How would you handle this case?

[TSDentSurg]

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I saw a patient in clinic today. This was a 50 year old Czech woman with a PMH significant for adult-onset diabetes. Her diabetes is well-controlled with metformin. She presented with a complaint of pain and mobility of #29. The pain gets worse upon biting down.

Upon oral examination, there was moderate gingivitis. Several restorations were present. Turning attention to #29, there was BOP, a 8 mm pocket, a small area of MLO decay. Periapical radiographs were taken which demonstrated the decay extended into the pulp chamber. Vertical bitewings demonstrated moderately severe periodontitis.

My consultant asked me to come up with three treatment alternatives to present to the patient (his clinic was closing, so we did a pulpotomy with ZOE to get the patient out of pain, and we'll see her tomorrow).

So, here's what I have:

Option 1: SRP+local abx, RCT+crown, splint to the stable #28 and #30. Perhaps this is all that's needed.
Option 2: GB/TR with L-PRF, RCT+crown, temporary splint to the stable #28 and #30 while waiting for graft integration
Option 3: Extract, place bone alloplast into socket, place and restore implant.
Option 4: Extract, fit Maryland bridge.

If it was just a periodontic lesion, we could just splint the affected tooth to a nearby stable one, do SRP+local abx, and hope that will save the tooth. If it was just an endodontic lesion, an RCT would save the tooth.

What would you guys do?

 

[TSDentSurg]

We saw the patient today, and she's grateful for the pulpotomy making her pain free. Me and my consultant presented the three treatment options, and she chose option #1. Hopefully the SRP, Arestin, and splinting will grant some attachment gain. We follow-up in three months.

 

[wigglytooth]

IMO that is a lot of hope going into arrestin in a 8 mm pocket. i would also re-eval after your SRP because the patient still might benefit from perio surgery before her final crown (how good are you in debriding 8mm pockets? studies show that around 6mm is when even seasoned clinicians start to fail).

look up the simon, glick, and frank articles on perio-endo lesions for classification and some guidelines. the cliff notes is do the definitive endo before the definitive perio. and do both before definitive restoration!

 

[TSDentSurg]

We've done the definitive endo. During our consultation, I strongly urged the patient to choose option #2 (GB/TR with L-PRF), as it will restore the lost bone. I told her the SRP+Arestin may not work with pockets this deep, and my consultant agreed. However, the patient wanted to try the cheapest option first that allowed her to keep the tooth.

In my mind, I was thinking "if you just want to be cheap, why care about saving the tooth and attempting to prevent it from falling out? Just let me extract it and make a Maryland bridge for you...it'd save us all time and effort." But that's 1920s dentistry.

Honestly, what's the point of attempting to save a massively-decayed tooth in a damaged periodontium? Why do patients care in that situation? If it was just the decayed tooth, or just the periodontitis, I can understand the desire to avoid extraction. But I can't understand it here. It's truly two separate disease processes that just happened to affect the same tooth; it's not an endodontic infection that spread into the periodontium, as there's no clinical or radiographic evidence of a periradicular abscess. And it's definitely not a perio-endo lesion, as there's obvious coronal decay.

I'm hoping and praying that we don't have to consider options #3 and 4 (extraction+implant or Maryland bridge).

At least the decay wasn't bad enough to also require crown lengthening...if it was, the consultant said he wouldn't even consider SRP+Arestin, he'd just do the GB/TR.

That pocket had so much calculus, I was quite surprised there wasn't also a periodontal abscess. I really wanted to just raise a flap.

After I got done taking the impression and making the temporary, I told the patient that she likely would need the GB/TR if there wasn't any attachment gain by the time the crown comes back from the lab, and I was pretty sure she need it. After we discharged her, my consultant told me "Get ready to learn how to harvest a ramus block graft, Lexi." (He doesn't use bone alloplast, as he prefers to use "real bone in real defects", and it is pretty expensive).

This is the one time I'm glad we don't have CEREC. If we made the permanent crown and fitted it today, we'd have an amazing time trying to get her to come back to evaluate whether the SRP and Arestin worked.

 

[Mackchops]

Impossible to tell without radiographs but based on what I understand from your description Im with wigglytooth - do the definitive endo (which you did) and watch. If it's a true perio-endo lesion (rare) then you would have to treat the perio (your GTR option), BUT if it's an endo lesion with secondary perio you do NOT put a scaler into that defect. Some people will clean the area with citric acid, but I've had pretty good luck (with an n of about 2...) just doing the endo and letting the otherwise healthy periodontum reattach. If you debride it, you'll remove healthy cementum and sharpeys fibers and doom the tooth to a permanent perio defect -- maybe even extraction and dealer's choice of prosthodontic replacement...

 

[TSDentSurg]

Do you think we should've also prescribed Periostat? When she comes in to have the permanent crown installed, I'm going to suggest it to my consultant, after we inform her that she really needs GB/TR.

If she refuses GB/TR, I'm going to recommend Periostat and quarterly SRP as an alternative to GB/TR.

GB/TR would save her a lot of time and money in the long run. If #29 falls out, I'm going to be pissed. Spent an hour and a half doing that RCT and making the crown prep.

If I see root recession when she comes back, that's it. She's getting GB/TR.

 

[Mackchops]

Why are you pushing grafting? And what would be the reason behind Periostat? Maybe I'm not understanding the case correctly, but are you dealing with a primary or secondary perio lesion?

 

[TSDentSurg]

Why are you pushing grafting? And what would be the reason behind Periostat? Maybe I'm not understanding the case correctly, but are you dealing with a primary or secondary perio lesion?

When me and my consultant examined the radiographs and asked the patient about her history with #29, we determined she had a true combined periodontic-endodontic lesion. According to her, it was mobile for quite sometime prior to the endodontic infection that prompted her presentation to our clinic.

She told us she would eat using the side contralateral to the mobile tooth to avoid discomfort.

My reasoning behind prescribing Periostat is that it's a collagenase inhibitor, and along with SRP, it will hopefully suppress the periodontitis from advancing.

But honestly, both me and my consultant agree grafting will definitively treat her. Now our biggest issue is convincing her to submit to this invasive, bloody, and costly surgery.

 

[TSDentSurg]

Okay, we saw the patient to install the permanent crown. The lab tech did a good job fabricating it, the shade matched well, and I only had to do minor occlusal adjustments. I then splint it to #28 and #30 after I cemented it.

Our lab seemed to get this one done fast...usually it takes them a week. Maybe they didn't have that much of a backlog.

I then probed the sulcus to a depth of 7 mm, and there was no bleeding. So the Arestin and SRP did work. Although the pocket is obviously still quite deep.

Me and my consultant then discussed treatment options for the perio lesion with her.

Treatment option #1: Periostat and quarterly SRP. Advantages are cost and low-risk, and it has a good chance of stopping progression of the lesion. Disadvantages are that it won't restore the lost bone, so the tooth will have to remain splinted forever, which could cause issues for the teeth it's splinted to.

Treatment option #2: GB/TR with L-PRF. Advantages are that it will restore the lost bone, and the tooth will only have to remain splinted until the graft integrates. Disadvantages are the risks of surgery and anesthesia(infection, bleeding, reaction to anesthesia), recovery time, pain, and failure of the graft.

We strongly urged her to choose surgery, as we explained that long-term splinting will cause periodontitis in #28 and #30.

She decided to go with option #2, as she didn't want to risk any further bone loss.

We've scheduled her for surgery tomorrow, as my consultant has an opening then.

I'm so excited! My first "big case"!

 

[Mackchops]

Grafting is fun... good luck.

Can you describe this perio lesion a little more? Is it circumfirential or isolated? Vertical or horizontal? 2-wall? 3-wall? How much tooth mobility? If it really is true endo-perio lesion, what is the etiology of the perio disease? I've never seen any literature for the use of low-dose doxy in localized perio disease - does she have perio anywhere else? How did you splint - did you use composite on your brand new crown?

Thanks for sharing.

 

[TSDentSurg]

Grafting is fun... good luck.

Can you describe this perio lesion a little more? Is it circumfirential or isolated? Vertical or horizontal? 2-wall? 3-wall? How much tooth mobility? If it really is true endo-perio lesion, what is the etiology of the perio disease? I've never seen any literature for the use of low-dose doxy in localized perio disease - does she have perio anywhere else? How did you splint - did you use composite on your brand new crown?

Thanks for sharing.

She has a three wall defect, both horizontal and vertical. Lingual side is normal, but buccal, mesial, and distal are pretty resorbed. Slightest bit of occlusal pressure will cause #29 to sway about like a sapling in a hurricane.

The other teeth have 4 and 5 mm pockets. I'm really not sure why this one is affected so severely. We'll be adding Periostat to treat those.

I splinted the crown to #28 and #30 using Ribbond and I etched the lingual side of the crown using 10% HF, applied composite, and affixed the splint.

 

[Mackchops]

Thanks for clarifying. Sounds like a fun one to graft. Let us know how it turned out!!