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Management and Follow-Up of the Combined Perio-Endo Lesion

Terry Pannkuk, DDS, MScDInstructional, Complications: Advanced Management, Endo-Perio Combined Lesions, Retreatment Strategies, Dismantling, Recall Observations, Sample Cases, All by Date

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Preoperative Periapical Radiograph (2007)

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Preoperative radiograph (horizontal, 2007)

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Initial access showing cast core in a septic pulp chamber space (2008)

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Continued access with complete removal of the pulp chamber portion of the cast core (2008)

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Deep "drill-out" of the casting in the MB canal system (2008)

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Extension of the access toward the palatal to remove the palatal canal casting (2008)

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Final removal of the cast core (2008)

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Identification of the previously missed MB2 system (2008)

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Final cleaning and shaping of all root canal systems on the first retreatment visit (2008)

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Placement of intracanal calcium hydroxide in each of the orifices with a small sponge spacer (2008)

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Removal of the loose crown and re-entry on the second retreatment visit one month later (2008)

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Placement of the amalgam core at the completion of endodontic treatment (2nd retreatment visit, 2008)

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Immediate post-treatment radiograph (2008)

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Recall periapical radiograph (2010)

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Recall radiograph (horizontal angle, 2010)

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Recall periapical radiograph (2014)

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Recall CBCT frontal capture section showing a slice highlighting the MB1 and MB2 canal systems (2014)

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Recall CBCT frontal capture section showing a slice through the DB and P roots (2014)

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Recall CBCT saggital capture section showing a slice through the palatal root (2014)

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Decision Tree

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Patient: 61 year-old male with a history of bypass heart surgery (at time of nonsurgical root canal treatment by the author)

Chief Complaint: gum sensitivity

Dental History: History of numerous crowns and previous root canal treatments and chronic periodontal disease with pocketing managed by a periodontist. The patient was referred by his periodontist to examine recently developed pocketing associated with tooth #14.

Significant Findings(Tooth #14): The radiograph series demonstrated previous root canal treatment filled slightly short, a suspected missed MB2 canal system and a small periapical radiolucency associated with the DB root. A 6mm pocket was probed into the buccal furcation and a 4 mm pocket at the lingual furcation bled upon probing. There was also a 6 mm pocket at the ML line angle which bled when probed. Mobility, percussion, and palpation findings were all within normal limits.

Pulp and Periradicular Diagnosis(#14): Previous root canal filling with chronic periradicular periodontitis (primary endodontic, secondary periodontal etiology suspected)

Treatment Prognosis: Guarded (#14)

Treatment Plan: Nonsurgical endodontic retreatment with exploration for fracture (#14)

Special Considerations of Performed Treatment: Combined endodontic and periodontal pathosis presents a special challenge especially when the tooth has been previously treated with endodontics. An untreated tooth with periodontal disease and a vital pulp likely has periodontal disease without an endodontic component and the prognosis completely depends upon the potential for success periodontal treatment without a need for endodontic treatment unless it is performed prophylactically in anticipation of retrograde pulpits as a later sequela.

In this case unsuccessful periodontal management of a furcation suggested that an endodontic disease vector might be the cause, especially with a deep core (suspected casting) which was likely placed without a rubber dam exposed to the oral environment.. Many dentists and periodontists ignore the likelihood of furcation accessory canals being a conduit for inflammatory mediators originating from a contaminated pulp chamber space to the periodontium of the furcation. Access revealed a cast core which was drilled out. No crown-root fracture was discovered. An untreated MB2 system was discovered as the access was strategically extended and the previous root filling was removed. All 4 root canal systems were cleaned, shaped, and filled with calcium hydroxide the first visit.

On the second visit, the crown loosened and was removed. The patient was asymptomatic and the prepared root canal system was obturated via the compaction of warmed gutta percha technique (Classic Schilder Technique). A custom fitted copper band was used as a matrix to place a bonded amalgam core and the patient was scheduled for a series of recall visits to monitor healing.

Recall:

7/19/ 2010 (First Recall Examination): The retreatment was completed 4/15/2008 and patient returned for post-treatment evaluation over two years later. The buccal furcation measured to an unchanged depth (6mm) although there was no bleeding upon probing. Here were no signs of recurrent endodontic pathosis. Reduction in the size of the DB root periapical radiolucency was noted. The patient’s dentist and periodontist were apprised of the findings and more rigorous periodontal management was instituted by the periodontist and general dentist.

10/7/2014 (Second Recall Examination): The post-treatment follow up examination after 6 years demonstrated much improved findings with the furcation probing measuring within the normal range. The mesiolingual measurement probed to 5mm and the mid-distal pocket to 4mm. There was no sign of recurrent endodontic pathosis. A CBCT scan revealed normal osseous findings with validated osseous regeneration.

Key Learning Points:

  1. Furcation involvement of previous endodontic-treated molars poses a special diagnostic challenge.

  2. Furcation accessory canals are often a source of septic transmission from an unclean pulp chamber to the periodontium.

  3. Coordinated endodontic treatment with follow-up periodontal management can lead to a stable and predictable long term successful result when furcation bone loss is associated with an endodontic etiology.

  4. CBCT imaging can more accurately quantitate osseous regeneration than traditional dental radiograpy.

Join the discussion

Respected sir,
What is the correct way to treat furcation accesory canal.

It’s rare that you can directly see a furcation accessory canal. It’s important to remove all tertiary (irritational) dentin which is likely infected. A properly extended access outline with direct visibility into each canal orifice facilitates more thorough cleaning. All pulp stones need to be carefully dissected from the pulp chamber floor. Strict aseptic isolation is important especially when placing the final core which should be placed immediately after root filling. The MIE proponents minimize the importance of meticulous debridement in favor of preserving tertiary dentine which is abnormal pathogenic dentine having no evidence-based rationale for saving.

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