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CASE REPORT
Year : 2019  |  Volume : 12  |  Issue : 1  |  Page : 55-58  

Palatogingival groove: A pathway to periodontal destruction


1 Department of Periodontology, Dentistry, UPUMS Saifai, Etawah, Uttar Pradesh, India
2 Department of Pathology, UPUMS Saifai, Etawah, Uttar Pradesh, India

Date of Submission21-Nov-2017
Date of Acceptance29-May-2018
Date of Web Publication22-Jan-2019

Correspondence Address:
Anshul Sawhney
Department of Periodontology, Dentistry UPUMS Saifai, Etawah - 206 130, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.MJDRDYPU_225_17

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  Abstract 


Palatogingival or radicular groove is another developmental aberration known to maximally affect the palatal surfaces of maxillary lateral incisors but is often missed during a routine. It is a malformation which presents as a groove or channel that begins in the central fossa, crosses the cingulum of the tooth and extends apically to or beyond the cementoenamel junction at varying distances and directions along the root surface. It serves as a perfect bacterial harbor predisposing to pocket formation, concomitant bone loss and pulpal involvement, thereby encouraging the development of endodontic-periodontal lesions. Depending on severity, the groove may render a direct communication between the periodontium and pulp cavity promoting effortless bacterial invasion. It creates an area where plaque accumulation can be difficult, if not impossible to control using oral hygiene measures. The diagnosis of these grooves is quite difficult, as they cannot be differentiated in the X-ray images. The treatment procedures employed for treating palatogingival grooves will include pulpectomy if the tooth is nonvital along with odontoplasty of the groove or restoration of the groove with glass ionomer cement after the elevation of mucoperiosteal flap. Bone defects around the involved teeth also have to be treated with grafts and membrane. This case report describes the diagnosis and treatment of a palatogingival groove on maxillary lateral incisor.

Keywords: Bone defects, endodontic-periodontal lesion, mucoperiosteal flap, palatogingival, radicular groove


How to cite this article:
Sawhney A, Thakur RK, Singh AK, Yadav BK, Ralli M. Palatogingival groove: A pathway to periodontal destruction. Med J DY Patil Vidyapeeth 2019;12:55-8

How to cite this URL:
Sawhney A, Thakur RK, Singh AK, Yadav BK, Ralli M. Palatogingival groove: A pathway to periodontal destruction. Med J DY Patil Vidyapeeth [serial online] 2019 [cited 2019 Jul 19];12:55-8. Available from: http://www.mjdrdypv.org/text.asp?2019/12/1/55/250433




  Introduction Top


Periodontitis is defined as the inflammatory disease of tooth-supporting structures caused by microorganisms or by group of specific microorganisms resulting in progressive destruction of the periodontal ligament and alveolar bone with pocket formation or recession or both.[1] The main etiology of periodontal disease is dental plaque and there are various other factors that are believed to play a contributory role in the causation and progression of periodontal diseases.

According to the American Academy of Periodontology International Workshop for Classification held during the year 1999, the developmental and acquired deformities and conditions were grouped together as an entity that could lead to periodontal destruction.

Developmental and acquired deformities are those conditions and structural changes to the tooth and soft tissue that could bear a significant threat to the periodontium and lead to definitive attachment loss. These developmental and acquired deformities are subclassified into the following:

  1. Localized tooth-related factors that predispose to plaque-induced gingivitis or periodontitis


    1. Tooth anatomic factors
    2. Dental restorations or appliances
    3. Root fractures
    4. Cervical root resorption and cemental tears.


  2. Mucogingival deformities and conditions around teeth
  3. Mucogingival deformities and conditions on edentulous ridges
  4. Occlusal trauma.


Palatogingival groove or radicular lingual groove (RLG) is a developmental anomaly in which an infolding of the inner enamel epithelium and Hertwig's epithelial root sheath create a groove that passes from the cingulum of maxillary incisors apically onto the root. RLGs can create periodontal and pulpal pathology. Such morphological features compromise patient self-care and favor accumulation of plaque, calculus and food debris. They facilitate growth and later provide anaerobic condition for bacterial selection and proliferation.[2]


  Case Report Top


A 23-year-old female patient reported to the Department of Periodontology and Implantology of UPUMS Saifai, Etawah, with chief complaint of sensitivity and pus discharge from the upper left lateral incisor region. On extraoral examination, there were no palpable lymph nodes, the face was bilaterally symmetrical, and the lips were competent.

On clinical examination, localized gingival inflammation was present with the accumulation of plaque and calculus. Periodontal examination revealed deep periodontal pocket measuring 10 mm on the distopalatal aspect of left lateral incisor using UNC-15 probe [Figure 1]. The patient had no significant tenderness to percussion or palpation in the maxillary anterior region. There was a presence of a fine groove which started at the cingulum and traveled apically and laterally. On radiographic examination, a tear-shaped radiolucency was present with localized bone loss in left lateral incisor, i.e., 22 [Figure 2]a and [Figure 2]b. The groove was present on the distopalatal aspect of the left lateral incisor. The use of digital orthopantomographs was also done apart from routine intraoral periapical radiographs (IOPAs). There was no mobility observed with the teeth.
Figure 1: Periodontal pocket measuring 10 mm using UNC-15 probe

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Figure 2: (a) Preoperative (orthopantomogram) showing teardrop radiolucency irt.22. (b) Preoperative (intraoral periapical) showing teardrop radiolucency irt.22

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The Phase I periodontal therapy consisted of oral hygiene instructions and scaling and root planing [Figure 3]. After reevaluation of Phase I therapy, a decision to perform periodontal surgery in the upper anterior region was taken. Pulp vitality revealed tooth to be nonvital. There was negative response to thermal and electric pulp vitality tests, while the adjacent teeth responded normally. Hence, prior root canal was done and was cleaned and shaped using stainless steel hand files. Access opening was done in respect to 22 [Figure 4]. Biomechanical preparation was done till 35 not using K-file [Figure 5], and curettage of the deep pocket area was done. Canal was debrided with 5.25% sodium hypochlorite and 2% chlorhexidine and filled with calcium hydroxide paste.
Figure 3: Phase I periodontal therapy

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Figure 4: Access opening irt 22 using round bur

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Figure 5: Biomechanical preparation till 35 not using K-file

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The access opening was then sealed with Cavit (3M, ESPE).

The patient was recalled after 2 weeks. A crevicular incision was given, and a full-thickness mucoperiosteal flap was reflected [Figure 6]. The defect was curetted, and all granulation tissue was debrided. Hence, the groove was clearly visible and was corrected using tapered fissure bur. Canal was dried using paper points, followed by obturation with gutta-percha and sealer. The defect was sealed with glass ionomer cement. Then, the flap was approximated back and sutured with 3–0 silk [Figure 7]. Periodontal pack was placed. Postoperative instructions and medications were given: (1) capsule amoxicillin 500 mg tid, (2) tablet Flagyl 400 mg tid, and (3) tablet Imol Plus bid.
Figure 6: Full-thickness flap is raised and debridement done

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Figure 7: 3–0 silk sutures and periodontal pack are placed

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Postoperative

The patient was asymptomatic postoperatively and sutures were removed after 7 days. The patient was recalled after 1 month of follow-up. Postoperative IOPA was taken [Figure 8].
Figure 8: Postoperative intraoral periapical showing obturation and defect sealing with glass ionomer cement

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  Discussion Top


The presence of a morphological defect called a palatogingival groove is considered to be an important contributing factor to the development of localized chronic periodontitis, for it favors the accumulation and proliferation of bacterial plaque deep into the periodontium. This anomaly affects maxillary incisors, especially lateral incisors. The first large survey of the incidence of palatoradicular groove (PRG) in the extracted teeth was conducted by Everett and Kramer.

Radicular groove can create periodontal and pulpal pathology. They are difficult to identify as an etiological factor. However, in this case, there was a pulpal involvement for which root canal treatment was done in respect to 22.

Radicular groove develops with the alteration in the growth of the inner enamel epithelium and Hertwig's epithelial root sheath and involves primarily the maxillary lateral incisors.[3] It has a similarity to dens invaginatus; however, it differs from it in such a way that dens invaginatus occurs due to an unfolding of the epithelium (resulting in groove) rather than an invagination (resulting in a circular opening). Removal of calculus from all the exposed surfaces of the root is very necessary if periodontal health is to be achieved.

Studies have demonstrated difficulty in calculus removal in case of sulcus depth >3 mm. Several studies have shown that small chunks of residual calculus remains attached to the proximal root surfaces subgingivally even after scaling & root planing was done carefully.[4],[5]

Recognizing palatogingival grooves as the initiator of pathology can often be difficult. The patient may present with pulpal involvement in the teeth that have no caries, history of trauma,[6],[7] and periradicular abscess also present in this case. Several authors have reported cases in which patients with pathological involvement received delayed or improper treatment since palatogingival grooves were not diagnosed.[8],[9] Conversely, the patient may demonstrate periradicular abscess formation in the teeth with vital pulps. Symptomatic patient may report with concurrent episodes of pain and swelling on the palate adjacent to the groove. Before the final diagnosis, one should look for periodontal abscess, vertical root fracture, juvenile periodontitis, or patent nasopalatine duct.[9]


  Conclusion Top


Successful management of PRG depends on meticulous examination, treating the groove based on its extension and depth and treating the resultant pathology.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Newmnan GM, Takei HH, Klokkevold RP, Carranza AF. Text Book of Clinical Periodontology. (South Asia Edition) 10th ed.. Elsevier 2006.  Back to cited text no. 1
    
2.
Gupta KK, Srivastava A, Srivastava S, Gupta J. Palatogingival groove – A silent killer: Treatment of an osseous defect due to it. J Indian Soc Periodontol 2011;15:169-72.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Johns DA, Shivashankar VY, Shobha K, Johns M. An innovative approach in the management of palatogingival groove using Biodentine™ and platelet-rich fibrin membrane. J Conserv Dent 2014;17:75-9.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Schwartz SA, Koch MA, Deas DE, Powell CA. Combined endodontic-periodontic treatment of a palatal groove: A case report. J Endod 2006;32:573-8.  Back to cited text no. 4
    
5.
Kozlovsky A, Tal H, Yechezkiely N, Mozes O. Facial radicular groove in a maxillary central incisor. A case report. J Periodontol 1988;59:615-7.  Back to cited text no. 5
    
6.
Liji P, Rameshkumar M. Integration of PRF and biodentine in palatogingival groove case. IOSR J Dent Med Sci 2013;6:26-30.  Back to cited text no. 6
    
7.
Bharti R, Chandra A, Tikku AP, Arya D. Palatogingival groove: A cause for periapical infection. Int J Prosthodont Rest Dent 2012;2:61-5.  Back to cited text no. 7
    
8.
Attam K, Tiwary R, Talwar S, Lamba AK. Palatogingival groove: Endodontic-periodontal management – Case report. J Endod 2010;36:1717-20.  Back to cited text no. 8
    
9.
Kishan KV, Hegde V, Ponnappa KC, Girish TN, Ponappa MC. Management of palato radicular groove in a maxillary lateral incisor. J Nat Sci Biol Med 2014;5:178-81.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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