A Perio-Endo Dilemma: What to Do?

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IT’S NOT ALWAYS EASY to determine whether the problem with the affected tooth is caused by periodontal disease or pulpal disease. Many times the periodontal disease mimics pulpal symptoms, and many times pulpal disease mimics periodontal disease. Yet, at other times the lesion is truly a combined lesion. Sometimes the diagnosis is extremely difficult to determine based on the clinical signs present. In a case that was presented in my office, the patient’s teeth were severely mobile. Despite the patient’s present clinical condition, his history determined my treatment plan. Since trauma to the teeth had caused the periodontal and pulpal disease, deciding which precipitated the other was impossible for me. Even though I could not determine the etiology, a successful treatment was possible.

The patient presented to me at my office with perio-endo lesions on teeth on the upper left quadrant. The patient was a 28-year-old Asian male. He was in good health and had good oral hygiene. The teeth of concern had no or minimal restorations. Teeth numbers 12, 13, and 14 had extreme mobility. Clinically, the patient stated that he felt that his teeth were “hanging on by a thread.” Teeth numbers 13 and 12 were extremely mobile. Tooth number 14 was the least mobile of the three. The patient was extremely distraught at the possibility of loosing three adjacent teeth. The patient’s history included a memorable fall as a child with injury to the side of his face that was of concern. He was referred to me by his periodontist for an endondontist consultation before the treatment plan was finalized. There were no radiolucencies on Teeth 12 or 13. However, tooth 14 had periapical pathology on the palatal root. I was surprised that the bone loss surrounding the teeth did not correlate to the mobility that was present.

The patient’s chief concern was that he did not want to be without teeth 12, 13, and 14 at such a young age. I sympathized with him. He was willing to have me try heroic measures rather than have the three teeth extracted. He understood that if the teeth did not respond well to therapy, they would be lost. He chose root canal therapy. I was glad that he was willing to try to save his teeth through root canal therapy despite the financial risks. Teeth 12, 13, and 14 were non-vital. I placed calcium hydroxide intra-medicament between appointments. The teeth decreased dramatically in mobility. Most importantly, the patient was able to retain the teeth.

Even when an endo-perio lesion’s clinical signs would logically condemn the tooth, sometimes teeth defy the practitioner’s logic. Sometimes, periodontal teeth that seem hopeless do gain a successful result after non-surgical root canal therapy. Predicting outcomes is not always possible in periodontal-endodontic lesions.

January - March 2011

Sometimes, periodontal teeth that seem hopeless do gain a successful result after non-surgical root canal therapy.