Management of endodontic-periodontic lesion of a maxillary lateral incisor with palatoradicular groove

Jayshree Ramakrishna Vishwas; Shoeb Yakub Shaikh; Varsha H. Tambe; Fareedi Mukram Ali; Mohammed Mustafa

doi:10.4103/1658-5984.132728

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CASE REPORT

Year : 2014 | Volume : 4 | Issue : 2 | Page : 83-86

Management of endodontic-periodontic lesion of a maxillary lateral incisor with palatoradicular groove

Jayshree Ramakrishna Vishwas¹, Shoeb Yakub Shaikh², Varsha H. Tambe³, Fareedi Mukram Ali⁴, Mohammed Mustafa⁵
¹ Department of Conservative Dentistry and Endodontics, SMBT Dental College and Hospitals, Amrutnagar, Sangamner ,Taluka, Maharashtra, India
² Department of Conservative and Endodonlogy, Rural Dental College, Loni, Rahata, Ahmednagar District, Maharashtra, India
³ Department of Conservative and Endodonlogy, SMBT Dental College and Hospitals, Amrutnagar, Sangamner Taluka, Maharashtra, India
⁴ Department of Oral and Maxillofacial Surgery, SMBT Dental College and Hospitals, Amrutnagar, Sangamner Taluka, Maharashtra, India
⁵ Department of Conservative Dental Sciences, Division of Endodontics, College of Dentistry, Salman Bin Abdulaziz University, Al Kharj, Kingdom of Saudi Arabia

Date of Web Publication

19-May-2014

Correspondence Address:
Fareedi Mukram Ali
Department of Oral and Maxillofacial Surgery, SMBT Dental College and Hospitals, Amrutnagar, Sangamner Taluka, Ahmednagar 422 608, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1658-5984.132728

Abstract

Presence of palatal radicular grooves are considered to be an important contributing factor to the development of localized periodontitis, as it favored the accumulation and proliferation of bacterial plaque deep into the periodontium. Pulp involvement could result due to the introduction of bacterial toxins through channels that existed between the root canal system and the groove. Early diagnosis, elimination of inflammation and correction of anatomic complications are the key to a favorable outcome for managing palatoradicular groove. Present report describes successful management with an interdisciplinary approach of maxillary lateral incisor with combined endodontic periodontic lesion associated with palatoradicular groove.

Keywords: Endodontic-periodontal lesion, maxillary incisor, palatoradicular groove

How to cite this article:
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

How to cite this URL:
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 [serial online] 2014 [cited 2023 Mar 22];4:83-6. Available from: https://www.saudiendodj.com/text.asp?2014/4/2/83/132728

Introduction

Dental morphological anomalies of the maxillary incisors are relatively common. In cases of tooth malformation, bacterial invasion and infection are often the cause of pulpal inflammation and tooth loss. ^[1] Dental plaque is an adherent biofilm of bacteria and their products that forms on all tooth surfaces and dental prosthesis. Periodontitis is an inflammatory disease characterized by destruction of the periodontal ligament and alveolar bone. ^[2] Local factors such as irregularities in root anatomy, developmental abnormalities, subgingival restoration margins and overhanging dental restorations play a significant role in the pathogenesis of periodontitis. Inherent anatomic and morphologic features of the teeth can have a significant impact on diagnosis, management and prognosis of the involved teeth. ^[3] Palatal radicular grooves, which have also been termed radicular lingual grooves and distolingual grooves, palatal gingival grooves and radicular palatal grooves are developmental anomalies that represent an in-folding of the enamel organ and the epithelial sheath of hertwigs. ^[4] Usually, these grooves start coronal to the cingulum and continue for varying distances and directions along the root. The groove is locus for plaque accumulation, which destroys the sulcular epithelium and later deeper part of the periodontium, finally resulting in the formation of a severe localized periodontal defect. ^[5] Palatal radicular grooves can vary in depth and complexity. Mild grooves terminate at the cementoenamel junction, whereas, moderate grooves continue apically along the root surface. ^[6] Present report describes successful management with an interdisciplinary approach of maxillary lateral incisor with combined endodontic-periodontal lesion associated with palatoradicular groove.

Case report

A 25-year-old male patient came to the Department of Conservative Dentistry and Endodontics, with a chief complaint of recurrent swelling, pus discharge and dull aching pain associated with maxillary right lateral incisor. Medical and dental history was non-contributory.

On clinical examination, there was no history of trauma and discoloration of tooth. It did not respond to thermal and electric pulp testing, which indicate pulpal necrosis. Periodontal examination revealed 8 mm deep pocket on palatal aspect of maxillary lateral incisor. A deep groove running from cingulum toward the root was seen on palatal aspect. Intraoral periapical radiograph showed diffuse radiolucency at the apex and a radiolucent line was seen adjacent to the root canal mimicking the two canals and angular bone defect on mesial side of the tooth [Figure 1]a. Based on clinical and radiographic findings, a diagnosis of endodontic-periodontal lesion was made. An endodontic treatment followed by periodontal surgery was planned for the tooth. It was explained to the patient and an informed consent was obtained from the patient.

Figure 1: Diagnostic radiograph showing a diffuse radiolucency at the apex of lateral incisor (a). Note radiolucent line running adjacent to the root canal on the distal aspect mimicking two canals. Master cone radiograph (b) and obturation (c)

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Involved tooth was isolated with a rubber dam, access opening was done and working length was estimated. Cleaning and shaping of the canal was done with K-files (Mani, Belgium) using a step back technique [Figure 1]b] and intracanal calcium hydroxide (Prodent, India) dressing was given for 1 week. After a week again the tooth was isolated, after irrigation canal was obturated by cold lateral condensation by Gutta-percha (Dentsply, Switerzland) and AH plus sealer (Dentsply, Germany) [Figure 1]c]. Postendodontic restoration was done [Figure 2]a] with Glass Ionomer Cement (GC Fuji II, Japan). Another day after achieving profound anesthesia a full thickness flap was reflected from palatal aspect to reveal the full extent of the groove [Figure 2]b]. It was running up to the apical third of the root. Scaling and root planning were carried out by Gracey curetts numbers 1 and 2. Radiculoplasty was undertaken using round bur after which groove was sealed with mineral trioxide aggregate (MTA) (Angelus, Brazil) [Figure 2]c]. The flap was replaced and suturing was done. Analgesics and antibiotics tablet ibugesic plus (ibuprofen 400 mg and paracetamol 325 mg, Cipla, India) thrice daily for 5 days and capsule amclaid 625 mg (amoxilcillin 500 mg and clavulanic acid 125 mg, Warren (Indoco) Remedies Ltd., India) twice daily for 5 days were prescribed. Healing was uneventful and sutures were removed after 1 week.{Figure 1}

Figure 2: Mirror view showing deep pocket (8 mm) on palatal aspect (a). The palatoradicular groove terminating until apical third of the root (b). Groove sealed with a mineral trioxide aggregate (c)

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After 3 months recall, the pocket depth was only 2 mm, which was a reduction of 6 mm in probing depth. After 6 months recall, the periodontal health of the tooth was stable and bleeding on probing was not observed [Figure 3]a]. Intraoral periapical radiograph showed continued healing [Figure 3]b] and the tooth was asymptomatic.

Figure 3: Clinical view after 6 months follow-up showing continued healing (a). Periapical radiograph after 6 months showing slight reduction of the periapical lesion (b)

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Discussion

For the sake of understanding PRGs have been classified as simple and complex. While simple groove results from partial in-folding of HERS, the complex one is characterized by direct communication with the pulp. The most complex form of groove may even separate an accessory root from the main root trunk. ^[7]

Presence of palatal radicular grooves are considered to be an important contributing factor to the development of localized periodontitis as it favored the accumulation and proliferation of bacterial plaque deep into the periodontium. ^[4]

These grooves usually began in the central fossa, crossed the cingulum and extended to various distances, depths and directions along the root. The fold usually extended as a twisting defect into the surface of the root to a depth of 2-3 mm and could present radiographically as a radiolucent parapulpal line. ^[1] Pulp involvement could result due to the introduction of bacterial toxins via channels that existed between the root canal system and the groove. ^[6]

Early diagnosis, elimination of inflammation and correction of anatomic complications are the key to a favorable outcome for managing palatoradicular groove.

Conventional root canal therapy will not be effective alone, because etiology was residing extraradicularly as a self-sustaining lesion. Trends in periodontal surgical therapy of palatoradicular groove include the use of alloplastic graft materials and mechanical barrier membrane to facilitate bone regeneration. We did not choose it because it may complicate the healing process and may adversely affect the outcome. ^[8]

Successful management of palatal radicular groove depends upon an ability to eradicate the inflammatory irritants, by elimination of the groove. Radiculoplasty is recommended for elimination of the groove, which can harbors bacteria and debris leading to local inflammatory reaction. ^[9]

In the present case, palatoradicular groove was primary etiological factor to develop the endodontic-periodontal lesion. Its elimination and sealing was of prime important so periodontal surgery was performed as early as possible for fast healing of both endodontic and periodontal lesion. Because these two entities have different healing pattern, healing of endodontic lesion will not affect periodontal outcome and vice versa. Depth of the groove was evaluated after reflecting the flap by using Williams graduated probe, which was around 3 mm.

Various materials and methods have been used by various practioners to obliterate the groove, which include amalgam, composite, MTA and Glass Ionomer Cement. MTA was initially introduced as a root-end filling material for surgical endodontic procedures. Since then, its clinical applications have broadened to include perforation repair, pulp capping, pulpotomy and apexification. During these procedures, the dental filling materials usually come into contact with the underlying tissues. The bond strength of most dental materials is significantly reduced by moisture contamination from the tissue, whereas MTA requires the presence of water for setting. Therefore, set MTA can acquire its optimal strength and produce excellent sealability in the presence of moisture. ^[10] MTA offers a biologically active substrate for bone cells and permits cementoblast attachment, growth and the production of mineralized matrix gene and osteocalcin expression. ^[11] MTA has an antibacterial effect, biocompatible, optimal strength and excellent sealability in the presence of moisture, ability to form cementum layer and hard tissue formation when used as root end filling material. Zhu et al. reported that human osteoblast-like Saos-2 cells attach and spread well on the surface of MTA after 1 day in Culture. ^[12] Balto demonstrated that human periodontal ligament fibroblasts were well attached and grew on MTA. ^[13] Although there are a number of studies, which have mentioned use of guided tissue regeneration. in the field of periodontal regeneration, literature does not reveal any study regarding use of MTA to seal palatoradicular groove. Because MTA has got all excellent properties in the field of regeneration for both hard and soft-tissues it was used to seal the groove.

In the present case, healing was uneventful in periapical and periodontal lesion and reduction in pocket depth.

Conclusion

A proper diagnosis of endo-perio lesion is essential for successful management of these complex cases. It is important to recognize the role of palatoradicular groove as a contributing factor in the progression of localized periodontic-endodontic lesions. Most of the diagnosed cases require an interdisciplinary approach for the successful management of this pathology.

References

1.	Ballal NV, Jothi V, Bhat KS, Bhat KM. Salvaging a tooth with a deep palatogingival groove: An endo-perio treatment: A case report. Int Endod J 2007;40:808-17.
2.	Van Dyke TE, Lester MA, Shapira L. The role of the host response in periodontal disease progression: Implications for future treatment strategies. J Periodontol 1993;64:792-806.
3.	Matthews DC, Tabesh M. Detection of localized tooth-related factors that predispose to periodontal infections. Periodontol 2000 2004;34:136-50.
4.	Shaju JP. Palatogingival developmental groove. Quintessence Int 2001;32:349. [PUBMED]
5.	Rethman MP. Treatment of a palatal-gingival groove using enamel matrix derivative. Compend Contin Educ Dent 2001;22:792-7. [PUBMED]
6.	Friedman S, Goultschin J. The radicular palatal groove: A therapeutic modality. Endod Dent Traumatol 1988;4:282-6. [PUBMED]
7.	Goon WW, Carpenter WM, Brace NM, Ahlfeld RJ. Complex facial radicular groove in a maxillary lateral incisor. J Endod 1991;17:244-8.
8.	Wang HL, MacNeil RL. Guided tissue regeneration. Absorbable barriers. Dent Clin North Am 1998;42:505-22.
9.	Zucchelli G, Mele M, Checchi L. The papilla amplification flap for the treatment of a localized periodontal defect associated with a palatal groove. J Periodontol 2006;77:1788-96.
10.	Torabinejad M, Higa RK, McKendry DJ, Pitt Ford TR. Dye leakage of four root end filling materials: Effects of blood contamination. J Endod 1994;20:159-63.
11.	Koh ET, McDonald F, Pitt Ford TR, Torabinejad M. Cellular response to mineral trioxide aggregate. J Endod 1998;24:543-7.
12.	Zhu Q, Haglund R, Safavi KE, Spangberg LS. Adhesion of human osteoblasts on root-end filling materials. J Endod 2000;26:404-6.
13.	Balto HA. Attachment and morphological behavior of human periodontal ligament fibroblasts to mineral trioxide aggregate: A scanning electron microscope study. J Endod 2004;30:25-9. [PUBMED]