SPREAD OF ODONTOGENIC INFECTION ORIGINATING FROM …
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SPREAD OF ODONTOGENIC INFECTION ORIGINATING FROM ENDO-PERIO LESION ENDOPERIODONTAL LESION – CASE REPORT 460 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.
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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 *****
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
461
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 44- year-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.
SPREAD OF ODONTOGENIC INFECTION ORIGINATING FROM ENDO-PERIO LESION ENDOPERIODONTAL LESION – CASE REPORT
462
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 ENDOPERIODONTAL LESION – CASE REPORT
463
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 ENDOPERIODONTAL LESION – CASE REPORT
464
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.
SPREAD OF ODONTOGENIC INFECTION ORIGINATING FROM ENDO-PERIO LESION ENDOPERIODONTAL LESION – CASE REPORT
465
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. 242- 53, 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 endodontic- periodontal lesion: a rational approach to treatment. J. Am. dent. Assoc. v. 126, p. 473-9, 1995.
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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 *****
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
461
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 44- year-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.
SPREAD OF ODONTOGENIC INFECTION ORIGINATING FROM ENDO-PERIO LESION ENDOPERIODONTAL LESION – CASE REPORT
462
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 ENDOPERIODONTAL LESION – CASE REPORT
463
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 ENDOPERIODONTAL LESION – CASE REPORT
464
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.
SPREAD OF ODONTOGENIC INFECTION ORIGINATING FROM ENDO-PERIO LESION ENDOPERIODONTAL LESION – CASE REPORT
465
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. 242- 53, 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 endodontic- periodontal lesion: a rational approach to treatment. J. Am. dent. Assoc. v. 126, p. 473-9, 1995.
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