Amniotic Membrane as Barrier Membrane in Endo-Perio Lesion – A Interdisci- plinary Approach

EndoPerio lesions are the most encountered complicated condition which is difficult to diagnose and treat. The challenge in treating an Endo-Perio lesion is rectifying the Endodontic infection and regeneration of the lost alveolar bone. There are many systematic approaches and materials that are available for the treatment of the Endo-Perio lesion. Membranes used in Guided Tissue Regeneration procedures should enhance the growth of lost periodontal structures and also adapt to the surface contours of the bone and root surfaces. Amniotic membrane has the ability to adapt to surfaces and acts as a reservoir of Stem Cells which enhances the healing process. This case report presents the successful treatment of a hopelessly diseased Endo-Perio lesion using Amniotic membrane as a barrier membrane in Guided Tissue Regeneration.


Introduction
The relationship between pulp and periodontium has been studied extensively regarding the diagnosis, treatment, and prognosis of the Endo -Perio lesions. Pulpal infection might proceed from the apical region through the periodontal ligament space to the marginal gingiva and give an appearance of periodontal tissue destruction, termed retrograde periodontitis [9].
The amount of bone destruction is based on the severity of the disease. Regenerative medicine is a field that is based on the concept of transplanting exogenous or stimulating endogenous stem cells to generate biological substitutes. Amnion derived cells have been reported to have the multipotent differential ability. This has attracted to become a source of stem cells for regenerative therapy [1]. In 1913, Salbella presented the first clinical report of the successful use of an amniotic membrane in the treatment of skin ulcerations. Amniotic Membrane is used in dentistry for various purposes. It is been used in treating root coverage procedures along with coronally advanced flap technique and double papilla graft [2,3,4,5,6]. It is also used in treating furcation defects as a barrier membrane in the regeneration of the intra bony pockets [7,8]. Hence The amniotic membrane serves as a better source for stem cells and may serve as an excellent barrier in Guided Tissue Regeneration procedures. The present case report describes the role of amniotic membrane as a barrier membrane in the salvation of a tooth with Endo -Perio lesion which had a questionable prognosis.

Structure of Amniotic Membrane [3]
Amniotic membranes develop from extra-embryonic tissue and consist of a material component (the deciduas) and

Freeze-dried irradiated (lyophilized)
After obtaining the Amniotic membrane from the placenta, it is freeze-dried at -60°C under vacuum (atmospheric pressure 102) for 48 hours. Then it is irradiated with 2.5 mega rads (25 K Gray) inside a batch type cobalt-60 irradiator. By the method of freeze-drying, there is sublimation of liquid moisture of membrane to the gaseous state without having undergone the intermediate solid stage. By this method, the membrane maintains its original size and shape by minimizing cell rupture. The freeze-dried membrane can be used immediately after soaking it in normal saline for 1 minute.

Properties of Amniotic Membrane
The Multi Potent Stem Cells (MPSC) present in the Amniotic Membrane have the ability to accelerate the inflammatory phase towards the proliferative phase which is critical for treating chronic wounds like periodontitis [4]. The properties of the amniotic membrane that accelerates wound healing are: • Immunomodulative and Immune Privilege • Anti-Microbial (broad-spectrum against bacteria, fungi, protozoa, and viruses) • Reduction of pain • Anti-Scarring and Anti-inflammatory effects • Tissue repair with enhanced bone remodeling, osteogenesis, and chondrogenesis.
• Accelerating fibrogenesis and angiogenesis • Increased extracellular matrix deposition • Potent source of mesenchymal stem cells

Postoperative Instructions
Analgesics were prescribed twice daily for three days for postoperative pain. 0.2% chlorhexidine digluconate was also prescribed to be used twice daily for 3 weeks. The patient was asked not to brush at the surgical site for 2 weeks.

Result
After 7 days of surgery, periodontal dressing and sutures were removed, healing was satisfactory (Figure: 11)

Conclusion
To conclude, Amniotic membrane demonstrated as an excellent source of Multipotent Stem Cells for the regeneration of tissues along with marked anti-inflammatory effect, reduced post-operative pain, reduced post-operative swelling. Newer GTR materials are expected to display biological and biomechanical properties vastly superior and complementary to"conventional" GTR materials. Amniotic membrane has the ability and potential to function as a barrier for GTR and the unique properties associated with this material can augment its potential as a matrix for periodontal regeneration.