7. Cracked Tooth Perio-Endo Flashcards
Pathways: Perforations
Prognosis
____ > Old
____ > Large
____> Crestal
- We see a lot in clinic when people put posts in teeth w/ out rubber dam
- Posts are over dimensional in terms of size of the RC space
- This is how a post comes out in the middle of a palatal root
- Post on D root with the post coming out of the RC space and perforating a root
- surgical repair when the post was cut back and filling material was placed over to make sure it doesn’t continue w/ inflammation.
fresh
small
coronal, apical
Pathways: fractures
Structure Loss: Any tooth that has a rct is more susceptible to fractures
b/c there is one connecting link b/t tooth structure loss and it fractures
all the teeth that req rct have ____ that goes to the pulp so they’ve lost tooth structure
• weaker in general to ____ forces
when we talk about restoring endodontically treated teeth most ppl recommend putting ____ on teeth in posterior area after the tooth has had endo treatment.
Less so b/c of any ____ deficiency you get from doing access prep and rct
More so b/c by the time you’ve done rct you’ve lost ____
• that overall loss is really what leads to increase risk of fracture.
decay mastication crowns structural tooth structure
Pathways: Fractures
- Large Taper Instruments: A lot of ppl have in the past instrumented very large tapers
• Area below the CEJ in the roots “peri-cervical” area – ____ third of root canal system and roots is particularly susceptible to fracture if ppl instrument w/ old tools that have large taper
• Bio Race system has 4 taper prep
• XP shaper you also kind of get 4 taper in MD directions
• In the past when ppl used hand instruments they used gates-glidden
burs to aggressively open up in coronal third of RC that causes a lot of taper prep
• Why? They had to use stainless steel instruments to get around curvature
• you had to open up in very ____ in the coronal third into the middle and weaken the tooth structure extensively.
• We believe w/ old style instrumentation and rct you get a lot of fracture in the root they are fractured out b/c of the large ____
cervical
wide
taper
Pathways: Fractures
- Big Ass Posts: Ppl placing posts that are too large in the teeth - you can cause a lot of fracture as well
a. Over dimensional size of the tooth: post is too ____ to put in RC
b. Metal posts have a diff ____ than denjn (composite reinforced posts are used more now to bond into rc)
• every jme you bite on tooth it flexes, parjcularly if you already have a restorajon on the tooth w/ margins - buccal cusps and walls that are filled w/ regular fillings
• When metal post is placed in tooth it works like a crowbar
• The metal doesn’t ____ in the same way of the denjn
• Diff b/c elasjcity modulus ____ the risk of fracture over jme
• We want ppl to go to ____ post b/c they have a similar elasjcity modulus as denjn plus they are bonded to root canal system a
• if we have to remove one of them they are ____ to remove in comparison to a metal jtanium or gold build up post
big elasticity modulus flex increases composite reinforced easy
- Fracture associated w/ extremely ____ root canal prep
- you see that it’s tapered and is gates-gliden
- looks like a boQle neck
- weakens quite a bit
- ____ shaped lesion around the root
- shows what fracture looks like aSer it has split the root
- Fairly large ____, retreatment of exisTng rct that was instrumented larger than it was before
- Fracture in palatal aspect of the palatal root
• They explored w a raised flat to look at the root, you can see it stained with ____, in this case the pic isn’t stained but you can see the fracture line that goes
down the root
tapered
C
instrumentation
methylene blue
Periodontal effects on the pulp
Majority of studies do not suggest a correlation between the ____ status and that of the ____.
periodontal
pulp
NO:
• Protective Action of Dentinal Fluid Flow: remember when we said if we have ____ pulp we have a pulp tissue pressure
• this will create a continuous ____ of dentinal fluid in the tubule
• if it is opened from the outer aspect of the root.
• Bacteria have a hard time getting into the tubules if there is
a ____ pulp tissue that continuously provides the outward dental fluid that they have to swim upstream to say they can’t get into the tubule.
• Immune Response of the Pulp: there is an immune system that protects the pulp if there is only a very ____ number of bugs going into the tubule.
• We know the tubules are large enough to let bugs get through but
that’s why these ppl say it protects from perio pockets and disease to affect the endo rc space and pulp going through tubules even if you have cemento-enamel defects.
vital
outflow
vital
small
YES:
But if you have pulp that is compromised (this is where the YES group
comes in) there can be an affect form perio system to root canal system •
Inflammation/Resorption:
• If these take place from outside it destroys the ____ and allows easier access into root canal system
• b/c you don’t have tubules anymore and
• have destruction that gets from outside to inside.
• the more probable reason for this if you have a pulp that
isn’t ____ anymore
• Ex pulp already affected by another disease like
some irreversible pulpitis going into pulpal necrosis
to pulp dying off - the immune system is ____
• Ex or if you have an aging pulp (more calcifications
and aprofic areas - ____ immune system
• the pulp may not be able to provide consistent dentinal
outflow through the tubules, bugs can get in and take over resistance of pulp.
Each of these aspects have some ____ to it
dentin healthy weaker diminished truth
Pathways: developmental anomalies
Developmental grooves
Max incisors:
____ > central
Enamel projections
32.6% in ____
____ (51.0%)
> ____ (45.6%)
> ____ (13.6%)
lateral molars ma 2nd max 2nd max 1st
Pathways: developmental anomalies
• Palatal grooves
• we see these once in a while and can’t do anything about
them
• Deep longitudinal groove
• ____ in lateral incisors in maxilla (they most often occur
here)
• ____ probing seen and it appears there is a vertical fracture
• it is narrow w/ probing
• Not typical generalized perio disease where we would have sloped craters,
• it might look narrow and deep
• Might mimic root fracture
• How do you find out if this is perio disease or if it’s something related
to endo disease?
• Student answer:
• ____ testing
• ____ testing
• make sure the pulp tissue in the pulp is alive
• Put cold test and see if it reacts
• In degenerating pulp in old pt if you don’t get a response what would you do?
• ____! - if cold doesn’t help try EPT it picks up more issues
• Enamel projections
• sometimes they have spawns coming out from enamel
• might be pearls or projections but they are anatomical variations that can cause perio disease
• Why? b/c it’s ____ for pt
• might continue to progress perio disease down into apical
portion of root
• you may think it’s endo-perio related disease but in reality it’s
pure perio if you did histology
vertically deep vitality sensitivity EPT uncleanable
Classification: Simon 1972
Endodontic Lesion
- (periodontal involvement) ->
Endodontic Lesion with Secondary ____ Involvement
Periodontal Lesion
- (periodontal involvement) -> Periodontal Lesion with Secondary ____ Involvement
- We may often mistake cases where you have deep ____ and pulp ____ for a combination of both diseases
- BUT…in reality you only have endo disease that has ____ associated that goes through perio ligament space.
- Lots of ppl shooting from hip (Joanna: meaning they are guessing and making shit up) and call it endo/perio lesion
- that is the most common reaction to get if you have deep probing on tooth or negative pulp vitality or pulp necrosis or you would have an existing rct when you go to restorative department
• Might be just endo disease w/ a drainage pathway not in form of a sinus tract going through the buccal mucosa but actually going through ____ space, and that’s why you have a deep probing
But we still have to teach this crap b/c its coming on the boards
periodontal
endodontic
probing
necrosis
sinus tract
perio ligament
• Idea is you have isolated endodontic lesions
• very distinct from true periodontic lesions
• Then remember you have pathways that might connect the endo and
periodontium, you have endo lesions plus a perio involvement that gets you to an endo lesion w/ a secondary perio involvement
• Most of the time this is really just a tooth w/ an endo disease and a ____ going through ____ space and not true perio involvement
• What might be and indication where you have endo disease on tooth plus perio disease if you have deep probing on tooth (other than just gently sloped craters)?
____
- If you can visualize that there is concrements + plaque which are another indication for perio disease then you have true perio involvement
- But when you just have a deep probing and the diagnosis of endo disease then you actually probably just have ____ disease
- we commonly mislabel them as “endodontic disease w/ secondary perio involvement” b/c that’s how this ancient classification was actually going about
- Then you have the other way around, perio disease w/ the idea now that the pulp can be affected by microorganisms in perio ligament space and you get a perio lesion w/ secondary endo involvement.
sinus tract
perio ligament
calculus and plaque
endo
Endodontic Lesion
Characteristics
Tooth \_\_\_\_ \_\_\_\_ pulp/ Hx of root canal treatment \_\_\_\_ Radiolucency at the apex \_\_\_\_ sensitivity \_\_\_\_ of pulpal origin !Gingival Sulcus or Fistula
- TRUE ENDO LESION
take an xray and you see apical periodontitis located around the apex of the root
Tooth Mobility:
• Typically a tooth mobility should be ____ if pt doesn’t have any other perio disease
• In the end perio will lead to tooth mobility
• If you have mobility of 0-1 it’s low, not typically a hint that you have true perio involvement other than having one pocket
Necrotic pulp/Swelling/Radiolucency:
• something has been going on for you to assume that the ____ seen on xray is truly coming from root canal system.
• Might be a ____, radiolucency apex.
mobility
swelling
percussion
sinus tract
little
radiolucency
swelling
- True Endo Lesion
Percussion Sensitivity:
• Could be the case for perio abscess will typically be located more in the cervical area of the root
• In this case it’s apically - if the tooth has percussion sensitivity that goes w/ ____ disease.
Sinus Tract:
• You night have ____ of origin
• that might be the deep pocket going down into the tooth or
• you might even see it coming out of the gingival sulcus or “fistula” < we
shouldn’t use this it should be sinus tract.
• The trick is that you should have ____ pulp vitality.
Is there is a scenario where you might have positive response to pulp test and you still have endo disease and it would be endo not perio?
• YES - ____!!!
• Vitality in one root and the other root might have apical periodontitis
• the decay might have been located in distal or mesial roots.
• Now the D is necrotic and M still has vital pulp tissue
• so you might have to explore more in terms of diagnostic means to
figure out if it’s endo or perio
• Then it becomes more important if you see generalized bone loss on pt or if you have calculus etc.
• these scenarios exist but this (pic on slide) is clear b/c you have a one
rooted tooth.
endo
sinus tract
negative
multi rooted tooth
Periodontal Lesion
Characteristics Chronic periodontitis Wide \_\_\_\_ Radiographic bone loss \_\_\_\_ pulp Plaque / calculus Previous \_\_\_\_ treatment
- TRUE PERIO LESION
• Striking reason number one: Wide Probing
• ____ bone loss all over the place for that pt not just an isolated
pocket
• furcation is something in this area which - might not be all the time for
perio disease (this could also be endo origin)
• ____:
• then you have calculus that’s a typical sign.
• Not everybody w/ perio disease has calculus b/c they may have just
come from ____ appointment
• important to talk to pt to see if they have these
probing
vital
periodontal
generalized
calculus
hygiene
