الحالة السريرية (2) : آفة لبية نسج داعمية

- تم إحالة مريضة -34 سنة- من قبل طبيب أسنانها ..

- الشكوى الرئيسية كانت وجود تورم على الناحية اللسانية للسن رقم 19
- الأمراض العامة : لا تشكو المريضة من أي مشكلة جهازية.
- سنياً : إن السن رقم 19 عليه تاج كامل وعلى الناحية اللسانية من السن يوجد جيب عميق قابل للسبر مع ملاحظة وجود تصريف قيحي في المنطقة .
- شعاعياً : إن السن رقم 19 قد أجريت له سابقاً معالجة لبية منذ 5 سنوات .
ملاحظة وجود شفوفية شعاعية في منقطة مفترق الجذور .
تم متابعة أصل الجيب بوضع قمع كوتابيركا ، حيث تبين شعاعياً أنه ينتهي إلى الجذر الوحشي.

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- التشخيص : تم وضع التشخيص بأن الآفة هي : أفة لبية بدئية مع آفة نسج داعمية ثانوية .
- الإجراءات العلاجية : أخذ القرار بإعادة معالجة قناة الجذر الوحشي ، تم إزالة التاج ثم تم إعادة معالجة قناة الجذر الوحشي ليتم حشيها بماءات الكالسيوم لمدة أسبوع. بالإضافة للمعالجة اللبية : تم تجريف الجيب الموجود عميقاً وإروائه بشكل جيد.

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- متابعة العلاج : بعد حوالي أسبوع ، تمت ملاحظة شفاء الجيب الموجود لسانياً .
تم إعادة حشي القناة الوحشية بالكوتابيركا ، ثم ختم منطقة مفترق الجذور بالــ MTA .
- متابعة الحالة : تم استدعاء المريض بعد شهرين ، حيث تبين أنه خلال هذه الفترة لم يلاحظ أي دليل على تشكل خراج لساني الجذر الوحشي ، كما أن الشفوفية الشعاعية في منطقة مفترق الجذور ظهرت بأنها تشفى .

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- نهاية المعالجة : إن المريض والطبيب كانا راضيين عن المعالجة ، لذلك تم إعادة إحالة المريضة لطبيبها الأسنان من أجل ترميم السن والتعويض ..

OK, but if you only depend on the radiographic findings, your diagnosis is incomplete, I know if we take a look at the Radio on the area of the distal root , apparently it's not involved, but you missed that the pocket is situated at thelingual site of the distal root which couldn't be shown radiographically, on the other hand the PDL widening at the mesial root without formation of a pocket around it doesn't indicate the pathogensis of the lesion from the mesial one, and it's just a normal reaction of the organ due the infectious environment.

In the definition of Endo - Perio Lesions:

- Primary Endo Lesion: An acute exacerbation of a chronic apical lesion in a tooth with a necrotic pulp may drain coronally through the periodontal ligament into the gingival sulcus, This condition may mimic clinically the presence of a periodontal abscess. In reality, it is a sinus tract from pulpal origin that opens through the periodontal ligament area. For diagnosis purposes, it is essential for the clinician to insert a gutta-percha cone, or another tracking instrument, into the sinus tract and to take one or more radiographs to determine the origin of the lesion. When the pocket is probed, it is narrow and lacks width. A similar situation occurs where drainage from the apex of a molar tooth extends coronally into the furcation area. This may also occur in the presence of lateral canals extending from a necrotic pulp into the furcation area.

- Primary Endodontid Lesion with Secondary Periodontal Involvement (This Case):
If after a period of time a suppurating primary endodontic disease remains untreated, it may then become secondarily involved with marginal periodontal breakdown. Plaque forms at the gingival margin of the sinus tract and leads to marginal periodontitis.
Symptoms may be acute, with periodontal abscess formation associated with pain, swelling, pus exudate, pocket formation, and tooth mobility. A more chronic response may sometimes occur without pain, and involves the sudden appearance of a pocket with bleeding on probing or exudation of pus.

I think you misundestood me
the tooth got an endodontic treatement from 5 years so we can safely say it wasn't that bad otherwise we would have troubles earlier,
anyway there are no edodontic lesion visible on radio examination (this is the only way to confirm endodontical problems , excepting vertical percussion but they didn't tell us how is the reaction here).

you have a perriodontal lesion with
wide horizontal bone loss around and between the roots and a WIDE periodontal pocket (gutta is running behind the tooth from mesial to distal so not only the distal root is concerned))
over all of that you have a crown presenting a serious over-contour and a bad occlusion ( the widening of the mesial root PDL is clearly due to an occlusion problem

this is a pure periodontal lesion that is caused by the bad crown.

ok now they did an endodontic retreatement which is justified because of the infection (high risk of contamination of the filling material) , they should have done that correctly and retreated both all the roots i think everyone agrees with me on that point

المشاركة الأصلية بواسطة Bassam AlRihawi

[left]I think you misundestood me
you have a perriodontal lesion with
wide horizontal bone loss around and between the roots and a WIDE periodontal pocket (gutta is running behind the tooth from mesial to distal so not only the distal root is concerned))

I'm not with you here, It's a vertical pocket ,despite it's wide one, therefore it's recomended to use bone grafts here or GTR. and I'm with you that it's inadequate endo treatment of both roots, but the author said he only achieved the re-treatment of the distal one, strange treatment.

المشاركة الأصلية بواسطة Bassam AlRihawi

[left]
over all of that you have a crown presenting a serious over-contour and a bad occlusion ( the widening of the mesial root PDL is clearly due to an occlusion problem

this is a pure periodontal lesion that is caused by the bad crown.

That could be a predisposing factor not an initiating factor for the destruction of periapical bone at the distal root which extended and might be associated with other factors such the occlusal trauma, the presense of infected untreated accessory canals ..etc , but as it's mentioned that the distal root has been re-treted alonoe with periodontal curretage of the pocket, thence the case has been resloved , and it'might be due to the removal of the crown.. but despitye that, I think it's not a pure Perio Lesion.

المشاركة الأصلية بواسطة Bassam AlRihawi

ok now they did an endodontic retreatement which is justified because of the infection (high risk of contamination of the filling material) , they should have done that correctly and retreated both all the roots i think everyone agrees with me on that point

I'm Agree u with this point..
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I was reading an article about Endo Perio Lesions, and I would like to write here what I've encountered which might help in our undersatnding of this strange diagnosis of this case:

"Advanced lesions and true-combined lesions are difficult to differentiate between, and therefore where doubt exists they should be considered endodontic in origin. '

But again, it's not clear why the distal root is only treated without re-treatment of the other one..