Treatment of a Periodontic-Endodontic Lesion in a Patient with Aggressive Periodontitis

Hindawi Publishing Corporation Case Reports in Dentistry Volume 2016, Article ID 7080781, 9 pages http://dx.doi.org/10.1155/2016/7080781 Case Report Treatment of a Periodontic-Endodontic Lesion in a Patient with Aggressive Periodontitis Mina D. Fahmy,1 Paul G. Luepke,1 Mohamed S. Ibrahim,1,2 and Arndt Guentsch1,3 1 Department of Surgical Sciences, Marquette University School of Dentistry, Milwaukee, WI 53233, USA Department of Endodontics, Faculty of Dentistry, Mansoura University, Mansoura 35516, Egypt 3 Center of Dental Medicine, Jena University Hospital, Friedrich-Schiller-University, An der Alten Post 4, 07743 Jena, Germany 2 Correspondence should be addressed to Arndt Guentsch; Received 7 March 2016; Revised 14 May 2016; Accepted 23 May 2016 Academic Editor: Stefan-Ioan Stratul Copyright © 2016 Mina D. Fahmy 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. Case Description. This case report describes the successful management of a left mandibular first molar with a combined periodontic-endodontic lesion in a 35-year-old Caucasian woman with aggressive periodontitis using a concerted approach including endodontic treatment, periodontal therapy, and a periodontal regenerative procedure using an enamel matrix derivate. In spite of anticipated poor prognosis, the tooth lesion healed. This case report also discusses the rationale behind different treatment interventions. Practical Implication. Periodontic-endodontic lesions can be successfully treated if dental professionals follow a concerted treatment protocol that integrates endodontic and periodontic specialties. General dentists can be the gatekeepers in managing these cases. 1. Introduction Decision-making processes of a tooth as having a good, questionable (but treatable), or hopeless prognosis (with extraction required) are based on periodontal, endodontic, and restorative parameters [1]. The periodontal classification of teeth is based on the amount of attachment loss and probing pocket depth or furcation involvement [2]. Besides the periodontal parameters, predisposing factors for tooth loss in patients with periodontitis are the presence of pulpal infection/necrosis and caries [3]. However, recent research has demonstrated that, even with periodontic-endodontic involvement, teeth regarded as hopeless can be successfully treated [4]. The interrelationship between the periodontium and pulp was first described by Simring and Goldberg in 1964 [5]. Simon and colleagues noted that combined periodonticendodontic lesions are composed of an endodontically induced periapical lesion on a tooth that is also periodontally compromised [6]. Communication exists between the periodontium and the pulpal tissues by means of canals. Langeland and colleagues discussed how pulpal inflammation from involved lateral canals or root caries causes damage to the pulp [7]. Thus, the extension of pulpal infections to the periodontium and vice versa may be attributed to these canals [8]. In animal studies, there is a high predominance of lateral canals in posterior teeth that communicate with the floor of the pulp and the periodontal ligament [9, 10]. Several other pathways which may act as potential facilitators of periodontally derived endodontic lesions have been noted in literature and include lingual grooves, root and tooth fractures, root anomalies, fibrinous communications, and trauma induced root resorption [11]. Where a periapical infection and/or inflammation exist, the periodontium can be significantly damaged. However, following proper root canal therapy (RCT), healing occurs without a residual effect [12]. Clinical presentation of periodontic and endodontic abscesses may bear close similarities, although differing in their point of origin. Combined periodontic-endodontic lesions occur as a result of the interaction between their respective disease origins on the same tooth, irrespective of the sequence in which the diseases occur [8]. Differential diagnoses and treatment methods are partially dependent on the evaluation of pulp vitality [12]. If periodontal pockets 2 exist, but the pulpal tissue reaction is normal, then either the acute or the chronic inflammation is of periodontal origin. However, when the pulp is found to be nonvital, the inflammatory process passing through the lateral canals or apical foramen causing a lesion in the periodontium is of endodontic origin [8]. When an infection and/or inflammation are evident within the pulp, with periodontal disease that was preexisting, the pulpitis may be considered secondary to the periodontal disease. Importantly, the existence of subgingival calculus and the intensity and location of inflammation both aid in determining the primary source of the disease [8, 13]. Evidently, combined pulpal and periodontal issues account for more than 50% of tooth mortality [14]. In addition, several studies have indicated that combined periodonticendodontic therapy is imperative for successful healing of such a combined lesion [13, 15] although the primary source of combined lesions is rarely precisely identified. This case report aims to illustrate a significant clinical case and a suggested evidence-based treatment protocol for periodonticendodontic lesions, which allows for maintaining teeth that may be considered hopeless. 2. Case Presentation A 35-year-old Caucasian female was referred to a periodontist, after a diagnostic periapical radiograph of tooth 36 (lower left first molar) at the general dentist’s office showed vertical bone loss extending to the apex of the distal root. The patient was generally in good health with good oral hygiene (Figure 1). She had never smoked and she routinely visited her general dentist for annual oral exams. The clinical examination demonstrated increased periodontal probing depths up to 12 mm on the distal root surface of tooth 36 and up to 8 mm on the mesial root surface of tooth 37, as well as 8 mm between teeth 46 and 47. Tooth 36 presented class 1 furcation involvement lingually. All teeth responded normally to cold and electric pulp testing (EPT), except tooth 36 which showed a delayed response and was diagnosed with asymptomatic irreversible pulpitis with asymptomatic lesion of endodontic origin. Radiographic examination revealed vertical bone loss on the distal root surface of tooth 36 extending to the root apex and alongside the mesial wall of the distal root and alveolar bone loss between teeth 25 and 26. The microbiological testing of the subgingival biofilm [16] resulted in the presence of Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Tannerella forsythia, and Treponema denticola (bacterial load ≧ 105 ). The periodontal diagnosis was aggressive periodontitis with a combined periodonticendodontic lesion (primary peri (...truncated)