lecture 6: further complications Flashcards
complicating factors for endo
- endo and perio
- fractures and cracks
- resorption
the combination of multiple challenges to a tooth will
- increase difficulty
- reduce the prognosis
- limit the outcome of tx
involvement of endo and perio in the same tooth results in
what is the limiting factor?
lesser prognosis than either ds alone
perio involvment is almost always the limiting factor
dental pulp is intimately associated with
periodontium
pulpal path can affect periodontium and peridontal path can infect pulp.
why are lateral canals signifcant?
because they allow pulpal ds to extend directly to peridontal tissues
what is the #1 internchage that occurs via mutliple pathways or following therapeutic procedures
apical foramen (natural or procedural) is the most direct/common
following SRP & other periodontal and surgical procedures
how can apical foramen serve as a pathway of communication?
basically: creates a pathway from infected periodontium to the pulp.
1. irritants from the invovled pulp may pass through apical foramina into periradicular tissues via inflammation or infection extension or during endodontic procedures
2. irritants from periodontal inflammation/injury/procedrues may pass thorugh apical foramina or accesorry (lateral) canals and directly invade the dental pulp.
how do lateral (accessory) canals serve as pathways of communication
irritants from plaque that reach around the lateral canals can initiate inflammation in the pulp followed by necrosis
canals can be up to 50 um or so wide, while the bacteria is aroun 0.5-1um.
how common are lateral canals in M
somewhat common 23 to 76%
how does cemental agenesis or loss function as a pathway of communication
- cementum is normally a natural protective barrier
- any void of cementum or enamel via agenesis, injury or agressive SRP will expose the dentinal tubules and pulp to attack from micro-organisms.
how can cementum be lost
- tooth brush abrasion
- erosion
- bulemia and other destructive habits
- bruxism
- trauma
- aggresive SRP
what might this be?
iatrogenic pathways of communication
if the anomaly or injury is apical to the gingival attachment
which is invovled: pulp? periodontium?
both the pulps and peri
if the anomaly or injury is apical to the gingvial attachment
what is involved? pulp? periodontium?
both the pulp and periodontium is involved
the progosnis decreases
why does the prognosis decrease with any perio involvment?
endo high prognosis (90%+) goes down because perio success depends largely on the pt and the pts motivation.
pure endo:
prognosis
dx
prognosis: the best of the 5.
dx: RCT only.
endo-perio
prognosis
dx
prognosis: poor prognosis due to perio. Dependent on ability to treat both entities succesfully.
dx: both RCT and Periodontal tx are indiciated. If pulp is necrotic, RCT 1st then perio.
pure perio
prognosis
dx
prognosis: dependent upon perio. Tx success and motivate pt
dx: Tx is limited only to peridontal tx. Remove causative factors and the pts ability to self-care.
perio- endo
prognosis
dx
primary perio lesion with 2ndary endo involvment
prognosis: poor due to perio.
dx: 1st do RCT followed by and dependent upon the pt.
“true” combined lesion
prognosis
dx
prognosis: the poorest prognosis, especially if VRF - hopeless
dx: do RCT 1st to manage acute symptoms. Again dependent on the pt.
pure endo pulpal dx and clues
clues: clinical pulpal dx indicates necrotic pulp
rapid onset
evidence of pulpal trauma
@ M, bone loss at furcation
minimal to no calculus, no evidence of generalized or advanced periodontitis
swelling is present in attached gingiva and tooth sore to biting or chewing.
DST originiating from apex or lateral canal. Not a classic DST but it serves the same purpose as the draining lesion.
perio-endo pulpal dx and clues
clues: Clinical pulpal dx is SIP or Necrotic pulp
pt has or needs an extensive restoration
VBL, inflamed tissue and calculus present (signs of periodont)
broad based probings, vertical and possible apical or lateral bone loss
infection from deep perio pocket invades the pulpal tissues via the apical foramen and causes pulpitis.
symptoms are acute and history of prev. extensive perio tx.
endo perio pulpa dx and clues
clues: clinical pulpal dx indicates necrotic pulp
evidence of periodontal ds with VBL, inflammed soft tissue and little to no calculus
XR changes noticed: pulpal space visible with linear or isolated calcific changes.
look for unusual deep pockets
little or no calculus in pockets
no generalized perio condition
pure perio pulpal dx and clues
clues: clincial pulpal dx: normal vital pulp.
no deep caries no other significant pulpal injury
VBL, inflammed soft tissue and calculus present (signs of periodontal ds)
generalized XR showing moderate to deep bony pockets (cone shaped and wide)
calculus present
diffuse inflammation
asymptomatic pt, pulp responds WNL.
“true” combined lesion pulpal dx and clues
clues: Clinical pulpal dx is necrotic pulp
tooth needs or has extensive restoration or has suffered trauma
evidence for the presence of periodontal ds with VBL, inflammed soft tissue and calculus present
broad based probing and intraboney perio pocket
communication with an isolated peri-radicular lesion of pulpal origin
acute or chronic symptoms (probs due to pulpal inflammation)
probing may reveal a VRF, then tx is TE.
internal resorption
it is routinely and succesfully tx with RCT (if NOT perforating)
endo only, execept if perforated.
IRR is a change in the nature of pulpal dendritic cells into clastic cells resulting in damage to the internal tooth structure (w/o proper repair)
external resorption
tx none are routinely predictable successful outcome
- ERR is a achange in the nature of PDL cells wihch causes largely osteoblastic cells to activate- clastic cells resulting in damage to the external tooth strucutre (WO proper repair)
why is it impt to know if it is IRR or ERR
bc IRR arises in the PULP cells and ERR arise in the PDL cells.
So if ERR, pulp is often necrotic while IRR is usually asymptomaitc, this changes your tx plan.
IRR or ERR and why
it is IRR because
- usually asymptomatic vital pulp
- symmetrical and well circumscribed lesion arising in the pulp and disrupts normal architecture of the canal
- interal defect: well-rounded with smooth borders
- no matter the angle, lesion remains centered on the root unless perforating to the F or L
- unable to probe lesion
- lamina dura and pdl in tact unless perforating
IRR or ERR and why
- pulp is often necrotic
- lesion which occurs on external surface
- detectable with explorer
- irregular shpaed lesion arising in the PDL which does not alter the normal architecture of the canal
- lesion “moves” as the horizontal angulaiton of the x-ray is changed
- lamina dura and pdl disrupted
replacement ERR
follows trauma (avulsion/intrusion), resportion occurs, loss is replaced by bone
creates ankylosed and submerged teeth
often unsuccesful
all resorptive defects require what
CBCT for evaluation
