lecture 6: further complications

Question 1

complicating factors for endo

Answer 1

• endo and perio
• fractures and cracks
• resorption

Question 2

the combination of multiple challenges to a tooth will

Answer 2

• increase difficulty
• reduce the prognosis
• limit the outcome of tx

Question 3

involvement of endo and perio in the same tooth results in

what is the limiting factor?

Answer 3

lesser prognosis than either ds alone

perio involvment is almost always the limiting factor

Question 4

dental pulp is intimately associated with

Answer 4

periodontium

pulpal path can affect periodontium and peridontal path can infect pulp.

Question 5

why are lateral canals signifcant?

Answer 5

because they allow pulpal ds to extend directly to peridontal tissues

Question 6

what is the #1 internchage that occurs via mutliple pathways or following therapeutic procedures

Answer 6

apical foramen (natural or procedural) is the most direct/common

following SRP & other periodontal and surgical procedures

Question 7

how can apical foramen serve as a pathway of communication?

Answer 7

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.

Question 8

how do lateral (accessory) canals serve as pathways of communication

Answer 8

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.

Question 9

how common are lateral canals in M

Answer 9

somewhat common 23 to 76%

Question 10

how does cemental agenesis or loss function as a pathway of communication

Answer 10

• 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.

Question 11

how can cementum be lost

Answer 11

• tooth brush abrasion
• erosion
• bulemia and other destructive habits
• bruxism
• trauma
• aggresive SRP

Question 12

what might this be?

Answer 12

iatrogenic pathways of communication

Question 13

if the anomaly or injury is apical to the gingival attachment

which is invovled: pulp? periodontium?

Answer 13

both the pulps and peri

Question 14

if the anomaly or injury is apical to the gingvial attachment

what is involved? pulp? periodontium?

Answer 14

both the pulp and periodontium is involved

the progosnis decreases

Question 15

why does the prognosis decrease with any perio involvment?

Answer 15

endo high prognosis (90%+) goes down because perio success depends largely on the pt and the pts motivation.

Question 16

pure endo:

prognosis

dx

Answer 16

prognosis: the best of the 5.
dx: RCT only.

Question 17

endo-perio

prognosis

dx

Answer 17

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.

Question 18

pure perio

prognosis

dx

Answer 18

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.

Question 19

perio- endo

prognosis

dx

Answer 19

primary perio lesion with 2ndary endo involvment

prognosis: poor due to perio.
dx: 1st do RCT followed by and dependent upon the pt.

Question 20

“true” combined lesion

prognosis

dx

Answer 20

prognosis: the poorest prognosis, especially if VRF - hopeless
dx: do RCT 1st to manage acute symptoms. Again dependent on the pt.

Question 21

pure endo pulpal dx and clues

Answer 21

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.

Question 22

perio-endo pulpal dx and clues

Answer 22

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.

Question 23

endo perio pulpa dx and clues

Answer 23

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

Question 24

pure perio pulpal dx and clues

Answer 24

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.

Question 25

“true” combined lesion pulpal dx and clues

Answer 25

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.

Question 26

internal resorption

Answer 26

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)

Question 27

external resorption

Answer 27

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)

Question 28

why is it impt to know if it is IRR or ERR

Answer 28

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.

Question 29

IRR or ERR and why

Answer 29

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

Question 30

IRR or ERR and why

Answer 30

• 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

Question 31

replacement ERR

Answer 31

follows trauma (avulsion/intrusion), resportion occurs, loss is replaced by bone

creates ankylosed and submerged teeth

often unsuccesful

Question 32

all resorptive defects require what

Answer 32

CBCT for evaluation