Hindawi

Case Reports in Dentistry

Volume 2018, Article ID 7084245, 7 pages
https://doi.org/10.1155/2018/7084245

Case Report
Successful Management of Teeth with Different Types of
Endodontic-Periodontal Lesions

Hind Alquthami ,1 Abdulaziz M. Almalik,2 Faisal F. Alzahrani,3 and Lana Badawi4

1
Department of Dentistry, Division of Endodontics, Prince Sultan Military Medical City, P.O. Box 7897, Riyadh 11159, Saudi Arabia
2
Department of Dentistry, Division of Periodontics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
3
Department of Dentistry, Division of Orthodontics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
4
Department of Dentistry, Division of Endodontics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia

Correspondence should be addressed to Hind Alquthami; halqathami@pscc.med.sa

Received 30 January 2018; Revised 17 April 2018; Accepted 6 May 2018; Published 29 May 2018

Academic Editor: Samir Nammour

Copyright © 2018 Hind Alquthami et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

Endodontic-periodontal diseases often present great challenges to the clinician in their diagnosis, management, and prognosis.
Understanding the disease process through cause-and-effect relationships between the pulp and supporting periodontal tissues
with the aid of rational classifications leads to successful treatment outcomes. In this report, we present several treatment
modalities in patients with different endodontic-periodontal lesions. A modification to the new endodontic-periodontic
classification, Al-Fouzan’s classification, was also added. The first case was classified as retrograde periodontal disease
(i.e., primary endodontic lesion with drainage through the periodontal ligament). The second case was diagnosed as an
iatrogenic periodontal lesion caused by root perforation. The third case was diagnosed as an iatrogenic periodontal lesion caused
by tooth trauma due to orthodontic treatment. The first two cases were managed with a nonsurgical approach, whereas the third
case was managed with nonsurgical and surgical approaches. All patients showed complete healing of soft and hard tissue
lesions. A thorough understanding of the disease history and the patient’s signs and symptoms, complete examination with full
investigation, and the use of a systematic step-by-step approach in the management of such challenging endodontic-periodontal
lesions with regular recall visits were very useful and successful.

1. Introduction common classifications of endodontic-periodontal lesions

were primary endodontic disease, primary periodontal
An endodontic-periodontal lesion consists of concurrent disease, and combined disease, depending on the cause of
pulpal and periodontal disease in the same tooth. The spread the lesion [3]. In 2014, Al-Fouzan [4] suggested a new
of infection between the dental pulp and the periodontal lig- endodontic-periodontal interrelationship classification, based
ament can occur through the apical foramen, lateral canals, on the primary disease and its secondary effect. The classi-
dentinal tubules, and palatogingival grooves. Moreover, non- fication is as follows.
anatomic factors can have a role in this communication such
as iatrogenic root canal perforations or a vertical root (1) Retrograde periodontal disease
fracture. These pathways cause the spread of infection and
bone destruction in a coronal-to-apical direction in the case (a) Primary endodontic lesion with drainage
of periodontal infection or in an apical-to-coronal direction through the periodontal ligament
in the case of endodontic infection [1]. (b) Primary endodontic lesion with secondary
In 1964, Simring and Goldberg [2] were the first to periodontal involvement
describe the relationship between pulpal and periodontal
disease and referred to it as an “endo-perio lesion.” The most (2) Primary periodontal lesion
2 Case Reports in Dentistry

(3) Primary periodontal lesion with secondary endodon- was referred to the endodontic specialist clinic at PSMMC
tic involvement complaining of pain and localized intraoral swelling in the
left first mandibular molar. One year earlier, the tooth had
(4) Combined endodontic-periodontal lesion undergone root canal treatment with cementation of the post
(5) Iatrogenic periodontal lesion and core and placement of a permanent crown. The clinical
examination revealed localized swelling in the gingival
This rational classification increases the understanding of sulcus. Periodontal probing through the furcation showed
the disease process and its origin. This understanding is increased probing values with a grade II defect [2] (Figure 2).
essential in determining the correct diagnosis and providing The radiographic examination revealed a large post in the
treatment with predictable success. The success rate of joined distal canal and a large furcal lesion related to the distal
endodontic-periodontal lesions without a regenerative pro- root opposite the post placement. Iatrogenic root perforation
cedure is between 27% and 37% [5]. These rates are much was suspected.
lower than the success rate of 95% with conventional nonsur- After the administration of local anesthesia (1.8 mL of
gical root canal therapy [6]. The use of barrier membranes lidocaine with 1 : 100,000 epinephrine), the crown was
and/or bone-grafting materials during treatment encourages removed with a crown removal instrument, and the post
the growth of surrounding lost tissues such as the periodontal was removed with an ultrasonic instrument using a light
ligament, bone cementum, and connective tissue while pre- brush and cutting motion to break up the cement around
venting unwanted cell types such as epithelial cells [7]. The the post. A paper point was used to check for the presence
aim of this paper was to present the diagnosis and manage- of blood spots to determine the location and size of the per-
ment of different endodontic-periodontal disease conditions foration. The perforation site was irrigated with 2.5% sodium
with or without the use of regenerative bone techniques. hypochlorite followed by drying of the canal and sealing of
the perforation with mineral trioxide aggregate (MTA;
2. Case Presentations Dentsply Tulsa Dental) mixed with saline and placed with a
microapical placement system (Dentsply Tulsa Dental) and
2.1. Case 1: Retrograde Periodontal Disease: A Primary condensed with a paper point (Figure 2). A wet cotton pellet
Endodontic Lesion with Drainage through the Periodontal was then placed on the MTA material. The tooth was tempo-
Ligament. A 55-year-old woman with a noncontributory rized with glass-ionomer cement and cementation of the
medical history was referred to the endodontic specialist crown. At the second visit, the cotton pellet was removed
clinic at Prince Sultan Military Medical City (PSMMC; and the MTA setting was checked.
Riyadh, Saudi Arabia) complaining of intraoral sinus with The patient was referred to the prosthodontics depart-
pus drainage in the right mandibular molar area. Clinical ment for permanent crown placement. Follow-up appoint-
and radiographic examinations revealed a large amalgam ments at 3 months, 6 months, 9 months, and up to 4 years
restoration with recurrent caries and periapical and furcal showed complete healing of the soft tissue and bone lesions
radiolucency related to tooth #46. There was localized swell- and a normal pocket depth of 3 mm.
ing in the gingival sulcus and the sinus in the gingival area.
Tooth mobility was grade II. A midbuccal area with a narrow 2.3. Case 3: Iatrogenic Periodontal Lesions: Dental Injury/
periodontal pocket > 10 mm was noted. The tooth had a Trauma. A 27-year-old woman with a noncontributory med-
negative response to the thermal vitality test (Endo-Ice; ical history was referred from the orthodontic department at
Hygenic Corp., Akron, OH, USA). The diagnosis was a PSMMC complaining of pus discharge from the gingival sul-
necrotic pulp and chronic apical abscess. cus and slight gingival swelling on the palatal side opposite
Endodontic treatment was accomplished in two visits tooth #22 (i.e., maxillary left lateral incisor) after orthodontic
with calcium hydroxide [Ca(OH)2] medication between treatment. Clinical and radiographic examinations revealed a
appointments. Local anesthesia (1.8 mL of lidocaine with sound tooth #22 with a mobility of grade II and a deep
epinephrine 1 : 100,000) was administered, and the tooth periodontal pocket > 10 mm mesial to tooth #22 with pus
was isolated with a rubber dam. An access opening was discharge from the pocket (Figure 3(a)). The thermal vitality
created and four canals were located. During the second visit, test demonstrated a negative response. Moreover, the area
the localized swelling and sinus opening were thoroughly was tender to percussion and palpation. Methylene blue stain
resolved, and the root canal treatment was completed with was applied to exclude the presence of a crack or root
RaCe NiTi rotary files (FKG Dentaire, La Chaux-de-Fonds, fracture. It showed a negative result. The radiographic
Switzerland) and 5.25% sodium hypochlorite irrigation. examination showed advanced bone resorption extending
The tooth was obturated with lateral condensation of gutta- from the mesial bone crest toward the apex of tooth #22
percha and AH Plus sealer (AH Plus; Dentsply Maillefer, (Figure 3(b)).
Tulsa, OK, USA). No periodontal treatment was adminis- The diagnosis was necrotic pulp due to trauma during
tered. Follow-up X-ray images were obtained from 1 year to orthodontic treatment with symptomatic apical periodonti-
6 years, which showed complete healing of the bone in the tis. The first stage of the treatment plan was endodontic treat-
periapical and furcation areas (Figure 1). ment, which was performed during two visits with calcium
hydroxide medication between appointments (Figure 3(b)).
2.2. Case 2: Iatrogenic Periodontal Lesion: Root Perforation. A Chemicomechanical debridement was administered with
30-year-old woman with a noncontributory medical history the ProFile.04 and ProFile.06 Taper Series 29 rotary
Case Reports in Dentistry 3

(a) (b)

(c)

Figure 1: Case 1. (a) The initial radiograph of tooth #46 shows periapical and furcation bone resorption. (b) The 1-year recall radiograph
shows healing of the bone lesion. (c) The 6-year follow-up radiograph shows tooth #46 with a permanent crown.

instruments (Tulsa Dental Products) and sodium hypo- with saline was placed into the bony defect with a plastic
chlorite. The canal was obturated with lateral condensation instrument, and a resorbable barrier membrane (CopiOs
of gutta-percha and AH Plus sealer (Dentsply Maillefer, membrane, Zimmer Biomet Dental) was placed above the
Tulsa, OK, USA) (Figure 3(b)). The second stage of the bone graft. The flap was then repositioned and sutured with
treatment plan, which was a surgical procedure, was per- 4-0 Vicryl thread (Ethicon Inc., Somerville, NJ, USA). The
formed after the permanent composite restoration and a patient was prescribed Augmentin (amoxicillin (875 mg)
follow-up period of 3 months. Before surgery, the patient and clavulanic acid (125 mg)) (GlaxoSmithKline (Ireland)
signed a consent form. Ltd.) 1 g twice daily for 5 days and ibuprofen (600 mg) orally
Local anesthesia (two 1.8 mL carpules of 2% lidocaine every 6 h for 2 days. Follow-up of the patient showed no
with 1 : 100,000 epinephrine) was then administered labially tooth mobility, a reduced pocket depth of 4 mm, and healing
and palatally. A mucoperiosteal flap was raised mesially to of the soft and hard tissues (Figure 3(e)).
the upper left canine tooth, and two vertical releasing
incisions were formed in the anterior palatal area opposite 3. Discussion
teeth #21 and #23. A horizontal incision was formed from
the left maxillary central incisor to the left maxillary canine. The management of endodontic-periodontal lesions is a true
After flap reflection, a sling suture was placed in the tissue challenge for the dentist because of the deleterious effects on
flap to secure it with the premolar tooth on the opposite side the tooth structure and the supporting periapical structures
of the maxillary arch to aid the surgeon in improving visual (i.e., bone and periodontal membrane). The key to success
and operative access by eliminating the need to manually in treating these cases depends on taking a correct history
retract the flap in the palatal area (Figure 3(c)) [8]. Cortical to determine the cause and reach an exact diagnosis of the
bone was absent on the mesial side of tooth #22. The root case development. In addition, a clinician’s ability to classify
surface was covered with black calculus and the area was a lesion makes the treatment strategy or protocol very clear
obliterated with granulation tissues. After removing the and precise. In this report, several successful endodontic-
granulation tissues and calculus from the root surface with periodontal lesion cases were presented with different
ultrasonic tips (Figures 3(c) and 3(d)), bone graft material treatment modalities and classified according to the new
(Puros Particulate Allograft; Zimmer Biomet Dental) mixed classification system reported by Al-Fouzan in 2014 [4].
4 Case Reports in Dentistry

(a) Post removal

(b) Preoperative, postoperative, and 9-month recall

(c) Four-year recall

Figure 2: (a) Tooth #36 has a perforation in the distal root. The post is shown after removal, as is a paper point with a blood spot. (b) The
mineral trioxide aggregate (MTA) repair. The recall examinations show osseous regeneration in the furcation. (c) The follow-up clinical
photograph of tooth #36 shows the final crown and normal soft tissue.

The classification of the first case was a primary endodontic Root perforation is an unnatural communication
lesion with drainage through the periodontal ligament between the root canal system and the supporting tissues of
through a fistula. The pulp was necrotic and there was a deep the teeth or the oral cavity [9]. One study [10] reported that
and narrow pocket in one tooth aspect. All of these factors 53% of iatrogenic perforations occur during the insertion of
confirmed the diagnosis and led to the correct treatment posts. Factors that affect the perforation prognosis depend
modality, which was endodontic treatment alone. The other on the location of the perforation, its duration, size of the
cases were diagnosed as iatrogenic periodontal lesions that perforation and tooth, sterilization of the perforation site,
resulted from the treatment modality: by tooth perforation and the material used to seal the perforation. Immediate
(as shown in the second case) or by dental trauma caused sealing of small perforations away from the coronal
by orthodontic treatment, which is not mentioned in the attachment of the tooth under aseptic conditions with com-
Al-Fouzan classification [4]. The authors of the current study patible materials are the most important factors for a good
suggest adding this category to Al-Fouzan’s classification prognosis [11, 12].
under “iatrogenic periodontal lesions” because trauma from Mineral trioxide aggregate is a bioceramic material,
orthodontic movement can cause pulp necrosis and thereby composed of tricalcium silicate, tricalcium aluminate,
lead to periodontal disease and pocket formation. tricalcium oxide, and silicate oxide, that forms a colloidal
Case Reports in Dentistry 5

(a)

(b) (i) Preoperative image. (ii) Calcium hydroxide [Ca(OH)2] placement.

(iii) Postoperative image. (iv) The 30-month recall image

(c)

(d)

(e)

Figure 3: (a) A deep periodontal pocket and drainage of pus through the gingival sulcus are visible. (b) Radiographs of tooth #22 exhibit (i) a
large lateral radiolucency on the mesial tooth surface extending from the bone crest to the root apex, (ii) calcium hydroxide [Ca(OH)2]
placement, (iii) root canal obturation, and (iv) bone healing. (c) Surgical exposure of tooth #22 shows calculus accumulation and
granulation tissue mesially with the absence of buccal bone. (d) Removal of calculus and granulation tissues and placement of the bone
graft. (e) Placement of the barrier membrane; the 30-month recall photograph shows normal gingival tissue.

gel on hydration and solidifies in approximately 3 hours. The Dental pulp is a soft connective tissue encased in a
calcium oxide in MTA reacts with tissue fluids to form rigid, noncompliant chamber; therefore, changes in pulpal
calcium hydroxide, which may then encourage hard tissue blood flow or vascular tissue pressure can have serious
deposition because of its high pH. In addition, several studies effects on the health of the pulp. Many studies [16, 17]
[13–15] have demonstrated the sealing ability of MTA. have explained the effects of orthodontic forces on teeth.
6 Case Reports in Dentistry

These forces influence blood flow and cellular metabolism exposed to the root apex. The root surface was covered
and lead to degenerative and/or inflammatory responses in with calculus and granulation tissues. The calculus and
the dental pulp. Spector et al. [18] reported two cases in granulation tissues were removed with ultrasonic scaling,
which teeth were devitalized during orthodontic therapy. followed by placing a bone graft and barrier membrane,
Hamersky et al. [19] used a radiorespirometric method which led to complete healing. Some studies have reported
to demonstrate a significant depression in the pulpal considerable success rates in managing such apicomarginal
respiratory rate when a tooth underwent orthodontic defects [26, 30, 31].
movement. In addition, as a person’s age increased, the Controversial findings challenge the current under-
relative amount of pulpal respiratory rate depression standing of the ideal interval between endodontic treat-
increased. Moreover, orthodontic forces may induce more ment and periodontal surgery. It has been reported that
rapid aging processes within the pulp because of blood root canal treatment performed 10 weeks, 3 months, or
flow interruption, and thereby reduce the pulp’s ability 6 months before periodontal surgery did not impair
to withstand future forces [16]. Orthodontically treated periodontal healing [32–34]. In the third case, root canal
teeth also show histologic findings similar to those of peri- treatment was performed 3-4 months before the periodontal
odontally involved teeth. surgery and showed no disruptive effect on complete bone
In endodontic-periodontal lesions, the cause of the healing. In conclusion, all cases presented in this report were
lesion is endodontic or periodontal in origin, and the successfully treated and showed great promise in manag-
patient may benefit from undergoing root canal therapy ing endodontic-periodontal lesions, which are a very
first [20, 21] because pulpal infection could promote mar- challenging disease condition that requires all possible
ginal epithelial downgrowth along the root surfaces of the treatment modalities reported in the literature such as
teeth [22]. Unhealed lesions with persistent infection were endodontic therapy, periodontal therapy, and regenerative
further managed through endodontic-periodontal surgery procedures to ensure satisfactory and complete healing.
or through periodontal regenerative surgery alone. This In this paper, we have added a modification to the latest
sequence of treatment conveys a good chance for primary endodontic-periodontal classification and highlighted the
healing, a better assessment of the periodontal conditions importance of using a step-by-step systematic approach for
of the involved teeth, and controls reinfection by bacteria managing such complex lesions.
or their by-products [20].
Regenerative techniques involve cell differentiation,
cell proliferation and induction, and/or tissue formation
Conflicts of Interest
conduction. All of these factors work together to com- The authors declare that there is no conflict of interest
plete the healing of damaged periapical tissues. This regarding the publication of this article.
healing can be obtained by using bone grafts (e.g., auto-
grafts, allografts, alloplasts, and xenografts), periodontal
membranes (e.g., nonabsorbable or absorbable of the natural Acknowledgments
or synthetic type), growth factors, or a combination of
these [7, 23]. The authors would like to thank Editage (http://www.editage.
In the first two cases, soft and hard tissue healing com/) for English language editing.
commenced with administering root canal therapy alone or
perforation repair. However, in the third case, follow-up References
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