|Year : 2017 | Volume
| Issue : 1 | Page : 7-14
Comparative evaluation of root canal treatment alone and in combination with periodontal flap surgery in the treatment of endodontic-periodontal lesions: Randomized controlled clinical trial
Saras Mediratta1, D Deepa2, Shobhana Misra3, Neha Mediratta1
1 Periodontist, Private Practice, New Delhi, India
2 Department of Periodontology, Subharti Dental College and Hospital, Meerut, Uttar Pradesh, India
3 Department of Periodontology, Theerthankar Mahaveer Dental College and Research Centre, Moradabad, Uttar Pradesh, India
|Date of Web Publication||29-May-2017|
Department of Periodontology, Subharti Dental College and Hospital, Meerut - 250 005, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Endodontic-periodontal lesions are described as the lesions due to inflammatory products found in varying degrees in both pulp and periodontal tissues. In all cases of concurrent periodontal and pulpal disorders, the clinician must determine whether the existing tissue change originated from one or both processes so that appropriate treatment could be initiated. Aims: The aim of the present randomized controlled clinical trial was to evaluate and compare the two treatment approaches for the treatment of primary endodontic lesions with secondary periodontal involvement, i.e., root canal treatment (RCT) with RCT and periodontal flap surgery. Subjects and Methods: In this study, twenty cases aged between 18 and 55 years with good systemic health diagnosed as cases of primary endodontic lesion with secondary periodontal involvement were selected for the study. In ten cases, only RCT was performed (control group), and in another ten, after 1 month of completion of RCT, periodontal flap surgery was performed (test group). The patients were evaluated for changes in the gingival index, plaque index, gingival bleeding index, probing depth (PD), and relative attachment level (RAL) at baseline, 1 month, and at 4 months postoperatively. Results and Conclusion: Results showed statistically significant (P < 0.05) reduction from baseline to 1 and 4 months in the PD and gain in RAL both on intergroup and intragroup comparison. Thus, from the results of the study, it could be concluded that both treatment approaches revealed a significant improvement in the PD reduction and attachment level gain 4 months postoperatively. However, test group showed a significant difference in the reduction of PD and gain in attachment level.
Keywords: Endodontic-periodontal lesions, periodontal flap surgery, primary endodontic secondary periodontal lesions, root canal treatment
|How to cite this article:|
Mediratta S, Deepa D, Misra S, Mediratta N. Comparative evaluation of root canal treatment alone and in combination with periodontal flap surgery in the treatment of endodontic-periodontal lesions: Randomized controlled clinical trial. J Interdiscip Dentistry 2017;7:7-14
|How to cite this URL:|
Mediratta S, Deepa D, Misra S, Mediratta N. Comparative evaluation of root canal treatment alone and in combination with periodontal flap surgery in the treatment of endodontic-periodontal lesions: Randomized controlled clinical trial. J Interdiscip Dentistry [serial online] 2017 [cited 2017 Dec 11];7:7-14. Available from: http://www.jidonline.com/text.asp?2017/7/1/7/207152
| Clinical Relevance to Interdisciplinary Dentistry|| |
Systematically planned interdisciplinary approach with accurate diagnosis and comprehensive treatment planning enables to attain patient comfort, function, predictability, longevity of restorative and maintenance care.
| Introduction|| |
Scientific advancements have segmented the field of dentistry into a vast number of specializations. However, there are instances where treatment from a single specialist will not eradicate the disease, the reason being intricate nature of tooth, with its surrounding environment. An interdisciplinary approach among professionals becomes important for complete rehabilitation.
The noxious stimuli responsible for pulp inflammation, necrosis, and dystrophy are multitude, ranging from bacterial invasion to hereditary dwarfism. Bacteria play an important role in the pathogenesis of both periodontal disease and caries. Kakehashi tested the influence of viable microorganisms on the fate of surgically exposed dental pulps and found that the presence of microbial flora is the major determinant in the healing of exposed rodent pulps. Jansson et al. concluded that pathogens in necrotic root canals may stimulate epithelial downgrowth along denuded dentin surfaces with marginal communication and thus augment periodontal disease. Rupf et al. studied the profiles of periodontal pathogens in pulpal and periodontal diseases associated with the same tooth. Specific polymerase chain reaction methods were used to detect Aggregatibacter actinomycetemcomitans, Tannerella forsythia, Eikenella corrodens, Fusobacterium nucleatum, Porphyromonas gingivalis, Prevotella intermedia, and Treponema denticola. These pathogens were found in all endodontic samples and the same pathogens were found in teeth with chronic apical periodontitis and chronic periodontitis. It is imperative to completely clean, shape, and obturate the canal system to enhance successful outcomes. Poor endodontic treatment allows canal reinfection, which may often lead to treatment failure.
Periodontal lesions are initiated by deposits of plaque and calculus. Inflammatory mediators cause destruction of gingival connective tissue, periodontal ligament, and alveolar bone. Migration of the lesion to the apex continues with drainage through the gingival sulcus preventing acute episodes.
Endodontic-periodontal lesions arise from inflammation or degeneration of both pulpal and periodontal tissue as a result of this intimate anatomic relationship. Seltzer et al. suggested that pulpal lesions have an effect on the severity of periodontal lesions. Inflammation of the periodontal membranes from inflamed and necrotic pulps readily spread through lateral and accessory foramina, especially in molars.
Paul and Hutter stated that a primary endodontic lesion that is draining through the periodontal attachment is usually treated with endodontic therapy. After an appropriate length of time, usually 1–2 months, the practitioner then reassesses the patient's periodontal health. The rationale for this therapy is to maximize endodontic healing before aggressively planning the tooth's root surface and to avoid inadvertent removal of healthy connective tissue fibers. If a lesion is relatively recent and treated expeditiously, most periodontists and endodontists believe that healing occurs by reattachment of these connective tissue fibers to the root surface.
Success of both periodontal and endodontic therapy on a given tooth depends on the diagnosis of the disease and elimination of the disease process whether they exist separately or as a combined lesion. Hence, the aim of the present randomized controlled clinical trial was to evaluate and compare the two treatment approaches for the treatment of primary endodontic lesions with secondary periodontal involvement, i.e., roots canal treatment with root canal treatment (RCT) and periodontal flap surgery.
| Subjects and Methods|| |
A sample size of 20 patients aged between 18 and 55 years with good systemic health diagnosed as cases of primary endodontic lesion with secondary periodontal involvement were selected for the study. Diagnosis was made on the basis of clinical findings such as caries involving pulp, bleeding on probing, probing depth (PD) ≥5 mm, attachment loss ≥5 mm, tenderness on percussion, and radiographic features such as alveolar bone destruction with apical pathology or lateral radiolucency. Only posterior teeth were included for this study. Patients having previous root filling, unrestorable tooth, fractured root/file in root canal, and internal or external root resorption and patients with systemic diseases and previous history of periodontal surgery were excluded from the study.
Patients so selected were equally divided into two groups, i.e., Groups A and B. Both the groups underwent scaling followed by RCT. In Group A patients, i.e., the control group, only RCT was performed. In Group B patients, i.e., the test group, after 1 month of completion of RCT, periodontal flap surgery was performed.
The parameters recorded at baseline, 1 month, and 4 months are gingival index (GI) (Loe and Silness 1963), plaque index (PI) (Silness and Loe 1964), gingival bleeding index (GBI) (Ainamo and Bay 1975), PD, relative attachment level (RAL), and radiographic bone level (radiographic assessment was done only by the amount of radiopacity as bone fill).,,
Occlusal stent preparation
The occlusal stent was made to cover the occlusal surfaces of the teeth being treated and were extended on the buccal and lingual surfaces to cover the coronal third of the teeth involved. A wire was placed on the buccal aspect of teeth during fabrication. This wire was then exposed by making grooves over the interdental areas on the buccal aspect of the teeth, such that the probe when inserted in the interproximal area was in contact with the wire; hence, the probe position and angulations remained the same for all pre- and post-operative measurements.
After local anesthetic administration (lignocaine hydrochloride 2% with 1:80,000 adrenaline), access to the pulp chamber was secured using a no. 8 round diamond bur including the use of Endo-Z bur (Dentsply). After flooding the chamber with sodium hypochlorite, in 1:1 concentration, canal negotiation was done with #10 or #15 K-files. Pulp removal was done with #10 or #15 barbed broach. After this, working length was determined by taking intraoral periapical (IOPA) radiograph. A devitalizer (Devitec ®) was then placed in the pulp chamber and closed dressing was placed and patients were recalled after 3 days. The patients were prescribed with amoxicillin 500 mg tds for 5 days and ibuprofen 400 mg tds for 5 days (only manual endodontic instruments were used with conventional protocol).
On the second visit, biomechanical preparation (BMP) of the root canals was done using ProTapers in the sequence of S1, Sx, S2, and F1 with intermittent irrigation with saline and sodium hypochlorite. After completing BMP, the canals were filled with calcium hydroxide paste (ApexCal ®), and a temporary restoration of Cavit ® was applied and patients were recalled after 5 days.
On the third visit, master cone radiograph was taken and the canals were dried using paper points and obturation was done. The tooth was then filled with temporary restoration of Cavit ®.
After 1 month of completion of RCT, the test group patients underwent periodontal flap surgery. After injecting local anesthesia (lignocaine hydrochloride 2% with 1:80,000 adrenaline), at the site of surgery, sulcular incisions were placed and full-thickness flaps were raised to retain sufficient tissue and to obtain primary closure. The defects were thoroughly debrided and root planed with hand and ultrasonic scalers. The flaps were trimmed and sutured back with silk (3-0) sutures [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5].
Patients in the surgical groups were subjected to a postoperative regimen of amoxicillin 500mg tds for 5 days and ibuprofen 400 mg tds for 5 days. The patients were given following postoperative instructions.
- Avoid intake of hot food for the first 24 h
- Avoid hard food for at least 1 week
- To avoid any undue trauma to the treated site
- All patients were placed on 0.2% chlorhexidine gluconate rinse, twice daily for 3–4 weeks
- All patients were explained that their full cooperation was necessary for the success of the treatment and were instructed to report at regular intervals.
Patients were recalled for suture removal after 1 week. Patients were reviewed at 1 month and 3 months postoperatively and parameters were recorded at 4 months interval [Figure 6] and [Figure 7]. Oral prophylaxis was done in cases of both groups at recall visits.
The data including GI, PI, GBI, PD, and RAL for both the treatment groups recorded at baseline, 1 month, and 4 months were tabulated and subjected to statistical analysis. The mean and the standard deviation of the clinical parameters at baseline, 1 month, and 4 months were calculated for both test and control groups. Student's paired t- test was used to compare data from baseline to that of 1 month and from baseline to 4 months for each treatment group. Comparison between the test and control groups (intergroup) at baseline, 1 month, and 4 months was accomplished using Student's unpaired t- test. The level of significance for the comparisons was set at P< 0.05.
| Results|| |
Results were obtained on the basis of the clinical evaluation of GI, PI, GBI, probing pocket depth, and RAL at baseline, 1 month, and 4 months postoperatively. The parameters recorded for both test and control groups at baseline showed no significant difference [Table 1]. The radiographs were taken preoperatively, at 1 month and 4 months postoperatively.
|Table 1: Mean of different parameters at baseline and level of significance|
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GI, PI, and GBI on intragroup comparison showed statistically significant (P < 0.05) reduction in values from baseline to 1 month [Table 2] and from 1 month to 4 months [Table 3] and [Graph 1],[Graph 2],[Graph 3]. When reduction in values for these indices from baseline to 1 month and from 1 month to 4 months was compared for both the test and control groups, it was found to be insignificant (P > 0.05) [Table 4] and [Table 5].
|Table 2: Within-group comparison (from baseline to 1 month) in test and control group for different parameters|
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|Table 3: Within-group comparison (from 1 to 4 months) in test and control group for gingival index|
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|Table 4: Between-group comparisons using unpaired t-test from 0 to 1 month for different parameters|
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|Table 5: Between-group comparisons using unpaired t-test from 1 to 4 months for different parameters|
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The pocket depth was calculated at baseline, i.e., after completion of scaling and postoperatively at 1 month and 4 months. The values for the test group and the control group reduced from baseline to 1 month [Table 2] and from 1 month to 4 months [Table 3]. There was a significant reduction in the PD at 1 month and 4 months on intragroup comparison [Table 6] and [Table 7]. The reduction in pocket depth from baseline to 1 month was calculated to be 1.2 ± 1.2293 for test group and 2.222 ± 1.5634 for control group. The reduction in the test group was found to be nonsignificant whereas the reduction in the control group was found to be significant [Table 2] and [Graph 4]. In the 1–4-month period, reduction in pocket depth was observed in test group and control group to be significant. The reduction was 3.8 ± 1.6193 and 1.7777 ± 0.8333 for test and control group, respectively, which was found to be statistically significant (P < 0.05) [Table 3]. Thus, the PD reduced effectively from baseline to 1 month and also from 1 month to 4 months in both the test and control groups respectively. However, the test group showed a significant reduction in PD at the end of 4 months.
|Table 6: Mean of different parameters at 1 month and level of significance|
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|Table 7: Mean of different parameters at 4 months and level of significance|
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The observations as shown in [Table 2] and [Table 3] depict gain in the attachment level values for the test group and the control group from baseline to 1 month and from 1 month to 4 months. The gain of attachment level was found to be significant at 1 month and 4 months on intragroup comparison [Table 6] and [Table 7]. The gain in attachment level from baseline to 1 month was calculated to be 1.3 ± 1.4181 for test group and 2.2 ± 1.9322 for control group [Table 2] and [Graph 5]. The gain in the test group was found to be nonsignificant (P > 0.05) whereas the gain in the control group was found to be significant [Table 2]. In the 1–4-month period, the gain in attachment level was observed in test group and control group to be significant. The gain was 2.7 ± 2.0575 and 1.6 ± 0.9660 for test and control groups, respectively [Table 3] and [Graph 5], which was found to be significant (P < 0.05).
| Discussion|| |
Treatment and prognosis of endodontic-periodontal lesions vary and depend on the cause and the correct diagnosis of each specific condition. The most accepted classification of endo-perio lesions was proposed by Simon et al. Endo-perio lesions were classified into five types, i.e., primary endodontic lesions, primary periodontal lesions, primary endodontic lesions with secondary periodontal involvement, primary periodontal lesions with secondary endodontic involvement, and true combined lesions. Belk and Gutmann added another category to this classification, concomitant endodontic and periodontal lesions. In this case, periodontal and pulpal diseases coexist, but with different etiology. Radiographically, the endodontic lesion and a noncommunicating periodontal pocket are observed.
Primary endodontic disease with secondary periodontal involvement should first be treated with endodontic therapy. Treatment results should be evaluated in 1–2 months and only then should periodontal treatment be considered. This sequence of treatment allows sufficient time for initial tissue healing and better assessment of the periodontal condition. It also reduces the potential risk of introducing bacteria and their byproducts during the initial healing phase. In this regard, it was suggested that the periodontal healing was adversely affected by aggressive removal of the periodontal ligament and underlying cementum during interim endodontic therapy. Areas of the roots that were not aggressively treated showed unremarkable healing. Prognosis of primary endodontic disease with secondary periodontal involvement depends primarily on the severity of periodontal involvement, endodontic treatment, periodontal treatment, and patient response.
There have been various case reports regarding the treatment of endodontic-periodontal lesions. Solomon et al., Vera et al.,Reddy et al., Patil et al., and Gorkhali and Pradhan treated the cases with endodontic therapy only whereas Rosenberg et al. treated the cases with RCT and periodontal flap surgery.,,,,, The results for all these case reports were conflicting. To the best of our knowledge, during the study, we could not find any literature on clinical studies conducted to evaluate these treatment approaches (i.e., only RCT with RCT and periodontal flap surgery).
It was with these factors in mind that the present study was planned to evaluate, clinically the effect of endodontic and periodontal treatment in the treatment of primary endodontic lesion with secondary periodontal involvement.
The results of the present study demonstrated a significant difference in the plaque, GI, and GBI scores within the intra- and inter-group comparison at 1 and 4 months from baseline for both control and test groups. The maintenance and significant improvement in these indices in the current study can be attributed to the fact that patients under observation were well motivated and hence regular in their follow-up. This was achieved by the reinforcement of plaque control measures and oral hygiene maintenance instructions at the various recall appointments. This also implies that there was an improvement in the gingival as well as the periodontal conditions of the patients during the study in the test and control groups.
A possible explanation for improvement in the plaque scores, GI, and GBI could be because of the so-called Hawthorne effect. The term was coined by Henry A. Landsberger when he was analyzing older experiments from 1924 to 1932 at the Hawthorne work factory. The Hawthorn effect is a form of reactivity whereby cases improve an aspect of their behavior being experimentally measured simply in response to the fact that they are being studied, not in response to any particular experimental manipulation.
In the present study, PD reduced significantly in control group from the baseline value of 7.5556 ± 1.5092 to 1 month and 4 months with a mean difference of 2.222 ± 1.5634 and 1.7777 ± 0.8333, respectively. The PD reduction observed after endodontic treatment alone is in accordance with case reports by Vera et al., Reddy et al., and Patil et al.,, In addition, there was a significant gain in the attachment level in this group from baseline value of 12.3 ± 1.4944 to 1 month and 4 months with a mean difference of 2.2 ± 1.9322 and 1.6 ± 0.9660, respectively. None of the previous workers have evaluated attachment gain in their work. In the test group, there was a reduction in the PDs from 8.2 ± 2.0449 at baseline to 7 ± 2.2608 at 1 month and 3.2 ± 1.9322 at 4 months. After applying paired t- test, an insignificant difference was obtained from baseline to 1 month, 0.0130 (P > 0.05), but a significant difference was obtained when a comparison was made between 1 month and 4 months, 0.0003 (P< 0.05).
These results are in accordance with previous results reported by Rosenberg et al. who reported a case of combined endo-perio lesion which was treated both endodontically and by periodontal flap surgery. This was a long-term follow–up, in which PD of 3mm was maintained over 10 years.
In a retrospective case–control study carried out by Saetervold et al., where the average pocket depth was ≥6 mm, it was seen that teeth which were not treated for their periodontal health and only endodontic treatment was instituted had a poor survival rate. Solomon et al. treated a case of true combined lesion involving the mandibular right second molar and concluded that resolution of the endodontic component of combined lesions allowed the tooth to be retained, albeit in a periodontally compromised state. With lesions of primary periodontal etiology and secondary pulpal necrosis, little or no improvement would be seen after endodontic treatment, leaving a very poor and often hopeless prognosis.
A gain in the attachment level was also observed in the present study. A nonsignificant difference was obtained from baseline to 1 month (0.0176, P > 0.05), but a significant difference was obtained from 1 to 4 months (0.0025, P< 0.05). None of the above-mentioned authors have evaluated gain in attachment level in their work.
In this clinical study, a trial was made by taking IOPA radiographs for the assessment of bone gain. The IOPA radiographs using long-cone paralleling technique were used as they are universally accepted conventional technique of radiographic evaluation. All the radiographs obtained were categorized as:
- Category 1: Radiographs where osseous involvement was quite evident and changes in radiolucency in these areas could be detected postsurgically
- Category 2: Radiographs where osseous involvement was evident but changes in radiolucency in these areas could not be detected postsurgically.
Overall, 98.33% of the IOPA radiographs had fallen into the category 1, but these were not quantified since these needed advanced diagnostic aids such as computer-assisted densitometric image analysis system (CADIA) and subtraction radiography.
| Summary and Conclusion|| |
The prognosis of the treated teeth was upgraded at the end of the study as judged by clinical parameters of assessment. No patient taking part in the study reported any local or systemic adverse reaction at any point of time. Thus, from this study, it could be concluded that both treatment approaches demonstrated a significant improvement in the PD and RAL at 4 months postoperatively. However, test group showed significant difference in the reduction of PD and gain in attachment level. Further long-term studies are recommended with radiographic assessment and with the use of regenerative bone grafts and guided tissue regeneration membrane after debridement.
However, the limitations of the present study are as follows: (1) larger sample size with long-term follow-up would have given more meaningful results and (2) bone grafts could have been used after the debridement of the defect and radiographic assessment using CADIA or digital subtraction radiography would have provided the quantification of new bone formation.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]