Endo-perio problems Flashcards
It’s the “Challenge of the Clinician” to discover all the ________ & treat within their scope of practice and to offer solutions within their ability or referral range.
problems
What is subjective data?
Medical and Dental History
What is objective data?
Clinical Exam and Radiographs
Is it possible to have both Endo &
Perio in the same tooth?
Yes
___________ health, function and stability is one of the basic requirements for any tooth being considered for endodontic treatment
Periodontal
If there is involvment of endo-perio in the same tooth what is the prognosis?
❖ Lesser prognosis of either disease alone.
❖ Perio involvement is always the limiting factor
What do you need to evaluate if the tooth has endo-perio issues?
❖ A Good diagnosis.
❖ Pulpal, periapical and Periodontal.
❖ Evaluate periodontal prognosis before you begin any treatment.
❖ Always communicate to your patient what are the treatment plans and possible outcomes.
Which has a better prognosis?
2
- 1 is exposed to the oral cavity (bacteria) and 2 is closer to the apex
Irritants from involved pulp may pass through apical foramina into periradicular tissues via…
inflammation or infection extension or during endodontic procedures
Irritants from periodontal inflammation/injury /procedures may pass through apical foramina or accessory (lateral) canals and directly invade the…
dental pulp
Irritants from plaque that reach periodontal tissues around ________________ canals may initiate inflammation in pulp followed by necrosis
lateral/accessory
Lateral canals may be _____ + wide; bugs are @ .5-1um
50um
Any void of cementum (or enamel) via agenesis, injury or aggressive SRP will expose…
dentinal tubules & pulp to attack from micro-organisms
What are the pathways of communication?
1: Apical Foramen: most direct/common pathway
#2: Lateral (accessory) canals
#3: areas of cemental agenesis or loss
#4: Iatrogenic
#5: Other (tooth brush abrasions, erosion, etc.)
Cementum is a natural protective barrier. _________% may have a VOID at CEJ)
18-25%
Most often lateral (accesory) canal are NOT visible radiographically but are discovered after __________.
obturation
What are other pathways of communcation?
❖ Tooth brush Abrasion
❖ Erosion
❖ Bulemia & other destructive habits
❖ Bruxism
❖ Trauma
What are iatrogenic pathways of communcation?
Problems that we create as endodontic perforations or post perforations
Any anomaly or injury providing access to the dentinal tubules also provides noxious access to the pulp such as…
cracks
If the anomaly or injury is _______ to the gingival attachment, both the Pulp and Periodontium are involved.
apical
What fractures are visible on the radiograph?
horizontal
What fractures are not visible on the radiograph?
vertical root fractures (J-shaped lesion/drop off pocket)
What are the classifications of endo-perio lesions?
- Pure Endo (Primary Endo Lesion)
- Pure Perio (Primary Perio Lesion)
- Endo-Perio (Primary Endo with secondary Involvement)
- Perio-Endo (Primary Perio with secondary Endo Involvement)
- “True” Combined Lesion (Combined vs.
Concomitant perio and endo involvement)
Which cateogory of endo-perio lesions has the best prognosis?
Pure endo (primary endo lesion)
What are the characteristics of a pure endo (primary endo lesion)
❖ With this Dx, only RCT is needed.
❖ It is not necessary to curette furcation region. It Will heal by itself once done the RCT.
❖ Minimal to no calculus & no evidence of generalized oradvanced 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
What is the most common cause of a pure endo (primary endo lesion)?
Caries, restorative procedures, and traumatic injuries
In a pure endo (primary endo lesion) the inflammatory process in the periodontium occuring as a result of root canal infection not only may be localized at the apex but also…
lateral of the root
In a pure endo (primary endo lesion) in molar teeth, the furcation area may appear to have…
significant bone loss
What is a pure perio (primary periodontal lesion)?
❖Prognosis totally dependent upon periodontal treatment, success and motivation of the patient.
❖Diffuse Inflammation
❖generalized, moderate to Deep pockets. Calculus present.
❖Asymptomatic patient & Pulp responds to sensibility testing WNL.
What is the treatment for a pure perio (primary periodontal lesion)?
Treatment is limited to periodontal therapy only with the prognosis dependant upon the ability to remove the causative factors and the patients ability to achieve meticuluos self-care practices.
What are the important facts of a pure perio (primary periodontal lesion)?
❖ClinicalPulpalDxindicates Normal Pulp (vital).
❖No Deep caries no other significant pulpal injury.
❖Evidence for the presence of periodontal disease with vertical bone loss inflamed tissue and calculus present.
What is a endo-perio (primary endo with secondary perio involvement)?
❖Whenthis Dx is both determined: Both RCT & Periodontal Tx are indicated.
❖Simultaneous manangement of endo and perio is preferable.
❖If Pulp is necrotic RCT is done first, then Perio.
❖Prognosis for resolution is dependant upon ability to treat BOTH entities successfully
What is the prognosis of endo-perio (primary endo with secondary perio involvement)?
Guarded to poor prognosis due to perio
What is a perio-endo (primary perio lesion with secondary endo lesion)?
❖Clinical & Radiographic assessments indicate broad-based probings, vertical & posible apical or lateral bone loss.
❖Infection from the Deep perio pocket invades the pulpal tissue via the apical foramen & causes pulpitis.
❖History of previous extensive perio treatment.
What is the prognosis of perio-endo (primary perio lesion with secondary endo lesion)?
Guarded to poor prognosis due to perio
What is the treatment for perio-endo (primary perio lesion with secondary endo lesion)?
Successfull treament is RCT 1st followed by and dependant upon the ablity to remove the causative factors for both periodontal disease and the patients ability to achieve meticuluos self care practices once the RCT has been successfully performed.
What are the important facts about perio-endo (primary perio lesion with secondary endo lesion)?
❖ Clinical Pulpal Dx indicates SIP or Necrotic Pulp.
❖ Tooth often may haveor needextensive restoration.
❖ Evidence for the presence of periodontal disease with vertical bone loss inflamed soft tissue and calculus present.
What is a “true combined lesion”?
Rare Combined or Concomitant Perio & Endo involvement. Remember combined is different than Concomitant
Which type of endo-perio lesion has the worst prognosis?
“True combined lesion”
Probably the poorest prognosis of all types especially if associated with VRF=hopeless
How do you treat “true combined lesion”?
Perform RCT first to manage acute symptoms (if any). Sucessful treatment depends upon the ability to remove all the causative factors for periodontal disease and the patients ability to achieve meticulous self-care practice once the RCT has been performed
What is a combined lesion?
Refers to two or more infectious processes that merge in such way that they are seen as a single pathology.
What is a concomitant lesion?
Refers to an infectious process that occurs simultaneously with another condition but remains distinct from each other. If this is not treated and progresses it can evolve in a combined lesion.
What are the symptoms/characteristics of a true combined lesion?
❖ Clinical & Radiographical assessments indicate broad based probings & infrabony perio pocket
❖ Symptoms maybe acute or chronic.
❖ Probing is deep often wide. Need to rule out root fracture.
❖ Clinical Pulp Dx indicates necrotic Pulp.
❖ Tooth often has or need extensive restoration or has suffered trauma.
❖ Evidence for the presence of periodontal disease with vertical bone loss inflamed soft tissue and calculus present.
Given sufficient time & adequate NEGLECT: many endo infections can progress to develop a ______ component.
perio
and vice versa
_______________ testing is one of the best means to differentiate endodontic from periodontal pathosis.
Pulp sensibility
What is the clinical difference in etiology, vitality, etc. between pulpal and periodontal disease?
What is the radiographic and therapy differences between pulpal and periodontal diseases?
What are the two types of resorption?
internal and external
What is internal resorption?
- Internal replacement resorption is a very rare condition which is defined as the process where the pulp and dentin are replaced by bone
- is rountinely and successfully treated with RCT (if not perforating)
What are the different types of internal resorption?
- internal surface resorption
- internal inflammatory resorption
What are the different types of external resorption?
- external surface resorption
- external inflammatory resorption
External inflammatory resorption can occur in two locations…
apical
lateral
What is external apical inflammatory (ERR)?
(cratering of the root apex acknoledge, shorten prep and obturation)
- expect Good outcome
EXTERNAL LATERAL INFLAMMATORY RESORPTION has been treated by several methods; what has been the outcome?
none have had a predictable successful outcome
Internal Resorption arises in the _______ cells
Pulp
What are the symptoms/characteristics of internal resorption?
❖ Usually asymptomatic VITAL PULP
❖ A symmetrical & well circumscribed lesion arising in the pulp which disrupts the normal architecture of the canal.
❖ Regardless of the angle exposed, radiographic lesion always remains centered on the root unless perforating to the facial or the lingual.
❖ Unable to probe lesion on exterior of tooth (unless perforating).
❖ Lamina dura and PDL intact around entire root surface (unless perforating).
What are the symptoms/characteristics of external resorption?
❖ 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 dura and PDL disrupted.
External Resorption arises in the _______ cells
PDL
What are other types of ERR (external root resorption)?
- external replacement resorption
- external pressure resorption
- orthodontic resorption
- physiological resorption
Treatment of Resorptive Defects:
- require CBCT evaluation
- refer anything you are uncertain about
REFER ALL RESORPTIONS at least for an _________
Opinion
Is this internal or external resorption?
external
