6. Cracked Tooth Perio-Endo Relationships Flashcards
- Diagnostics are always important for perio endo lesions and we have new tests that we need to perform aside from the normal tests that we perform thermal tests, EPT, percussion, palpation, but now more important is probing versus sounding where you have anesthetized the patient before the probing then bit tests, transillumination, and mobility that come in addition to the usual tests that are specific for endo perio lesions or lesions where you have perio involvement and for cases with vertical root fracture or crack
- ____ fracture is a death sentence for the tooth unless it is a ____ tooth and just one of the roots are affected you can remove that root and still save the tooth
vertical root
multirooted
Intraoral Exam Periodontal
____: wide, gently sloping craters around multiple teeth
____: isolated vertical loss (fracture/sinus tract)
- There are slight differences if we are looking at a disease or probing depending on if it is related to a perio issue or endo issue
- Endo related issue is a crack in the root so when you walk around the probe going from mesial to distal on both buccal and lingual there is a width of the probing that you are detecting and if you are encountering a perio lesion this is something that is wider from a mesial distal direction then if you compare this to an endo lesion that means you have a crack and an infection inside the pulp space like a vertical root fractures where microbes go into the pulp structure and cause inflammation of the pulp where that crack is propagating in the root and you get break down of the perio tissues and this is very narrow and isolated vertical loss of the bone structure
periodontal
endodontic
Clinical ex
We would do an exploratory surgery where we raise the flap with anesthesia and check if there is root fracture and you would see that there would be very narrow bone loss in MD direction and goes all the way along the crack and there is a faint blue line along the root that we stain with ____ that we use for root and surgical procedures and finds organic tissues like leakages or PDL and stains cracks and fractures
• We see the fracture line here
methylene blue
Interpretation Periodontal
- Very often we have radio for the root fractures and we see a ____ shaped lesions where there is a radio halo around the root structure just like seen here in the apical area and is a typical thing seen
- Small ____ probing and J shaped lesions are characteristic of this
J
vertical
Interpretation periodontal
May have an implication of the perio tissues that is originally only coming from an endo lesion
Have the normal progression of the tooth infection that then once goes through tooth forms and apical perio
If this becomes a chronic apical abscess and in the lower posterior mand and see because the cortical plate of the bone is so thick that you wouldn’t see the sinus tract and it looks for the pathway of least ____ and get a sinus tract that is going through the perio space and that is how you get a ____ shaped lesion
- This doesn’t have to be just a vertical root fracture but could be an endo lesions that goes up the ____ ligament forming a sinus tract there and drains into the sulcus and into the oral cavity
- In contrast to the perio where you have infection on the cementum and inflammation breaking down perio structure and plaque on the root surface and the break down is form the perio margin
resistance
J
perio
Craze Lines Incomplete cracks in teeth confined to \_\_\_\_ only Extend \_\_\_\_ \_\_\_\_ No \_\_\_\_ required
• If you have vertical root fracture where you have combo of apical perio and bone loss all the way around the root
• there can be early forms of the root fracture starting form minimal cracks or craze line into the roots
• There is no need for treatment for craze lines in the enamel structures and many of us have or will have these
• These are tiny little lines in the enamel and there is no need for treatment and usually asymptomatic and goes from occlusal to gingival direction
• Don’t need to do anything about this
• Can have these for many years without
complications
enamel
occluso-gingivally
asymptomatic
treatment
Fractured Cusp
Complete/incomplete fracture initiated from crown and extending ____
____ & facio-lingually
Extensive caries or large restorations
Brief, ____ pain on mastication & with cold, pain on masticatory ____
• Most severe
• See the connection to the trauma to what we see
• But there may not be pulpal exposure and may just
effect the enamel and the dentin
• May be ____ especially if there is no
mobility
• If becomes mobile or extends into the cervical portion of the root then we want to remove the broken portion and replace with a filling or do a complete coronal coverage to protect the tooth from a more severe fracture in the future
• Can use ____ like UV or LED light placed next to the tooth and the point where the transillumination of the light is impede and the transmission of the light stops is by the fracture in that crown
• Can see this in the picture
• May or may not have pain
• Only pain if the ____ are exposed and you get movement of the fluid in them
• Usually pain on ____ from biting on a cotton roll
subgingivally
mesio-distally
sharp
release
asymptomatic
dentinal tubules
release
Cracked Tooth
Incomplete fracture initiated from the crown and extending ____
____
Parafunctional habits, trauma, restorative procedures
Localized pain on mastication (____ or release), ____ brief pain to cold
This is the next worse thing
• Seeing more cracked teeth because people are more stressed and they are grinding their teeth
• You see these cracks where there is no restoration too
• Usually goes from mesial to distal in the tooth and also extends towards the cervical area into the root going below the bone level into a root canal or we see going through the complete pulp floor we recommend extraction
• If we see something going through the pulp floor or below the CEJ area then we cant do any complete coronal coverage and if cant seal this area there will always be a pathway for microbes to get back into the tooth and will affect the tooth and that is why these teeth have a bad prognosis and should be removed
• If you see a tooth with no restoration or if people have a very shallow restoration for very long time and they come with all of the symptoms of ____ pulpitis but don’t see any ____ then this would be an indication that this person has a cracked tooth
subgingivally
mesio-distally
pressure
sharp
irreversible
decay
Cracked tooth
Tooth slooth test of individual cusps gives pain on ____ when tooth is cracked (fluid movement)
Good tooth to diagnose is a tooth slooth that is better than cotton roll or wooden stick
• Put it on one particular ____ on the adjacent teeth and have the patient bite down when they bite down and ask if hurts or not and ask when if was like when biting down or releasing
• Don’t see anything for the adjacent teeth
• Test each cusp
• Then move on to the desired tooth and
this is where you’ll find pain
release
cusp
Treatment of Cracked Tooth • • Location and Extend of Crack
Remove the dentin until crack disappears
If fracture doesn’t terminate on root surface, tooth is restored to bind the fractured segments
Permanent restoration - Full crown is indicated, avoiding posts
If fracture extends through the chamber floor, ____ is indicated
Trying to remove the crack and see how deep it goes
If doesn’t terminate on the root surface below the bone level then can restore the tooth
But if goes below the CEJ then the prognosis for the tooth is really bad and the tooth is ____ because if you have a crack that expands and get complete vertical root fracture will always have invasion of microbes into the area and will have breakdown of bone and this will be bad prognosis for an implant that you would want to place in the area from loss of vertical bone structure
extraction
extracted
Split tooth
Complete fracture initiated from the crown and extending ____
____
Marked pain on ____, periodontal abscess
Visual separation of segments, wedging of segments
If the crack continues and the crack syndrome expands and goes deeper then becomes a split
tooth
•
What is characteristic for split tooth is the patient more often feels pain on ____ and may see that there is a ____ in the area of split and if gets worse and may see there are mobile parts and the parts can split apart and move away form each other and usually a bad sign
• Tooth has to be extracted
subgingivally mesio-distally mastication mastication perio abscess
Treatment of split tooth
Location and extent of crack
If the fracture is deep apically, ____ is indicated
If fracture is not too far apical, remove the fractured segment, crown lengthening or orthodontic extrusion segments
•
If fracture extends apically then extraction is indicated
If this is more to the coronal may still be able to save the tooth with ____ or ortho extrusion to have a good coronal restoration that will seal the tooth off
extraction
crown lengthening
Vertical root fracture (VRF)
“A longitudinally oriented fracture occuring most frequently in endodontically ____ teeth.
Characterized by a crack that begins in the root and extends toward occlusal surface usually in a ____ plane”
• Have the vertical bone loss and can stain
• Indication for ____ unless if this is on
a mesial buccal root of max molar where can take the one root out and with the remaining root can be left if not mobile
• Would be a root ____ or root resection or trisection or hemi section of tooth
• But most likely the tooth is lost completely
treated
bucco-lingual
extraction
amputation
Vertical root fracture - demographics
•
Shows how often this happens in teeth
• Teeth where this most commonly
occurs are ____, mand 1st molars, and mand 2nd molars
• Reason is that these teeth have very slim ____ roots and the molars have a figure ____ shape about them
• Max 1st molar would be in fourth most common because these roots are ____ and thin and get a lot of masticatory stress
max PM
narrow
8
short
Complete VRF
Why do fractures tend to occur in ____ direction ?
bucco-lingual
Factors influencing location & direction of vertical root fractures
\_\_\_\_ morphology Root canal shape \_\_\_\_ of dentin Irregularity of root surface \_\_\_\_ application
external root
thickness
point of force
Detection of vertical root fractures
- direct ____
- broad based and mid-root ____
Sometimes you can see the vertical root fracture directly
• May not just be in the crown but may see soft tissue involvement
Sometimes you have to do indirect exploratory surgery or probing
May start in the coronal aspect of the tooth but can also start in the apical aspect of the root may be connect to wrong forces brought on the tooth like if RCT done along time ago and might see micro cracks in the apical area and to have continuous occlusal forces may also see the fracture begin in the apical area
inspection
swelling
Detection of Vertical Root Fractures - Probing
Pocket adjacent to the ____ site
Deep, ____, isolated periodontal pockets
Deep probing in ____ positions on opposite sides of the infection - Pathognomic of VRF
Have to ____ the probe and make sure that you find the pocket that is very narrow
• Cant just probe mesial and distal
Probing and there is nothing crazy then all of a sudden for one spot there is a 8 or 9 or 10 mm depth pocket
fracture
narrow
2
walk
Detection of Vertical Root Fractures - Sinus Tract
Multiple ____ tracts
Located close to the ____
Two sinus tracts at both ____ aspects - Pathognomic for VRF
sinus
gingival margin
buccal and lingual
Detection of Vertical Root Fractures - Other Tests
____ Staining
____ Test
• •
Tooth slooth in action
Also showing with methylene blue dye to see the fracture as well
• Where microscope comes in handy to identify the root fracture
methylene blue dye
tooth slooth
Detection of VRF - transillumination
Light is ____
Fractured segment on the other side of the crack will appear ____
interrupted
darker
Detection of Vertical Root Fractures - Radiographs
• Radiographs show the ____ shaped lesion
• Can see tooth split completely but
usually don’t see it that way
J
Horizontally angulated radiographs
Usually have to take radio Can also take cone beam CT
• But there are not really good results if not really evident
• Not high enough to identify the tooth structure
• Reliability is like 50-60%
Better to identify the root fracture with ____ radio and changing the angulation in the ____ direction to expose more of the fracture line
• Can see it if you are hitting the fracture in a degree ____ in an angulation in a direction where the root fracture is taking place
• Using the SLOB rule
Most of the time these vertical root fractures are taking place on buccal or lingual surface and very rare
that you would see in the mesial or distal aspects but can see this apical fractures
• Usually the bone loss is on the buccal and sometimes lingual
PA
mesial distal
mesial or distal
Vertically angulated radiographs
Can see the fracture lines here
With vertical angulations you can see them but if taken ____ on we cant see them
straight
Angulated radiographs
X-ray beam must pass almost ____ down fracture line
Fracture line evident when x-ray beam is within ____° of fracture plane.
X ray beam must pass through the fracture line at ____ degrees in one direction
directly
4
3-5
Root filling
- cement ____
- ____ besides root filling
- ____ root-end filling
Bone resorption patterns
- widening of ____ space
- ____-like radiolucency
- ____-shaped radiolucency
• There are other give away where sometimes you see filling material extruded out from a fracture line that can be if you had a RCT done a long time ago but could also just be a missed canal that someone didn’t fill so that is why it is important to do the angulations of the fracture and if there is an extreme mesial distal angulation you would still see the missed canal
• If you fracture the root doing the root filling may see the sealer come out of the root
• Can also see a J shaped lesion
• Also if you have a large ____ in a small root could be a give
away because can cause the fracture from a weakened structure
trail
space
dislodged
PDL
halo
J
post
Detection of Vertical Root Fractures - CBCT
No evaluator was able to detect vertical root fracture in this tooth in ____!
Exploratory surgery and after a root end surgery where take away the apex of the tooth Can see stained in the methylene blue showing the fracture line
• Clearly see with microscope
CBCT
Detection of Vertical Root Fractures - Exploratory
Clinical evaluation after ____
Other examples of ____ surgery
flap and staining
Detection of Vertical Root Fractures - Pathogenesis
Going through the progression of the disease
• Starting ____ and extends into the PDL and get ____ fracture and then microbes invade the fracture space and debris impacted in the area that is nutrition for the microbes and may see sealer come out if worked on and get progressive inflammation and perio breakdown down to the root
coronally
soft tissue
Vertical root fractures - treatment
Multi-rooted teeth \_\_\_\_ Elimination Root Amputation \_\_\_\_ Extraction
Single-rooted teeth
____
Single rooted tooth most likely extracted but in very rare cases can to apical surgery if very apical to remove the crack line
• Only if 2-5mm of the root is involved apically
• So need enough root structure in the end so there is no mobility
• Multi if apical portion same thing or take out one root or hemisects where you take away the root and part of the crown as well
• Sometimes you have to do an extraction because may be better with just having an implant
fracture
hemisection
extraction
Endontium - Periodontium
Function of a tooth depends
on the health and vitality of the ____ and not on the status of the pulp
• Very important that the PDL tissues are ____ and more teeth are lost for these reasons then endo
periodontium
intact
Etiology
Main cause of pulpal disease?
____ Infection
Necrotic pulp
Microbes will cause pulpal breakdown.
Microbes are first in localized areas of necrotic pulp tissue, then invade entire root canal space and dentinal tubules upon complete necrosis.
• •
This is a microbial infection
• This includes fungi and virus too but
main infection is from bacteria Microbes cause break down of the pulpal tissues and there is necrosis and invasion of these areas by the bacteria and in the end you get apical perio
microbial
____ caused significant reductions in initiation and progression of lesions in the soft tissues of the periodontium.
Reinstitution of ____ results in healthy gingival conditions and re-establishment of the original bacterial flora.
penicillin or streptomycin
oral hygiene
Etiology
Bacteria in RC Bacteria in periodontal pocket
…bacteria in root canals of caries-free teeth with advanced periodontitis generally resembled those found in the adjacent ____.
Morphological classification obtained from interference microscopy showed similar ____ of morphotypes in the two sites.
Studies have indicated that ____ can occur between infected pulps and deep periodontal pockets. Similarities in the microfloras from adjacent sites… infection might spread from one site to the other.
People have found that there is close resemblance between the types of bacteria in primary endo infection in comparison to perio pockets and also in the PDL
• People suspect that here are infection crossing over from PDL into the pulpal tissues and vice versa
• Cross infections
• Commensalism is also taking place
where they are working together seen in both tissues
periodontal pockets
proportions
cross-infection
Microbial flora
Endo Perio
Necrotic pulp
✦ ____% gram(-)rods
✦ B.gingivalis,B.endo dontalis, B.buccae in acute apical abscess
✦ Spirochetes in non exposed ____ and abscesses
Periodontal pocket
✦ ____ %gram(-) anaerobic rods
✦ High quantity of B.gingivalis in advanced periodontitis
✦ Spirochetes in ____ pockets
- More gram negative rods in ____ pulp as compared to perio pocket
- Can see similar bacteria are found in these types of infection
- If you have a deep perio probing and test for spirochetes if you have higher number in the ____ tissues then in the endo portion and see by percentage that there is perio or endo lesion first in origin, but was never really developed
- Research perspective is plausible but clinically this test does not work
90
root canals
74.9
periodontal
necrotic
perio
Interactive pathways
Anatomical pathways: \_\_\_\_ Dentinal tubules \_\_\_\_ canals & lateral canals Furcation canal \_\_\_\_ variations
Non-physiological pathways:
____
Root fracture
apical foramen
accessory
developmental
perforation
Effect of pulp vitality
As long as the pulp maintains ____ functions, it is unlikely to produce irritants sufficient to cause marginal breakdown
vital
- But if you have pulp necrosis and infection in the root canal then has been shown that more likely to have marginal ____ and perio disease with breakdown of perio tissues
- ____ may be prompted by pulpal pathology and disease
gingivitis
breakdown
Majority of studies suggest a correlation between the ____ status and a reduced level of ____,
endodontic
bone
Pathways: Apical foramen
Major direct pathway between pulp and periodontium connecting circulatory systems of two tissues
If you have severe breakdown of PDL where you loose all of the buccal tissue this could be an entrance of the microbes into the root canal system with retrograde infection coming from the ____
Most likely related to general bone loss on a tooth with ____ roots
• So with a max molar the palatal root is longer but the others are shorter and bone loss on the ____ roots and then there is a deeper pocket that opens the apical portion of the root structure that causes retrograde infection of the pulp tissues
apical foramen
shorter
shorter
Pathways: Apical Foramen
- Classic endo disease where the apical perio and all of the immune competent cells with innate and adaptive are trying to fight off the microbes and byproducts coming out of the ____ system
- Any apical perio is the inflammation of the ____ and classical pathway of connection of the pulpal tissues to the PDL that most commonly comes up in endo
root canal
PDL
Pathways: accessory and lateral canals
Root canal ramifications
Also have lateral canals that are not the same size as the main canal or the apical foramen so there can be ramifications in the apical delta of the root canal
• ____ lateral canals
Theoretically these can be found anywhere in the root but mainly found in the ____ portion (17%) and less common in the ____ (2%)
• Can see the break down of perio tissues in and infected tooth
apical
apical
coronal
Pathways: accessory and lateral canals
Can the inflammatory process proceed through lateral canals ?
“ Granulation tissue was occasionally found attached to, and obviously emanating from, inflamed pulp tissue in ____ and accessory foramina. ”
• Can see form histological view and can see there is break down in the PDL and cementum and dentin and can see a large lateral canal and might get ____ moving from inside RC and going into the PDL causing inflammation
lateral canals
infection
Pathways: accessory and lateral canals
• Much more rare to see it is lateral canals in the furcation area of multi rooted teeth called ____ canals
• Red arrows
• These are small connections between the
pulp floor and chamber and the furcation area and PDL
furcation
Pathways: Dentinal Tubules
Microorganisms can penetrate into dentinal tubules
In vivo conditions may stimulate bacteria and promote ____ growth in dentinal tubules.
May have bacteria inside the dentinal tubules and the depth of infection can deep into these
• Shown in vitro and vivo studies going to the cementum and 2mm deep in non vital teeth
intratubular
