CASE REPORT

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Geetha Ari, Anil Kumar K, Thyagarajan Ramakrishnan

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Treatment of an intrabony defect combined with an endodontic lesion: a case report

Geetha Ari, MDS
Senior Lecturer, Department of Periodontics, Meenakshi Ammal Dental College, Maduravoyal, Chennai, India

Key words

guided tissue regeneration, intrabony defect, periodontalendodontic lesion, periobone-G, platelet-rich brin

Anil Kumar K, MDS

Senior Lecturer, Meenakshi Ammal Dental College and Hospital, Maduravoyal, Chennai, India

The aim of periodontal therapy is resolution of inammation in the supporting structures of the tooth. Endodontic therapy deals with the disease of the pulp and periapical tissues. Researchers and clinicians have long recognised that an intimate relationship exists between the pulp of a tooth and its surrounding periodontium. The present report describes the use of PRF (platelet-rich brin) gel in combination with an intrabony defect and a periapical lesion. The tooth was root canal treated followed by periodontal therapy. A combination of PRF gel, hydroxyapatite graft and guided tissue regeneration (GTR) membrane was used to achieve faster healing of the periapical lesion and intrabony defect. After 1 year, the absence of a periradicular lesion, pain and swelling along with tooth stability and adequate radiographic bone structure indicated a successful outcome.

Thyagarajan Ramakrishnan, MDS

Professor, Department of Periodontics, Meenakshi Ammal Dental College, Maduravoyal, Chennai, India Correspondence to: Geetha Ari Department of Periodontics, Meenakshi Ammal Dental College, Maduravoyal, Chennai 600095, India Email: rashmetachn@yahoo.com

Introduction
Periodontal therapy is mainly aimed at removal of local factors, which leads to resolution of inammation in the supporting structures of the tooth. This therapy predominantly involves scaling and root planing as the main therapy, combined with hard and soft tissue surgery. With proper postoperative maintenance care, resolution of inammation occurs, leading to arrest of disease progression. The relationship between the pulp tissue and the surrounding periodontal tissues has been widely documented1. In the treatment of periodontalendodontic lesions, appropriate diagnosis, identication of

the primary cause and proper planning and performance of the treatment is crucial. Combined periodontalendodontic therapy is widely used because of the close proximity of the pulp and periodontal structures and their mutual involvement in disease. The prognosis of the combined periodontal endodontic diseases depends upon the severity of the periodontal disease and the response of the periodontal treatment. Occasionally, by-products of the necrotic infected pulp tissue penetrate through accessory canals or furcational canals, resulting in inammation of the periodontal tissues, often indistinguishable from a solely periodontal disease. The amount of tissue

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Case report
A 33-year-old female patient was referred to the Department of Periodontics, Meenakshi Ammal Dental College, from the Department of Oral Medicine and Radiology. The patient complained of tooth pain that was dull and excruciating, pus discharge and swelling in the mandibular left posterior region (Fig 1). On examination, inammation of the attached gingiva and pain on percussion were present. An abnormal painful response to percussion on tooth 36 indicated that inammation of the periodontal ligament could be of pulpal or periodontal origin. The tooth showed attrition and presented with plaque and calculus. Pulp sensitivity testing was performed using hot and cold and the results were conrmed using a pulse oximeter8, which indicated no response, hence the pulp of tooth 36 was considered to be non-vital. Periodontal probing revealed a pocket depth of 8 mm and clinical attachment loss of 10 mm in relation to tooth 36. There were no other periodontally involved teeth in the remaining dentition. Radiographic examination demonstrated severe bone loss around the mesial aspect of tooth 36 (Fig 2). The initial phase of treatment included complete scaling and root planing. After drainage of the abscess, antibiotics (amoxicillin 500 mg, 3 times a day for 5 days) and analgesics (ibuprofen 400 mg, 3 times a day for 3 days) were prescribed. The patient was referred to the Department of Endodontics for root canal treatment of tooth 369. After 3 months, the patient was recalled and surgical treatment was planned for the treatment of the intrabony defect with bone graft, PRF and GTR membrane.

Presurgical therapy
The initial phase of treatment included complete scaling and root planing. Periodontal parameters (probing depth, mobility and radiographic evidence of bone loss) were assessed before and after surgery.

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destruction is directly correlated with the total microbial content in the root canal system2 and over time these tissues are exposed to the infection3. Yamasaki et al4 have reported that periradicular lesions may initially expand horizontally through cancellous bone and then proceed vertically. The periodontalendodontic lesion is used to describe lesions due to inammatory products found in varying degrees in both the periodontium and the pulpal tissues. Inammatory symptoms typical of peridontal disease, such as deep periodontal pockets with or without swelling and suppuration of the marginal gingiva, increased tooth mobility and angular bony defects may also represent symptoms of a pathological condition present in the root canal system of the tooth. Platelet-rich plasma (PRP) has become a valuable adjunct in wound healing in dentistry. Post-surgically, blood clots initiate the healing and regeneration of hard and soft tissues. PRP is a platelet concentrate that has been used widely to accelerate soft and hard tissue healing. Platelet-rich brin (PRF) belongs to a new generation of platelet concentrates, with simplied processing and without biochemical blood sampling. The use of platelet gel to improve bone regeneration is a recent technique in implantology and periodontology. PRF was rst developed in France by Choukroun et al5 for specic use in oral and maxillofacial surgery. This second generation platelet concentrate eliminated the risk associated with the use of bovine thrombin6. El-Sharkawy et al7 have studied the regenerative potential of PRP, suggesting that the administration of growth factors may be combined with tissue regeneration techniques in the repair of intrabony defects, furcations and cyst cavities to improve the outcome of these treatments. Clinicians and scientists are investigating the use of PRF in dentistry as a way to enhance the bodys natural wound healing mechanisms. The present article reports on a tooth with a combined lesion that has been treated using both endodontic and periodontal measures. In this case, following root canal treatment, the tooth was treated using bone grafting with PRF gel and guided tissue regeneration (GTR) membrane under open ap debridement. Hopefully, in the future it will be

possible to obtain intrabony defects.

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Fig 1 Preoperative clinical situation showing teeth 35 and 36.

Fig 2 Preoperative radiograph of tooth 36 showing periapical radiolucency and intrabony defect at the mesial aspect.

Fig 3 Working length radiograph.

Fig 4

Masterpoint radiograph.

Management Root canal therapy

The rst step in the treatment plan after phase 1 therapy was to deal with the endodontic procedure. An access cavity was created with EX24bur (nonend-cutting tapered ssure; Mani, Tochigi, Japan) and a rubber dam was placed. The root canals were instrumented carefully with K-les (Mani) with the aim of cleaning the root canal walls of debris. After instrumentation, a needle was placed to within 1 mm of the apex, and the canal was slowly ushed with 5 mL of 5% sodium hypochlorite (NaOCl) irrigant (Niclor, Ogna, Milan, Italy). Saline (5 mL of 0.9% normal saline; Fresenius, Kabi, India) in a 5 mL irrigation syringe was used as a nal rinse. The root canals were dried with sterile paper points and calcium hydroxide (Ultracal XS, Ultradent, South Jordan, UT, USA) was placed in the root canals.

After 2 weeks, the calcium hydroxide dressing was removed after placement of a rubber dam, and repeated rinsing with 5% NaOCl was performed followed by rinsing with normal saline. The root canals were dried with sterile paper points and obturated using the lateral compaction technique and sealer (AH Plus, Dentsply DeTrey, Konstanz, Germany) (Figs 3 to 5). A postoperative radiograph was performed at 3 months (Fig 6).

Periodontal therapy
After 3 months, the patient was recalled for management of the intrabony defect. After proper isolation of the surgical eld, the operative sites were anaesthetised using 2% xylocaine hydrochloride with adrenaline (1:200000). Crevicular incisions were made using a BardParker No.15 blade (BD, Franklin Lakes, NJ, USA) on the facial and lingual surfaces of each tooth, with segment or area in-

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Fig 5 Postoperative radiograph.

Fig 6

Three-month follow-up radiograph.

Fig 7 Flap reected.

Fig 8 Placement of Williams probe in relation to teeth 35 and 36.

volved. A full-thickness mucoperiosteal ap was reected using a periosteal elevator, taking care to preserve the maximum amount of gingival connective tissue in the ap. The defect was thoroughly debrided and the root surface was then planed and the ap trimmed to remove granulation tissue tags and minimise bleeding (Figs 7 and 8). This was followed by irrigation with Betadine (Purdue Products, Stamford, CT, USA) and sterile saline solution.

The resultant product consisted of the following three layers (Fig 9): the upper layer of acellular PPP (platelet-poor plasma) PRF clot in the middle red blood cells at the bottom. Because of the absence of an anticoagulant, blood begins to coagulate as soon as it comes in contact with the glass surface. Therefore, for successful preparation of PRF, speedy blood collection and immediate centrifugation, before the clotting cascade is initiated, is absolutely essential. PRF can be obtained in the form of a membrane by squeezing out the uids in the brin clot10. After debridement, bone graft (Periobone-G, Top-Notch, Health Care Products, Kerala, India) was mixed with the PRF gel derivative in a sterile dappen dish to a paste-like consistency (Fig 10). This was placed into the periodontal defects to the level of the

PRF preparation
The advantages of PRF over PRP are its simplied preparation and lack of biochemical handling of the blood. A blood sample of the patient was drawn in 10 mL test tubes without an anticoagulant and centrifuged immediately. Blood was centrifuged using a tabletop centrifuge (REMY Laboratories, Chennai, Tamilnadu, India) for 12 min at 2500 rpm.

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Fig 9 PRF gel.

Fig 10

PRF gel with bone graft.

Fig 11 PRF gel with bone graft placed.

Fig 12 Placement of GTR membrane (Healiguide) in relation to tooth 36.

Fig 13 Placement of sutures.

Fig 14

Placement of Coe-Pak (GC America).

surrounding bony walls, taking care not to overll (Fig 11). It has been suggested that under-lling or overlling may be counterproductive because it may preclude proper ap closure, thereby retarding healing and possibly resulting in loss of the graft material. This was followed by placement of a GTR

membrane over the defect (Fig 12). The mucoperiosteal ap was replaced and primary wound closure was achieved by means of black silk 4-0 sutures (Fig 13) and Coe-PakTM (GC America, Alsip, IL, USA) was placed (Fig 14). After a period of 7 to 10 days the sutures were removed.

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Fig 15 Twelve-month follow-up radiograph.

Fig 16 Twelve-month post-operative view showing reduced pocket depth.

Post operative care

Following surgery, the patient was instructed to avoid chewing in the surgical area during the rst postoperative day. Systemic antibiotics (amoxicillin 500 mg, 3 times a day for 5 days) and analgesics (ibuprofen 400 mg, 3 times a day for 3 days) were prescribed. The patient was instructed to rinse daily with a solution of 0.2% chlorhexidine digluconate for 7 days. Recall appointments were scheduled after 10 days, and at 9 and 12 months.

Healing
After 10 days, the sutures were removed and healing was found to be adequate. Re-evaluation of the patient after 9 and 12 months revealed satisfactory bone ll and complete soft tissue healing. Periapical radiographs taken at the 9- and 12-month followup appointments indicated radiographic bone ll in relation to tooth 36 and healing of the periapical lesion (Fig 15). The probing depth reduced from 8 mm to 3 mm (Fig 16). The biological principle was based upon the use of mechanical barriers to allow selective cell repopulation of the root surface by periodontal ligament cells, as proposed by Melcher11.

Discussion
Periodontalendodontic lesions develop by either periodontal destruction combining apically with an existing periapical lesion, or an endodontic lesion

combining with an existing periodontal lesion. It has long been recognised that an intimate relationship exists between the pulp of a tooth and its surrounding periodontium. Seltzer et al12 concluded that an established endodontic lesion could progress through the main or accessory canals to produce periodontal breakdown. A more controversial hypothesis has also been suggested, that of the spread of infection from a periodontal pocket into the root canal system itself13. The regeneration of a new attachment apparatus is one of the most challenging aspects of periodontal therapy. Periodontal regeneration is now understood in the treatment of many periodontal defects, and is at the forefront of periodontal research. The goal is to regenerate the components of the periodontium that have been lost through periodontitis. The use of bone grafts and bone substitutes, guided tissue regeneration and, more recently, the application of polypeptide growth factors to the surgical wound are some commonly used techniques to promote periodontal regeneration. PRP and platelet concentrates made from autologous blood are used to deliver growth factors in high concentration to the site of a bone defect. Autologous PRP enhances wound healing in different organ systems and improves the osseous wound healing of autogenous bone grafts in both quality and quantity. PRF belongs to a new generation of platelet concentrate, with simplied processing and without biochemical blood handling. PRF was rst developed in France by Choukroun et al5. This second generation platelet concentrate eliminated the risk associated with the use of bovine thrombin. The practical uses

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bility. Anderegg et al18 showed that the vertical component of the defect can predict the extent of osseous repair following regenerative surgery. Although the vertical component in this case was extensive, the lack of mobility and the presence of good bone support on the buccal side were factors that favoured the use of regenerative procedures instead of root resection. Understanding the periodontalendodontic continuum is a vital part of successful endodontic and periodontal therapy. On occasion, patients with pulpal disease may also present with inammatory periodontal disease. In such cases the lesions can be independent of each other or can be combined or communicating with each other. For these types of lesions, endodontic therapy should be performed rst. Diagnosis of primary endodontic disease and primary periodontal disease usually presents no clinical difculty. In primary endodontic disease the pulp is infected and non-vital. In primary periodontal disease the pulp is vital and responds to sensitivity testing. Treatment results should be evaluated in 2 to 3 months and only then should periodontal treatment be considered. This sequence of treatment allows sufcient time for initial tissue healing and better assessment of the periodontal condition. It also reduces the potential risk of introducing bacteria and their by-products during the initial healing phase19. In the present case, endodontic therapy was performed rst, followed by periodontal therapy after 3 months. The postoperative radiograph taken at the 1-year follow-up examination showed complete resolution of the periapical lesion and bone ll of the intrabony defect. Endodontic therapy results in resolution of the endodontic lesion but has little effect on the periodontal lesion. Therefore, it is essential that the periodontal problem was also treated to obtain the optimal therapeutic outcome. Within the limit of the present report, a combination of bone graft with PRF gel and GTR led to a favourable clinical improvement in periodontal intrabony defects. Further studies are necessary to assess the long-term effectiveness of this combined therapy in the treatment of intrabony defects.

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of PRP and PRF in clinical practice need to be examined. As they utilise the patients own blood, the risk of human-to-human disease transmission is virtually eliminated, making it a safer treatment method14. Several treatment modalities have been proposed to treat periodontally involved teeth. Surgical therapy involving regenerative procedures is indicated in periodontal intrabony defects. The regenerative procedures used in the present case include bone grafts in combination with PRF gel and GTR. PRF is an autologous source of platelets and is used to enhance the results of the regenerative procedure. The results of the present case suggest that a combination of PRF gel and bone graft aids regeneration in the treatment of intrabony defects. PRF is in the form of a platelet gel, and in combination with bone graft offers several advantages, including the promotion of wound healing, bone growth and maturation, graft stabilisation, wound sealing and haemostasis, and ease of handling graft materials. The bone graft used in the present case was a hydroxyapatite (HA) material (Periobone-G). This is an osteoconductive bone void ller which physically lls bone defects, providing a matrix or scaffolding for bone formation. It has been shown that porous HA bone grafting materials have excellent osteoconductive properties that permit outgrowth of osteogenic cells from existing bone surfaces into the adjacent bone graft material. As there are no organic components in HA, this bone graft material does not induce any allergic reaction and is clinically well tolerated15. By lling the defect, it also prevents collapse of the soft tissues into the bone defect and, if appropriately porous, facilitates stabilisation of the blood clot and ingrowth of new blood vessels. The combination of bone graft (Periobone-G) and GTR (HealiguideTM, Encoll, Newark, CA, USA) has been shown to be effective in promoting clinical signs of periodontal regeneration in intrabony defects in humans16. A possible explanation for the benets of using GTR membranes with bone grafts is that an improved space is provided by the barrier, which is conducive to cell events leading to periodontal regeneration and facilitation of mineralised tissue formation due to osteoconductive properties possibly inherent in the graft material17. It is believed that while a barrier addresses dynamics of cell migration, osseous grafts play an active role in promoting the formation of alveolar bone.

pyrig No Co t fo rP The case presented was more amenable to reub lica generative therapy than root resection as there was tio complete bone support on the buccal side when the t ess c e n en ap was raised. Clinically, the tooth showed no mo-

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Periodontol 1967;38:124-129. 13. Meister F, Lommel TJ, Gerstein H. Endodontic perforations which resulted in alveolar bone loss. Oral Surg Oral Med Oral Pathol 1979;47:463-470. 14. Lekovic V, Camargo PM, Weinlaender M, Vasilic N, Kenney EB. Comparison of platelet rich plasma, bovine porous bone mineral, and guided tissue regeneration versus platelet-rich plasma and bovine porous bone mineral in the treatment of intrabony defects: a reentry study. J Periodontol 2002;73:198-205. 15. Kenney EB, Lekovic V, Han T, Carranza FA. The use of a porous hydroxyapatite implant in periodontal defects. Clinical results after six months. J Periodontol 1985;56:82-88. 16. Becker W, Becker BE, Mellonig J, Caffesse RG, Warrer G, Caton JG et al. A prospective multi-center study evaluating periodontal regeneration for class II furcation and intrabony defect after treatment with a bioabsorbable barrier membrane: 1 year results. J Periodontol 1996;67:641-649. 17. Camargo PM, Lekovic V, Weinlaender M, Vasilic N, Madzarevic M, Kenney EB. Platelet-rich plasma and bovine porous mineral combined with guided tissue regeneration in the treatment of intrabony defects in humans. J Periodont Res 2002:37;300-306. 18. Anderegg CR, Martin SJ, Gray JL, Mellonig JT, Gher ME. Clinical evaluation of the use of decalcied freeze-dried bone allograft with guided tissue regeneration in the treatment of molar furcation invasions. J Periodontol 1991;62:264-268. 19. Agrawal PK. Combined periodontal-endodontic lesion. Government Dental College Alumni Association, Jaipur. Available at: www.gdcaaj.com/articles%20pdf/pkagrawal. pdf. Accessed 10 May 2010.

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