Claudia Hoffman
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 HE
CHIEF COMPLAINT of a fifty-five-year-old male who presented to our
office was, “I have had pain in my lower jaw off and on for the past
year and now it has stopped hurting but I have a pimple on my
gum.” The patient’s medical and social history was
unremarkable. The extra-oral and intra-oral exam were within
normal limits. The patient’s dental history included a temporary crown
on # 19 and a fistula at the gingival line below # 19. (See
Figure 1.)
The patient stated that the tooth had a history of
slight discomfort off and on for the past year, and it had been
prepared for a crown due to a mesial crack in the tooth. Upon
clinical exam, # 19 tested non-vital with no pain. The
radiographic exam showed a loss of bone in the furcation resembling a
grade III “through and through” furcation defect. The fistula was
close to the gingival margin on the buccal. The probing was 3–4
mm all around the tooth except around the sinus tract, which had a
narrow defect. The tooth had class I mobility.
The patient was anesthetized, and a rubber dam was
placed. The tooth was accessed and was nonvital as
expected. The tooth was examined under a microscope to rule out
any existing fracture in the tooth. After careful irrigation and
debridement, the tooth was packed with calcium hydroxide. The
patient was told not to take any antibiotics and return in one
week. The rationale for avoiding antibiotics was to see whether
the root canal treatment took care of the correct etiology of the
problem.
The patient returned in seven days asymptomatic with
no fistula present. The root canal was completed, and it was
clear that necrotic pulp had affected the periodontium, but the problem
was a primary endodontic lesion.
Endodontic lesions usually resorb bone apically, but
they can resorb bone laterally. Therefore, if bone is resorbed
laterally the periodontal attachment apparatus is involved. This
case illustrates how an endodontic infection caused an inflammatory
process in the periodontium of a multi-rooted tooth by spreading
laterally, creating the appearance of a Class III furcation defect that
would have resulted from periodontal disease. This
case was primarily an endodontic problem that manifested itself through
the periodontal ligament, but I expect complete resolution after
conventional endodontic therapy with no concurrent periodontal
treatment.
The close relationship between the pulp and
periodontium must always be considered, and it can often be
complex. Clinicians need to evaluate both entities carefully to
make sure to treat the true causative agent.
I will show a six-month recall in another four
months, but presently the patient is doing well with no residual
symptoms.
July - August 2007
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FIGURE 1: Showing a temporary crown on #19 and a fistula at the gingival line below #19.
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