Immediate Verses Delayed Surgical Periodontal Therapy After Endodontic Treatment in Endo Perio Lesion With Communication
Condition: Attachment Loss; Tooth,Non Vital
MeSH terms: Tooth, Nonvital
Study type: Interventional

Summary: 
      The aim of the study is to conduct a prospective randomized clinical trial to evaluate the
      effect of immediate and delayed surgical periodontal therapy after non-surgical endodontic
      treatment on periodontal healing of the concurrent endodontic -periodontal lesion with
      communication.
    

Detailed description: 
      Observations based upon review articles and case reports has suggested, if the root canal
      system is infected, endodontic treatment should be commenced prior to any periodontal therapy
      in order to remove the intra canal infection before any cementum is removed in case of
      concurrent endodontic-periodontic lesions without communication. This avoids several
      complications and provides a more favourable environment for periodontal repair. Treatment
      results of endodontic therapy should be evaluated in 2-3 months and only then periodontal
      treatment should be considered. But review articles states that teeth that have concurrent
      endodontic and periodontal diseases that communicate with each other will require
      comprehensive treatment with both endodontic and periodontal management. Ideally both
      infections should be removed before the root canal filling and any final restorations are
      provided. Completion of the root canal filling should be delayed until the periodontal
      prognosis has been reassessed and determined following initial, and often further,
      periodontal treatment. Though Infected root canal systems and periodontal pockets have
      similar microbiological flora, there are more microbes and more species of spirochetes in
      periodontal pockets than in infected root canal systems, and the microflora in infected root
      canals of teeth that have concurrent endodontic and periodontal diseases is more complex than
      in teeth with infection confined to the periapical region. So the outcome of endodontic
      treatment may be affected if the root canal filling is placed while there is still a
      periodontal infection present that communicates with the root canal system since
      cross-seeding through the apical or lateral foramina is possible. An In-vitro study on human
      extracted teeth states that despite thorough cleaning and disinfection of the root canal
      system during endodontic treatment, bacteria from the periodontal lesion may re-invade the
      root canal system since root canal fillings do not seal canals completely.

      All the above findings are based on microbiological,histological,case-reports,retrospective
      and in-vitro studies.The timing of periodontal treatment in concurrent endodontic
      -periodontal lesions with communication still remains a issue of debate.No prospective human
      clinical trial(randomized) has been conducted till date to ascertain whether surgical
      periodontal treatment should be given immediately after completion of non-surgical endodontic
      treatment or 2-3 months after completion of non-surgical endodontic treatment.

      Thus the aim of our study is to conduct a prospective randomized clinical trial to evaluate
      the effect of immediate and delayed surgical periodontal therapy after non-surgical
      endodontic treatment for the management of concurrent endodontic -periodontal lesion with
      communication.

      MATERIAL AND METHOD This randomized clinical trial will be conducted in Department of
      Periodontics and Oral Implantology in collaboration with Department of Conservative Dentistry
      and Endodontics, Post Graduate Institute of Dental Sciences, Rohtak.

      STUDY POPULATION Patients were recruited from regular out patient department of the
      department of periodontics and oral implantology,department of conservative dentistry and
      endodontics and department of oral medicine, diagnosis and radiology. The study will be
      conducted as follows:-

        1. Immediate surgery group Treatment involves surgical periodontal therapy in form of open
           flap debridement immediately after non-surgical endodontic treatment.

        2. Delayed surgery group Treatment involves surgical periodontal therapy in form of open
           flap debridement 3 months after completion of non-surgical endodontic treatment.
           INCLUSION CRITERIA Patients of age 18 years and above with a clinical and radiographic
           diagnosis of combined endodontic periodontal lesion and having generalized chronic
           periodontitis with at least one non vital tooth having apical radiolucency with
           communication.

             -  Wide base pocket, deep pocket depth

             -  Non vital tooth (confirmed by heat test, cold test and electronic pulp test)

             -  Radiographic periapical alveolar bone destruction with apical communication

             -  Patients having generalized chronic periodontitis [≥2 interproximal sites with
                clinical attachment level (CAL) ≥ 4mm,not on same tooth(moderate) or ≥2
                interproximal sites with clinical attachment level (CAL)≥6mm ,not on same tooth
                (severe)]26

      EXCLUSION CRITERIA

        -  Systemic illness known to affect the periodontium or outcome of periodontal therapy.

        -  Patient taking medications such as corticosteroids or calcium channel blockers, which
           are known to interfere periodontal wound healing or patient on long term NSAID therapy.

        -  Patients allergic to medication (local anaesthetic, antibiotics, NSAID).

        -  Pregnant or lactating mothers.

        -  Smokers and tobacco chewers.

        -  Grade 3 mobile teeth.

        -  Unrestorable tooth.

        -  Fractured/perforated roots.

        -  Developing permanent tooth.

        -  Previously root canal filled.

        -  History of recent periodontal treatment within 6 months prior to study.

      Prior informed consent will be taken from each patient after explaining the procedure in
      patient's language along with risk and benefits involved.

      METHODOLOGY Patients were randomly allocated to group1 and group 2. The study will be
      conducted as follows:-

        1. Presurgical therapy:- which will be including

             -  Oral hygiene instructions

             -  Full mouth supragingival and subgingival scaling and root planning with ultrasonic
                scaler, hand scaler and curettes.

             -  Conventional root canal therapy will be initiated in both the groups before
                definite periodontal surgical therapy.

        2. Surgical therapy:- In group 1 periodontal surgical procedure in the form of open flap
           debridement will be performed immediately after obturation of the root canal system In
           group 2 periodontal surgical procedure in the form of open flap debridement will be
           performed 3 months after obturation of the root canal system Prior to surgery, a probing
           stent will be fabricated for every patient,relative to which attachment loss will be
           measured.

      CLINICAL PARAMETERS

        1. Full mouth indices to be recorded at baseline

             -  Bleeding on probing

             -  Probing Pocket depth

             -  Attachment loss

        2. Site specific indices

             -  Plaque index

             -  Gingival index

             -  Relative Probing Pocket depth

             -  Relative attachment loss

             -  Bleeding on probing

             -  Tooth mobility

             -  Relative gingival marginal level Using periodontal probe at 6 sites (mesial,
                distal, median points at buccal and lingual aspects) per tooth.

      Customized bite blocks and parallel angle technique will be used to obtain radiographs
      Clinical parameters will be recorded at baseline, 3 months and 6 months for Group 1(immediate
      surgery) Clinical parameters will be recorded at baseline, 3 months, 6 months and 9 months
      for Group 2(delayed surgery) PERIODONTAL PROCEDURE This involves supragingival and
      subgingival scaling and root planning to be performed with ultrasonic scaler, hand scaler and
      curette and will be completed in minimum two sessions.

      CONVENTIONAL ENDODONTIC PROCEDURE After achieving local anaesthesia, access opening will be
      made with the help of round bur. Then the root canal will be thoroughly debrided followed by
      copious irrigation and subsequently prepared with the help of endo files. After preparation
      of the canal, calcium hydroxide intracanal medicament will be placed with the help of 27
      gauge endodontic syringe for 10 days and access cavity will be sealed with suitable sealer.
      Obturation will be performed with gutta percha and zinc oxide eugenol based sealer.

      PERIODONTAL SURGICAL PROCEDURE After administration of local anaesthesia, buccal and
      lingual/palatal intracrevicular incision will be made and mucoperiosteal flaps will be
      reflected including atleast one tooth ahead and another behind the tooth. Meticulous defect
      debridement and root planning will be carried out using area specific curettes and scalers
      with special effort to remove all the granulation tissue. After instrumentation, the root
      surfaces will be washed with saline solution in attempt to remove any remaining detached
      fragments from the defect and surgical field. After debridement mucoperiosteal flaps will be
      repositioned and secured by using 3-0 non-absorbable black silk surgical suture. The surgical
      area will be protected and covered with periodontal dressing and post operative instructions
      will be given.

      Processing of Data Data recorded will be processed by standard statistical analysis.
    

Intervention name(s): Immediate periodontal surgery; Delayed periodontal surgery
Intervention type(s): Procedure; Procedure
Intervention description(s): Treatment involves immediate surgical periodontal therapy in form of open flap debridement after non surgical endodontic treatment and obturation with gutta-percha and zinc oxide eugenol (ZOE) sealer. in concurrent endodontic periodontal lesions with communication .; Treatment involves surgical periodontal therapy after 3 months of non surgical endodontic treatment and obturation with gutta-percha and zinc oxide eugenol (ZOE) sealer. in the form of open flap debridement in concurrent endodontic periodontal lesions with communication .
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Care Provider, Investigator)
Primary purpose: Treatment
Keywords: endodontic treatment; open flap debridement