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CASE REPORT
Year : 2020  |  Volume : 10  |  Issue : 3  |  Page : 279-282

Healing of an endodontic-periodontal lesion caused by trauma. A Case report


1 Department of Endodontics, Dental Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
2 Department of Dental, Ministry of Health, Riyadh, Saudi Arabia
3 Prince Abdulrahman Advanced Dental Institute, Riyadh, Saudi Arabia

Date of Submission02-Oct-2019
Date of Decision23-Dec-2019
Date of Acceptance14-Jan-2020
Date of Web Publication27-Aug-2020

Correspondence Address:
Dr. Hind Alquthami
Department of Endodontics, Dental Center, Prince Sultan Military Medical City, P.O. Box: 7897, Riyadh 11159
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sej.sej_184_19

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  Abstract 


Endodontic-periodontal lesions can originate from infections of the periodontium or tissues of the dental pulp. Dental trauma to the face can affect teeth and cause pulp necrosis, which, in turn, leads to periodontal breakdown, pocket formation, and alveolar bone loss. These types of lesions are categorized as retrograde periodontal lesions of endodontic origin, which is the same condition of the case presented in this report. A 37-year-old healthy male had trauma 6 months ago and reported with a chief complaint of oral pain while biting on his maxillary right canine. Clinical examination revealed Grade II mobility and a deep periodontal pocket. Radiographic examinations showed an advanced bone resorption around the tooth. Pulp necrosis with symptomatic apical periodontitis was diagnosed. Root canal treatment was performed and the case was followed for one year. Thorough history taking and investigation led to successful outcome, with the tooth exhibiting complete soft - and hard-tissue healing.

Keywords: Alveolar bone fracture, dental trauma, endodontic-periodontal lesions, luxative injuries


How to cite this article:
Alquthami H, Alquthami A, Alghofili A, Alrushoud SS. Healing of an endodontic-periodontal lesion caused by trauma. A Case report. Saudi Endod J 2020;10:279-82

How to cite this URL:
Alquthami H, Alquthami A, Alghofili A, Alrushoud SS. Healing of an endodontic-periodontal lesion caused by trauma. A Case report. Saudi Endod J [serial online] 2020 [cited 2020 Oct 31];10:279-82. Available from: https://www.saudiendodj.com/text.asp?2020/10/3/279/293577




  Introduction Top


One potential cause of the development of endodontic-periodontal lesion is traumatic injury to the orofacial region. These lesions can occur distinctly or in combination. Communication between both tissues can occur via the apical foramen, accessory canals, or exposed dentinal tubules, enabling a bi-directional spread of infection and/or inflammation.[1],[2] Over time, untreated teeth that have been devitalized due to trauma can undergo secondary consequential periodontal breakdown, pocket formation, and alveolar bone loss.[1],[2],[3]

Successful treatment outcomes in endodontic-periodontal lesions depend on accurate history taking, appropriate investigations, accurate diagnosis, and immediate implementation of appropriate treatment strategies.

Many systems have been proposed for the classification of endodontic-periodontal lesions, with the most common being that described by Simon et al. in 2013.[4] This classification is based on the initial cause of the disease. In 2014, Al-Fouzan[1] proposed another classification system for endodontic-periodontal lesions based on the primary origin of disease and its secondary effects.

These classification systems are based on the origins of different conditions and on the combined nature of the process of development of endodontic-periodontal lesions. Understanding these aspects is essential for achieving predictable results when treating such lesions. The objective of this case report was to highlight the importance of accurate history taking of the late trauma case, to emphasize the rule of radiographic and cone-beam investigations to reach the correct diagnosis and classification of the pulp and periodontal condition, and to know how this information allows a better selection of therapeutic measures.


  Case Report Top


A 37-year-old male reported to the department of endodontics with the chief complaint of oral pain, especially while biting using the upper right anterior teeth, which he had been experiencing for 1 month. He had received a blow to his face before 6 months. His medical history was unremarkable. Clinical examination revealed Grade II mobility and a deep periodontal pocket [>13 mm; [Figure 1]a of tooth number 13 (maxillary right canine). The tooth had an intact crown, was tender to percussion and palpation, and yielded a negative response in the thermal vitality test (Endo-Ice; Hygienic Corp., Akron, OH, USA). Methylene blue staining was performed to exclude the presence of a crack or root fracture, and the result was negative.
Figure 1: (a) A deep periodontal pocket (>13 mm) associated with tooth #13 (maxillary right canine). (b) Initial radiograph of tooth #13 depicting bone resorption on the mesial and distal surfaces of the tooth from the coronal direction, extending toward the apical third of the root. (c) Cone-beam computed tomography depicting extensive bone resorption around the tooth and displacement of the tooth in the distal and buccal directions. (d) Fracture of the alveolar bone in the buccal cortical plate. (e) Splint placement. (f) Postoperative radiograph after completion of the endodontic treatment. (g) One-year recall radiograph depicting healed bony lesion

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Radiographic examination revealed a radiolucency involving the mesial and distal surfaces of the tooth and bone loss from the coronal direction, extending toward the apical third of the root [Figure 1]b. A fracture in the alveolar bone was suspected, which was subsequently confirmed through cone-beam computed tomography (CBCT) [Figure 1]c and [Figure 1]d. CBCT revealed advanced bone resorption around the tooth, fracture of buccal alveolar bone, and displacement of the tooth in distal and buccal directions. Pulp necrosis with symptomatic apical periodontitis was diagnosed.

Endodontic treatment was accomplished in two visits, with calcium hydroxide medication placed into the root canal between appointments. Before treatment, the patient signed a consent form. Local anesthesia with 1.8 mL of lidocaine with epinephrine (1:100,000) was administered, and the tooth was stabilized by splinting it to the adjacent teeth using an orthodontic wire and a composite resin [Figure 1]e. The tooth was isolated using a rubber dam. An access opening was created, and one canal was located. The initial file length was 25 mm as determined by the apex locator (Root ZX, J. Morita, Tokyo, Japan) and confirmed on periapical radiograph. Chemomechanical debridement was performed with ProFile. 04 and ProFile. 06 taper rotary instruments (Dentsply Tulsa Dental, Tulsa, OK, USA) and sodium hypochlorite. Obturation of the canal was performed with warm vertical compaction of gutta-percha size 0.04 cone and a root canal sealer (AH Plus, Dentsply Maillefer, Tulsa, OK, USA) [Figure 1]f. Composite resin was used to seal the access cavity. The splint was removed after 4 weeks. Complete healing of the bony lesion and absences of tooth mobility with a normal pocket depth of 3 mm were achieved over the course of follow-up appointments at 3 months, 6 months, and 1 year [Figure 1]g.


  Discussion Top


Dental trauma to the face can affect the pulp and the periodontal supporting structures of the affected tooth, especially in tooth luxation and alveolar bone fractures, like the presented case in this report. Luxation injuries involve displacement of a tooth from its normal position in the alveolus and can result in damage to the periodontium. The damage can be detected immediately after the injury or later. Some sequelae such as pulp necrosis, pulp chamber and canal calcifications or obliterations, and root and bone resorption may be detected during follow-up appointments.[5],[6],[7],[8]

Several factors influence the prognosis in such cases, including the severity of injury, the time elapsed between dental trauma and treatment, the stage of root apex closure, the type of splint used, and the splinting time.[8],[9] All of these factors had been evaluated in this case report. The patient in this report had received a blow to his face accidentally and neglected seeking of immediate dental care for 6 months until clinical signs and symptoms had appeared.[10] The presence of close apex tooth with Grade II mobility and alveolar bone fracture together with pulp necrosis could affect the prognosis of such dentoalveolar trauma cases.

Fracture of the alveolar process can involve the facial or lingual plates or both, and such fractures are usually accompanied by injury of one or more teeth. Although intraoral and extraoral radiographies can aid the detection of these fractures, CBCT images can reveal better details pertaining to the extension of the fracture line and the involvement of one or two cortical plates. It can also facilitate better assessment of the fracture width, displacement of teeth or bone fragments, and the continuity of jaw outline.[11],[12]

Displacement of teeth in luxation injuries has the potential to disrupt the neurovascular supply to the pulp. Crushing of the periodontal fibers and restriction/compression of channels of blood supply (apical canal and lateral canal) to the pulp cause ischemia, which can lead to necrosis. Further, root maturity and the degree and direction of tooth displacement have a significant influence on the onset of ischemic necrosis. This highlights the rationale for repositioning and splinting teeth following injury.[13],[14] Unfortunately, the delayed splinting of the tooth in the present case led to all the mentioned undesired complications.

The reported prevalence of pulp necrosis in luxated teeth varies with the type and severity of trauma and ranges from 17% to 100%.[15],[16],[17] The delayed seeking of treatment after trauma in the presented case led to pulp necrosis, periodontal breakdown, and the development of endodontic-periodontal lesions with bone resorption and pocket formation. This type of lesion due to dental trauma has been highlighted in literature as one of the causes that lead to endodontic-periodontal lesions. Such lesions are primarily endodontic, which subsequently affect the periodontium through the apical foramen and lateral canal as had seen in the final radiograph of this case report [Figure f].[1],[3]

Adequate splinting has been advocated after repositioning of luxated teeth and/or fractured alveolar bone, both for stabilization and for optimizing healing outcomes with respect to the tooth pulp and the supporting periodontal apparatus. The International Association of Dental Traumatology guidelines recommend that splinting should be flexible rather than rigid and that splinting should be employed for a relatively short period.[18] They recommend a flexible splint for 4 weeks for lateral luxation injuries as well as for alveolar bone fractures.[17],[18] Such splinting has often been achieved with the use of composite resin and light wire, as we had applied in the present case. The recommended postsplint follow-up periods are 6–8 weeks, 4 months, 6 months, 1 year, and 5 years, and they should include clinical and radiographic examinations.[19],[20],[21],[22] This protocol was applied in the presented case in this report, and complete soft- and hard-tissue healing and normal pocket depth 3 mm have been reported at follow-up periods of 8 weeks, 6 months, and up to 1 year.


  Conclusion Top


This case report highlights the importance of using the recent classification in understanding the nature of developed endodontic-periodontal lesions and how to manage through conservative approach, root canal therapy, and tooth splinting. The correct diagnosis of late dentoalveolar luxated injury and management of its complications in conjunction with a thorough understanding of the causative factors and the clinician's experience can negate the loss of the teeth involved.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Al-Fouzan KS. A new classification of endodontic-periodontal lesions. Int J Dent 2014;2014:1-7.  Back to cited text no. 1
    
2.
Zehnder M, Gold SI, Hasselgren G. Pathologic interactions in pulpal and periodontal tissues. J Clin Periodontol 2002;29:663-71.  Back to cited text no. 2
    
3.
Alquthami H, Almalik AM, Alzahrani FF, Badawi L. Successful management of teeth with different types of endodontic-periodontal lesions. Case Rep Dent 2018;2018:1-7.  Back to cited text no. 3
    
4.
Simon JH, Glick DH, Frank AL. The relationship of endodontic-periodontic lesions. J Endod 2013;39:e41-6.  Back to cited text no. 4
    
5.
Breik O. Discuss how the management of trauma to the dentition is influenced by the type and severity of injury. Aust Endod J 2008;34:120-5.  Back to cited text no. 5
    
6.
Andreasen JO. Luxation of permanent teeth due to trauma. A clinical and radiographic follow-up study of 189 injured teeth. Scand J Dent Res 1970;78:273-86.  Back to cited text no. 6
    
7.
Hecova H, Tzigkounakis V, Merglova V, Netolicky J. A retrospective study of 889 injured permanent teeth. Dent Traumatol 2010;26:466-75.  Back to cited text no. 7
    
8.
Andreasen FM, Pedersen BV. Prognosis of luxated permanent teeth-the development of pulp necrosis. Endod Dent Traumatol 1985;1:207-20.  Back to cited text no. 8
    
9.
Andreasen JO, Bakland LK, Andreasen FM. Traumatic intrusion of permanent teeth. Part 2. A clinical study of the effect of preinjury and injury factors, such as sex, age, stage of root development, tooth location, and extent of injury including number of intruded teeth on 140 intruded permanent teeth. Dent Traumatol 2006;22:90-8.  Back to cited text no. 9
    
10.
Al-Nazhan S, Andreasen JO, Al-Bawardi S, Al-Rouq S. Evaluation of the effect of delayed management of traumatized permanent teeth. J Endod 1995;21:391-3.  Back to cited text no. 10
    
11.
Alimohammadi R. Imaging of dentoalveolar and jaw trauma. Radiol Clin North Am 2018;56:105-24.  Back to cited text no. 11
    
12.
Farmakis ER, Damaskos S, Konstandinidis C. Cone beam computed tomography imaging as a diagnostic tool in determining root fracture in endodontically treated teeth. Saudi Endod J 2012;2:22-8.  Back to cited text no. 12
  [Full text]  
13.
Lam R. Epidemiology and outcomes of traumatic dental injuries: A review of the literature. Aust Dent J 2016;61 Suppl 1:4-20.  Back to cited text no. 13
    
14.
Lee R, Barrett EJ, Kenny DJ. Clinical outcomes for permanent incisor luxations in a pediatric population. II. Extrusions. Dent Traumatol 2003;19:274-9.  Back to cited text no. 14
    
15.
Nikoui M, Kenny DJ, Barrett EJ. Clinical outcomes for permanent incisor luxations in a pediatric population. III. Lateral luxations. Dent Traumatol 2003;19:280-5.  Back to cited text no. 15
    
16.
Love RM. Effects of dental trauma on the pulp. Pract Periodontics Aesthet Dent 1997;9:427-36.  Back to cited text no. 16
    
17.
Humphrey JM, Kenny DJ, Barrett EJ. Clinical outcomes for permanent incisor luxations in a pediatric population. I. Intrusions. Dent Traumatol 2003;19:266-73.  Back to cited text no. 17
    
18.
International Dental Association of Dental Traumatology. Available from: https://www.iadt-dentaltrauma.org/Published%20Guidelines%20Combined_2018.pdf. [Last accessed on 2019 Jul 24].  Back to cited text no. 18
    
19.
Kahler B, Hu JY, Marriot-Smith CS, Heithersay GS. Splinting of teeth following trauma: A review and a new splinting recommendation. Aust Dent J 2016;61 Suppl 1:59-73.  Back to cited text no. 19
    
20.
Ngassapa DN, Freihofer HP, Maltha JC. The reaction of the periodontium to different types of splints. (I). Clinical aspects. Int J Oral Maxillofac Surg 1986;15:240-9.  Back to cited text no. 20
    
21.
Andreasen FM, Zhijie Y, Thomsen BL, Andersen PK. Occurrence of pulp canal obliteration after luxation injuries in the permanent dentition. Endod Dent Traumatol 1987;3:103-15.  Back to cited text no. 21
    
22.
Oikarinen K, Gundlach KK, Pfeifer G. Late complications of luxation injuries to teeth. Endod Dent Traumatol 1987;3:296-303.  Back to cited text no. 22
    


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