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Azerbaycan Saytlari

 »  Home  »  Endodontic Articles 7  »  Hemisection for treatment of an advanced endodontic-periodontal lesion
Hemisection for treatment of an advanced endodontic-periodontal lesion
Case report - Dental history.

Case report.
A 62-year-old woman presented in April 2000 to inquire about options for preserving tooth 46 (Figs 2 and 3). The tooth was characterized by gingival reddening and swelling at its distobuccal aspect. The patient complained of periodic discharge of pus from the periodontal pocket, sensitivity on percussion, tooth mobility, and intermittent pain.
Radiographs from 1994 documented a bony defect around tooth 46, which continuously expanded over the years (Fig. 4 a–c). The patient suspected a special predisposition to disease because she had been diagnosed with polyarthritis and osteoporosis in 1980, which together with a history of injuries had already required surgical procedures in two joints. Several degenerative phenomena along the spinal cord were also recorded. The patient herself complained of poor metabolic disposition and/or impaired immune defence mechanisms resulting from a severe disease of unknown aetiology in early childhood as well as malnutrition in childhood and adolescence (1946–54). She regularly took minerals, vitamins, and enzymes to compensate for these reported deficiencies.
The patient also mentioned stress-dependent headaches dating back to an accidentrelated head contusion. In addition, she had been afflicted with unilateral stress-independent headache attacks at a more distal cranial location for 2 or 3 years, which were becoming increasingly frequent and intense. She was considering seeing a neurologist and wanted to find out whether these attacks might be connected with the dental lesion. Likewise, the patient showed erythrocyte-sedimentation rates near the upper tolerance limit for a number of years without any other clinical phenomena to match this finding.

Figure 2. Adequate restorations (partial gold crown/inlay) on tooth 46/47.

Adequate restorations on tooth

Figure 3. Recession in the area of the distal vestibular root of tooth 46 involving loss of the interdental papilla.

Recession in the area of the distal vestibular root of tooth 46 involving loss of the interdental papillaFigure 4. Region 46 on DTPs obtained in 12/94 (a), 12/96 (b) and 3/00 (c).

Region 46 on DTPs obtained

Figure 5. Significantly increased probing depth on the distal vestibular segment of tooth 46.

Significantly increased probing depth on the distal vestibular segment of tooth 46

Dental history.
Around the year 1991, tooth 46 had been restored with a partial gold crown. A year later, it had caused non-specific symptoms, which were managed by local periodontal treatment and short-wave therapy. When symptoms recurred 3 years later, the patient decided to change her dentist. A panoramic tomograph (DPT) and a single-tooth radiograph of region 46 revealed a mild-furcal involvement and circumradicular radiopacity around the distal root, as an almost complete loss of the interdental septum of teeth 46/47.
Over the next few months, the dentist treated the affected site nine times with a corticosteroid ointment. At first, the patient was largely free of symptoms. A DPT obtained at a routine dental check-up in late 1996, revealed that the bony defect in region 46 had expanded further, but no treatment had been performed. At the next routine examinations in 1998 and 1999, the patient had mild complaints. The situation deteriorated in early 2000, with intermittent pain, local swelling, and increased discharge of pus from the periodontal pocket of tooth 46. Over the next 2 weeks the affected site was treated six times with metronidazole gel, and another DPT was taken, which showed that the bony defect had expanded even further. The dentist now performed flap surgery for subgingival calculus removal, and root planing in an attempt to preserve the tooth. Extraction of the tooth was also discussed as an alternative.
In April 2000, the situation in region 46 was characterized by a negative pulp-vitality test, and a positive percussion test. The distal gingival tissues were reddened and swollen. There was a distal vestibular recession of 4 mm, and circumferential probing depths in the area of the distal root were 8–12 mm(Fig. 5), classes II and III tooth mobility, and the furcation was probable throughout (grade III furcal lesion). A standard single-tooth radiograph obtained to achieve a more detailed view revealed the extensive circumradicular bone loss predominantly in the distal root area, the mesial root still showing interradicular bone structures in its upper-third and mesioproximal bone structures over two-thirds of the root length (Fig. 15a).
The patient exhibited good oral hygiene and no missing teeth. Apart from tooth 46, the periodontal situation (DPT taken on March 2000) was normal and there were no clinical signs of gingivitis.