Lecture 2 (8/29) Flashcards
Provides an ideal environment for bacterial colonization:
Root canal system
Why is the RC system an ideal environment for bacterial colonization:
- Warm
- Moist
- Nutritious (has lots of substrate)
Describe the climate of the RC system:
Variable but largely anaerobic climate
What allows the RC system to be largely protected from the host defenses?
Due to lack of circulation in disease pulpT
What does the lack of circulation in diseased pulp allow for?
The area to be protected from the host defenses
Because the root canal system of a disease pulp does not have circulation allowing it to evade host defenses, it is considered a:
Privileged sanctuary
The basic science most closely associated with the practice of endodontics:
Microbiology
By using a special “anaerobic glove box” technique, ________ bacteria were successfully culture from _____
Anaerobic; the canal system
Sundqvist, ‘76 proved that many of the pathological bacteria found in the RC system are:
Black pigmented anaerobic gram negative rods
The black pigmented anaerobic gram negative rods found to be pathogenic in the canal system by Sundqvist include (6):
- Porphyromonas
- Prevotella Nigrescens (most frequent in endo infections)
- Peptostreptococcus
- Fusobacterium
- Eubacterium
- Actinomyces
The black pigmented anaerobic gram negative rods found to be pathogenic bacteria in the canal systems by Sundqvist release ____ also known as _____ that cause: (3)
Lipopolysaccharides (LPS); endotoxins
Cause: Fever, Collagenolysis, osteolysis
The LPS (also known as endotoxins) released by the black pigmented anaerobic rods can cause:
- fever
- collagenolysis
- osteolysis
The root canal walls/spaces are conductive for the formation of:
Biofilm
A complex, colonized community of bacteria:
Biofilm
In an infection, ____ is adhered to root canal walls
Biofilm
“Floating bacteria”:
Planktonic
Riccuci sates that with apical periodontitis:
NO single microorganism is responsible
Progression of RC system infection:
- Carious lesion or trauma opens tubules to ______
- Bacterial inflame the ______
- _____ may overcome pulpal defenses and _____ may form in the ______
- Infection increases in pulp and ______ begins
- _____ involves the entire ____
- Infection uses “portals of exit” (_____ and ____) to invade ______ (______)
- _____ infection occurs beyond the ____ (____)
- bacterial invasion
- pulp locally
- inflammation; localized abscesses; coronal pulp
- necrosis
- necrosis; entire RC system
- apical foramen & lateral canals; peri-radicular tissues; apical periodontitis
- periradicular; apex; apical abscess
During the progression of RC system infections:
What causes the tubules to open allowing for bacterial invasion?
Carious lesion or trauma
During the progression of RC system infections:
What is the significance of a carious lesion or trauma?
opens the tubules to bacterial invasion
During the progression of RC system infections:
Initially, where does inflammation from the bacteria occur?
locally within the pulp
During the progression of RC system infections:
What happens when inflammation overcomes the pulpal defenses?
Localized abscesses may form in coronal pulp
During the progression of RC system infections:
Localized abscesses may form in the coronal pulp once what occurs?
Once inflammation overcomes the pulpal defenses
During the progression of RC system infections:
When localized abscesses form due to the inflammation overcoming the pulpal defenses, where are these abscesses forming?
Coronal pulp
During the progression of RC system infections:
Once infection increases in the pulp, what may begin?
Necrosis
During the progression of RC system infections:
The process of necrosis involves:
The entire RC system
During the progression of RC system infections:
What are the “portals of exit” used by the infection to invade peri-radicular tissues?
apical foramen & lateral canals
During the progression of RC system infections:
Once the infection invades the peri-radicular tissues this is considered:
Apical periodontitis
During the progression of RC system infections:
Where does the peri-radicular infection occur?
Beyond the apex
During the progression of RC system infections:
Describe an apical abscess:
Peri-radicular infection beyond the apex
During the progression of RC system infections:
When a peri-radicular infection occurs beyond the apex:
Apical abscess
The biofilm must accomplish 6 things to cause:
Disease within the RC system
What 6 things must a biofilm accomplish in order to cause disease within the RC system?
- MO must adhere to host surfaces
- Obtain nutrients from the host
- Mutliply
- Invade tissue
- Overcome host defenses
- Induce tissue damage
How could we describe a biofilm?
- Complex
- Variable
- Constantly changing
A multicellular microbial community characterized by cells that are firmly attached to a surface and enmeshed in a self produced matrix of extracellular polymeric substance (EPS), usually polysaccharide:
Biofilm
Biofilm are usefully enmeshed in a self produced matrix of:
Extracellular polymeric substance (EPS), usually polysaccharide
Bacteria that appear to be the most common microorganisms in primary endodontic infections:
Anaerobic gram negative
List the most common anaerobic gram negative microorganisms in primary endodontics infections:
- Porphyromonas
- Prevotella
- Propionibacterium
- Peptostreptococcus
- Streptococcus
- Actinomyces
- Olsenella
Porphyromonas
Prevotella
Propionibacterium
Peptostreptococcus
Streptococcus
Actinomyces
Olsenella
What do all of these microorganisms have in common?
Anaerobic Gram negative
The longer the infection exists within the RC system, the more ____ is consumed by bacterial activity and the more _____ the RC system environment becomes
Oxygen; anaerobic
The longer the infection exists within the RC system, the more oxygen is consumed by bacterial activity and the more anaerobic the RC environment becomes.
Therefore _____ infections within the RC system tend to favor _____ bacterial flora
chronic infections; anerobic
Explain why chronic infections within the RC system tend to favor anaerobic bacterial flora:
Because the longer the infection exists within the RC, the more the bacteria consume the oxygen leaving the RC environment to be more anaerobic
What type of bacteria do chronic infections in the RC system favor?
anaerobic bacterial flora
As a rule _______ is responsible for an endo infection
NO ONE organism
All endo infections are ______ (____)
mixed; polymicrobial
Endo infections are mostly caused by ____ & ____ _____
Facultative & Obligate anaerobes
Aerobes which can also survive in an anaerobic environment:
Facultative anaerobes
Facultative anaerobes may become more numerous & virulent with:
The addition of oxygen
Bacterial species that must have anaerobic environment to survive:
Obligate anaerobe
Bacterial species that CANNOT survive in aerobic environments:
Obligate anaerobe
______ liberates O2
NaOCl
Biofilm becomes more varied, complex, and difficult to control when the tooth is further challenged by _______ Or ____ (_________)
Salivary contact or operative contamination (New BUGS or altered environement)
____ becomes more varied, complex, and difficult to control when the tooth is further challenged by salivary contact or operative contamination (new BUGS or altered environment)
biofilm
Biofilm becomes more varied, complex, and difficult to control when the tooth is further challenged by salivary contact or operative contamination (new BUGS or altered environment)
SO _______ of rubber dam or temporary AND ______ during treatment (leaky dental dam, etc.)
avoid leakage; avoid iatrogenic contamination
How do we destroy the bacteria in RC treatment?
8.3% Sodium Hypochlorite (NaOCl)
Our major weapons in destroying bacteria in RC system”
Cleaning and shaping with NaOCl and Intra-canal medications
How does the NaOCl work to kill RC bacteria?
Kills directly or starves them out
What makes some RCs resistant to mechanical shaping?
Diverse shapes
(Files never reach ALL spaces in the complex pulpal system)
What implication does the diverse shape of RCs have on mechanical shaping?
Files never reach ALL spaces in the complex pulpal system
Due to the diverse shapes of RC systems, files never reach ALL spaces in the complex pulpal system, therefore correct use of _____ is extremely important in _____
NaOCl; Eliminationg microorganisms in theses spaces
What are the six functions of NaOCl in root canal systems?
- disinfects over time
- dilutes & inactivates toxins
- dissolves substrate over time
- dissolves nevrotic tissue overtime
- flushes and floats out debris
- lubricates canal
Typical RC treatment case requires about ____ of _____ as irritant PER VISIT
10-12 cc. of NaOCl
______ degrades rapidly to ___ (salt water) in the canal, therefore must be replenished @3-5 minutes
NaOCl; NaCl
NaOCl degrades rapidly to NaCl (salt water) in the canal, therefore must be:
Replenished @3-5 minutes
NaOCl must be in contact with shaped canal a minimum of ______ after canal enlarged to _____ or larger
minimum of 30 minutes; #30
During RC treatment, why must the canal be enlarged to #30 or greater?
A canal smaller than #30 will seldom if ever allow any irrigant to reach the apical 1/3 of the canal
enlarging the canal to #30 or larger allows for:
Irrigant to reach the apical 1/3 of the canal
Medications are placed _____ the canal system _____ appointment
within; between
The medications that are placed within the canal system between appointments are inter to increase ______ and to further decrease _____ within the RC system
local anti-microbial action; the microbial challenge
Historically, many harsh medications were used in RC treatment which were ____ & ____ to healthy tissue
Toxic; damaging
Some of the medications that were historically used for RC treatment are now recognized as _____ and are no longer acceptable for use
Carcinogenic
Due to their toxic/and carcinogenic nature, the following formulations are no longer acceptable for use in RC treatment (4):
- CMCP
- Formocresol
- Cresatin
- Beachwood Creosote
Near universal acceptance as the intracanal medication of choice, especially in necrotic cases:
CaOH
The pH of the intracanal medication CaOH:
Between 11-12
CaOH discourages ____ microbial growth
MOST
What four characteristics of CaOH make it a widely accepted intracanal medication?
- discourages MOST microbial growth
- Long lasting (effective over extended periods)
- No reported allergic responses
- Easy to apply & remove as paste
What is CaOH available in clinical as?
Ultracal
Use of antibiotics to relieve pain=
USELESS
Systemic antibiotics are ONLY useful in: (2)
- Acute P-R infections (swelling & fever)
- Immunologically suppressed patients
What type of infection would present as swelling & fever and may require the use of antibiotic treatment?
Acute P-R infections
Healthy patients WITHOUT systemic signs & symptoms of infections but WITH the following conditions do NOT require antibiotics (4):
- Symptomatic pulpitis
- Symptomatic apical periodontitis
- A draining sinus tract
- Localized swelling
Healthy patients that present with symptomatic pulpitis, symptomatic apical periodontitis, a draining sinus tract or localized swelling, that are otherwise healthy without systemic signs and symptoms of infection do NOT require:
Treatment with antibiotics
What indicates performance of an I&D?
Usually fluctuant swelling
Drainage of fluctuant swelling is accomplished by:
I&D (incision & drainage)
Following treatment of I&D we are committed to:
Following acute patient daily & documenting progress
When do we use antibiotics in endodontics?
In CONJUNCTION with definitive procedures to deride and drain when there is:
- Persistant or spreading infection
- Systemic involvement with temperature of 100+ degrees
- Medically compromised patient
- Pre-med when indicated
If bacteria from the infected pulp tissue gain entry into the periradicular tissue and the immune system is unable to suppress the invade, an otherwise healthy patient eventually showed signs and symptoms of:
An acute periradicular abscess, cellulitis or both
If bacteria from the infected pulp tissue gain entry into the periradicular tissue and the immune system is unable to suppress the invade, an otherwise healthy patient eventually showed signs and symptoms of an acute periradicular abscess, cellulitis or both.
Clinically, the patient experiences:
Swelling, fever and mild to severe pain
a patient may develop acute periradicular abscess, cellulitis or both if the bacteria from the infected pulp tissue gains entry into the ______ and the _____ is unable to suppress this invasion
periradicular tissue; immune system
Depending on the relationship of the apices of the involved tooth to the muscular attachments, virulence factors and host resistance, the swelling may be localized to ______ or may extend into ______ resulting in ______
Localized to the vestibule; extend into a fascial space; cellulitis
When swelling extends into the fascial space:
Cellulitis
What factors may determine whether swelling will remain localized to the vestibule or whether it will extend into the fascial space resulting in cellulitis?
- relationship of apices of involved tooth to muscular attachments
- virulence factors
- host resistance
A patient presenting with cellulitis generally will also have ________ such as: (5)
Systemic manifestations:
- fever
- chills
- lymphadenopathy
- headache
- nausea
In cases of cellulitis with systemic manifestations, because the reaction to the infection may occur very quickly, the involved tooth may or may not show radiographic evidence of:
A widened periodontal ligament space
In cases of cellulitis with systemic manifestations, because the reaction to the infection may occur very quickly, the involved tooth may or may not show radiographic evidence of a widened periodontal ligament space.
However in most cases, the tooth elicits a positive response to ______, and the periradicular area is ___________
Positive response to percussion;
tender to palpation
In cases of cellulitis with systemic manifestations, because the reaction to the infection may occur very quickly, the involved tooth may or may not show radiographic evidence of a widened periodontal ligament space.
However in most cases, the tooth elicits a positive response to percussion, and the periradicular area is tender to palpation.
Describe this case:
This is a serious (critical infection) in fascial plane
______ are important in relation to where the lesion “points”
muscle attachements
If lesion exits coronal to muscle attachment, it is generally on ____ or ____ and we have a localized abscess (which is more easily treated due to no systemic involvement)
attached gingiva or alveolar mucosa
If lesion exits coronal to muscle attachment, it is generally on attached gingiva or alveolar mucosa and we have a:
localized abscess
______ is more easily treated because no systemic involvement
Localized abscess
The following image would be diagnosed as a:
Localized abscess
What could be diagnosed looking at the following patient?
What treatment may be required?
Fluctuant swelling; I&D
_____ are potential anatomic areas that exist between the fascia and underlying organs and other tissues
Fascial spaces
Development of a critical infection:
During an infection, these spaces are formed as a result of the spread of purulent exudate
Fascial spaces
Development of a critical infection:
During an infection, fascial spaces are formed as a result of:
Spread of purulent exudate
The spread of infections of odontogenic origin into the fascial spaces of the head and neck is determined by the _____ of ____ of the involved tooth in relation to its overlying _______ or ______ ______ and the relationship of the apex to the ________
location; the root end; buccal or lingual cortical plate; attachment of a muscle
The spread of infections of ________ origin into the fascial spaces of the head and neck is determined by the location of the root end of the involved tooth in relation to its overlying buccal or lingual cortical plate and the relationship of the apex to the attachment of a muscle
Odontogenic
If the source of the infection is a mandibular molar and the apices of the molar lie closer to the lingual cortical plate and above the attachment of the mylohyoid muscle of the floor of the mouth, the purulent exudate breaks through the cortical plate into the _________
If the apices lies below (or apical) to the attachment of the mylohyoid muscle, the infection spreads into the ________
Sublingual space; submandibular space
Infections that spread into the fascial spaces are critical and have the potential to be ______ if not _____
Lethal; treated aggressively
Label the following image:
A: submandibular space
We should be especially vigilant with infections of ______ (especially _______) when cellulitis occurs in the submandibular space with swallowing difficulty
Mandibular molars; 2nd & 3rd molars
We should be especially vigilant with infections of mandibular molars (especially 2nd & 3rd molars) when:
Cellulitis occurs in the submandibular space with swallowing difficulty
We are especially vigilant with infections of mandibular molars when cellulitis occurs in submandibular space with swallowing difficulty, why?
Access from S-M space to sublingual & submental spaces (all 3 = ludwigs angina) & infection in these spaces can be life threatening
What can you diagnose looking at the following image?
Cellulitis with involvement of the submandibular spave
This is cellulitis with involvement of the submandibular space. The infection has pointed apical to the attachment of the _____ muscle and superior to the ____ muscle
What treatment is indicated?
mylohyoid muscle; platysma muscle
I&D; Referral
Endodontic infections may be classified according to:
- location
- symptoms (acute or chronic)
- degree of virulence or organization (localized or diffuse & spreading)
How might you describe the symptoms of an endodontic infection?
Acute or chronic
How might you describe the degree of virulence or organization of an infection?
Localized or diffused & spreading
How might you classify the location of an endodontic infection?
- intraradicular
- extraradicular
Location of endodontic infection that is caused by bugs colonizing within the RCS:
intraradicular
Location of endodontic infection that is usually a sequel to untreated intraradicular infection:
extraradicular
Location of endodontic infection characterized by microbial invasion of the periradicular tissues resulting in inflammation & infection. AAA or CAA
extraradicular
Intraradicular infection is caused by bugs colonizing within the ____. Extraradicular infection is caused by microbial invasion of the ____ tissues.
RCS; periradicular tissues
What are the three subclasses of intraradicular infections?
- Primary infections
- Secondary infection
- Persistant infection
Intraradicular infection caused by bugs that initially invade and colonize necrotic pulp tissues within the RCS:
Primary infection
Intraradicular infection caused by bugs not present in the primary infection but introduced into the RCS sometime following professional intervention (secondary to professional intervention; iatrogenic by definition)
Secondary infection
Secondary intraradicular infections are secondary to professional intervention meaning they are:
Iatrogenic by definition
Example of a secondary infection is when symptoms arise in a previously ________ infected tooth if operation allowed R. Dam leakage or placed leaky temporary.
asymptomatic
Intraradicular infection caused by bugs that were embers of a primary or secondary infection and in some way, resisted intracanal antimicrobial procedures and were able to endure periods of nutrient deprivatino within the RCS. (i.e.) FAILURE TO HEAL
Persistant infection
How can we describe a persistant intraradicular infection?
FAILURE of RCT TO HEAL
The ability to form _____ has been regarded as a virulence factor
BIO
The ability to form BIO has been regarded as a virulence factor. Neighboring cells of difference species can produce enzymes such as ____, ____ and ____ that are retained in the biofilm matrix and can protect other bacteria against antibiotics and host defenses.
B-lactamase, Catalase, proteinases
In an endodontic infection, bacterial products contribute to:
Virulence
____ can cause direct tissue damage & osseous breakdown by releasing enzymes, endotoxins/exotoxins, LPS & peptides/amino acids
Gram negative anaerobes
Gram negative anaerobes can cause ___ & ___ by releasing enzymes, endotoxins,/exotoxins LPS & peptides/amino acids
Direct tissue damage & osseous breakdown
Gram negative anaerobes can cause direct tissue damage & osseous breakdown by releasing:
- enzymes
- endotoxins/exotoxins
- LPS
- peptides/amino acids
What are some enzymes that are released by gram negative anaerobes that can caused direct tissue damage & osseous breakdown?
- collagenase
- chondroitinase
- hyaluronidase
Toxic substances associated with the outer cell walls that are released upon destruction of cell walls and exotoxins:
Endotoxins
An endotoxin in the cell wall of gram negative bugs:
LPS
Bacteria responsible for causing serious suppurative infections:
Staph. Aureus (S. Pyogenes)
Is Staph. Aureus (S. Pyogenes) gram negative or gram positive?
Gram positive
What is the oxygen requirement for Staph. Aureus (S, Pyogenes)?
Facultative anaerobe
Staph aureus (AKA) S. Pyogenes (Gram +) is thought to produce:
Penicillinase
A B-lactamase that has the potential to render Penicillin ineffective:
Penicillinase
What bacteria is thought to be responsible for the production of penicillinase?
S. Aureus (S. Pyogenes)
Staph aureus (S. Pyogenes) treatment:
Augmentin
Augmentin is the combination of:
Amoxicillin + Clavulanic acid
Clavulanic acid inhibits:
Penicillinase
