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

Abstract

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.

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.

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.

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.