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Year : 2007  |  Volume : 10  |  Issue : 4  |  Page : 129-133
Treatment of an isolated furcation involved endodontically treated tooth - a case report


Department of Periodontics, Meenakshi Ammal Medical College and Hospital, Maduravoyal, Chennai - 600 095, India

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   Abstract 

Thu successful long-term management of multi­-rooted teeth with attachment loss extending into the furcation has been one of the greatest challenges to dentist. Furcation-involvement is not a separate entity but just an extension of inflammation into the: bi or trifurcation region. However treatment of lesions extending into this region becomes complicated due to the difficulty in instrumentation. Several treatment modalities have been proposed based on the grade of furcation involvement. This paper presents a case report of an endodontically, treated tooth with a furcation involvement. The interdependence of perio-endo lesions and the consequences of inadequate periodontal therapy following endodontic therapy is stressed in this Paper.

Keywords: Furcation, regeneration, bioactive glass

How to cite this article:
Raja S, Nath G, Emmadi P, Ramakrishnan, Ahathya. Treatment of an isolated furcation involved endodontically treated tooth - a case report. J Conserv Dent 2007;10:129-33

How to cite this URL:
Raja S, Nath G, Emmadi P, Ramakrishnan, Ahathya. Treatment of an isolated furcation involved endodontically treated tooth - a case report. J Conserv Dent [serial online] 2007 [cited 2018 Dec 14];10:129-33. Available from: http://www.jcd.org.in/text.asp?2007/10/4/129/43033

   Introduction Top


Periodontal therapy is mainly aimed at removal of local factors which lead to the resolution of inflammation in the supporting structures of the tooth. This therapy predominantly involves scaling and root planning as a monotherapy or combined with hard and soft tissue surgery. Combined with a proper postoperative maintenance care resolution of inflammation occurs leading to an arrest of disease progression [1] . In the course of delivering periodontal treatment, the clinician is often faced with the problem of treating teeth that have advanced periodontal destruction and whose long-term prognosis is judged poor. In some cases, only one or two teeth are in this category while in other patients, many teeth can be involved [2] . Reports in the literature show that, when compared to other teeth, molars are more vulnerable to attachment loss and are more prone to extraction [3] . Molar teeth with furcation involvement are the most common teeth to be lost [4] .

The etiologies of furcation involvement may include anatomic factors, extension of inflammatory periodontal disease, trauma from occlusion, pulpo-periodontal disease and root fracture involving furcations [5] . Successful treatment to retain furcation-involved teeth remains one of the most difficult treatments in overall periodontal therapy. Using the treatment protocol of scaling & root planning as a single measure or combined with surgical procedures and proper maintenance care, in multirooted teeth with furcation involvement, a high percentage of tooth mortality has been reported. Hirschfeld and Wasserman reported a percentage of tooth loss in furcation-involved molars of 31.4% compared to 4.9% in single-rooted teeth after a mean maintenance period of 22 years [6] . McFall obtained similar results in 100 periodontally treated patients maintained for 15 to 29 years. In this study a frequency of tooth loss of 57% was shown for furcation-involved teeth and 7% for single-rooted teeth [7] .

Methods for the treatment of furcation-involved molars have shown varying degrees of success. Although early or incipient Class I furcation defects are generally considered maintainable by non-surgical therapy and effective plaque control, the successful maintenance of more advanced furcations (Class 11 & III) usually requires surgical management. Surgery permits access for root debridement and detoxification, odontoplasty, osseous recontouring, and periodontal regeneration, with the objectives of arresting the disease process, preserving periodontal attachment and in the case of regenerative therapy, closure of the furcation to the oral environment [8] . This paper aims at presenting a case report that involves an isolated furcation-involved endodontically treated tooth and its treatment.


   Case Report Top


A 21-year old female patient reported to the Department of Periodontics with a complaint of pain and abscess formation in relation to her right lower first molar. A history of root canal therapy for the tooth 5 years back was elicited from the patient. Periodontal examination showed a grade III furcation in relation to 46. Clinically the tooth revealed a deep pocket measuring 10 mm on the lingual aspect of 46 and no mobility. There were no other periodontally involved teeth in the remaining dentition. Radiographically (film based IOPA) the tooth in question showed extensive bone loss and a slightly over extended root canal filling in the mesial root. A digital IOPA was taken in order to verify the amount of bone support. The digital IOPA revealed the presence of some bone support. The bone loss in this case could be attributable to either trauma from occlusion, the over extended root canal filling, an existing furcation involvement at the time of endodontic treatment which was not treated or the presence of lateral canals that were missed during endodontic therapy.

At the initial visit the abscess was drained, scaling and root planning was done followed by occlusal evaluation to identify any occlusal trauma which in this case was absent. Subsequently a full thickness mucoperiosteal flap was raised. Upon flap elevation the vertical and the horizontal component of the bone loss in the furcation was measured. The vertical component of the bone loss was around 10 mm and the horizontal component was 5mm at the roof of the furca. The defect was thoroughly debrided and the overextended gutta percha point was corrected. Autologous blood was drawn from the patient and centrifuged to obtain platelet-rich fibrin (PRF). This PRF was mixed with bioactive bone substitutes (Perioglass®) which was placed in the defect, a resorbable collagen membrane (Healiguide®) was placed over it and the flap was sutured. Postoperative radiograph showed satisfactory fill of the defect. Reevalution of the patient after three months revealed satisfactory bone fill and complete soft tissue healing [Figure 1].


   Discussions Top


Trauma from occlusion has been shown to affect the bone loss in the furcation region. Wang et at have also studied the relationship between restoration and furcation involvement on molar teeth. [9] The results of this study showed that molars with a crown or proximal restoration had a significantly higher percentage of furcation involvement but no greater mobility when compared with teeth with no restorations. In this case report although the tooth in question had an extensive restoration there was no trauma from occlusion. Hence this was ruled out as the cause for the bone loss.

Results obtained from studies have revealed the positive effects of bone grafts for the treatment of furcation defects especially vertical defect fill [10] . According Tsao et al additional membrane placement does not seem to enhance the treatment outcome achieved by bone graft alone. However in this case due to the magnitude of the lesion a resorbable GTR membrane was placed to support the graft in place and for ideal healing outcome. Several treatment modalities have been made use of to treat furcation involved teeth. Surgical therapy involving regenerative procedures are indicated in class II and III furcation involvements. The regenerative procedures used in these cases include bone grafts and guided tissue regeneration. The bone graft used in this report was a bioactive glass material. This material consists of sodium and calcium salts, phosphates, and silicon dioxide. For dental applications, it is used in the form of irregular particles measuring 90 to 170 µm (Perioglas, Block Drug, Jersey City, NJ). When this material comes into contact with tissue fluids, the surface of the particles becomes coated with hydroxycarbonate apatite, and incorporates organic proteins such as chondroitin sulphate and glycosaminoglycans, and attracts osteoblasts that rapidly form bone. [11] In addition to this PRF which is an autologous source of platelets was used to enhance the results of the regenerative procedure. Platelets are a rich source of growth factors such as platelet-derived growth factor, transforming growth factor-β and insulin-like growth factor. The use of autologous PRF is said to enhance the wound healing process due to the high concentration of platelets present in it.

Other treatment modalities that have been used successfully are root resection and hemisection procedures. In an attempt to eliminate the defect and to create access within the interradicular area root resection has been proposed in the literature [12] . The case presented in this report was more amenable to regenerative therapy than root resection since there was complete bone support seen on the buccal side when the flap was raised. Moreover clinically the tooth showed no mobility. Anderegg et al [13] have shown 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 prompted us to make use of regenerative procedures instead of root resection.

Understanding the periodontic-endodontic continuum is a vital part of successful endodontic and periodontal therapy. Patients with pulpal disease may have a healthy periodontium, gingivitis or varying amounts of attachment loss (periodontitis) on the affected or adjacent teeth. Patients with pulpal disease present only diagnostic and treatment decisions relative to the endodontic lesion. In such cases debridement of the pulp chamber and canal, as well as the completion of appropriate endodontic therapy, are sufficient to result in healing of the lesion. Periodontal treatment is not required in the absence of any periodontal involvement. On occasion patients with pulpal disease may also present with inflammatory periodontal disease. In such cases the lesions can be independent of each other or can be combined or communicating with each other. The involvement of the apical periodontium by a pulpal lesion may obscure the symptoms of periodontitis [14] . Since periodontitis is most often a chronic slowly progressing disease in such cases treatment of the pulpal problem provides relief to the patient. Therefore the coexisting periodontal lesion is ignored.

In this case the most probable cause for the abscess could have been the presence of a coexisting periodontal problem which was missed at the time of initial diagnosis and hence not treated. The other causes for such an extensive lesion such as TFO were non existent. The healing of an endodontic lesion is highly predictable, but the repair or regeneration of periodontal tissues is less predictable. Endodontic therapy should precede periodontal pocket elimination procedures. However endodontic therapy results in resolution of the endodontic lesion but has little effect on the periodontal lesion. Therefore it is absolutely essential that the periodontal problem also be treated to obtain optimal therapeutic outcome.

 
   References Top

1.Lindhe J, Westfelt E Nyman S, Socransky SS, Haffajee AD. Long term effect of surgical/non­surgical treatment of periodontal disease. Journal of Clin Periodontol 1984;11:448-458.  Back to cited text no. 1    
2.Chace R Sr., Low SB. Survival characteristics of periodontally involved teeth: A 40-Year study. J Periodontol 1993;64:701-705.  Back to cited text no. 2    
3.Ramfjord SP, Knowles JW, Morrison EC et al. Results of periodontal therapy related to tooth type. J Periodontol 1980;51:270-273  Back to cited text no. 3    
4.Ramfjord SP, Caffesse RG, Morrison EC, et al. 4 modalities of periodontal treatment compared over 5 years. J Clin Periodontol 1987;14:445­-452.  Back to cited text no. 4  [PUBMED]  
5.Newell DH. The diagnosis and treatment of molar furcation invasions. Dent Clin North Am 1998;42:301-337.  Back to cited text no. 5  [PUBMED]  
6.Hirschfeld L, Wasserman B. A long-term survey of tooth-loss in 600 treated periodontal patients. J Periodontol 1978;49:225-237.  Back to cited text no. 6  [PUBMED]  
7.McFall WT. Tooth loss in 100 treated patients with periodontal disease: a long-term study. J Periodontol 1982;53:539-549  Back to cited text no. 7    
8.Bowers GM, Schallhorn RG, McClain PK, Morrison GM et al. Factors influencing the outcome of regenerative therapy in mandibular class 11 furcations: Part I. J Periodontol 2003; 74:1255-1268  Back to cited text no. 8    
9.Wang H, Burgett FG, Shyr Y. The relationship between restoration and furcation involvement on molar teeth. .1 Periodontol 1993;64:302-305  Back to cited text no. 9    
10.Tsao Y, Neiva R, Al-Shammari K, Oh T, Wang H. Factors influencing treatment outcomes in mandibular class II furcation defects. J Periodontol 2006;77:641-646  Back to cited text no. 10    
11.Andereeg CR, Alexander DC, Friedman M. A bioactive glass particulate in the treatment of molar furcations.. J Periodontol 1999;70:384  Back to cited text no. 11    
12.Langer B, Stein SD, Wagenberg B. An evaluation of root resection. A ten years study. J Periodontol 1981;52:719-722.  Back to cited text no. 12    
13.Anderegg CR, Martin SJ, Gray JL, Mellonig JT, Gher ME. Clinical evaluation of the use of decalcified freeze-dried bone allograft with guided tissue regeneration in the treatment of molar furcation invasions. J Periodontol 1991;62:264-268  Back to cited text no. 13  [PUBMED]  
14.Newman MG, Takei HH, Klokkevold PR, Carranza FA. In Clinical Periodontology. Tenth edition. P 879-880  Back to cited text no. 14    

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Correspondence Address:
Sunitha Raja
Department of Periodontics, Meenakshi Ammal Medical College and Hospital, Maduravoyal, Chennai - 600 095
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-0707.43033

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