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J Clin Exp Dent. 2014;6(1):e91-5. Different kinds of endo-perio lesions

Journal section: Periodontology
Publication Types: Case Report
A case series associated with different kinds of endo-perio lesions
Hacer Aksel 1, Ahmet Serper 1
1 Department of Endodontics, Faculty of Dentistry, Hacettepe University, Ankara, Turkey
Correspondence:
Hacettepe University
Faculty of Dentistry
Department of Endodontics
Sihhiye, 06100 Ankara, Turkey
hacer.yilmaz@hacettepe.edu.tr
Received: 20/07/2013
Accepted: 21/11/2013
Abstract
Pulpal and periodontal problems are responsible for more than half of the tooth mortality. There are some articles
published in the literature about this issue. Many of them are quite old. There has been also lack of knowledge
about the effect of endodontic treatment on the periodontal tissue healing and suitable treatment interval between
endodontic and periodontal treatments. In this case report, different kinds of endo-perio lesion were treated with
sequential endodontic and periodontal treatment. The follow-up radiographs showed complete healing of the hard
and soft tissue lesions. The tooth with endo-perio lesions should be evaluated thoroughly in terms of any cracks
and fracture, especially furcation areas for a long term prognosis. In this case report, it was showed that 3 months
treatment intervals between endodontic treatment and periodontal surgery has no harmful effect on periodontal
tissue healing.
Key words: Endo-perio lesion, furcation, mandibular molar, bone graft, crack line, treatment interval.
Aksel H, Serper A. A case series associated with different kinds of endoperio
lesions. J Clin Exp Dent. 2014;6(1):e91-5.
http://www.medicinaoral.com/odo/volumenes/v6i1/jcedv6i1p91.pdf
Article Number: 51219 http://www.medicinaoral.com/odo/indice.htm
Medicina Oral S. L. C.I.F. B 96689336 - eISSN: 1989-5488
eMail: jced@jced.es
Indexed in:
Scopus
DOI System
doi:10.4317/jced.51219
http://dx.doi.org/10.4317/jced.51219
Introduction
Dental pulp and periodontal tissues are closely related
that are ectomesenchymal in origin (1). The pulp originates
from the dental papilla and the periodontal ligament
from the dental follicle and they are separated by
Hertwigs epithelial root sheat.
Pulpal and periodontal problems are responsible for
more than half of the tooth mortality (2). The relationship
between periodontal and pulpal disease was first described
by Simring and Goldberg in 1964 (3). Since then,
the term endo-perio lesion has been used to describe
this type of lesions due to same inflammatory products
found in both periodontal and pulpal tissues.
The vast majority of pulpal and periodontal diseases
are caused by bacterial infection. It has been suggested
that cross-infection between the root canal and the periodontal
ligament can occur via the anatomical (apical
foramen, lateral and accessory canals, dentinal tubules
and palato-gingival grooves) and non-physiological pathways
(iatrogenic root canal perforations and vertical
root fractures) (4). These pathways determine the spread
of infection. Periodontal disease causes destruction of
bone in a coronal-to-apical direction while direction of
the endodontic lesions is from apex to coronal. When the
pulp is infected, it elicits an inflammatory response of
periodontal ligament. However, the effect of periodontal
inflammation on the pulpal tissue remains controversial
(5). Clinically, the pulp is not affected by periodontal disease
until accessory canals are exposed to the oral environment
or microvasculature of the apical foramen is
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J Clin Exp Dent. 2014;6(1):e91-5. Different kinds of endo-perio lesions
damaged (6).
The classification of endo-perio lesions by Simon et al.
is that primary endodontic diseases, primary periodontal
diseases and combined disease including primary endodontic
disease with secondary periodontal involvement,
primary periodontal disease with secondary endodontic
involvement and true combined disease (7). This classification
has been used and given very valuable guidance
to make sound clinical decisions.
The main factors to take into account for treatment decision-
making are pulp vitality and type and extent of
periodontal defect. The differential diagnosis of endodontic
and periodontal diseases can be challenged but a
correct diagnosis has a vital importance so that appropriate
treatment can be provided.
The aim of this study was to present the diagnosis and
management of different types endo-perio lesions and
emphasize the importance of the correct treatment sequence.
Primary Endodontic Disease
- Case 1
A 21-year-old male patient, with a noncontributory medical
history was referred for the treatment of pain and
intraoral localized swelling in the left mandibular first
molar. Clinical and radiographic examinations revealed
large caries and periapical and furcal lesions related to
tooth #36 (Fig. 1). There was a localized swelling on
the gingival sulcus. The tooth mobility was grade II
and periodontal probing through the furcation showed
increased probing values with grade II defect (Fig. 1).
An electric pulp test (Parkell Electronics Division, Farmingdale,
NY) displayed negative response. Endodontic
treatment was administered in two visits, with an interappointment
calcium hydroxide medication. A week later,
the localized swelling was quite resolved, the symptoms
of the tooth was disappeared and the root canal treatment
was completed. No periodontal treatment was rendered.
A year follow-up radiograph showed complete soft and
hard tissue repairs in the periapical and furcal area of
tooth #36 (Fig. 1).
- Case 2
A 45-year-old female patient, whose medical history was
noncontributory, came to our department for evaluation
and treatment of tooth #46. She complained discomfort
on chewing, related to tooth #46. Clinical and radiographic
examination revealed a sinus tract and radiolucent
lesion in the furcal and distal side of tooth #46 (Fig. 1).
Periodontal probings were increased at the furcal and
distal side of tooth #46. The tooth gave negative response
to vitality tests. After endodontic access cavity
was established, a mesio-distal crack line was observed
(Fig. 1). Root canal treatment completed and occlusal
reduction was performed. The patient was referred for
prosthetic crown. After a year following period, the re-
Fig. 1. Case 1- a) Initial radiograph of tooth #36. b) Intraoral film
showing increased probing depth values in the furcation area. c) A
year recall radiograph showing complete healing. Case 2- d) Initial
radiograph showing increased bone lesion in the furcation and distal
side of the tooth #46. e) Access opening showing mesio-distal
crack line in the pulp floor. f) A year recall radiograph showing
healing of the bone lesion.
pair of lesion was observed and the tooth was asymptomatic
(Fig. 1).
Primary periodontal disease with secondary endodontic
involvement
- Case 3
A 42-year-old male patient, whose medical history was
noncontributory, came to our department with a history
of acute pain and localized swelling in the left mandibular
molar area. Radiographic examination presented
severe bone loss around the distal root of tooth #37 (Fig.
2). The cause of the bone loss was considered related to
the uncleaning space between second and third molar.
The rest of the dentition had normal periodontal values.
The tooth #37 was nonresponsive to vitality tests. After
completion of root canal treatment, the patient was referred
for extraction of the third molar tooth (Fig. 2). At
the 6 month recall visit, the complete repair of the bony
lesion was observed (Fig. 2).
Fig. 2. a) Initial radiograph of tooth #37. b) Final radiograph after
obturation of the root canals. c) A year recall radiograph showing
complete healing of the bone lesion.
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J Clin Exp Dent. 2014;6(1):e91-5. Different kinds of endo-perio lesions
detect non-sensitive reaction represented a necrotic pulp
was reported as 89% with the cold test and 88% with the
electrical test (8).
The infected root canal can cause a chronic inflammatory
reaction which extends the gingival sulcus and drains
through the sinus tracts. If the rest of the dentition is
periodontally healthy and any root cracks and fractures
has been ruled out, healing of the periodontal tissues
can be expected after endodontic treatment as it was
observed in case 1 and 2. Therefore, further treatment
requirements should always considered followed by an
observation period of at least 3 months. Conversely, there
has been a debate in the literature about the impact
of the endodontic treatment on the healing potential of
the periodontium. Some studies have been reported that
endodontic treatment may cause an inhibitory effect on
periodontal wound healing (9,10) while some of them
(11,12) have been demonstrated no significant effects.
The possible influence of endodontic treatment on the
healing response of furcation defects is related to the
accessory canals and permeable areas of dentin and cementum.
Accessory canals in the whole furcation area
of molars are found in 3060% of molars and predispose
this area to be a zone of intense communication between
pulpal and periodontal tissues (13). These canals
are mostly observed in the furcation area of mandibular
molars (14).
Proper endodontic treatment is a key factor for treatment
success. Poor endodontic treatment allows canal re-infection
and in this way, leads to the treatment failure
(15). Moreover, there are other contributing factors to
cause endo-perio lesions. The tooth should be always
evaluated in terms of any artificial pathways between
periodontal and pulpal tissues such as cracks and fractures.
The source of both infections should be removed.
In case 3, the lesion might be caused primarily by periodontal
pathogens due to the inaccessible area between
Primary endodontic disease with secondary
periodontal involvement
- Case 4
A 45-year-old woman presented to inquire about options
for preserving tooth #36. The patients medical status
was noncontributory. The tooth was characterized by
gingival reddening and swelling at the buccal side. The
patient complained of periodic discharge of pus from the
periodontal pocket, sensitivity on percussion, tooth mobility,
and intermittent pain.
Radiographs displayed a bony defect in the furcal and
periapical area of tooth #36, which had unsuccessful
root canal treatment (Fig. 3). The probing depth in the
furcal area was 12 mm and probable throughout (grade
III furcal lesion). The patient informed about the methods
and risks of the treatment. Endodontic retreatment
was performed and treatment results were evaluated 3
months later which showed that the furcation lesion still
remained intact (Fig. 3). Therefore, periodontal regenerative
surgery was planned for the treatment of the furcation
defect.
After administering of local anesthesia, a mucoperiosteal
flap was raised at the buccal aspect, following intracrevicular
incisions and vertical releasing incision.
A vertical releasing incision was placed, extending into
the alveolar mucosa not closer than one tooth to the involved
area. After reflection thorough degranulation and
debridement was done at the defect area. Also thorough
scaling and root planning was carried out on the exposed
root surface area of the defect. After instrumentation,
the root surfaces were washed with saline solution
to attempt to remove any remaining detached fragments
from the defect and surgical field. After that, the bone
defect was filled with a xenograft material (Osteobiol
GenOs, Tecnoss) and stabilized in the furcation area
(Fig. 3). Primary soft tissue closure of the flap was done
with nonresorbable black silk [3-0] suture (Ethicon, Inc.
Somerville, NJ) using interrupted suturing technique.
The patient was advised proper plaque control, and prescribed
0.12% chlorhexidine mouthwash for rinsing twice
daily, for a week. The sutures were removed 10 days
after surgery. A year recall radiograph showed complete
bone repair in the furcation defect (Fig. 3).
Discussion
The endo-perio lesions present challenges to clinicians
as far as diagnosis and prognosis of the involved teeth
are concerned. Correct diagnosis is essential prerequisite
to determine the treatment and long-term prognosis.
Diagnosis of primary endodontic disease and primary
periodontal disease usually presents no clinical difficulty.
The first step for proper diagnosis is the vitality tests.
Although the vitality test cannot provide the histological
status of the dental pulp, their ability to register pulp
vitality is quite satisfied. The ability of vitality tests to
Fig. 3. a) Initial radiograph of tooth #36. b) 3 months recall radiograph
showing bone lesion in the furcation area. c) Intraoral film
showing furcation lesion during periodontal surgery. d) Intraoral
film showing bone graft material placement to the furcation lesion.
e) Two year recall radiograph showing complete healing of the furcation
lesion.
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J Clin Exp Dent. 2014;6(1):e91-5. Different kinds of endo-perio lesions
riodontal healing (12). In the present case report, root
canal treatment was performed 3-4 months before the
periodontal surgery showed no disruptive effect on the
complete healing of the furcation lesion of the mandibular
molar. This result should be confirmed by future
clinical studies.
The treatment planning given in this case report can guide
the clinician to deal with the treatment of different
types endo-perio lesions. In this case report, treatment
strategies were given in related to the different kinds of
endo-perio lesions. Treatment outcomes will be more
predictable if the clinician has more through knowledge
about the diagnosis, treatment sequences and intervals.
Thereby, the immediate and true management of the endo-
perio lesions can impede the loss of the natural tooth
and delay the more complex treatments.
References
1. Mandel E, Machtou P, Torabinejad M. Clinical diagnosis and
treatment of endodontic and periodontal lesions. Quintessence Int.
1993;24:135-9.
2. Bender IB. Factors influencing the radiographic appearance of bony
lesions. J Endod. 1997;23:5-14.
3. Simring, Marvin, Goldberg. The pulpal pocket approach: retrograde
periodontitis. J Periodontol. 1964;35:22-48.
4. Zehnder M, Gold SI, Hasselgren G. Pathologic interactions in pulpal
and periodontal tissues. J Clin Periodontol. 2002;29:663-71.
5. Seltzer S, Bender IB, Ziontz M. The interrelationship of pulp and
periodontal disease. Oral Surg Oral Med Oral Pathol. 1963;16:1474-
90.
6. Rubach WC, Mitchell DF. Periodontal disease, accessory canals and
pulp pathosis. Periodontol. 1965;36:34-8.
7. Simon JH, Glick DH, Frank AL. The relationship of endodonticperiodontic
lesions. J Endod. 2013;39:41-6.
8. Petersson K, Sderstrm C, Kiani-Anaraki M, Lvy G. Evaluation
of the ability of thermal and electrical tests to register pulp vitality.
Endod Dent Traumatol. 1999;15:127-31.
9. Morris ML. Healing of human periodontal tissues following
surgical detachment and extirpation of vital pulps. J Periodontol.
1960;31:23-6.
10. Sanders JJ, Sepe WW, Bowers GM, Koch RW, Williams JE, Lekas
JS et al. Clinical evaluation of freeze-dried bone allografts in periodontal
osseous defects. Part III. Composite freeze-dried bone allografts
with and without autogenous bone grafts. J Periodontol. 1983;54:1-8.
11. Perlmutter S, Tagger M, Tagger E, Abram M. Effect of the endodontic
status of the tooth on experimental periodontal reattachment in
baboons: a preliminary investigation. Oral Surg Oral Med Oral Pathol.
1987;63:232-6.
12. de Miranda JL, Santana CM, Santana RB. Influence of endodontic
treatment in the post-surgical healing of human Class II furcation defects.
J Periodontol. 2013;84:51-7.
13. Lowman JV, Burke RS, Pelleu GB. Patent accessory canals: incidence
in molar furcation region. Oral Surg Oral Med Oral Pathol
1973;36:580-4.
14. Gutmann JL. Prevalence, location, and patency of accessory
canals in the furcation region of permanent molars. J Periodontol.
1978;49:21-6.
15. Peters LB, Wesselink PR, Moorer WR. The fate and the role of
bacteria left in root dentinal tubules. Int Endod J. 1995;28:95-9.
mandibular second and third molar teeth . In this process,
chronic marginal periodontitis progresses apically
along the root surface. Although in most cases, pulptests
indicate a clinically normal pulpal reaction, there
was a pulp necrosis in tooth #37. Because of the fact
that the periodontal infection reached to the apical foramen
so microvasculature of the apical foramen could
be destroyed. The treatment depends on the endodontic
treatment of tooth #37 and extraction of the impacted
third molar tooth.
In this case report, the cleaning and shaping of the root
canals were performed in combination with irrigation
with sodium hypochlorite and additional interappointment
calcium hydroxide medication to render the root
canal system free of cultivable bacteria.
Calcium hydroxide is bactericidal, anti-inflammatory
and proteolytic and inhibits resorption and favors repair.
It also inhibits periodontal contamination from instrumented
canals via patent channels connecting the pulp
and periodontium before periodontal treatment removes
the contaminants. We observed that the sinus tracts
extending into the furcation area were disappeared 1-2
weeks later and the canals are eventually filled with a
conventional obturation.
When periodontal and pulpal lesions occur concurrently,
it has been described as combined lesion. In this condition,
the treatment and prognosis of the tooth are different
from those of teeth involved with only primary endodontic
disease. The tooth now requires both endodontic
and periodontal treatments. If the endodontic treatment
is adequate, the prognosis depends on the severity of
the periodontal damage and the efficacy of periodontal
treatment. If an increased periodontal tissue destruction
occur and cannot be replaced with periodontal regenerative
techniques, the extraction of the tooth seems the
only solution. The bony lesion of case 4 had endodontic
and periodontal lesions and first treated with endodontic
therapy. Treatment results were evaluated in 23 months
and then periodontal treatment was considered. This
sequence of treatment allows sufficient time for initial
tissue healing and better assessment of the periodontal
condition. This case demonstrates that proper diagnosis,
followed by removal of etiological factors and utilizing
the guided tissue regeneration technique combined with
osseous grafting, will restore health and function to a
tooth with severe attachment loss caused by an endoperio
lesion.
The ideal interval between the endodontic treatment and
periodontal surgery has also been challenged by controversial
findings. It was reported that root canal treatment
performed 2.5 months before periodontal surgery not to
impair periodontal healing (11). Miranda et al. suggest
that endodontic treatment performed 6 months before
the surgical debridement of the furcation of mandibular
molars did not impair the clinical parameters of pee95
J Clin Exp Dent. 2014;6(1):e91-5. Different kinds of endo-perio lesions
Acknowledgements
We wish to confirm that there are no known conflicts of interest associated
with this publication and there has been no significant financial
support for this work that could have influenced its outcome.
Conflict of interest
The authors report no conflicts of interest. The authors alone are responsible
for the content and writing of the paper.
pengantar

Dental pulp dan jaringan periodontal berhubungan erat dengan ectomesenchymal in origin (1). Pulp
berasal dari papilla gigi dan ligamentum periodontal dari folikel gigi dan dipisahkan oleh sheeping's
epithelial root sheat.

Masalah pulpa dan periodontal bertanggung jawab atas lebih dari separuh angka kematian gigi (2).
Hubungan antara penyakit periodontal dan pulpal pertama kali dijelaskan oleh Simring dan Goldberg
pada tahun 1964 (3). Sejak itu, istilah "lesi endo-perio" telah digunakan untuk menggambarkan jenis lesi
ini karena produk inflamasi yang sama ditemukan di jaringan periodontal dan pulpal. Sebagian besar
penyakit pulpa dan periodontal

disebabkan oleh infeksi bakteri. Telah disarankan bahwa infeksi silang antara saluran akar dan
ligamentum periodontal dapat terjadi melalui saluran anatomis (foramen apikal, kanal lateral dan
aksesori, tubulus dentinal dan alur palato-gingiva) dan jalur non-fisiologis (perforasi saluran akar
iatrogenik dan vertikal fraktur akar) (4). Jalur ini menentukan penyebaran infeksi. Penyakit periodontal
menyebabkan kerusakan tulang pada arah koronal-ke-apikal sementara arah lesi endodontik berasal
dari puncak ke koronal. Ketika pulp terinfeksi, ia menimbulkan respons inflamasi ligamentum
periodontal. Namun, efek radang periodontal pada jaringan pulpa tetap kontroversial (5). Secara klinis,
pulpa tidak terpengaruh oleh penyakit periodontal sampai kanal aksesori terkena lingkungan mulut atau
mikrovaskular foramen apikal rusak (6).

Klasifikasi lesi endo-perio oleh Simon dkk adalah bahwa penyakit endodontik primer, penyakit
periodontal primer dan penyakit gabungan termasuk penyakit endodontik primer dengan keterlibatan
periodontal sekunder, penyakit periodontal primer dengan keterlibatan endodontik sekunder dan
penyakit gabungan sejati (7). Klasifikasi ini telah digunakan dan diberi bimbingan yang sangat berharga

membuat keputusan klinis yang sehat. Faktor utama yang harus dipertimbangkan dalam pembuatan
keputusan perawatan adalah vitalitas pulpa dan jenis dan tingkat kerusakan periodontal. Diagnosis
banding penyakit endodontik dan periodontal dapat ditantang namun diagnosis yang benar sangat
penting sehingga perawatan yang tepat dapat diberikan.

Tujuan dari penelitian ini adalah untuk menyajikan diagnosis dan pengelolaan berbagai jenis lesi endo-
perio dan menekankan pentingnya urutan perawatan yang benar.

Penyakit Endodontik Primer

- Kasus 1

Seorang pasien laki-laki berusia 21 tahun, dengan riwayat medis nonkopi dirujuk untuk pengobatan
nyeri dan pembengkakan lokal intraoral pada molar pertama mandibula kiri. Pemeriksaan klinis dan
radiografi menunjukkan karies besar dan lesi periapikal dan furcal yang berhubungan dengan gigi # 36
(Gambar 1). Ada pembengkakan lokal pada sulkus gingiva. Mobilitas gigi adalah kelas II dan pemeriksaan
periodontal melalui furkasi menunjukkan peningkatan nilai probing dengan defisiensi grade II (Gambar
1). Uji elektrik bubur kertas (Parkell Electronics Division, Farmingdale, NY) menunjukkan respons negatif.
Perawatan endodontik diberikan dalam dua kunjungan, dengan interpelasi
obat kalsium hidroksida. Seminggu kemudian, pembengkakan lokal cukup terselesaikan, gejala gigi
hilang dan perawatan saluran akar selesai. Tidak ada pengobatan periodontal yang diberikan. Radiografi
follow up setahun mengikuti perbaikan jaringan lunak dan keras di daerah periapikal dan furkal

gigi # 36 (Gambar 1). - Kasus 2 Seorang pasien wanita berusia 45 tahun, yang riwayat kesehatannya
adalah

nonkontribusi, datang ke departemen kami untuk evaluasi dan perawatan gigi # 46. Dia mengeluh
ketidaknyamanan saat mengunyah, terkait dengan gigi # 46. Pemeriksaan klinis dan radiografi
menunjukkan saluran sinus dan lesi radiolusen di gigi furkal dan distal gigi. 46 (Gambar 1). Percobaan
periodontal meningkat pada gigi furkal dan distal gigi. 46. Gigi memberikan respon negatif terhadap tes
vitalitas. Setelah rongga akses endodontik terbentuk, garis retak mesio-distal diamati

(Gambar 1). Pengobatan saluran akar selesai dan pengurangan oklusal dilakukan. Pasien dirujuk untuk
mahkota buatan. Setelah satu tahun mengikuti periode,

Gambar 1. Kasus 1- a) Radiografi gigi awal # 36. b) Film intraoral menunjukkan nilai kedalaman probing
yang meningkat di daerah furcation. c) Radiografi tahun yang menunjukkan penyembuhan sempurna.
Kasus 2- d) Radiografi awal yang menunjukkan peningkatan lesi tulang pada furkasi dan sisi distal gigi #
46. e) Pembukaan akses yang menunjukkan garis retak mesio-distal di lantai pulpa. f) radiograf ingat
tahun menunjukkan penyembuhan lesi tulang. Pasangan lesi diamati dan gigi asimtomatik (Gambar 1).

Penyakit periodontal primer dengan endodontik sekunder

keterlibatan

- Kasus 3

Seorang pasien laki-laki berusia 42 tahun, yang riwayat kesehatannya

Tidak ada kontribusi, datang ke departemen kami dengan sebuah sejarah

nyeri akut dan pembengkakan lokal pada mandibula kiri

daerah molar. Pemeriksaan radiografi dipaparkan

Kerusakan tulang yang parah di sekitar akar distal gigi # 37 (Gbr.

2). Penyebab keropos tulang dianggap terkait

ruang yang tidak bersih antara molar kedua dan ketiga.

Sisa gigi memiliki nilai periodontal normal.

Gigi # 37 tidak responsif terhadap tes vitalitas. Setelah

Selesainya perawatan saluran akar, pasien dirujuk

untuk ekstraksi gigi molar ketiga (Gambar 2). Di

kunjungan recall 6 bulan, perbaikan lengkap dari tulangnya

lesi diamati (Gambar 2).

Gambar 2. a) Radiografi gigi awal # 37. b) radiograf akhir sesudahnya

obturasi saluran akar. c) radiograf ingat tahun yang menunjukkan

penyembuhan lengkap dari lesi tulang.

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J Clin Exp Dent. 2014; 6 (1): e91-5. Berbagai jenis lesi endo-perio

mendeteksi reaksi yang tidak sensitif mewakili pulp nekrotik

dilaporkan 89% dengan uji dingin dan 88% dengan

uji kelistrikan (8).

Saluran akar yang terinfeksi dapat menyebabkan peradangan kronis

reaksi yang memperpanjang sulkus gingiva dan saluran pembuangan

melalui saluran sinus. Jika sisa gigi itu

periodontally sehat dan setiap akar retak dan patah tulang

telah dikesampingkan, penyembuhan jaringan periodontal

Bisa diharapkan setelah perawatan endodontik seperti apa adanya

diamati pada kasus 1 dan 2. Oleh karena itu, perawatan lebih lanjut

persyaratan harus selalu dipertimbangkan diikuti oleh

periode pengamatan minimal 3 bulan. Sebaliknya, disana

telah menjadi perdebatan dalam literatur tentang dampaknya

dari perawatan endodontik pada potensi penyembuhan

periodontium. Beberapa penelitian telah melaporkan hal itu

Perawatan endodontik dapat menyebabkan efek penghambatan

penyembuhan luka periodontal (9,10) sementara beberapa di antaranya

(11,12) telah ditunjukkan tidak ada efek signifikan.

Kemungkinan pengaruh perawatan endodontik pada

Respon penyembuhan kerusakan furkasi berhubungan dengan

kanal aksesori dan daerah permeabel dentin dan sementum.

Kanal aksesori di seluruh area furcation

geraham ditemukan pada 30-60% geraham dan predisposisi

daerah ini menjadi zona komunikasi yang intens antara

pulpa dan jaringan periodontal (13). Kanal ini

Sebagian besar diamati di daerah furkasi mandibula

geraham (14).

Perawatan endodontik yang tepat merupakan faktor kunci untuk pengobatan

keberhasilan. Pengobatan endodontik yang buruk memungkinkan infeksi saluran pernapasan

dan dengan cara ini, menyebabkan kegagalan pengobatan

(15). Selain itu, ada faktor lain yang berkontribusi

menyebabkan lesi endo-perio. Gigi harus selalu

dievaluasi dalam hal jalur buatan manapun antara

jaringan periodontal dan pulpal seperti retak dan patah tulang.

Sumber kedua infeksi harus dilepas.

Dalam kasus 3, lesi mungkin disebabkan terutama oleh periodontal

patogen karena daerah yang tidak dapat diakses antara pulpa dan jaringan periodontal (13). Kanal ini

Sebagian besar diamati di daerah furkasi mandibula

geraham (14).

Perawatan endodontik yang tepat merupakan faktor kunci untuk pengobatan

keberhasilan. Pengobatan endodontik yang buruk memungkinkan infeksi saluran pernapasan

dan dengan cara ini, menyebabkan kegagalan pengobatan

(15). Selain itu, ada faktor lain yang berkontribusi

menyebabkan lesi endo-perio. Gigi harus selalu

dievaluasi dalam hal jalur buatan manapun antara

jaringan periodontal dan pulpal seperti retak dan patah tulang.

Sumber kedua infeksi harus dilepas.

Dalam kasus 3, lesi mungkin disebabkan terutama oleh periodontal

patogen karena daerah yang tidak dapat diakses antara

Penyakit endodontik primer dengan sekunder

keterlibatan periodontal

- Kasus 4
Seorang wanita berusia 45 tahun hadir untuk menanyakan tentang pilihan

untuk melestarikan gigi # 36. Status medis pasien

tidak bersumber. Gigi itu ditandai oleh

gingival memerah dan bengkak pada sisi bukal. Itu

pasien mengeluh debit nanah periodik dari

saku periodontal, kepekaan pada perkusi, mobilitas gigi,

dan nyeri intermiten.

Radiograf menunjukkan cacat tulang pada furcal dan

daerah periapikal gigi # 36, yang tidak berhasil

perawatan saluran akar (Gambar 3). Kedalaman probing dalam

daerah furcal adalah 12 mm dan kemungkinan di seluruh (kelas

III lesi furcal). Pasien diberitahu tentang metode tersebut

dan risiko pengobatan. Penundaan endodontik

dilakukan dan hasil pengobatan dievaluasi 3

bulan kemudian yang menunjukkan bahwa lesi furkasi masih ada

tetap utuh (Gambar 3). Oleh karena itu, regenerasi periodontal

Operasi direncanakan untuk perawatan furkasi

cacat.

Setelah pemberian anestesi lokal, mucoperiosteal

flap diangkat pada aspek bukal, mengikuti intracrevicular

sayatan dan sayatan melepaskan vertikal.

Sebuah sayatan pelepas vertikal ditempatkan, membentang menjadi

Mukosa alveolar tidak lebih dekat dari satu gigi dengan yang terlibat

daerah. Setelah refleksi degranulasi menyeluruh dan

debridement dilakukan di daerah cacat. Juga teliti

Penskalaan dan perencanaan akar dilakukan pada yang terbuka

luas permukaan akar dari cacat. Setelah instrumentasi,

Permukaan akar dicuci dengan larutan garam

untuk mencoba menghapus sisa fragmen yang terpisah

dari bidang cacat dan bedah. Setelah itu, tulangnya

Cacat diisi dengan bahan xenograft (Osteobiol

GenOs, Tecnoss) dan distabilkan di daerah furcation

(Gambar 3). Penutupan jaringan lunak primer dari flap sudah dilakukan

dengan sutra hitam tak tertahankan [3-0] jahitan (Ethicon, Inc.

Somerville, NJ) menggunakan teknik penjahitan tersela.

Pasien disarankan melakukan kontrol plak yang tepat, dan diresepkan

0.12% obat kumur chlorhexidine untuk pembilasan dua kali

setiap hari, selama seminggu. Jahitan dilepas 10 hari

setelah operasi Radiografi setahun ingat menunjukkan lengkap

Perbaikan tulang dalam defek furkasi (Gambar 3).

Diskusi

Lesi endo-perio menghadirkan tantangan pada dokter

sejauh diagnosis dan prognosis gigi yang terlibat

Prihatin Diagnosis yang benar adalah prasyarat yang penting

untuk menentukan pengobatan dan prognosis jangka panjang.

Diagnosis penyakit endodontik primer dan primer

Penyakit periodontal biasanya tidak menimbulkan kesulitan klinis.

Langkah pertama untuk diagnosis yang tepat adalah tes vitalitas.

Meski tes vitalitas tidak bisa memberikan histologis

status pulpa gigi, kemampuan mereka untuk mendaftarkan bubur kertas

vitalitasnya cukup memuaskan. Kemampuan tes vitalitas untuk

Gambar 3. a) Radiografi gigi awal # 36. b) radiograf ingat 3 bulan

menunjukkan lesi tulang di daerah furkasi. c) Film intraoral

menunjukkan lesi furkasi selama operasi periodontal. d) Intraoral

film yang menunjukkan penempatan material cangkok tulang ke lesi furkasi.

e) Radiografi dua tahun yang menunjukkan penyembuhan lengkap dari furkasi

luka.
e94

J Clin Exp Dent. 2014; 6 (1): e91-5. Berbagai jenis lesi endo-perio

penyembuhan riodontal (12). Dalam laporan kasus sekarang, root

Perawatan kanal dilakukan 3-4 bulan sebelum

operasi periodontal menunjukkan tidak ada efek mengganggu pada

penyembuhan lengkap dari lesi furkasi mandibula

geraham. Hasil ini harus dikonfirmasi oleh masa depan

Studi klinis

Perencanaan perawatan yang diberikan dalam laporan kasus ini dapat dipandu

dokter untuk menangani perlakuan yang berbeda

lesi endo-perio tipe. Dalam hal ini lapor, pengobatan

Strategi diberikan dalam kaitannya dengan berbagai jenis

lesi endo-perio. Hasil pengobatan akan lebih banyak

Dapat diprediksi jika dokter memiliki lebih banyak melalui pengetahuan

tentang diagnosis, urutan perawatan dan interval.

Dengan demikian, pengelolaan langsung endo-

Lesi perio bisa menghambat hilangnya gigi alami

dan menunda perawatan yang lebih kompleks