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endo > endo-perio > Flashcards

endo-perio Flashcards

1
Q

REGULARLY: ANY combination of multiple challenges to a tooth will have what effects?

A
  • Increase the Difficulty *
    *Reduce the Prognosis *
  • Limit the Outcome of TX *
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2
Q

Periodontal health, function
& stability as a requirement

A

Periodontal health, function & stability is one of the Basic Requirements for any tooth being considered for Endodontic Tx. Also RESTORABILITY & ESTHETICS

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3
Q

NVOLVEMENT of Endo and Perio in the same tooth :

A
  • LESSER PROGNOSIS than either disease ALONE
  • PERIO involvement is almost always the LIMITING FACTOR
  • Now you need Endo Pulpal & Periapical Dx but ALSO a Periodontal Dx and some idea of the Periodontal Prognosis BEFORE you begin any Tx.
    Helpful to know what came 1st (Endo or Perio)
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4
Q

pulp and periodontium relation

A
  • Dental Pulp intimately associated with Periodontium and vice-versa:
  • Pulpal path. can infect periodontium
  • Periodontal path. can infect pulp
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5
Q

interchange btwn pulp/PA routes

A

multiple pathways or following therapeutic procedures:
1.** Apical foramen #1** (Natural or Procedural)
1. Accessory or lateral canals
1. Dentinal Tubules/Caries
1. Areas of cemental agenesis
1. Resorptive defects
1. Tooth Cracks or Fractures
1. Following SRP & other periodontal & surgical procedures

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6
Q

significance of lat canals

A

Lateral canals are significant because they allow pulpal disease to extend directly to periodontal tissues.

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7
Q

pulp to PA via apical foramen

A

Irritants from involved pulp may pass through apical foramina into periradicular tissues via inflammation or infection extension or during endodontic procedures

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8
Q

PA to pulp via apical foramen

A

Irritants from periodontal inflammation/injury /procedures may pass through apical foramina or
accessory (lateral) canals and directly invade the dental pulp.

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9
Q

plaque and lateral canals

A

Irritants from plaque that reach periodontal
tissues around lateral/accessory canals may
initiate inflammation in pulp followed by
necrosis.
Lateral canals may be 50um + wide; bugs are @
.5-1um

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10
Q

dx pulp and lateral canals

A

– Irritants from diseased
pulp may pass through
lateral canals into
periodontal tissues

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11
Q

can we see lat canals on radio

A

– Most often lateral (accessory) canals are NOT visible radiographically but are discovered following obturation.

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12
Q

incidence rate of lateral canals

molars?

A

(somewhat common) 23-76% incidence In molars

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13
Q

areas of cementum agenesis as a passage

% with void at CEJ

A

– Cementum is a natural protective barrier
– 18-25% may have a VOID @ CEJ)
– Any void of cementum (or enamel) via agenesis,injury
or aggressive SRP will expose dentinal tubules & pulp to attack from micro-organisms (from perio)

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14
Q

where is cementum thinnest/ possibly void

A

CEJ

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15
Q

ways we can lose cementum

A

-Tooth brush Abrasion
- Erosion
- Bulemia & other destructive habits
- Bruxism
- Trauma

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16
Q

iatrogenic pathways of comm

A

Problems we create as Endodontic Perforations or Post perforations, great decrease in prognosis

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17
Q

cracks as a pathway

when can both pulp/perio be involved?

A

Any anomaly or injury providing access to the dentinal tubules also provides noxious access to the pulp.
If the anomaly or injury is apical to the gingival attachment, both the Pulp and Periodontium are involved= **Prognosis decreases **

18
Q

can we only have pulp or perio involvement?

A

You are NEVER dealing with PULP or
PERIODONTIUM alone. Both must be a
CONSIDERATION in ALL TREATMENT

19
Q

A CLASSIFICATION of ENDO – PERIO LESIONS

A
  1. Pure Endo (Primary Endo Lesion)
  2. Pure Perio (Primary Perio Lesion)
  3. Endo-Perio (Primary Endo with 2ndary Perio Involvement)
  4. Perio-Endo (Primary Perio with secondary Endo
    Involvement)
  5. “True” Combined Lesion (Combined or Concomitant perio& endo involvement)
20
Q

why does prognosis decrease so much with both endo/perio involved?

A

We know that most properly selected endo will
have 90+ percentage success (largely regardless
of the cooperation of the patient)
Perio success, on the other hand, depends largely upon
the ability to motivate the patient to take care of their
shortcomings which were responsible for the perio
disease in the 1st place.

21
Q

Pure Endo: Primary Endo Lesion

A

BEST PROGNOSIS of the 5 Categories*
With this Dx: RCT ONLY is indicated:Sinus tract & furca
should heal w/o Tx following RCT

Do not curette furcation region or use caustic,
inflammatory medications in the pulp chamber.

Pulpal injury initiates forthcoming LEO. Extension
of the pulpal inflammation procedes to the canals,
out the apex and irritates the periodontium (P/A
tissues) creating periodontal disease and loss of
bone.

A Drainage Tract originating from the apex or a lateral
canal may form along the root surface and exit via the
gingival sulcus. This is NOT a true perio pocket. Also is
NOT a classic Draining Sinus Tract (DST) but it serves the same purpose of draining the lesion (via the Sulcus)

CLUES: Clinical Pulpal DX indicates Necrotic Pulp
Often a Rapid Onset + evidence of pulpal damage (caries, trauma, etc.)
In molar teeth, the furcation area may appear to have significant bone loss.
Minimal to no calculus & no evidence of generalized or advanced periodontitis
Tooth mobile or exhibits a narrow channel sinus tract (perhaps via sulcus)
Swelling present in the attached gingiva and tooth sore to biting or chewing.

22
Q

Pure Perio: (Primary Perio lesion

A

Prognosis totally dependent upon perio. Tx success and motivation of patient.

When this Dx is determined:TX is limited to Periodontal Therapy ONLY with the prognosis dependent upon the ability to remove the causative factors and the patient’s
ability to achieve meticulous self-care practices.

Clinical & radiographic assessments indicate generalized, moderate to deep bony pockets (cone shaped and wide)** Calculus present**
Diffuse inflammation
Asymptomatic patient & pulp responds to sensibility testing WNL

CLUES: Clinical Pulpal Dx indicates Normal Pulp (VITAL)
No deep caries nor other significant pulpal injury
Evidence for the presence of periodontal disease with vertical bone loss, Inflamed soft tissue and calculus present.

23
Q

Endo-Perio: (Primary Endo with
2ndary Perio Involvement)

A

Guarded to poor prognosis due to perio.

When this Dx is determined: Both RCT & Periodontal Tx are indicated. Simultaneous management of endo and perio is preferable. If pulp is necrotic, RCT is 1st, then perio.Prognosis for resolution is dependent upon ability to treat BOTH entities successfully

Look for some unusual deep pockets
Little or no calculus in pockets
No generalized perio condition

CLUES: Clinical Pulpal Dx indicates Necrotic Pulp
Evidence for the presence of periodontal disease with vertical bone loss, Inflamed soft tissue and little or no calculus
Radiographic changes in the pulpal space visible with linear or isolated calcific changes

24
Q

Perio - Endo: (Primary Perio lesion with
2ndary Endo Involvement)

A

Guarded to poor prognosis due to perio.

Successful TX is RCT 1st followed by and dependent upon the ability to remove the causative factors for
both periodontal disease and the patient’s ability to
achieve meticulous self-care practices once the
RCT has been successfully performed

Clinical & radiographic assessments indicate broad-
based probings, vertical & possible apical or lateral
bone loss.
Infection from the deep perio pocket invades the
pulpal tissue via the apical foramen & causes pulpitis
Symptoms acute & history of previous extensive
perio TX

CLUES: Clinical Pulpal Dx indicates SIP or Necrotic Pulp
Tooth often may have or needs extensive restoration
Evidence for the presence of periodontal disease with vertical bone loss, Inflamed soft tissue and calculus present.

25
Q

True Combined Lesion:

A

RARE Combined or Concomitant Perio
& Endo involvemen

Probably the poorest prognosis of all types
(especially if associated with a VRF = hopeless)

Perform RCT first to manage acute symptoms
(if any). Treat periodontal concomitantly. Successful TX is dependent upon the ability to remove all causative factors for periodontal disease and the patient’s ability to achieve meticulous self-care practices once the
RCT has been performed.

Clinical & radiographic assessments indicate broad
based probings & intraboney perio pocket
Communication with an isolated peri-radicular lesion
of pulpal origin (same as 4. but both lesions develop
at the same time)
Symptoms may be acute or chronic (if present – due
to pulpal inflammation)
Probing may reveal vertical fracture (generally TE)

CLUES: Clinical Pulpal Dx indicates Necrotic Pulp
Tooth often has or needs extensive restoration or has suffered trauma
Evidence for the presence of periodontal disease with vertical bone loss,
Inflamed soft tissue and calculus present.

26
Q

perio or endo dx given enough time and neglect

A

– Given sufficient TIME & adequate NEGLECT,
many endo infections can progress to develop a
perio component.
– Given sufficient TIME & adequate NEGLECT,
many perio infections can progress to develop an
endo component.

The more time that passes; the more difficult & confusing the Dx.

27
Q

best tool to distinguish endo/perio dx

A

Pulp sensibility

28
Q

Pulpal Inflammation
impact on Periodontium

A
  • Process Rapid & Acute
  • Pulpal symptoms often present
  • Radiographic appearance of extension to the periodontium usually an Isolated Finding
  • Pocket narrow, drop-off, no calculus
29
Q

Periodontal Inflammation
impact on the Pulp

A
  • Process Chronic
  • Pulp undergoes Slow Degeneration
  • Pulpal symptoms usually absent
  • Generalized periodontal disease usually present
  • Pockets Wide base,Cone-shaped, usually calculus
    present
30
Q

DIFFERENTIAL Dx: Fractures (radio app)

A
  • VRF (Often invisible on XR)
  • HRF (Commonly visible on XR)
  • Developmental Groove (Dens en Dente, seen on radio)
31
Q

VRF indications

A

J-shaped lesion
Drop-off Pocket

32
Q

HRF tx

A

if apical, leave alone
if above gingiva=non-restorable

33
Q

IRR

A

NTERNAL RESORPTION is routinely and successfully treated with RCT (if NOT perforating)

Think of IRR as a change in the nature of PULPAL dendritic cells into clastic cells resulting in
damage to the internal tooth structure (W/O PROPER REPAIR)

34
Q

ERR

A

Invasive EXTERNAL (of several types) resorption has been treated by several methods; None have routinely predictable successful outcome . . . over time.

Think of ERR as a change in the nature of PDL cells which causes largely osteoblastic cells to activate –clastic cells resulting in damage to the external tooth structure (W/O PROPER REPAIR)

Endo and perio tx

35
Q
  • IRR: (arises in the PULP cells)
    – symptoms
    – app
    – probed?
    – Lamina dura and PDL
A

– Usually asymptomatic VITAL PULP (found on XR)
– A symmetrical & well circumscribed lesion
– Internal defect
– always remains centered on the root unless perforating to the facial or the lingual.
– Unable to probe lesion on exterior of tooth
– Lamina dura and PDL intact around entire root surface

36
Q

ERR: (arises in the PDL cells)
Pulp?
occurs where?
Often may be detected by?
app?
SLOB?
LD/PDL

A

Pulp is often Necrotic
A lesion which occurs on the external surface of the root
Often may be detected by an explorer on the exterior root surface
An irregular shaped lesion arising in the PDL which does not alter the normal architecture of the canal
Lesion “MOVES” as the horizontal angulation of the X-ray is changed.
Lamina dure and PDL disrupted.

37
Q

Other types of ERR (External Root Resorption)

A
  • Surface ERR
  • Chronic Apical Inflammatory ERR
  • Replacement ERR
38
Q

Surface ERR

A

(Self-limiting, Not discovered clinically) IGNORE

39
Q

Chronic Apical Inflammatory ERR

A

(Cratering of root apex – acknowledge, shorten prep and obturation) Expect good outcome.

40
Q

Replacement ERR

A

Follows severe trauma (Avulsion/Intrusion), Resorption occurs, Loss replaced by Bone) Creates Ankylosed & Submerged teeth. Often unsuccessful; Consider as a “Temporary Measure” only.

41
Q

Treatment of Resorptive Defects::

A
  • All resorptive defects require CBCT for evaluation
    REFER anything you are uncertain about Dx or Tx.
    REFER ALL RESORPTIONS at least for an Opinion

endo (22 decks)

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