal of regenerative therapy is predictable regeneration of lost periodontal tissue including bone defects. Bone grafting is the most common form of regenerative therapy, and many bone substitutes are available such as autografts, allografts, xenografts, and synthetic grafts. Although autogenous bone is still gold standard in bone regeneration procedures, due to its donor site morbidity and lesser quantity available, various other alternative products are preferred. Demineralized freeze-dried bone allografts (DFDBAs) have been used extensively in periodontal therapy as they have enhanced osteogenic potential and have shown significant improvements in bone augmentation procedures.[2] All other bone allografts are osteoconductive, but DFDBAs also provide an osteoinductive effect. It is used because it contains bone morphogenetic protein (BMP), which induces new bone formation during healing process.[3] DFDBA has its own limitations regarding availability of graft material, for which the operator has to depend on a hospital source. Moreover, possibility of an immunological reaction and transmission of infective diseases are other disadvantages of DFDBA.[4] This study presents a case report in which bilateral 3-wall intrabony defects in both maxillary canines were successfully treated with interdisciplinary approach, with combined endodontic treatment and DFDBA for bone regeneration.


  Case Report Top


A 35-year-old female visited the department with complaints of pus drainage from upper right and left canines from the past 10 days. On periodontal examination, gingiva in maxillary anterior region was inflamed and edematous, bleeding on probing, and pus drainage from gingival sulcus area; periodontal pocket depths were 13 mm in tooth #13 (maxillary right canine) and 10 mm in tooth #23 (maxillary left canine) on mesial aspect [Figure 1]a and [Figure 1]b. On hard tissue examination, both teeth were sensitive to vertical percussion with Grade I mobility. Pulp vitality tests showed no response in both teeth. On radiographic examination, deep vertical defects were present on a mesial aspect of tooth #13 and #23 extending up to the root apex [Figure 1]c and [Figure 1]d. Therefore, considering dental history, clinical tests, and radiographs, the case was diagnosed as pulpal necrosis with localized chronic periodontal abscess “combined periodontal-endodontic lesion.” An interdisciplinary approach involving endodontic and periodontal therapies was planned. After patient's consent, conventional root canal treatment was started in both teeth under rubber dam isolation. The access opening was carried out, and then the necrotic pulp tissue was removed and working length was estimated. The canal was enlarged to size 35 using K-type files in a step-back technique. During instrumentation, the canal was copiously irrigated with 3% sodium hypochlorite. The canal was dried with sterile paper points and filled with calcium hydroxide powder mixed with normal saline (Prodent, India). The access cavity was sealed with zinc oxide-eugenol cement. At recall after a week, the tooth was asymptomatic and the soft tissue in relation to the tooth was healthy. The intracanal dressing was removed and root canal obturation was done using gutta-percha points and AH plus sealer (Dentsply, Germany) by the lateral condensation method (Hygenic, Akron, OH, USA). After reevaluation of phase-I (after 4 weeks), surgery was planned. Under local anesthesia, papilla preservation flap was raised and abundant granulation tissue was observed with severe root exposure due to dehiscence in tooth #13 and #23 [Figure 2]a,[Figure 2]b,[Figure 2]c. The root surfaces and apical area were thoroughly planed with the help of curettes. After thorough root planing and apical curettage, the large osseous defects were filled with DFDBA (Tata Memorial Hospital, Mumbai, India) covering the root surface [Figure 2]d. Flap was repositioned and sutured with 3-0 silk nonresorbable interrupted sutures, and Coe-Pak (GC, USA) was applied [Figure 2]e,[Figure 2]f,[Figure 2]g. Postoperative instructions were given to the patient, and analgesic (ibuprofen 400 mg thrice daily) was prescribed for 5 days. The patient was instructed to use 0.2% of chlorhexidine mouth rinse for a week from the 2nd day after periodontal surgery. The patient was monitored on weekly schedule postoperatively, to ensure good oral hygiene in surgical area. Healing was satisfactory with no postoperative complications [Figure 3]a. Supportive periodontal maintenance at 3 months was prescribed to maintain periodontal health and to reevaluate this area. Reevaluation after 1 year showed complete healing with healthy gingiva. Results were satisfactory, mobility was reduced to less than Grade I, probing depths were minimal, and the patient was asymptomatic. The radiographs after 1 year follow-up showed evidence of apparent bone fill with gain in periodontal support [Figure 3]b and [Figure 3]c.
Figure 1: Periodontal probing of tooth #13 (a) and tooth #23 (b) Preoperative radiograph with bone destruction of tooth #13 (c) and #23 (d)

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Figure 2: Papilla preservation flap incisions from tooth #13-#23 (a) Intrabony defect of tooth #13 (b) and #23 (c) DFDBA placed (d) Suturing of the flap (e and f) and Coe-Pak application (g)

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Figure 3: Postoperative gingival healing from tooth #13-#23 (a) Postoperative radiograph after 1 year follow up showing evidence of apparent bone fill with gain in periodontal support (b and c)

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  Discussion Top


There is a strict relationship between the pulp and periodontium. At times, the extent of osseous destruction can lead to complex pathological conditions involving the pulpal and periodontal tissues and can pose a challenge to the clinician for the diagnosis and clinical management.[5],[6] The correct diagnosis of periodontal-endodontic lesions is of fundamental importance to determine the treatment and prognosis of a case. The periodontal-endodontic lesions have received several classifications, of which most commonly used is the classification of Simon et al.[7] In our case, there was bone loss till periapical region, mesial to both canines. Since there was good bone support on the distal sides of tooth #13 and #23, extraction was not considered. There was pulpal and periodontal involvement, and hence this type of lesion requires both endodontic and periodontal therapies.[8] Various treatment modalities have been advocated for regeneration of osseous defects. DFDBA is most commonly used because of the presence of BMP which facilitates new bone formation by allowing undifferentiated mesenchymal progenitor cells that undergo phenotypic conversion to the osteoblasts.[9] In this case, DFDBA was well tolerated by the patient with no adverse effects such as periodontal abscess, inflammation, or allergic reaction in the treated surgical site. Although the clinical parameters, i.e. probing pocket depth reduction, clinical attachment level gain, and radiographic evidence of bone fill, have proved to be consistent with the successful regenerative therapy, Schwartz et al. have shown that there is a wide variety of DFDBA products on the market which have different inductive capabilities.[10] These differences may be related to the origin and methods of preparation of DFDBA and if the preparation methods were the same in different bone banks, this would be due to individual donors' ages and sexes, disease and injury, medical treatment, or genetic differences. Furthermore, the variations of time between death and bone extraction may result in significant loss of the bone inductive ability. There are many differences in size and the surface shape of DFDBA particles that may affect their inductive ability.[11] Thus, careful evaluation of clinical signs and appropriate diagnostic tests are of paramount importance to serve with appropriate treatment.


  Conclusion Top


The knowledge of etiology of disease is extremely important, to differentiate the types of periodontal-endodontic lesions regarding its origin. Removal of etiologic factors accounting for tissue destruction, the lesion may respond to both endodontic and periodontal therapies. However, because of the limited amount of intraoral donor bone, it is preferable to use DFDBA for the treatment of large osseous defects with a predictable prognosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Shenoy N, Shenoy A. Endo-perio lesions: Diagnosis and clinical considerations. Indian J Dent Res 2010;21:579-85.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Aspriello SD, Ferrante L, Rubini C, Piemontese M. Comparative study of DFDBA in combination with enamel matrix derivative versus DFDBA alone for treatment of periodontal intrabony defects at 12 months post-surgery. Clin Oral Investig 2011;15:225-32.  Back to cited text no. 2
    
3.
Vaziri S, Vahabi S, Torshabi M, Hematzadeh S.In vitro assay for osteoinductive activity of different demineralized freeze-dried bone allograft. J Periodontal Implant Sci 2012;42:224-30.  Back to cited text no. 3
    
4.
Jindal V, Gill AS, Kapoor D, Gupta H. The comparative efficacy of decalcified allogenic bone matrix and intra-oral free osseous autografts in the treatment of periodontal intrabony defects. J Indian Soc Periodontol 2013;17:91-5.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Verma PK, Srivastava R, Gupta KK, Srivastava A. Combined endodontic – Periodontal lesion: A clinical dilemma. J Interdiscip Dent 2011;1:119-24.  Back to cited text no. 5
    
6.
Vishwas JR, Shaikh SY, Tambe VH, Ali FM, Mustafa M. Management of endodontic-periodontic lesion of a maxillary lateral incisor with palatoradicular groove. Saudi Endod J 2014;4:83-6.  Back to cited text no. 6
  [Full text]  
7.
Simon JH, Glick DH, Frank AL. The relationship of endodontic-periodontic lesions. J Periodontol 1972;43:202-8.  Back to cited text no. 7
    
8.
Sunitha VR, Emmadi P, Namasivayam A, Thyegarajan R, Rajaraman V. The periodontal – endodontic continuum: A review. J Conserv Dent 2008;11:54-62.  Back to cited text no. 8
    
9.
Behfarnia P, Shahabooei M, Mashhadiabbas F, Fakhari E. Comparison of bone regeneration using three demineralized freeze-dried bone allografts: A histological and histomorphometric study in rabbit calvaria. Dent Res J (Isfahan) 2012;9:554-60.  Back to cited text no. 9
    
10.
Schwartz Z, Somers A, Mellonig JT, Carnes DL Jr., Dean DD, Cochran DL, et al. Ability of commercial demineralized freeze-dried bone allograft to induce new bone formation is dependent on donor age but not gender. J Periodontol 1998;69:470-8.  Back to cited text no. 10
    
11.
Miron RJ, Bosshardt DD, Laugisch O, Dard M, Gemperli AC, Buser D, et al. In vitro evaluation of demineralized freeze-dried bone allograft in combination with enamel matrix derivative. J Periodontol 2013;84:1646-54.  Back to cited text no. 11
    


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