Retrospective Gauging of Survival Rate and Clinical and Radiological Changes Following Regenerative Periodontal Therapy in Endodontic-Periodontal Lesions

ABSTRACT

Background:

Endodontic-periodontal lesions present an open wound that might need surgical management using the GTR (guided tissue regeneration) to be managed using a combined approach.

Aim:

To assess the survival rate and clinical and radiological changes following regenerative periodontal therapy in endodontic-periodontal lesions.

Methods:

The study assessed 104 cases in 82 subjects with a minimum 2-year follow-up. Following scaling and root planning with/without endodontic management, regenerative procedures using DBBM with 10% collagen (Group I) or DBBM with collagen membrane (Group II) were done. radiographic bone gain, mobility, relative clinical attachment levels, gingival recession, probing pocket depth, bleeding on probing, and plaque index changes were assessed.

Results:

In both groups, radiographic bone gains and improved clinical parameters were seen. Greater, but statistically nonsignificant probing depth reduction was seen in the DBBM + 10% collagen group compared to the DBBM + collagen membrane group with 4.54 ± 1.04 mm and 4.06 ± 0.80 mm respectively. Comparable radiographic bone gain was seen in Groups I and II with 5.13 ± 1.52 mm and 5.33 ± 1.82 mm. A 92.33% 5-year survival rate was reported following the regenerative surgery.

Conclusions:

Improved radiographic bone and clinical attachment levels are seen following regenerative procedures with DBBM with 10% collagen in endodontic-periodontal lesions. Strict supportive periodontal therapy and oral hygiene can help maintain the successful results of regenerative medicine.

INTRODUCTION

Endodontic-periodontal lesion is a pathological communication in periodontal and endodontic tissues of a tooth. The etiological factor in these lesions is primarily bacterial. Anatomic and nonphysiological connections between periodontal tissue and pulp are seen where bacteria and bacterial products are seen. Nonphysiological connections arise from cracking, vertical root fracture, pulp chamber perforations, and root canal, whereas anatomic connections are related to dentinal tubules, accessory foramina, lateral canal, and apical foramen.[1]

Combined collagen membrane and DBBM resulted in more bone formation compared to DBBM alone. Membrane use is linked to various disadvantages including second surgery need for nonresorbable membrane removal, gingival recession, and increased infection risk. Also, using bone grafts and membranes in thin biotypes or narrow interdental spaces can lead to a gingival recession, which further delays wound healing and cause membrane exposure.[2]

The present study was aimed at assessing the survival rate and clinical and radiological changes following regenerative periodontal therapy in endodontic-periodontal lesions with DBBM and 10% collagen or DBBM with a collagen membrane.

MATERIALS AND METHODS

The study was done at the Department of Periodontology and Oral Implantology, Hazaribagh College of Dental Sciences and Hospital, Jharkhand. All the participants were asked to sign an informed consent for study participation.

The inclusion criteria for the study were subjects that fulfilled the maintenance program, had a minimum of 2 mm keratinized tissue, had deep and wide pockets on one tooth surface (Grade 2) or Grade 3 for periodontitis subjects with deep pockets on more than one surface, radiographic bone loss from margins to apex, probing depth ≥5 mm on one/more site, and subjects with no maintenance/active periodontal therapy in last 3 months. Exclusion criteria were subjects with root perforation, vertical/horizontal tooth fracture, pregnancy, requiring/on antibiotics in the past 3 months, smokers, diabetics, and use of NSAIDs.

The study included 82 subjects with 104 sites needing periodontal regeneration. At baseline, tooth mobility, RAL (relative clinical attachment level), GR (gingival recession), PPD (probing pocket depth), BOP (bleeding on probing), and PI (plaque index) were recorded. Hu-Friedy UNC-15 probe was used for PPD recording at 6 sites per tooth (mesiobuccal, midbuccal, distobuccal, mesiolingual, midlingual, and distolingual) in mm from the free gingival margin to the base of the sulcus. Gingival margin to CEJ (cementoenamel junction) defined GR. The sum of GR and PPD calculated RAL. Also, PPDD and RALD were assessed at the deepest PPD. PI was recorded utilizing the Silness and Loe index.[3] BOP was recorded after 30 s of probing as +/- at 6 sites followed by calculating the percent ratio of BOP + sites number relative to a total of 6 sites. Periotest Classic (Medizintechnik Gulden e. K., Modautal, Germany) was used to evaluate mobility.

Spearman correlation coefficient was also used for correlation in clinical parameters. Statistical analysis was performed with SPSS version 21.0 (IBM Corp, Armonk, NY, USA) software. Results were considered statistically significant with P < .05.

RESULTS

There were 38.46% (n = 40) males and 61.53% (n = 64) females in the present study. One- and 2-wall defects were seen in 65.38% (n = 68) and 34.61% (n = 36) subjects, respectively. The most common site was maxillary posterior in 46.15% (n = 48) subjects followed by mandibular posteriors with 23.07% (n = 24) subjects, mandibular anterior in 9.61% (n = 10), 7.69% (n = 8) subjects in maxillary premolars and anterior each, and mandibular premolars in 5.76% (n = 6) subjects, respectively. Endodontic management was done in 86.53% (n = 90) subjects, GTR was used in 50% (n = 52) subjects, and new prosthesis was needed in 76.92% (n = 80) subjects. 88.46% (n = 92) teeth survived following treatment and 11.53% (n = 12) teeth needed extraction with the most common reason being fracture in 5.76% (n = 6) subjects [Table 1].

Table 1.

Demographic data of study participants

Characteristics	Number (n=104)	Percentage (%)
Gender	-	-
Males	40	38.46
Females	64	61.53
Defect type
1-wall	68	65.38
2-wall	36	34.61
3-wall	0	-
Sites	-	-
Mandibular posterior	24	23.07
Mandibular premolar	6	5.76
Mandibular anterior	10	9.61
Maxillary posterior	48	46.15
Maxillary premolar	8	7.69
Maxillary anterior	8	7.69
Endodontic management	-	-
Yes	90	86.53
No	14	13.46
GTR	-	-
Yes	52	50
No	52	50
Prosthesis change	-	-
Yes	80	76.92
No	24	23.07
Survived teeth	92	88.46
Teeth extracted (cause)	12	11.53
Strategic causes	2	1.92
Endodontic failure	2	1.92
Improper oral hygiene	2	1.92
Fracture	6	5.76

For the comparison of radiographic and clinical features at baseline and 12 months in study participants, CEJ-BD distance was significantly higher at baseline with 9.84 ± 1.42 mm compared to 4.56 ± 1.04 mm at 2 months with P < .001. A similar significant reduction was seen in mobility from baseline to 12 months with P < .001. RALD (deepest RAL) and RAL also showed significant reduction from baseline to 12 months with P < .001. The gingival recession increased significantly from baseline to 12 months from 1.41 ± 0.56 to 2.18 ± 0.79 mm with P < .001. PPDD (probing pocket depth deepest) and PPD decreased significantly from baseline to 12 months with P < .001, respectively. BOP% decreased significantly from baseline to 12 months with P < .001. A significant reduction in plaque index was also seen from baseline to 12 months with P < .001 as shown in Table 2. For radiographic assessment, the correction factor was 1.02 ± 0.04, and good agreement was depicted. The intraclass correlation coefficient for radiographic assessment was 0.925 and 0.980 at baseline and 12 months, respectively [Table 2].

Table 2.

Comparison of radiographic and clinical features at baseline and 12 months

Parameter	Baseline	12 months	P
CEJ-BD (mm)	9.84±1.42	4.56±1.04	<0.001*
Mobility	26.44±2.26	10.29±2.02	<0.001*
RALD (mm)	9.01±1.03	5.47±1.07	<0.001*
RAL (mm)	6.56±0.97	5.14±0.75	<0.001*
Gingival recession (mm)	1.41±0.56	2.18±0.79	<0.001*
PPDD (mm)	7.57±0.87	3.33±0.46	<0.001*
PPD (mm)	5.12±0.81	2.94±0.29	<0.001*
BOP (%)	48.06±9.69	13.76±6.35	<0.001*
PI	1.04±0.27	0.72±0.20	<0.001*

DISCUSSION

Periodontal regeneration aimed to increase bone and periodontal attachment in severely compromised teeth, minimize GR, and decrease PPD as reported by Cortellini P et al.[2] in 2015. Since the 1970s, enamel matrix proteins, growth and differentiation factors, GTR, root surface demineralization, various bone grafts/substitutes, and their combinations have been used as suggested by Sculean A et al.[4] in 2015. The study used DBBM with 10% collagen without or without membrane. A collagen membrane with a modified papilla preservation flap was applied when the interdental space width was <2 mm. When the width was <2 mm, DBBM with 10% collagen and no membrane was placed. The present study did not use membranes in <2 mm interdental papilla with inflammation as it would hamper healing.

Another recent data by Sculean A et al.[4] in 2015 reported in nonguided regeneration, the long junctional epithelium is not necessarily formed. Space provision and wound stability are vital for unfolding innate regenerative potential in periodontium.

The present study reported a 92% 5-year survival rate following regeneration in endo-periodontal lesions. These findings were similar to Schmidt JC et al.[5] in 2014 where authors reported a survival rate of 72-100% in endo-periodontal lesions.

The effect of mobility on regenerative therapy is controversial in the literature, various studies advocated splinting mobile teeth before regeneration to help in healing as reported by Siciliano VI et al.[6] in 2011 and Cortellini P et al.[7] in 2011.

CONCLUSIONS

Periodontal regeneration with DBBM and 10% collagen resulted in improved radiographic bone gain and clinical attachment level in endodontic-periodontal lesions and helps in periodontal healing in teeth involved apically. For successful results maintenance, strict SPT and oral hygiene instructions play a vital role.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.