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Dental Tribune United Kingdom Edition

February 25- March 3, 201316 Perio Tribune United Kingdom Edition page 15DTß fracture. The gingiva in relation to the involved tooth appeared soft and oedematous whereas the generalised consistency of the gingiva was firm and resilient (Fig 1). Bleeding on probing was also present in the same area. Peri- odontal probing depths were me- sially 10mm, distally 3mm, bucca- lly 6mm and lingually 3mm. The tooth showed grade I mobility and grade II furcation involvement. The patient experienced pain on vertical percussion. A periapical radiograph showed widening of the periodontal ligament space, radiolucency in the furcation area and differential bone loss along the mesial root (Fig 2). Electric pulp vitality test resulted in re- sponse, thus indicating of a vital pulp. A periodontal abscess asso- ciated with mandibular right first molar was diagnosed. The lesion was diagnosed to be of primary periodontal origin with secondary endodontic involvement. Emergency Treatment: The abscess was drained through the pocket and a thorough irriga- tion with Betadine was performed. Antibiotics were not prescribed as the patient was afebrile and there was no evidence of regional lym- phadenopathy. Phase I therapy: The patient was recalled for scaling and root planning after four days. Patient continued to complain of mild pain though the swelling had reduced. After evaluation of the Phase I therapy, endodontic ther- apy was initiated. Definitive treatment: An ac- cess cavity was prepared and the root canal system was cleaned and shaped during the first session using Protaper (Denstply) alongwith copius irrigation with 5.25 per cent sodium hypochlorite and saline. The patient returned af- ter one week and the endodontic treatment was completed using six per cent gutta percha and AH Plus sealer (Dentsply Maillefer). Post endodontic restoration was done with silver amalgam. (Fig 3) After the endodontic treat- ment, the patient was asympto- matic and the gingiva appeared healthy. However, the pocket probing depths were still nine and 5mm mesially and buccally re- spectively. Access flap surgery was performedtoeliminatethepocket. After flap reflection, debridement of the defect and furcation was performed using hand curettes (Hu Freidy®) and ultrasonic in- strumentation (Figure 4). The in- trabony defect was a combination of two and three wall defect. Two wall defect in the coronal portion of the mesial root and three wall defect apically (Fig 5). Freeze dried bone allograft (FDBA) was placed in the furcation as well in the intrabony defect (Fig 6). The flaps were approximated with the help of 3-0 black braided silk su- ture (Sterisil®). The graft mate- rial was completely covered and the flap was closely adapted to the tooth. Periodontal dressing was placed. Amoxicillin 500mg tid was prescribed for five days to assure minimal infection during healing phase. Immediate post operative radiograph was taken which shows evidence of graft material in the defect and the fur- cation area (Fig 7). Patient was recalled after a week for removal of sutures. Patient was recalled at regu- lar intervals for maintenance program and oral hygiene in- structions were reinforced. There was no evidence of antigenic re- sponse to the graft. Radiographs were taken at the intervals of six months and one year. The ra- diographic picture clearly shows bone fill in the furcation and in- trabony defect after one year (Fig 8). Thus the tooth was success- fully treated by endodontic and periodontal interventions with satisfactory results. Discussion: In periodontitis, a periodontal ab- scess represents a period of active bone destruction (exacerbation), although such events also occur without abscess formation. The existence of tortuous pocket may favour the formation of abscesses (Carranza 1990). The marginal closure of the periodontal pocket, may lead to an extension of the infection into the surrounding periodontal tissues due to the pressure of the suppuration in- side the closed pocket (Kareha et al 1981, Newman and Sims 1979). Changes in the composition of the microflora, bacterial viru- lence, or in host defences could also make the pocket lumen inef- ficient to drain the increased sup- puration. In the absence of periodonti- tis, periodontal abscess can oc- cur due to impaction of foreign bodies, lateral perforation of the root during Root canal therapy or hairline longitudinal fracture of teeth (Carranza 1990, Abrams et al 1992), infection of lateral cysts (Kareha et al 1981), local factors affecting the morphology of the root. The presence of external root resorption (Yusof and Ghaz- ali 1989), an invaginated tooth (Chen et al 1990), or a cracked tooth (Goose 1981) have also been suggested as predisposing factors for periodontal abscess formation. In this case, periodontal ab- scess was a result of Chronic Periodontitis with secondary endodontic involvement. It has been suggested that intrapulpal infection tends to promote mar- ginal epithelial down growth along a denuded dentin surface (Blomlof et al.1992). Additional- ly, experimentally induced peri- odontal defects in infected teeth were associated with 20 per cent more epithelial down growth than non-infected teeth. Non-in- fected teeth showed 10 per cent more connective tissue coverage than infected teeth (Janson et al 1995). Hence, the endodontic therapy was performed before a definitive periodontal therapy. Periodontal surgical proce- dures result in a harmonious anatomical relationship between the tooth and gingiva as well as correction of any underlying osseous defects which leads to positive correlation between the contour of the gingiva and the topography of the underlying alveolar bone. Persisting osse- ous irregularities may result in residual deep sulci or pockets making a sustainable level of acceptable plaque control more difficult, thus increasing the chances of further periodontal breakdown. Periodontitis is a chronic immune-inflammatory disease caused due to infection by spe- cific micro-organisms. A chronic lesion consists of macrophages, plasma cells, granulation tissue and destructed collagen fibres. An acute inflammatory response results in dynamic healing re- sponse to appropriate therapy Fig 2-pre-op Fig 3-after endo therapy Fig 4-intra-op showing furcation and a combined 2& 3 wall defect Fig 5-Intra-bony defect Fig 6-FDBA bone graft placed Fig 7-Immediate post-op IOPA Fig 8-1 year Post-op