Endo-Perio Flashcards
its the “challenge of the clinician” to ______ and treat within their scope of practice and to ______ within their ability or referral range.
discover all the problems; offer solutions
what is characteristic of a drop off pocket: endo or perio
endo
any combination of multiple challenges to a tooth will:
- increase the difficulty
- reduce the prognosis
- limit the outcome of treatment
involvement of endo and perio in the same tooth:
- lesser the prognosis than either disease alone
- perio involvement is almost always the limiting factor
what dx do you need before tx in endo-perio lesions
endo pulpal and periapical dx and periodontal dx
what are the requirements for any tooth being considered for endodontic tx
- periodontal health
- function and stability
- restorability and esthetics
what happens in lateral canals
irritants from diseased pulp may pass through lateral canals into periodontal tissues
are lateral canals visible on xrays
not usually
how are lateral canals usually discovered
following obturation
what is the incidence of lateral canals
23-76% in molars
what are the pathways of communication
- lateral canals
- areas of cemental agenesis or loss
describe cementum agenesis
- any void of cementum or enamel via agenesis, injury or aggressive SRP will expose dentinal tubules and pulp to attach from micro- organisms
where is cementum the thinnest
at the CEJ
what percentage has a void of cementum at the CEF
18-25%
what can cemental agensis be caused by
- erosion
- tooth brush abrasion
- bulemia and other destructive habits
- bruxism
- trauma
if the anomaly or injury is apical to the gingival attachment what is involved and what is the result
- both the pulp and periodontium are involved
-prognosis decreases
are you ever dealing with pulp or periodontium alone
no
what are the differential dx for fractures
- VRF
- HRF
- developmental groove - dens in dente
are VRF often visible on XR
yes
what is the success rate of endodontically treated cracked teeth with radicular extensions
90.6%
what is the differential and percentage between both for VRF
- endo lesion- 50%
- VRF- 50%
where does the VRF start
starts mid root and spreads coronally and apically
what are the classifications of endo-perio lesions
- pure endo - primary endo lesion
- pure perio - primary perio lesion
- endo-perio - primary endo with secondary perio involvement
- perio-endo - primary perio with secondary endo involvement
- true combined lesion - combined vs concomitant perio and endo involvement
what does perio success depend on
the ability to motivate the patient to take care of their shortcomings which were responsible for the perio disease in the first place
what is a concomitnat endo perio lesion
endo and perio lesions are separate isolated lesions
what is the 3rd section for AAP staging and grading
- endo perio lesion with root damage
- endo perio lesion without root damage
which category has the best prognosis
pure endo
describe pure endo lesion
- pulpal injury initiates forthcoming LEO
- extension of pulpal inflammation procedes to the canals out the apex and irritates the periodontium creating periodontal disease and loss of bone
what is the relationship of a DST in a pure endo lesion with perio
- a drainage tract originating from the apex or a lateral canal may form along the root surface and exit via the gingival sulcus
- this i snot a true perio pocket
- this is not a classic DST but it serves the same purpose of draining the lesion
what are the clues for a clinical pulp dx indicating necrotic pulp in pure endo
- rapid onset and evidence of pulpal damage such as caries or trauma
- in molar teeth the furcation area may appear to have significant bone loss
- minimal to no calculus and no evidence of generalized or advanced perio
- tooth mobile or exhbitis a narrow channel sinus tract
- swelling present in the attached gingiva and tooth sore to biting or chewing
what is the tx for pure endo
- RCT only is indicated
- sinus tract and furca should heal without tx following RCT
- do not curette furcation region or use caustic inflammatory medications in the pulp chamber
describe a pure perio lesion
- clinical and radiographic assessments indicate generalized, moderate to deep bony pockets (cone shaped and wide)
- calculus present
- diffuse inflammation
- asymptomatic patient and pulp responds to sensibility testing WNL
what are the clues to clinical pulp dx indicating normal pulp in pure perio
- no deep caries nor other significant pulpal injury
- evidence for the presence of periodontal disease with vertical bone loss, inflamted soft tissue and calculus present
what is the treatment for pure perio
- limited tx to perio therapy only with the prognosis dependent upon the ability to remove the causative factors and the patients ability to achieve meticulous self care practives
are there caries or pulp injuries in pure perio
no
what is the prognosis and why for endo-perio lesions
guarded to poor due to perio but prognosis for resolution is dependent on ability to treat both entities successfully
describe endo-perio lesions
- look for some unusual deep pockets
- little or no calculus in pockets
- no generalized perio condition
should you treat endo or perio first in endo-perio lesions
endo
what are the clues of clinical pulpal dx indicating in necrotic pulp in endo-perio lesions
- evidence for the presence of periodontal diseases with vertical bone loss, inflamted soft tissue and little or no calculus
- radiographic changes in the pulpal space visible with linear or isolated calcific changes
what is the tx for endo perio lesions
- both RCT and perio tx are indicated
- simultaneous management of endo and perio is preferrable
- if pulp is necrotic RCT first then endo
describe perio endo lesions
- clinical and radiographic assessments indicate broad based probings, vertical and possible apical or lateral bone loss
- infection from the deep perio pocket invades the pulpal tissues via the apical foramen and causes pulpitis
- symptoms acute and history of previous extensive perio tx
what are the clues for clinical pulpal dx indicates SIP or necrotic pulp in perio endo lesions
- 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
what is the tx for perio endo lesions
- successful tx is RCT first then depending on the ability to remove the causative factors for both periodontal disease and the patients ability to achieve meticulous self care practices once the RCT has been successfully performed
which category has the poorest prognosis
true combined lesion
what is the prognosis for a tooth with a true combined lesion and a VRF
hopeless
describe a true combined lesion
- clinical and radiographic assessments indicate broad based probings and intraboney perio pocket
- communication with an isolates peri-radicular lesion of pulpal origin
- symptoms may be acute or chronic due to pulpal inflammation
- probing is deep and often wide. need to rule out fracture - generally TE
what are the clues for clinical pulpal dx that indicate necrotic pulp in a true combined lesion
- 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
what is the tx for a true combined lesion
- manage acute symptoms
- treat periodontal concomitantly
- successful tx is dependent on the ability to remove all causative factors for periodontal disease and the patients ability to achieve meticulous self care practice once the RCT has been performed
as a result of common pulpal-periodontal communications and interactions given sufficient time and adequate neglect:
- many endo infections can progress to develop a perio component
- many perio infections can progress to develop an endo component
the more time that passes for endo-perio lesions the more _____ the dx
difficult and confusing
what is one of the best means to differentiate endodontic from periodontal pathosis
pulp sensibility
what is the pulpal infection impact on the periodontium
- process rapid and acute
- pulpal symptoms often present
- radiographic apperance of extension to the periodontium usually an isolated finding
- pocket narrow, drop off, no calculus
what is the periodontal infection impact on the pulp
- process chronic
- pulp undergoes slow degeneration
- pulpal symptoms usually absent
- generalized periodontal disease usually present
- pockets wide base, cone-shaped, usually calculus present
what are the two general types of resorption
internal and external
what is a differential dx for endo-perio lesions
resorption
what is happening to the cells in internal resorption
a change in the nature of pulpal dendritic cells into clastic cells resulting in damage to the internal tooth structure without proper repair
what is the tx for internal resorption
routinely and successfully treated with RCT if not perforating
what is happening to the cells in external root resorption
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 without proper repair
what is the treatment for external root resorption
no routinely predictable and successful outcome over time exist
describe IRR
- usually asymptomatic vital pulp found on XR
- a symmetrical and well circumscribed lesion arising in the pulp which disrupts the normal architecture of the canal
- internal defect: well rounded with smooth borders, integral with pulp
- regardless of the angle exposed, radiographic lesion always remains centered on the root unless perforating to the facial or lingual
- unable to probe the lesion on exterior of tooth unless perforating
- lamina dura and PDL intact around entire root surface unless perforating
describe ERR
- 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 xray is changed
- lamina dura and PDL are disrupted
is IRR or ERR symptomatic
neither are
what are the types of ERR
- surface ERR
- chronic apical inflammatory ERR
- replacement ERR
describe surface ERR and what is the tx
- self limiting
- not discovered clinically
-ignore
describe chronic apical inflammatory ERR and what is the outcome
- cratering of root apex
- shorten prep and obturation
- expect good outcome
describe replacement ERR and prognosis
- follows severe trauma such as avulsion/intrusion
- resorption occurs
- loss replaced by bone
- creates ankylosed and submerged teeth
- often successful
- consider as a temporary measure only
all resorptive defects require _____ for evaluation
CBCT
