Multidisciplinary management of concomitant pulpal and periodontal lesion: A case report.

In this case report, the management of a concomitant endodontic-periodontal lesion case is described. A 31-year-old patient presented with symptomatic apical periodontitis of tooth #36 due to failed endodontic treatment and a generalized aggressive periodontitis. Following full-mouth scaling and root-planing, a root-canal retreatment (tooth #36) was initiated. While the distal and mesio-buccal canals were successfully treated, a transportation perforation of the mesio-lingual canal occurred and was repaired by the MTA. An apical microsurgery of the mesial root combined with surgical periodontal debridement for the lower left quadrant was performed. Three weeks later, resective and regenerative periodontal surgeries of the other 3 quadrants were accomplished. Because of the 6-month post-operative healing, the regenerative periodontal surgery for the lower-left quadrant was performed. The 6-month post-operative recall showed complete healing of the mesial root lesion and reduction of the distal root lesion. The multidisciplinary approach and advanced armamentarium contributed to favourable outcome.

Introduction

The dental pulp and the surrounding periodontium communicate through dentinal tubules, lateral canals, developmental grooves and apical foramina, which are potential portals for transmission of disease between both tissues. Diagnosis and therefore differentiation of endodontic and periodontal diseases is challenging because they may have similar clinical characteristics and may impact each other.

Several classifications have been suggested for periodontal-endodontic lesions. Torabinejad & Trope classified them as endodontic origin, periodontal origin, combined endodontic-periodontal lesions, separate endodontic and periodontal lesions, lesions with communication or lesions without communication. A recent classification categorized lesions based on the primary disease with its secondary effect into retrograde periodontal disease (either as primary endodontic lesion with drainage through the periodontal ligament or primary endodontic lesion with secondary periodontal involvement), primary periodontal lesion, primary periodontal lesion with secondary endodontic involvement, combined endodontic-periodontal lesion, or iatrogenic periodontal lesions.

However, a commonly used classification categorizes endodontic-periodontal lesions as Primary Endodontic lesions, Primary Periodontal lesions and Combined lesions. Another category, Concomitant Pulpal and Periodontal lesions, was added later and includes the two separate lesion types simultaneously in which both disease states exist but with different causative factors and with no evidence that either disease has influenced the other.

The combined endodontic-periodontal lesions were investigated; thus, different treatment strategies were described.6, 7, 8 Oh et al. proposed the following 4-phase treatment algorithm: (i) pre-surgical (determining periodontal/regenerative prognosis), (ii) endodontics, (iii) periodontal surgical, and (iv) post-guided-tissue regeneration reevaluation protocol. Tseng et al. reported treatment of a true combined endodontic-periodontal lesion by a nonsurgical root-canal-retreatment followed immediately by a periodontal treatment including guided tissue regeneration. Karabucak and Setzer treated two cases; confirming the effectiveness of an apical surgery supported by periodontal guided tissue regeneration.

The aim of this work is to describe the multidisciplinary clinical management of a concomitant endodontic-periodontal lesion.

Case report

A 31-year-old female patient presented to the endodontic specialty clinic at the dental hospital, King AbdulAziz University, KSA, with a chief complaint, “I have pain when chewing on lower left molars, and a bad mouth smell.” Dental history revealed a five-year old root-canal-treatment (tooth #36) and multiple permanent restorations. Clinical examination (Figure 1A) showed a defective composite restoration on tooth #36, a missing tooth #46, normal response to cold test for #37 and Halitosis, despite fair oral hygiene. Teeth #36 and #37 had 5–6 mm buccal and lingual periodontal pockets. Tooth #36 showed buccal grade-1 furcation involvement with grade-1 mobility. Teeth #37 and #47 showed buccal grade-2 furcation involvement with grade-2 mobility. The three teeth were tender on percussion and palpation. Radiographic examination revealed a previous substandard root-canal-treatment of tooth #36 with apical radiolucency (Figure 1B) and severe vertical bone loss at the proximal area between teeth #36 & #37 and the mesial area of #47 (Figure 1C). A generalized aggressive periodontitis and a previously treated tooth (#36) with symptomatic apical periodontitis were the final diagnosis. The treatment plan involved saving tooth #36 and included the following stages:

Figure 1

(A) Pre-operative clinical view. (B) Pre-operative periapical radiograph. (C) Panoramic radiograph showing bilateral vertical bone loss (arrows). (D–F) Retreatment procedures radiographs. (G–I) Cone Beam Computerized Tomography (CBCT) assessment of lower left quadrant.

Initial Periodontal Treatment

Full-mouth scaling and root planing were combined with adjunctive antibiotic coverage as described by Lindhe et al. (Augmentin 1 gm twice/day and Metronidazole 500 mg 3 times/day for 2 weeks).

Endodontic Treatment (tooth #36)

The defective composite restoration was removed, and the tooth (#36) was rebuilt with glass-ionomer cement (GIC) (Fuji IX GP®, GC, Chicago, IL). The old gutta-percha filling was removed using ProTaper Universal Retreatment® files (Dentsply Tulsa Dental, Tulsa, OK) (Figure 1D–F). The distal and mesio-buccal canals were successfully cleaned and shaped up to X3 ProTaper-Next, files (Dentsply Tulsa Dental, Tulsa, OK). However, a transportation perforation occurred while negotiating the mesio-lingual canal. The distal and mesio-buccal canals were obturated with gutta-percha and sealer using the continuous wave technique. The perforated mesio-lingual canal was repaired with ProRoot MTA cement (Dentsply Tulsa Dental, Tulsa, OK). The tooth was restored with GIC for one week and later replaced with composite (GC America, Chicago, IL) (Figure 1F).

Surgical Endodontic and Periodontal Treatment

A decision on apical microsurgery of the mesial root combined with a surgical periodontal debridement was agreed. A preoperative Cone-Beam-Computerized-Tomography (CBCT) showed 4.5 mm between the mesial root apex (tooth #36) and the mental foramen and 4.4 mm between the root apices and the mandibular canal. The CBCT also showed 8.8 mm bucco-lingual thickness of the mesial root. Following local anaesthesia, a vertical incision mesial to tooth #34 and a sulcular incision extending from tooth #34 to #37 distal surface, a triangular full-thickness flap was reflected to perform periodontal debridement (Figure 2). Under microscope magnification and following an osteotomy, the apical 4 mm of the mesial root (tooth #36) was resected, the canals were identified and two 3 mm retrograde cavities were prepared using surgical ultrasonic tips (Satelec/Acteon, Merignac, France) and were filled with MTA (Figure 3). The flap was replaced, sutured and a post-surgery radiograph was taken. Three weeks later, resective and regenerative periodontal surgeries of the other three quadrants were performed. (Figure 4A–C). Six months post-apical surgery, good healing of periapical and periodontal tissues of tooth #36 was observed clinically and radiographically (Figure 4D and E). Therefore, the regenerative periodontal surgery for the lower left quadrant using a bone graft and a collagen membrane were performed (Figure 4D–I).

Figure 2

Regenerative periodontal surgery of lower left quadrant.

Figure 3

Some steps of apical microsurgery of mesial root of tooth #36; (A) Working length determination (B) Osteotomy. (C) Root after resection. (D) Retro-cavity preparation. (E) MTA retro-filling. (F) Suturing.

Figure 4

Radiographic assessment of treatment outcome. (A) Pre-Operative Radiographs. (B) Post-Apical Surgery radiograph. (C) 6 months follow up radiographs. (D) 1 year follow up radiographs.

Follow-up

The 6-month post-periodontal surgery clinical and radiographic follow-up revealed normal response of teeth #36 and 37 to palpation and percussion, normal mobility, improved periodontal and almost complete healing of the mesial root lesion and a significant reduction of the distal root lesion (Figure 3A–D). However, taking radiographic images with the same angle in a standardized method would have better confirmed the healing of periapical tissues. Nevertheless, efforts were made to take the follow-up radiograph from a similar angle to that taken at the time of the procedure.

Discussion

Proper management of endodontic-periodontal lesions requires precise diagnosis and identification of aetiological factors. This case presented a treatment of a concomitant pulpal-periodontal lesion. This disease may progress undiagnosed, and the treatment is rendered to only one of the diseased tissues; thus, the other may respond favourably. Management of such lesions necessitates dealing with both diseases concomitantly.

For this case, the chief complaint was pain on biting on the left area, which suggests the presence of an apical or periodontal disease. Clinical investigation revealed tenderness of tooth #36 on percussion, periodontal pockets and halitosis. The radiographic examination showed apical radiolucency of both roots of tooth #36 and vertical bone loss in that area. Considering the dental history (previous root canal treatment), the case was diagnosed as previously treated tooth (#36) with symptomatic apical periodontitis associated with generalized aggressive periodontitis.

Periapical radiographs provide limited information because the three-dimensional anatomy is represented in a two-dimensional image. In contrast, the CBCT eliminates superimposition of the surrounding structures, detects undiagnosed lesions and can differentiate between apical cysts and granuloma.12, 13, 14 However, for the latter, it should be noted that recent studies showed that CBCT is not a reliable method for differentiating radicular cysts from granuloma lesions. Nevertheless, it is well-accepted that histopathological examination of the lesion biopsy remain the standard procedure for differential diagnosis. Unfortunately, biopsy has not been considered for this case, which can be counted as one limitation. Additionally, CBCT enables accurate 3-D measurements. Therefore, CBCT is an important tool in diagnosis and treatment planning. The treatment of generalized aggressive periodontitis included several surgical and non-surgical procedures supplemented by antibiotics.

Failed endodontic treatments can be managed by surgical or non-surgical retreatment. The most common aetiology of such cases is persistent intra-radicular infection. This infection is usually subsequent to sub-standard root-canal-treatment without rubber-dam augmented by defective coronal restorations. Therefore, the non-surgical root canal retreatment was preferred because it enabled cleaning and disinfecting of infected root-canals. However, the transportation perforation rendered the cleaning procedures of the apical part of the mesio-lingual canal. Consequently, an apical microsurgery was performed to resect the un-negotiated part of the root-canal, which might be highly colonized by bacteria.15, 16 Performing the endodontic retreatment and the apical microsurgery under the high magnification of a dental operating microscope showed no signs of cracks or fractures of the offending tooth. In addition, CBCT investigation ruled out other possible aetiological factors, such as vertical root fracture.

Kim & Kratchman divided endodontic-periodontal lesions undergoing apical microsurgery into 6 categories to assess treatment modalities. Accordingly, the severe classes (the endodontic lesion communicates with the periodontal defect) require a concurrent bone graft and membrane-barrier techniques in addition to endodontic microsurgery for a more predictable outcome. However, for lesions without such communication, neither operating problems nor adverse effects on the treatment outcome are observed.18, 19 Since the mesial-root lesion was large but did not communicate with a periodontal defect, the apical microsurgery was performed without guided-tissue-regeneration procedures. The distal root was not resected because the distal canals were cleaned and shaped, then filled to the full working length, and it was adjacent to anatomical challenges (the mandibular canal). Additionally, we tried not to sacrifice additional root structure, which may enhance tooth retention. Moreover, osteotomy and resection in such cases may result in complicated communication with the periodontal defect.18, 19

Observing good healing of the endodontic lesion prior to the regenerative periodontal surgery was promising; creating a favourable environment for periodontal repair by bone-grafting and membrane. One year post-endodontic intervention (6 months after the final periodontal surgery), a healed apical lesion of the mesial-root was noticed with significant reduction of the distal-root lesion and bone formation at the periodontal bone defect. Advanced innovations, such as magnification, ultrasonics and biocompatible retrograde-filling materials (i.e., MTA), have contributed to better outcomes of endodontic microsurgery (up to 94%) compared to conventional surgery (54%).21, 22 The good healing in the current case may be attributed also to the combined management of endodontic retreatment and apical microsurgery. Healing of the mesial root lesion after its apical resection was faster than that of the distal root (treated without apical surgery). This finding could be attributed to the creation of a clean wound without irritation to the alveolar bone. Non-surgical retreatment does not include curettage of the inflamed tissues. Subsequently, the body has to remove the tissues as part of the healing response. This removal necessitated a longer follow up for the distal-root lesion compared to the resected mesial-root to assure a better outcome.

Conclusions

Eliminating possible aetiological factors and a multidisciplinary approach are essential factors for successful management of endodontic-periodontal lesions. Recent advances in endodontic armamentarium and materials offer better control and precise management of the disease.

Authors' contribution

MAA and HYE performed the treatment and wrote the first draft of the manuscript. AS and AM finalised writing the manuscript. AS retrieved references from the literature and revised the mauscript. AM acted as a corresponding author.

Conflict of interest

The authors have no conflict of interest to declare.