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BDS3 Perio > perio-endo and periodontal abscess > Flashcards

perio-endo and periodontal abscess Flashcards

1
Q

3 most common reasons for people to attend dentist

A
  1. Periapical
  2. Pericoronal
  3. Periodontal
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2
Q

gingival abscess

A

no attachment loss

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3
Q

periodontal abscess

A

associated with periodontal bone loss

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4
Q

2 periodontal infection classifications in acute periodontal conditions

A
  • gingival abscess
  • periodontal abscess
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5
Q

4 types of abscesses of periodontium

A

gingival abscess

periodontal abscess

pericoronal abscess

endodontic-periodontal lesion

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6
Q

gingival abscess

A
  • Localised to gingival margin
  • Cause trauma, food impaction, stitch abscess if surgery recent
    • Localised to gingival not associated with gingivitis
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7
Q

periodontal abscess

A

usually related to preexisting deep pocket also associated with food packing and tightening of gingival margin post HPT

  • coronal tighten
  • less flow of plaque and bacteria/toxins/neutrophil out of gingival crevice
  • gets trapped in depth of pocket causes change in environment in depth of pocket = acute infection
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8
Q

pericoronal abscess

A
  • associated with partially erupted tooth most commonly 8s (oral surgery)
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9
Q

endodontic-periodontal lesion

A
  • tooth is suffering from varying degrees of endodontic and periodontal disease co-existing
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10
Q

SDCEP definition of periodontal abscess

A

Infection in a periodontal pocket which can be acute or chronic and asymptomatic if freely draining (SDCEP)

  • Pus is oozing out – somewhere to go = no pressure building up
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11
Q

periodontal abscess effect

A

Rapid destruction of periodontal tissues, with a negative effect on the prognosis of the affected tooth

  • Chronic inflammatory process of periodontitis – many years*
  • Acute infection with suppuration – increased rate*
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12
Q

do periodontal abscessed teeth get extracted

A

yes

45% of teeth with periodontal abscess found during periodontal maintenance were extracted (main reason)

  • Suppurating, causing issues = extract
    • Benefit to extract the tooth outweighs trying to treat the recurrent abscesses
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13
Q

10 signs and symptoms of periodontal abscess

A
  • Swelling
  • Pain usually less than periapical
  • Tooth may be TTP in lateral direction rather than tapping on the top
  • Deep periodontal pocket
  • Bleeding
  • Suppuration as it is an abscess
  • Enlarged regional lymph nodes regional lymphadenopathy
  • Fever
  • Tooth usually vital problem lies in periodontium rather than pulpal space
  • Commonly pre-existing periodontal disease most common reason
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14
Q

where is the pathology here

A
  • Lower right 3*
  • Between 3 and 2 localised small swelling*
  • Not far down enough to be related to apex – periodontium*
  • Check clinical probing depth, sensibility, radiograph*
  • White lump between centrals – healed sinus, bony defect*
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15
Q

why do yuo want to carry out careful sub-gingival instrumentation short of the base of the pocket

A

to avoid iatrogenic damage

don’t want to be too aggressive

  • may remove progenitor cells
  • Down to bone – recession rather than healing (avoid going done to base of pocket)
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16
Q

SDCEP local measures of peirodontal abscess management

A
  • Carry out careful sub-gingival instrumentation short of the base of the periodontal pocket to avoid iatrogenic damage; local anaesthesia may be required.
  • If pus is present in a periodontal abscess, drain by incision or through the periodontal pocket.
    • Probe in to try and let it drain
  • Recommend optimal analgesia.
  • Do not prescribe antibiotics unless there are signs of spreading infection or systemic involvement.
  • Recommend the use of 0.2% chlorhexidine mouthwash until the acute symptoms subside.

Following acute management, review and carry out definitive periodontal instrumentation and arrange an appropriate recall interval.

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17
Q

signs of spreading infection or systemic involvement

require AB

A

Fever, lymphadenopathy, extra oral swelling – rare in periodontal abscess

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18
Q

when can systemic antibiotics be given as tx for periodontal abscess

A

Only if signs of spread and systemic effects or if symptoms do not resolve with local measures

  • Careful RSD
  • Penicillin V 250mg(preferred) or Amoxicillin 500mg 5 days
    • Narrower spectrum antibiotic – cause less resistance

Or (if allergic to penicillin)

  • Metronidazole 400mg 5 days

MUST only be used in conjunction with mechanical therapy in order to reduce the bacterial load and disrupt the biofilm

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19
Q

perio endo lesion aetiology

A

more complex

involve both pulpal tissues and periodontal tissues

Teeth often have more than one thing going on

  • Deep restorations with endodontic pins
  • Chronic periodontitis
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20
Q

endo-periosteal lesions

A

pathological communication between the endodontic and periodontal tissues of a given tooth

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21
Q

what happends to periodontium in perio-endo lesion

A

Normally periodontium is intact – cuff around the tooth

  • Coalescesd together = problem

Initial presentation – not much different – pain, swelling, suppuration, BOP

Can see access cavity through the gold onlay

Localised gingival swelling

Examine entire tooth and cause of it

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22
Q

dentine connection

A

not solid

porous substance, dentinal tubules – bacteria can go through

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23
Q

communication between periodontal and periapical tissues can be

A

microscopic or macroscopic

  • dentine
  • lateral and/or apical canals
    • caries/trauma breach pulpal space leach to PDL
    • infection via PDL breach pulpal space
  • fractures
  • iatrogenic damage
    *
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24
Q

acute perio-endo infection causes (2)

A
  • Trauma
    • Dentoalveolar – significant amount causes perio-endo communication
      • Root fractures
      • Resorption in longer term
  • Perforation
    • One cone in canal, other out of canal in mesial aspect and into periodontal tissue (iatrogenic damage)
25
Q

chronic perio-endo lesion cause

A

pre-existing periodontitis

  • slow and chronic progression without evident symptoms
26
Q

9 signs of perio-endo lesions

A
  • deep periodontal pockets reaching or close to the apex
  • negative or altered response to pulp vitality tests
  • bone resorption in the apical or furcation region
    • horizontal, apical, furcation
  • spontaneous pain
  • Pain on palpation and percussion
  • Purulent exudate
  • tooth mobility
    • reduced periodontal support
  • sinus tract
    • draining buccal or palatal to the tooth
  • crown, and gingival colour alterations
    • dark, red, brown, blue possible
27
Q

different ways of PDL-pulpal communication

A

lateral canals

furcal canal

apical foramen

perio develops to perio endo

28
Q

describe a

A

necrotic pulp has bacteria, pus, infection

rather than discharging buccally (more common) it is discharging up through PDL (left) and on the right a cervical lateral canal – discharge into PDL – pocketing

  • necrotic tooth can exude bacteria into PDL and cause inflammatory response causing increase in clinical probing depth

periodontal tx

29
Q

describe B

A

microscopic level between floor of and furcation (furcal canal) – furcation disease – see furcal pathology rather than periapical on radiograph

Periodontal tx

30
Q

descrive C

A

necrotic pulp pus oozing up through ligament – not root canal treated,

plaque mineralises becomes calculus – contaminated root surface

  • (from top down – plaque in mouth; and bottom up – apex)

impact of good root canal treatment = will not get complete bony healing because there is still plaque covering root surface

  • need endodontic treatment and subsequent periodontal treatment
31
Q

describe D

A

periodontitis is very severe – tooth unrestored, pulp vital,

perio-endo lesion because as periodontal pocket developed to the apex – pulp get infected with bacteria from pocket = detrimental impact.

Start with perio and end with perio-endo lesion

32
Q

exposed dentinal tubules

A
  • application of soluble material from bacterial plaque to exposed dentin can cause pulpal inflammation
    • normally covered over with cementum in health
  • Exposure of dentin at the cemento– enamel junction occurs in about 18% of teeth in general and in 25% of anterior teeth in particular
    • potential for ingress of bacteria and their products
33
Q

lateral and accessory canals occurance

A

30–40% of all teeth have lateral and accessory canals,

  • 17% of teeth presented multiple canal systems in the apical third of the root, about 9% in the middle third and fewer than 2% in the coronal third
    • Apical third – not normally affect by mild-moderate periodontitis
    • Contaminated with periodontal bacteria = infect pulp

study

  • Only 2% of lateral and accessory canals were associated with the involved periodontal pocket
  • Doesn’t happen often – body protection
    • Not normally result in periodontal pocket
34
Q

furcal canals occurance

A

furcation of molars may also be a direct pathway of communication between the pulp and the periodontium

  • The incidence of furcal canals may vary from 23% to 76%.
    • Not all of these canals extend the full length from the pulp chamber to the floor of the furcation
35
Q

furcal/lateral communication

A

Pulp space with cleft through the tooth – communication

  • Pulpal inflammation may cause an inflammatory reaction in the interradicular periodontal tissues.

patent small portals of exit are a potential pathway for:

  • microorganisms
  • toxic by-products

Pulp to the periodontal ligament and vice versa (non-vital or inflamed)

36
Q

apical foramen communcation

A

Main route of communication between the pulp and the periodontium

  • Non-vital tooth with necrotic contents to inflame PDL
    • Microbial and inflammatory by-products
  • Or PDL to progress to apex and bacteria to ingress cause pathology
    • portal of entry for inflammatory by-products
37
Q

perforation effect

A
  • communication between the root-canal system and either peri-radicular tissues, periodontal ligament or the oral cavity.
38
Q

possible causes of perforation (3)

A
  • extensive dental caries
    • tooth unrestorable – need ex
      • Dress the tooth – inform pt and make arrangement for extract
  • resorption
    • tooth eaten away out in our in out due to communication - not see until investigate
  • operator error
    • e.g. root-canal instrumentation or post preparation
    • Iatrogenic
    • Off course of canal
39
Q

developmental groove

what and where

A
  • invagination
  • vertical developmental radicular groove
  • Especially upper incisors
40
Q

developmental groove effect on PDL

A

If epithelial attachment remains intact, the periodontium remains healthy but if attachment is breached the groove becomes contaminated, a self-sustaining infrabony pocket can form along its entire length

  • Rapid severe localised attachment loss down length of groove
  • provides a place for accumulation of bacterial biofilm and a route for the progression of periodontitis that may also affect the pulp if it extends to the apex.

Radiographically, the area of bone destruction follows the course of the groove

41
Q

developmental groove leading to perio endo lesion

A

if attachment is breached the groove becomes contaminated, a self-sustaining infrabony pocket can form along its entire length

  • Rapid severe localised attachment loss down length of groove
  • provides a place for accumulation of bacterial biofilm and a route for the progression of periodontitis that may also affect the pulp if it extends to the apex.

Radiographically, the area of bone destruction follows the course of the groove

42
Q

2018 classification first assesses

A

endo-periosteal lesion with or without root damage

43
Q

possible diagnoses for endo-periostal lesion with root damage (3)

A

root fracture or cracking (vertical)

root canal or pulp chamber perforation

external root resorption

44
Q

prognosis of perio endo due to root damage

A

poor

45
Q

endo-perio lesions with no root damage then looks at

A

if pt a periodontitis pt

46
Q

3 grades for endo-perio lesions with no root damage and pt is/isn’t periodontitis pt

A

grade 1 - narrow deep periodontal pcoket in 1 tooth surface

grade 2 - wide deep periodontal pocket in 1 tooth surface

grade 3 - deep periodontal pockets in more than 1 tooth surface

47
Q

4 possible endo-perio lesion associated with trauma and iatrogenic factors

A
  • root/pulp chamber furcation perforation
    • e.g. because of root canal instrumentation or to tooth preparation for post‐retained restorations
  • root fracture or cracking
    • e.g., because of trauma or tooth preparation for post‐retained restorations - failed
  • external root resorption
    • e.g., because of trauma, idiopathic cervical root resorption
  • pulp necrosis
    • e.g. because of trauma
    • draining through periodontium
48
Q

SDCEP tx for perio endo lesions

A

Carry out endodontic treatment of the affected tooth (non-vital)

  • Recommend optimal analgesia.
  • Do not prescribe antibiotics unless there are signs of spreading infection or systemic involvement.
  • Recommend the use of 0.2% chlorhexidine mouthwash until the acute symptoms subside.

Following acute management of the lesion, review within ten days and then carry out supra- and sub-gingival instrumentation if necessary and arrange an appropriate recall interval

49
Q

tx sequence for perio-endo lesions

A

endo tx precedes periodontal tx

  • allow tissues to heal a bit before RSD – hopefully allow some long junctional epithelium attachment
  • but root still colonised by plaque so needs RSD

then may be necessary for

  • Surgical investigation and treatment
    • cracked, perforations, enamel pearns, invaginations etc
    • lift flap to carry out more advanced tx
50
Q

tx sequence for endodontic lesion

A

endo tx only will be sufficient to allow healing (root not colonised yet by plaque)

51
Q

possible addtional treatment for EPL

A

more abnormal extraradicular - enamel pearls, invaginations etc

  • Non surgical scaling unlikely to be successful
    • Surgical instrumentation and mechanical removal needed
  • Sometimes more advanced techniques – need special training
    • Guided tissue regeneration
    • Emdogain
52
Q

issue here

A

Tooth prev RCT

Large furcation involvement – need re RCT treated

Primarily endo lesion – redo and wait for healing to reassess

Multiple lateral canals

New RCT has lead to furcal healing

53
Q

issue here and how was it addressed

A

Moderate to severe cervical bone loss

  • Endo tx improvement in intraradicualr area – healing taken place
  • Combined lesion

Bone loss as a result of apical destruction – heal through good RCT

BUT

  • 6 months post op
    • Still deep pocketing – GP point
    • Still got ongoing suppuration to do with distal root – think of more complex interventions
54
Q

technique here

A

Open flap debridement

Bone loss limited around distal aspect

Peroration through buccal

Crater/gutter around distal root

  • remove granulation tissue and perio tx (endo done already)
55
Q

what tx here

A

localised severe walled defect

not responded to initial Endo tx alone

  • flap raised
  • granuloma removed
  • bone substitute placed to fill in gap
  • guided tissue regeneration – filler scaffold for bony healing

= reduction in clinical probing depth

56
Q

tx here

A
  • Significant distal bone loss*
  • Membrane used for guided tissue regeneration*
  • Need specialist level of skill*
57
Q

does endodontic disease affect periodontal health

A
  • When the pulp becomes infected, it elicits an inflammatory response in the periodontal ligament at the apical foramen and/or adjacent to openings of the small portals of exit
  • Non-vital tooth – detriment to perio? Yes*

study

  • endo infection in mandibular molars was associated with more attachment loss in the furcal area.
  • endo infection in molars associated with periodontal disease might enhance periodontitis progression by spreading pathogens through accessory canals and dentinal tubules.
  • endo tx successfully, the perio disease disappeared.
58
Q

does periodontal disease affect endodontics

A

Controversial, Many conflicting studies

  • no effect on the pulp, at least until it involves the apex
    • or lateral/accessory canal
    • Bacteria access through the lateral or accessory canal into the pulp causing chronic inflammation and possibly pulp necrosis.
    • If protected by cementum, necrosis usually does not occur.
      • If the blood supply from the apical foramen is still intact, the pulp will remain vital
    • if during scaling, curettage or periodontal surgery accessory canals are severed and/ or opened to the oral environment then invasion can occur

Periodontal disease on the pulp is degenerative and causes calcification, fibrosis and collagen resorption, as well as a direct inflammatory affect

BDS3 Perio (7 decks)

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