Perio–Endo Interrelationships
Abdullah Alqaied and Maobin Yang
Chief Complaint
“I have pain when I bite hard on my tooth.”
Medical History
The patient (Pt) was a 38-year-old male. Vital signs were as follows: blood pressure (BP) 109/70 mmHg, pulse 77 beats per minute (BPM), respiratory rate (RR) 18 breaths per minute. The Pt was not treated for any medical condition. A complete review of systems was unremarkable. The Pt was not taking any medications and had no known drug allergies (NKDA). There were no contraindications to dental treatment (Tx).
The Pt was American Society of Anesthesiologists Physical Status Scale (ASA) Class I.
Dental History
The Pt was referred for evaluation and treatment of tooth #30. Pt reported dull pain when biting on tooth #30. The symptoms had started about two months previously but the symptoms were never severe enough to seek immediate dental care. Tooth #30 had an occlusal (O) composite restoration; the Pt did not recall when it was placed. The Pt was missing all the 3rd molars. Pt did not keep regular dental visits with the general dentist (GD) and had poor oral hygiene.
Clinical Evaluation (Diagnostic Procedures)
Examinations
The Pt was well developed, alert and cooperative.
Extra-oral examination (EOE)
Examination revealed no swelling, extra-oral fistula or lymphadenopathy of the submandibular and neck areas.
Intra-oral examination (IOE)
Soft tissue appeared healthy with no signs of intra-oral swelling or sinus tract. No swelling or fluctuance was noted. Pt had minor gingivitis and moderate subgingival calculus. Tooth #30 had O composite restoration, and class I furcation involvement. Pt had several restored teeth without visible caries, recurrent caries or cracks.
Diagnostic Tests
| Tooth | #28 | #29 | #30 | #31 |
| Percussion | – | – | + | – |
| Palpation | – | – | + | – |
| Endo lce® | + | + | – | + |
| Mobility | WNL | WNL | WNL | WNL |
| EPT (Value) | + (32) | + (36) | – | + (35) |
| PPD (BOP) | <4 mm (+) | <4 mm (+) | <4 mm (+) | <4 mm (+) |
EPT: Electric pulp testing; PPD: Peridontal pocket depth; BOP: Bleeding on probing; WNL: Within normal limits +: Response; -: No response.
Radiographic Findings
A periapical radiograph (PA) showed teeth #29–31. Tooth #30 had a furcal radiolucent lesion, widened periodontal ligament (PDL) space around the mesial (M) root, and an internal resorptive defect in the distal (D) aspect of the pulp chamber. Normal PA structure was seen around tooth #29, the D root of tooth #30, and the M and D roots of tooth #31 (Figure 22.1). A bitewing radiograph revealed tooth #30 with deep O restoration. The internal resorptive defect was located about the orifice level of the D canal. Teeth #2, #3, and #31 were restored with no signs of recurrent caries. The remaining teeth were non-carious and non-restored. The bitewing radiograph showed moderate subgingival calculus and minor loss of bone height (Figure 22.2).
Figure 22.1 Preoperative periapical radiograph of tooth #30.
Figure 22.2 Preoperative bitewing radiograph of tooth #30.
Pretreatment Diagnosis
Pulpal
Pulp Necrosis, tooth #30
Apical
Symptomatic Apical Periodontitis, tooth #30
Endo–perio lesion (Primary Endodontic Lesion)
Treatment Plan
Recommended:
Emergency:Pulp debridement, tooth #30
Definitive:Non-surgical Root Canal Treatment (NSRCT), tooth #30
Alternative
Extraction and replacement with implant or fixed partial denture or no treatment
Restorative
Post, core and crown
Prognosis
| Favorable | Questionable | Unfavorable |
| X |
Clinical Procedures: Treatment Record
First visit (Day 1): Upon completion of reviewed medical history (RMHX), EOE, and IOE, treatment options were reviewed with the Pt, who decided to retain the tooth by having a root canal treatment (RCT). Pt was advised that the internal resorptive defect needed to be evaluated during the treatment procedure to evaluate if the tooth was restorable. Pt was aware of the Tx risks and benefits. Informed consent was obtained. Anesthesia was administered with 36 mg of lidocaine with 0.018 mg of epinephrine administered via inferior alveolar nerve block (IANB). Rubber dam (RD) isolation was used and disinfection accomplished. Access cavity and chamber unroofing were completed using a sterile bur. An internal resorptive defect was found in the D lingual (L) aspect of the pulp chamber (Figure 22.3). No bleeding was detected from the resorptive defect. Initial canal instrumentation and negotiation were completed using sizes #8, #10, and #15 K-file. Canal instrumentation was continued under copious irrigation with 0.5% sodium hypochlorite (NaOCl). Working length (WL) measurements were determined using an electronic apex locator and a WL radiograph (Figure 22.4). Coronal flaring was completed with SX, S1, and S2 ProTaper® Universal files (Dentsply Sirona, Ballaigues, Switzerland) under copious irrigation. Canal instrumentation was completed to size #30, .06 taper master apical file (MAF) for the MB and ML canals and to size #40, .06 taper (MAF) for D canal using EndoSequence®file (Brasseler USA, Savannah, GA, USA). Canals were dried with paper points (PPs). Canals and pulp chamber were soaked with 17% Ethylenediaminetetraacetic acid (EDTA) for 1 minute, dried with PPs, and soaked with 2% iodine–potassium iodide (IKI) for 10 minutes. After the 10 minutes, canals were dried again with PPs, and a slurry of calcium hydroxide (Ca(OH)2) was introduced into the canals using a Lentulo® Spiral Filler (Dentsply Sirona, Ballaigues, Switzerland) and packed with a PP. A slurry of Ca(OH)2 was packed into the resorptive defect as well. The tooth was temporized with CavitTM (3M, Two Harbors, MN, USA) and Fuji IX GP® (GC America Inc., Alsip, IL, USA). Occlusion was adjusted. Postoperative instructions (POI) were given to the Pt, who was instructed to take 600mg ibuprofen every 6 to 8 hours (q6-8hrs) as needed (PRN) for pain. Pt was asked to call if symptoms appeared. Pt was instructed to schedule a second appointment to complete the treatment after 7-10 days.
Figure 22.3 Internal resorptive defect was found in the DL aspect of the pulp chamber of tooth #30.
Figure 22.4 Radiograph to measure the working length of tooth #30.
Second visit (5-week follow-up): Pt visited for completion of NSRCT tooth #30: Pt presented asymptomatic. Vital signs were as follows: BP 120/71 mmHg, pulse 81 BPM, and RR 15 breaths per minute. Anesthesia: 36 mg of lidocaine with 0.018 mg of epinephrine was administered via IANB. RD isolation, followed by disinfection. Access was re-established and Ca(OH)2 was removed by copious irrigation with 0.5% NaOCl and minimal instrumentation. Hard structure was evident in the resorptive defect with no signs of bleeding or external communication. Gutta-percha (GP) cone fit was verified with a radiograph (Figure 22.5). Canals were soaked with 17% EDTA for 1 minute followed by 2% potassium iodide for 10 minutes. Canals were dried with PPs. Canals were obturated with GP and AH26® Root Canal Sealer (Dentsply Sirona, Konstanz, Germany) by warm vertical condensation. Alcohol was used to remove excess sealer. The D canal was covered with a thin layer of CavitTM. The resorptive defect and adjacent dentin were etched with 37% phosphoric acid for 1 minute and then rinsed with sterile water. The pulp chamber was dried. A bonding agent was applied and light-cured for 20 seconds. A-3 composite restoration was placed over the resorptive defect and light-cured for 40 seconds (Figure 22.6). The tooth was temporized with CavitTM and Fuji IX GP® and occlusion was checked. Postoperative radiographs were taken (Figures 22.7 and 22.8). POI were given. A letter was generated instructing the general dentist (GD) to use one of the M canals if a post and core was needed. The letter was given to the Pt and the importance of permanent coronal restoration and follow-up appointment were emphasized.
Figure 22.5 Radiograph with the master cones fit of tooth #30.
Figure 22.6 Composite restoration was placed over the resorptive defect of tooth #30.
Figure 22.7 Postoperative radiograph of tooth #30.
Figure 22.8 Postoperative radiograph of tooth #30 from a different angle.
Working length, apical size, and obturation technique
| Canal | Working Length | Apical Size, Taper | Obturation Materials and Techniques |
| MB | 20.0 mm | 30, .06 | AH26® sealer, Warm vertical condensation |
| ML | 20.5 mm | 30, .06 | AH26® sealer, Warm vertical condensation |
| D | 19.0 mm | 40, .06 | AH26® sealer, Warm vertical condensation |
Post-Treatment Evaluation
Third visit (1-year follow-up): RMHX. Pt was asymptomatic. Tooth #30 was not sensitive to percussion, and palpation and gingiva appeared normal. PPD was <4mm, there was no BOP, and mobility was WNL. A PA radiograph showed almost complete healing ofthe furcal lesion. PA radiographs revealed normal PDL space around the M root (Figure 22.9). Pt stated that the GD restored the tooth within two months of the completion of NSRCT. He did not report back for placement of permanent crown. Tooth #30 had post, core and temporary crown. Pt was instructed to get the tooth permanently restored to avoid complications. Prognosis was favorable. Pt was advised to schedule another follow-up appointment to monitor healing.
Figure 22.9 One-year follow-up radiograph of tooth #30.
Fourth visit (20-month follow-up): RMHX. Pt was asymptomatic. Tooth #30 was not sensitive to percussion and palpation. Gingiva appeared normal. PPD was <4mm, no BOP and mobility was WNL. A PA radiograph showed almost complete healing of the furcal lesion (possible scar tissue) and normal PA tissue. Tooth #30 had post, core and a well-fitting crown (Figure 22.10).
Figure 22.10 Twenty-month follow-up radiograph of tooth #30.
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