Endo / Perio Connection Flashcards
4 major endo- perio connection
- lateral canals
- dentinal tubules
- apical foramina
- iatrogenic perforation
lateral canals?
while migrating apically and forming the rooth the epithelial sheath of hertwig
- can have discontinuties
- run across blood vessels
these disruptions lead to the formation of lateral canals
most frequent area of lateral canals?
APICAL THIRD
- do not forget they are in the FURCATIONS OF MOLARS
describe dentinal tubules
number and size
- decrease from pulp to cementum
- decrease from cervical to apical
dentinal fluid - basic
content of the dentinal tubules
pressure within the dentinal fluid
approx. 14 cm H20 - 10.3 mmHg
some pressure directed outwards
features of dentinal fluid
protective and transport media
brannstrom’s hydrodynamic theory
the rapid movement of dentinal fluid in the dentinal tubules stimulates the A-delta nerve fibers located in the odontblastic layer of the pulp
- mechano-stimualtion
significance with the apical foramen
most significant pathway of communication between pulp and periodontium
periodontal aspects of clinical exam imoortance
PD (probing depth)
bleeding on probing
purulence
mobility
density of marginal bone
SOAP format
S - subjective findings
O - Objective Findigns
A - Assessment (diagnostic pulpal-peri-radicular)
P - Pain of treatment
- endo
- perio
- prosth
what compromises subjective findings
- chief complaint
2. history of present condition
what compromises objective findings
- clinical exam
- radiogrpahic exam
diagnostic tests
heat test have to keep for longer?
yes - because C fibers are slower to respond
tracing the sinus tract importance?
NEED TO SEE WHERE IT ENDS – so maybe a vertical radiograph will be beneficial
is there maxillary sinus involvement?
accuracy of CBCT is in determining vertical root fractures?
HELPFUL
- 86% vs 66% (when using a PA)
which slices in CBCT are most accurate?
AXIAL slices
average sensitivity of CBCT for vertical root fracture
50%
dentin infection how?
- death of odontoblast
- dead tract
- bacterial infiltration
pulpal response to carious lesion
- pulpal inflammation
- local tissue destruction
- formation of microabscesses
- attempt to wall off infection
frequently overlooked findings radiographically
- sinus tract
- resorptive defect
- perforation
- bone rarefraction pattern /
clinical diagnosis (3) these are NOT WHAT
- cracked tooth
- VRF
- endo-perio lesion
*these are NOT describing pulpal or perio diagnose
is there an effect of periodontal inflammation on the pulp?
- general
yes and no
- research defending both sides
likely in extreme conditions
classification on endo-perio lesions
Simon 1972
- primary endodontic lesion with secondary periodontal involvement
- primary periodontic lesion with secondary endodontic involvment
- true combined endo-perio lesion
primary perio with 2nd endo
can reach apex and then effect the pulp
- irreversible pulpitis stage or necrotic
combined?
endodontic disease - bacteria wants to go out
and at same time
- perio lesion from crest of bone down and they meet
endodontic drainage?
path of least resistance?
endodontic drainage?
path of least resistance?
- so case dependent
spread of odontogenic infection
anatomic position of tooth in relation to buccal and lingual cortical plates \relationship of apex of tooth to closest muscle attachment
main features of primary endo secondary perio
- pulp necrosis
- good oral hygeine
- no perio disease
- intrasulcular drainage
- tunnel/ narrow probing
- furcation involvment - non angular crestal bone loss
main features of primary perio secondary endo
- chronic disease
- angular bone loss – slow destruction of attachment apparatus
- pain is low intensity to hard to localize
- tooth may be vital
- corono-apical direction
- produces wide probing
- looser gingival margina
- pulp will survive unless foramen area is compromised
common ways endo -peerio lesions
although they are uncommon they are associated with endo-perio lesions
- enamel pearl
- usually in molar furcation areas - cemental tear
- piece of radio-opacity - palatal groove
- on upper anterior teeth
importance of probing?
narrow or wide?
narrow – endo more likely
VRF hard to diagnose?
yes - because they mimic endo-perio lesions
severity of periodontal disease correlate with pulpal necrosis?
some studies show both (yes and no)
- pulp can affect the periodontium
- there is more epithelium around infected teeth
- there is more connective tissue around non-infective teeth
so before perio procedure need to makesure you have a healthy pulp situation
Tx. strategies and clinical outcome depends on?
- extent of perio disease
- assessment of therapeutic prognosis, with the intended regenerative procedure
- tooth mobility
- properly performed root canal treatment
- appropriate healing time
NEED GOOD PERIO PROGNOSIS
- then do endo and then wait 2/3 months for healing
steps to examine a tooth with a crack
- perio probing
- radiographic examination
- restoration removal
- staining
- transilluminaiton
- wedging forces
- surgical assessment
classification of cracked teeth
- craze lines
- fracture cusp?
- cracked tooth
- split tooth
- vertical root fracture (VRF)
*goes in order of not as ‘big of a problem to more’
craze lines usually present as? where?
on posterior teeth
- marginal ridges
extend B and or L
anterior teeth
- long vertical
clinical
- enamel (limited to here usually), no symptoms, esthetic concerns
depending on how light hits it?
diagnose craze lines?
transillumination
- DD = fractured cusp
transillumination differentitates?
Light is still PASSING THROUGH CRAZE LINE
- IF CROSSES OVER – MEANS CRACK IS NOT DEEP – SO NOT A CRACK – CRAZE LINE
IN CRACK
LIGHT STOPS AT FX LINE - does not cross over line
fractured cusp
complete or incomplete
- cna look like a craze line
- surrounds a cusp M-D and B-L
- above or below CEJ
- LIGHT STOPS AT FX LINE
craze lines limited to?
enamel
- if crosses into dentin - it is a crack
bite test
cusp specific
- pressure on specific cusp on the tooth to break down bite test into the different points on the same tooth
flexure??
- will be pain and pulp reation
NOT USEFUL ON PREVIOUSLY TREATED
- no pulpal response
fractured cusp treatemtn
- assess pulp vitality
- remove effected pulp
- assess restorability
- restore cusp or full cuspal protection
+/- RCT (seldom needed if just a fracture in the cusp)
- if pulp involvement obviuoustl treat this - if not move onto the restorative component
fractuer cusp different from cracked tooth?
YES
cracked tooth starts where?
STARTS AT CROWN LEVEL
- called greenstick fracture / incomplete fracture
cracked tooth usually extends?
M-D : marginal ridges (centered)
- if apically (+/- pulpal involvement)
diagnostic clues for cracked tooth
PAIN ON RELEASE
- place instrument in crack
- use wedging test
no movement?
cracked tooth
piece breaks off with wedge test
fractured cusp
crown and root movement with wedge test
split tooth
cracked tooth tx. planning? guided by?
guided by endo diagnosis
- pulp and periapical) and perio diagnosis
- endo tx if needed
exaplin prognosis and different options
tx considerations with cracked tooth
chasing the crack line in a vital tooth
prognosis of cracked tooth
based on clinical findings and clinical judgement
share findings with pt. and discuss
if left unprotected – can naturally lead to a split tooth
clinical research studies are limited
prognosis of split tooth
poor
- probably needs extraction
split tooth
complete fracture
crown down to apical area
M-D direction
tooth segments are seprate
- wedge test
VRF characteristics
initiated at the ROOT at any level
- usually extend towards the occlusal surface/ chewing surface
- usually are found when surrounding bone and gum become infected
B-L direction
complete or indirect
VRF diagnostic clues
- minimal
- mimics endo- perio lesions
- almost always associated with RCT
- narrow deep or rectangular pattern probing
VRF pathognomonic signs
sinus tract AND narrow isolated probing AND previous RCT
- independent of presence of post
- may be presence of amalgam in canal orrifice
VRF tx
extraction
hemisection or root amputation when indicated
VRF prevention
avoid excessive removal of tooth structure
avoid wedging forces especially if lateral condensation is used
avoid post placement unless needed for crown retention
VRF prevention
avoid excessive removal of tooth structure
avoid wedging forces especially if lateral condensation is used
avoid post placement unless needed for crown retention
crack goes M-D what type?
crack tooth
not syndrome
prognosis if crack is identified early enough?
dont jump to endo
- crown can be protective to a certain extent
Ng. et all 2011 importance? conditions found to improve tooth survival?
conditions to improve tooth survival:
- patency of canal is acheived
- absnence of root filling extrusion
- teeth with cast restoration after tx
- teeth with adjacent teeth present
- no cast and pore for support
fracture necrosis associated with?
pulp necrosis in the absence of restorations, caries, or luxations injuries, is likely caused by a longitudinal fracture extending from occlusal surface into the pulp
extractions may be considered tx of choice
cemental tear?
basically necrotic cementum with microorganisms
-piece of cementum that detaches from the root
how involvement of a palato-ginginval groove can present
- no cavitities or restoration
- poor oral hygeine
- negative pulp test
positive percussion
PD WNL except a drop of 10mm on PL + pus
mobility WNL
TX of palato-gingival groove
prophy
NSRCT
- scaling and root planning
open flap depridement in apex area
treat surface
bone graft and collagen membrane
CHX use
follow up
direction of crack for cracked tooth vs VRF
VRF- from B-L
cracked tooth - from M-D
