SPREAD OF ODONTOGENIC INFECTION ORIGINATING FROM ENDO-PERIO LESION
ENDOPERIODONTAL LESION – CASE REPORT
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SPREAD OF ODONTOGENIC INFECTION
ORIGINATING FROM ENDO-PERIO LESION
ENDOPERIODONTAL LESION – CASE REPORT
INFECÇÃO ODONTOGÊNICA ORIGINADA DE UMA
LESÃO ENDO-PERIODONTAL –
RELATO DE CASO
Paulo Ricardo Saquete MARTINS FILHO *
Luiz Carlos Ferreira da SILVA **
Marta Rabello PIVA ***
Daniele Machado REINHEIMER ****
Katheryne Sue DEJEAN *****
_________________________________________________
* Health Science Post-Graduation, Nucleus of Post-Graduation in Medicine, Federal University of
Sergipe, Aracaju, SE, Brazil. Professor, Department of Oral Pathology, School of
Dentistry, Federal University of Sergipe, SE, Brazil. Rua Cláudio Batista, s/n. Bairro
Sanatório,
Aracaju,
SE,
Brazil.
E-mail:
[email protected]
/
[email protected]
** Professor, Department of Oral Surgery, School of Dentistry, Federal University of Sergipe,
Aracaju, SE, Brazil.
*** Professor, Department of Oral Pathology, School of Dentistry, Federal University of Sergipe,
Aracaju, SE, Brazil.
**** Dental Surgeon Graduated from School of Dentistry, Federal University of Sergipe, Aracaju,
SE, Brazil.
***** Student, School of Dentistry, Federal University of Sergipe, Aracaju, SE, Brazil.
SPREAD OF ODONTOGENIC INFECTION ORIGINATING FROM ENDO-PERIO LESION
ENDOPERIODONTAL LESION – CASE REPORT
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ABSTRACT
The endoperiodontal lesion is a condition characterized by the
association of periodontal and pulpal disease in the same dental element. While
the deleterious effects of pulpal disease on the periodontium are well documented,
the converse effect of periodontal disease on the pulp remains unclear. The
present study report a rare case of abscess spread into submandibular space from
primary periodontal infection with secondary endodontic involvement in a 44year-old man without systemic disease.
RESUMO
A lesão endoperiodontal é uma condição caracterizada pela
associação de doença periodontal e pulpar em um mesmo elemento dentário.
Enquanto os efeitos deletérios da doença pulpar no periodonto são bem
documentados, o efeito inverso permanece obscuro. O presente estudo relata um
raro caso de disseminação de um abscesso para o espaço submandibular
decorrente de uma infecção periodontal primária com envolvimento endodôntico
secundário em um homem de 44 anos sem doença sistêmica associada.
Uniterms: Endoperiodontal Lesion, Odontogenic Infection, Periodontitis.
Unitermos: Lesão Endoperiodontal, Infecção Odontogênica, Periodontite.
INTRODUCTION
The endo-perio lesion is a condition characterized by the
association of periodontal and pulpal disease in the same dental element. The
relationship between these two diseases was first described by SIMRING;
GOLDBERG (1964) (10), which stated that pulpal infection may cause a tissue
destructive process that proceeds from the root apex toward the gingival margin.
While the deleterious effects of pulpal disease on the periodontium
are well documented, the reverse effect of periodontal disease on the pulp remains
unclear. However, some authors have suggested a solid association between
periodontal disease and inflammatory and degenerative processes in the dental
pulp (1, 3, 5, 7, 9). This present study report a rare case of abscess spread into
submandibular space from primary periodontal infection with secondary
endodontic involvement in a 44-year-old man without systemic disease.
CASE REPORT
A 44-year-old male complaining malaise, fever and facial swelling
were referred by an emergency physician for dental consultation regarding a
suspected odontogenic infection. On clinical examination, a well-defined, soft,
tenderness swelling of 6 x 4 cm in the right submandibular region was noted
(Figures 1 and 2). His vital signs were as follow: temperature, 37.8ºC; pulse, 80
beats / min; respiratory rate, 22 breaths / min; and blood pressure, 130 / 80 mm
Hg. The patient’s past medical history was not-contributory.
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Intra-oral examination revealed poor oral hygiene and the presence
of only one tooth (third molar) in the right side of the jawbone. Third molar
presented high degree of mobility and non-carious lesion was observed.
However, a negative answer to the pulp vitality test was performed. Periodontal
exam revealed a 12 mm probing depth on the distal root and periapical
radiography showed periodontal bone loss around distal root with furcation
involvement (Figure 3). Thus, on the basis of the clinical and radiographic
features, was established a diagnosis of primary periodontal lesion with secondary
endodontic involvement. By needle aspiration, purulent exudate was found
confirming the spread of this infection into the submandibular space.
Figures 1 and 2 - Clinical photograph showing facial swelling in the submandibular region. After
diagnosis, incision and drainage were performed with basis at the point of maximum
fluctuation (arrow) (2).
SPREAD OF ODONTOGENIC INFECTION ORIGINATING FROM ENDO-PERIO LESION
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Figure 3 - Periapical radiography of mandibular third molar involved with the infection.
Oral amoxicillin was started, the third molar was extracted and
incision and drainage were performed. Three days after admission, the swelling
was reduced significantly. The 30 days’ follow-up examination revealed no
evidence of residual infection (Figure 4).
Figure 4 - Imperceptible scar at the site of incision.
SPREAD OF ODONTOGENIC INFECTION ORIGINATING FROM ENDO-PERIO LESION
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DISCUSSION
The relationship between pulpal and periodontal disease can be
traced to embryological development, since the pulp and the periodontium are
derived from a common mesodermal source (4). The pulp can be invaded from the
periodontium through dentin tubules, lateral and accessory canals and the apical
foramen; although evidence exists for such canals of communication, a
mechanism for the direct transmission of periodontal infection into the pulp
tissues remains unclear.
Still there is no consensus about the deleterious effect of the
periodontal infections at the pulp organ, even so if it knows that the main pathway
of communication between both structures is the apical dental foramen. The
apical dental foramen could serve as an open way of entrance for periodontal
bacteria in the dental pulp, promoting situations of degenerative and necrotic
nature (3, 5, 7, 11).
Some studies had suggested that the communication between pulp
and periodontium can occur not only by apical dental foramen. RUBACH;
MITCHELL (1965)(9) had suggested that the periodontal disease affect the pulp
health when it has exposition of the accessory canals to the oral cavity, what it
would allow that bacteria proceeding from this region invaded the pulp provoking
a chronic inflammatory reaction followed of necrosis to the pulp. ADRIAENS;
DE BOEVER; LOESCHE (1988)(1) and ADRIAENS et al., (1988)(2)
demonstrated that bacteria proceeding from periodontal pocket have the capacity
to cross the root canals in direction to the pulp and suggested that the dentin
tubules can serve as reservoir for these microorganisms.
It is very rare to find a tooth without pulp vitality and free of caries,
restoration work or trauma (8). However, these features were found in our case,
but the patient had severe periodontal disease-associated. Bacteria from
periodontal pocket probably had access to dental pulp via apical foramen and/or
dentin tubules and caused an inflammatory irreversible process, leading to death
of tooth (Figure 5).
Figure 5 - Primary periodontal lesion with secondary endodontic involvement. Proposal for a
physiopathological mechanism based on case report.
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Although to be common the involvement of facial spaces as a result
of the spread of infections by pulp origin, the same does not happen when the
origin of the infection is periodontal. Therefore, the reported case is rare in
dentistry literature, especially due to absence of patient’s systemic health
alterations.
REFERENCES
1. ADRIAENS, P. A.; DE BOEVER, J. A.; LOESCHE, W. J. Bacterial invasion
in root cementum and radicular dentin of periodontally diseased teeth in humans.
A reservoir of periodontopathic bacteria. J. Periodontol. v. 59, p. 222-230, 1988.
2. ADRIAENS, P. A.; EDWARDS, C. A.; DE BOEVER, J. A. et al.,
Ultrastructural observations on bacterial invasion in cementum and radicular
dentin of periodontally diseased human teeth. J. Periodontol. v. 59, p. 493-503,
1988.
3. BERGENHOLTZ, G.; LINDHE, J. Effect of experimentally induced marginal
periodontotitis and periodontal scalling on the dental pulp. J. Clin. Periodontol. v.
5, p. 59-73, 1978.
4. BHASKAR, S. N. Orban’s oral histology and embryology. St. Louis: Ed.
Mosby; 1991.
5. CZARNECKI, R. T.; SCHILDER, H. A histologic evaluation of the human
pulp in teeth with varying degrees of periodontal disease. J. Endod. v. 5, p. 24253, 1979.
6. KURIHARA, H.; ISOSHIMA, O. A microbiological and immunological study
of endodontic-periodontic lesions. J. Endod. v. 21, p. 617-621, 1995.
7. LANGELAND, K.; RODRIGUES, H.; DOWDEN, W. Periodontal disease,
bacteria, and pulpal histopathology. Oral Surg. Oral Med. Oral Pathol. v. 37, p.
257-70, 1974.
8. LÓPEZ-PÍRIZ, R.; AGUILAR, L.; GIMENEZ, M. J. Management of
odontogenic infection of pulpal and periodontal origin. Oral Med. Oral Patol.
Oral Cir. Bucal. v. 12, n. 2, p. 154-9, 2007.
9. RUBACH, W. C.; MITCHELL, D. F. Periodontal disease, accessory canals and
pulp pathosis. J. Periodontol. v. 36, p. 34-38, 1965.
10. SIMRING, M.; GOLDBERG, M. The pulpal pocket approach: retrograde
periodontitis. J. Periodontol. v. 35, p. 22-48, 1964.
11. SOLOMON, C.; CHALFIN, H.; KELLERT, M. et al., The endodonticperiodontal lesion: a rational approach to treatment. J. Am. dent. Assoc. v. 126, p.
473-9, 1995.
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