Treatment of an Endo-Perio Lesion with Ozone Gas in a Patient with Aggressive Periodontitis: A Clinical Case Report and Literature Review

Figures & data

Figure 1 (A) Intraoral view of the upper right quadrant at baseline; calculus and gum bleeding is visible. (B) Intraoral view of the frontal lower teeth at baseline; small amounts of calculus and pus discharge are visible.

Figure 2 Panoramic radiograph at baseline.

Figure 3 (A) Upper right quadrant after antibiotic therapy. (B) Frontal lower teeth after antibiotic therapy.

Figure 4 Intraoral view of the frontal lower teeth 14 days after SRP and splinting.

Figure 5 Intraoral view 6 months after SRP.

Figure 6 Panoramic radiograph 6 months after SRP: tooth #43 showed an extensive periapical lesion with well-defined borders and bone loss extruding onto the root’s mesial surface.

Figure 7 “Walking” probing of the periodontal pocket using a Naber periodontal probe. Distal buccal point (A), middle buccal point (B), mesial buccal point (C), all measurements are 2 mm probing depth. (D) Narrow and deep 8 mm periodontal pocket on the mesial tooth surface.

Figure 8 (A) No bleeding was observed immediately after endodontic access opening. (B) Instrumentation of the root canal using an iRace rotary endodontic instrument. (C) Passive ultrasound irrigation with an ultrasound tip. (D) Treating the root canal with ozone gas.

Figure 9 (A) Working length confirmation. (B) Immediately after obturation. (C) Six-month follow-up showing complete healing of the bone defect in the periapical area and interdental septum.

Figure 10 Prozone ozone generator.

Table 1 Summarizing of Clinical Parameters, Treatment Protocols, and Healing Data of Case Studies with PESP Lesion Type

Authors, Year	Systemic Disease	Age	Tooth	Endo-Perio Lesion Type^a	Vitality Test	Baseline RVG^c	PD^d	Tooth Mobility	Furcation Involvement	Splinting	Treatment	Healing
Jivoinovici et al, 2017^Citation36	Not reported	38	#22	PESP^b	Negative	Periodontal space widening with periapical and lateral radiolucency and triangulation on the interdental septum	4 mm	Not reported	–	No	RCT^e, intracanal medicament CH^f between appointments SRP^g	12-months RVG noted a decrease until no radiolucent periapical and side
	Not reported	58	#34	PESP	Negative	Periodontal space widening with periapical radiolucency, circumscribed and lateral, located on mesial and distal sides of the tooth	Not reported	Not reported	–	No	RCT, intracanal medicament CH between appointments SRP	6-months RVG showed reduced periapical radiolucency
	Not reported	39	#47	PESP	Negative	Periapical radiolucent mesial and distal to the roots, radiolucency at furcation	6 mm	Not reported	Involved	No	RCT, intracanal medicament CH between appointments SRP	12-months RVG showed tendency of healing and periapical osteitis, remineralization of the interdental septum with a radiolucent decrease in furcation
	Not reported	35	#26	PESP	Tooth has filled root canals	Periapical radiolucency at the mesial root and disto-vestibular and vestibular bone demineralization of furcation	Not reported	Not reported	Involved	No	RCT, intracanal medicament CH between appointments SRP	1 year RVG showed reduction radiolucent of distal septum circumscribing apexes and disto-mesial buccal roots and the furcation
	Not reported	25	#11, 21	PESP	Not reported	Periapical radiolucent and demineralization on the mesial interdental septum	Not reported	Not reported	–	No	RCT, intracanal medicament CH between appointments SRP	1.5 year RVG presented a decrease in the apical radiolucent
Kambale et al, 2014^Citation37	Healthy	32	#47	PESP	Negative	Furcation area and periapical region of mesial and distal root, extruding along the lateral surface of root	10 mm	Not reported	Grade III	No	RCT, 2 months break, periodontal regenerative surgery with grafting	2-months RVG showed furcation involvement is still prevailed Six months of postoperative therapy, the normal probing depth of 2 mm was achieved
Lata Goyal, 2014^Citation38		35	#22	PESP	Negative	Radiolucency along the distal side of the entire root surface to the apex	8 mm	Not reported	-	No	RCT, regenerative periodontal surgery with PRP and grafting	6-months RVG showed complete healing, 12-months RVG showed stability
Aksel and Serper, 2014^Citation16	Healthy	45	#36	PESP	Tooth has filled root canals	Bony defect in the furcal and periapical area	12 mm	Yes	Grade III	No	RCT, 3 months later regenerative periodontal surgery	3-month RVG showed that the furcation lesion still remained intact 2-year recall radiograph showing complete healing of the furcation
Hind Alquthami et al, 2018^Citation23	Noncontributory	55	#46	PESP	Negative	Periapical and furcal radiolucency	10 mm (narrow)	Grade II	Involved	No	RCT in two visits with calcium hydroxide 5.25% sodium hypochlorite irrigation. No periodontal treatment was administered	Follow-ups 1 year to 6 years showed complete healing of the bone in the periapical and furcation areas
	Noncontributory	30	#36	PESP	Negative	Large furcal lesion related to the distal root opposite the post placement	Increased values	Not reported	Grade II	No	2.5% sodium hypochlorite followed by drying of the canal and sealing of the perforation with MTA	3, 6, 9-months and up to 4 years follow-up appointments showed complete healing of the soft tissue and bone lesions and a pocket depth of 3 mm.
	Noncontributory	27	#22	PESP	Negative	Advanced bone resorption extending from the mesial bone crest toward the apex	10 mm	Grade II	–	No	RCT in two visits with calcium hydroxide medication between appointments, periodontal regeneration, grafting after 3 months.	30-month RVG showed complete healing

Notes: ^aAccording to Rotstein and Simon's⁴ classification.^bPrimary endodontic lesion with secondary periodontal involvement. ^cRadiovisiography. ^dPeriodontal pocket depth. ^eRoot canal treatment. ^fCalcium hydroxide. ^gScaling and root planing.

Table 2 Summarizing of Clinical Parameters, Treatment Protocols, and Healing Data of Case Studies with PPSE Lesion Type

Authors, Year	Systemic Disease	Age	Tooth	Endo-Perio Lesion Type^a	Vitality Test	Baseline RVG^c	PD^d	Tooth Mobility	Furcation Involvement	Splinting	Treatment	Healing
Varughese et al, 2015^Citation39	Healthy	40	#16	PPSE^b	Partially vital pulp	Radiolucency of 0.5x1 mm at the apical region of the palatal root	9 mm	Grade I	Not reported	No	SRP^e, systemic antibiotic (Amoxicillin/500 mg/thrice daily/5 days) RCT^f, irrigation 5.25% SH^g, intracanal medicament CH^h between appointments. 3 months after RCT, root resection and periodontal regenerative surgery with PRF^i, graft and GTR^j	6-months RVG showed decreasing of radiolucency, 12-months RVG showed complete healing
Pico-Blanco et al, 2016^Citation35	Healthy	Not reported	#23	PPSE	Negative	The baseline radiograph showing bone destruction beyond the apex	12 mm	Grade III	–	Yes	RCT with 5.25% SH irrigation, SRP, 3 months break, periodontal regenerative surgery with grafting and GTR	14-month follow-up radiograph showing resolution of the bone defect
	Healthy	Not reported	#21	PPSE	Negative	Distal extensive bone destruction	13 mm	Grade II	–	Yes	RCT with 5.25% SH irrigation, SRP, 3 months break, periodontal regenerative surgery with grafting and GTR	2-year follow-up radiograph showed resolution of the bone defect
	Healthy	Not reported	#21	PPSE	Negative	An endodontic periodontal lesion involving the apex of tooth	8 mm	Grade III	–	Yes	RCT with 5.25% SH irrigation, SRP, 3 months break, periodontal regenerative surgery with grafting and GTR	3-year follow-up radiograph showing resolution of the apical lesion
	Healthy	Not reported	#11,21	PPSE	Negative	Baseline radiograph showing extensive bone destruction	6 mm	Grade II	–	No	RCT with 5.25% SH irrigation, SRP, 3 months break, periodontal regenerative surgery with grafting and GTR	6-year follow-up radiograph showing complete resolution of the apical lesion and bone maintenance
	Healthy	Not reported	#11	PPSE	Negative	Baseline radiograph showing extensive bone destruction	10 mm	Grade III	–	No	RCT with 5.25% SH irrigation, SRP, 3 months break, periodontal regenerative surgery with grafting and GTR	17-yer follow-up RVG showed resolution of the apical lesion
Dhoum et al, 2018^Citation31	Uncontrolled diabetes type 2	50	#13	PPSE	Negative	Severe bone loss related to a periapical lesion	12 mm	Grade III	-	Yes, 6 months after RCT	SRP, RCT with Amoxicillin 2 days before and a week following the procedure, 2.5% SH, intracanal medicament CH between appointments. Open flap surgery 6 month after RCT	2 weeks follow-up RVG showed beginning of bone reorganization. 2-month RVG showed stabilization of the radiolucent image. 12-month (6 months after open flap) showed partial healing of bone radiolucency, 18-months RVG showed decreasing of radiolucency, 39-month RVG showed disappearing of former radiolucency
Aksel and Serper, 2014^Citation16	Healthy	42	#37	PPSE	Negative	Severe bone loss around the distal root of tooth #37 related to the uncleaning space between second and third molar	Not reported	Not reported	Involved	No	RCT, extraction of third molar	6 month recall visit, the complete repair of the bony lesion; 1 year recall radiograph showing complete healing of the bone lesion
Makino-Oi et al, 2017^Citation40	Not reported	60	#16, 27	PPSE	Negative	Periapical radiolucency suggested perio-endo lesion	7–9 mm	Yes	Grade I–II	No	No treatment was done, teeth were extracted because of poor prognosis (furcation involvement and mobility)	-
Nadig et al, 2016^Citation42	Not reported	35	#11	PPSE (radicular groove)	Not reported	Extensive peri-radicular radiolucency involving the apical and middle one-third of the mesial aspect of root	13 mm	Not reported	-	No	SRP, RCT, calcium hydroxide for 3 weeks, obturation, 8 weeks later radicularplasty, periodontal surgery with grafting and PRF	1-year follow-up RVG significant reduction in radiolucency around the root surface
Gandhi et al, 2011^Citation43	Not reported	30	#22	PPSE (radicular groove)	Not reported	Showed an accessory root surrounded by a large radiolucent area	10 mm	Yes	-	No	Conventional root canal treatment, radiculopathy, root resection of accessory root and surgical curettage of the periodontal defect	Progression of hard tissue healing was observed in the periapical radiograph taken 1 year postoperatively
Praveena Devi et al, 2019^Citation44	Not reported	19	#22	PPSE (radicular groove)	Negative	Peri-apical radiograph of the tooth showed a lateral and periapical radiolucency	10 mm	Yes	-	No	Combination of endodontic and periodontal treatment Calcium hydroxide intracanal medicament 5.2% NaClO followed by placement of intracanal medicament for another week. 6 weeks post-endodontic radicularplasty, periodontal surgery with grafting	Radiographic complete bone fill was evident after 6 months
Kavarthapu and Malaiappan, 2019^Citation10	Healthy	28	#46	PPSE (aggressive peridontitis)	Negative	Radiolucency surrounding the distal root with furcation involvement and vertical bone loss up to apical third of the distal root	8 mm	Grade II	Grade II	No	Initial Phase I therapy, RCT, review was made after a month, when the site is probed, a 6 mm pocket was present with bleeding on probing flap surgery and regenerative surgery with PRF	3 months postoperative, radiographs shows the formation of bone around the distal root of 46 9 months postoperative follow-up shows bone formation circumscribing the distal root
Mayuri Naik et al, 2014^Citation45	Not reported	22	#12	PPSE (radicular groove)	Negative	Extensive periradicular radiolucency involving the apical one-third of the root	10 mm	Not reported	-	No	RCT: 5.25% sodium hypochlorite and 2% chlorhexidine, rinsed with 17% EDTA followed by full strength NaOCl, filled with calcium hydroxide and sealed with Cavit. Obturation was completed 3 weeks after the initial visit. 1 month later an exploratory surgery was planned. After flap access, a narrow palatal bony defect, scaling, Odontoplasty was performed on the palatal aspect of the root, followed by filling of the groove with Biodentine	Follow-up radiograph at 6 months reducing of radiolucency of the osseous defect
Mina D. Fahmy et al 2016^Citation41	Healthy	35	#36	PPSE (aggressive periodontitis)	Delayed	Bone resorption around distal root	12 mm	Not reported	Grade I	No	Oral prophylaxis session, RCT was in two visits; calcium hydroxide for 7 days. Shortly after RCT SRP, antibiotics (amoxicillin 500 mg three times a day and metronidazole 400 mg three times a day for 8 days). Regenerative periodontal therapy using Emdogain 4 weeks after anti-infective therapy	6 months follow-up showed gain of bone structure in comparison to the baseline visit 24 months after regenerative surgery panoramic radiograph showed progressive periodontal healing
Kumar et al, 2017^Citation46	Not reported	34	#11	PPSE	Vital	Intrabony defect with radiolucency in the mesiodistal region	6 mm	Grade II	–	Yes	SRP, antibiotics (amoxicillin 500 mg thrice daily/5 days). RCT and splinting was done within a week. After reevaluation at 3rd month, periodontal regenerative therapy with amniotic membrane and grafting was initiated	9th and 12th month indicated radiographic bone fill in relation to 11

Notes: ^aAccording to Rotstein and Simon's⁴ classification. ^bPrimary periodontal lesion with a secondary endodontic involvement. ^cRadiovisiography. ^dPeriodontal pocket depth. ^eScaling and root planing. ^fRoot canal treatment. ^gSodium hypochlorite. ^hCalcium hydroxide. ⁱPlatelet rich fibrin. ^1jGuided tissue regeneration.

Table 3 Summarizing of Clinical Parameters, Treatment Protocols and Healing Data of Case Studies with Primary Endodontic Diseases

Authors, Year	Systemic Disease	Age	Tooth	Endo-Perio Lesion Type^a	Vitality Test	Baseline RVG^b	PD^c	Tooth Mobility	Furcation Involvement	Splinting	Treatment	Healing
Aksel and Serper, 2014^Citation16	Healthy	21	#36	Primary endodontic diseases	Negative	Bone resorption in periapical and furcal area	Increased values	Grade II	Grade II	No	RCT^d with intracanal medicament CH^e for 2 weeks between appointments. No SRP^f or regenerative surgery	1 year recall radiograph showing complete healing
	Healthy	45	#46	Primary endodontic diseases	Negative	Baseline RVG showed increased bone lesion in the furcation	Increased values	Not reported	Involved	No	RCT with intracanal medicament CH for 2 weeks between appointments. No SRP or regenerative surgery	1 year RVG showed the repair of lesion

Notes: ^aAccording to Rotstein and Simon's⁴ classification. ^bRadiovisiography. ^cPeriodontal pocket depth. ^dRoot canal treatment. ^eCalcium hydroxide. ^fScaling and root planing.

Table 4 Summarizing of Clinical Parameter, Treatment, and Healing Data of a Case with True Combined Lesion

Authors, Year	Systemic Disease	Age	Tooth	Endo-Perio Lesion Type^a	Vitality Test	Baseline RVG^b	PD^c	Tooth Mobility	Furcation Involvement	Splinting	Treatment	Healing
Al Attas et al, 2017^Citation60	Not reported	31	#36	True combined lesion (generalized aggressive periodontitis)	Tooth has filled root canals	Apical radiolucency and resorption of interdental septum distally from the tooth	6 mm	Grade I	Grade I	No	SRP^d, systemic antibiotics Augmentin 1 gm twice/day and Metronidazole 500 mg 3 times/day for 2 weeks. RCT^e, mesial root resection, periodontal regenerative surgery	6-month RVG showed complete healing of the mesial root lesion and a significant reduction of the distal root lesion, and healing of interdental bone, 12-month RVG showed further improvement

Notes: ^aAccording to Rotstein and Simons's⁴ classification. ^bRadiovisiography. ^cPeriodontal pocket depth. ^dScaling and root planing. ^eRoot canal treatment.

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