Successful Management of Moderate Periapical Lesion with Extra Oral Draining Sinus Tract via Non Surgical Endodontic Therapy

INTRODUCTION

The pulp is the formative organ of the tooth and is highly resistant. Its resistance depends on cellular activity, nutritional supply, age, and other metabolic and physiologic parameters.

Mild to moderate inflammatory condition of the pulp caused by noxious stimuli in which pulp is capable of returning to un-inflamed state following removal of the stimuli is known as reversible pulpitis.

On the other hand, persistent inflammatory condition of the pulp, symptomatic or asymptotic caused by a noxious stimulus is indicative of irreversible pulpitis1,3. This inflammatory reaction produces peri apical micro abscess around the apex of tooth. In most cases inflammation remains localized to the peri apical region. The main causes of periapical lesion are

1. Infection
2. Trauma
3. Chemical irritation

Treatment for moderate peri apical lesion is usually completed successfully via nonsurgical endodontic therapy only. For moderate to large periapical lesions, there remains a dilemma in dentist’s mind as to the effectiveness of non surgical endodontic therapy alone. Surgical therapy involves morbidity for patient in terms of healing and also calls for higher expertise and expense of materials on the surgeon’s part. In this case report we have attempted nonsurgical endodontic therapy with regular intra canal medication and dressings to resolve moderate periapical lesion with extra oral draining sinus tract.

CASE REPORT

A 23 year old medically healthy girl reported to clinic with complain of pain and draining pus extra orally from left side lower back region of face since 1 month. Patient had history of fever and pus draining through skin for some time. She was treated by general physician with oral antibiotics and extra oral dressings. She was advised to go for plastic surgery and was referred to dental expert for opinion. On extra oral examination, skin over lower border of mandible in lower left side of jaw was red and indurate and pus was draining out.

On palpation swelling was hard and extended till floor of mouth. Unilateral submandibular lymph nodes were enlarged. On intra oral examination and with routine dental x-rays, decay was present with lower left second molar (37) tooth and pus discharge was associated with the same tooth. Radiograph showed widening of periodontal ligament space and radiolucency in relation to apex of mesial and distal roots of the same tooth. Diffuse radiolucency extended up to the lower border of mandible and radiographic findings co related with the clinical findings. Thermal pulp testing was done to check vitality, and it was confirmed that tooth was non vital.

Treatment planning was done taking into consideration patient’s financial status and non surgical endodontic treatment was the first choice. Root canal treatment was started for tooth 37 and sodium hypochlorite was used for root canal irrigation and calcium hydroxide with iodoform dressing was placed. Patient was recalled for every 15 days to repeat the intra canal medicament dressing. Once the intra and extra oral sinus tract healed up completely, final obturation was done using gutta percha after two months.

Further recall was scheduled at 3 to 4 months interval. Final follow up was done after 1 year. During every recall visit, clinically the intra oral and extra oral tissues exhibited complete signs of healing with no pus discharge. Patient reported no more symptoms and was completely satisfied with the treatment.

DISCUSSION

Once pulp gets necrotic due to irreversible pulpitis, its environment becomes suitable to allow microorganism to multiply and release various toxins into periapical tissues and in turn leads to periapical abscess in bony trabeculae of jaw. But when purulent exudate (peri apical abscess) increases it starts penetrating cortical plate and sinus tract starts developing towards least resistant area. These sinus tracts were originally thought to be lined by epithelium and therefore to require a surgical intervention apart from the endodontic treatment. But later, studies suggested that it was lined by granulation tissue and not epithelium, which means that it could be intraoral or extra oral and that it could be treated by a non-surgical endodontic treatment. 2, 5

Adequate measures which are used to eliminate the intra canal microorganisms would ensure a complete healing with a non surgical endodontic treatment. Various studies have proved that chlorhexidine and sodium hypochlorite were the best among the irrigants , as they could reduce the bacterial counts rapidly. Both these irrigants eliminate the gram positive and the gram negative anaerobic bacteria in 15 minutes. Irrigation solutions help reduce the microbial flora of the infected canals, and the use of a tissue-dissolving

Formulation can help eliminate the necrotic tissue. In our patient, the canals were irrigated with abundant 5% sodium hypochlorite – this contributing to improve bacterial elimination. However, the concentrations used in other studies are 1%, and 5.25%. Instrumentation and irrigation reduce bacterial presence, though an agent with bactericidal action is still needed to ensure optimum disinfection. 7

Complete healing of the extra oral sinus indicates the adequacy of the disinfection procedure and it confirms the existing opinion of the management of such an endodontic infection as a non surgical procedure. Though endodontic treatment is indicated in situations with draining sinus tracts, the treatment of the cases with extra oral sinuses is not attempted in single visit.. This case report establishes that an endodontic infection with an extra oral sinus can also heal with a non surgical endodontic treatment alone.

Calcium hydroxide with iodoform was used as intra canal dressing. Since its introduction by Hermann, Calcium hydroxide has been regarded as the choice of material. Once applied, calcium hydroxide ions break down into calcium and hydroxyl ions which exhibit great affinity towards biologically active substances. High alkaline environment produced by hydroxyl ions becomes the catalyst for rapid destruction of structural lipids and lipoproteins present inside the bacterial cells. By virtue of it s high alkalinity, Calcium hydroxide, is capable of activating tissue enzymes which favor tissue restoration through mineralization such as alkaline phosphatase. The phosphate ions thus released, react with calcium ions from the blood stream to form calcium phosphate which is the molecular unit of hydroxyapatite. It has been observed that formation of mineralized tissue occurs after 7-10 day contact with calcium hydroxide.

To improve the properties like radiopacity, flow, and consistency of calcium hydroxide various substances have been added as in Metapex. The oily vehicles present in Metapex are responsible for the lowest solubility and diffusion of the paste within the tissues. Iodoform is incorporated to improve the antibacterial properties of the material and BaSO4 as radiopaque agent.8,4

Extension of the material beyond the apex has, been advocated by some authors due to benefits of calcium hydroxide6. Souza et al9 suggested that the action of calcium hydroxide beyond the apex may be attributed to properties such as: anti-inflammatory activity, neutralization of acidity beyond apex due to high alkalinity, stimulation of remineralization due to activation of alkaline phosphatase in the peri apical region and antimicrobial as well as bactericidal properties inherent in the paste.

Sahli proposed that the necrotizing ability of calcium hydroxide may destroy any epithelium present thereby allowing a connective tissue invagination into the lesion with ultimate healing.10

CONCLUSION

Periapical lesions present challenges to the clinicians in their proper diagnosis, treatment planning and prognosis of involved teeth. In this case report non surgical treatment for moderately large peri apical lesion with draining extra oral sinus tract was successfully done using non surgical endodontic therapy with medicament dressing (calcium hydroxide and iodoform) alone and at one year follow up clinical and radiographic resolution of the lesion was observed without further need for surgical intervention. Thus it could be concluded that treatment outcomes will be more predictable if clinician has through knowledge about diagnosis, treatment sequences and final prognosis.

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