W8 - Interdisciplinary Perio Part 2 - Sharma Flashcards
What are the 3 main pathways of perio/endo pathology
How can the dentinal tubules be exposed iatrogenically?
Aggressive root planing
4 types of endo-perio lesions
this is prior to 2017 classification
Anatomical entities responsible for endo-perio lesions (6)
Lingual grooves
fractures
Root anomalies
Intermediate bifurcation ridges
Cervical enamel projections
Trauma-induced RR
How are perio-endo lesions described?
Primary _____ secondary ______
depends on what happened first
Can also be a true combined lesion (when hard to say what happened first)
What is the modern (2017+) endo-perio lesion classification
What determines a hopeless prognosis for a tooth with endo-perio lesion
EPLs associated with trauma or iatrogenic factors
(ex. perforation)
What determines a poor or favourable prognosis for a tooth with endo-perio lesion
EPLs associated with endodontic and periodontal lesions and depends on extent of periodontal involvement
- (vs epls associated with trauma or iatrogenic factors which will have poor prognosis)
Describe the effect of pulpal disease on periodontium
If vital → no effect
Necrosis → bone resorp, PARL
3 endo procedures that can affect periodontium
Extirpation
Cleaning and shaping
Vert root fracture during obturation or post placement
How does periodontium get affected by endodontic shaping? (3)
Debris pushed into PFL
extension of files or filling materials
perforation of the pulp chamber floor
periodontal procedures that can affect pulp
Deep curettage → damage apical vessels
Scaling/debridement → remove cementum leading to open dentinal tubules and possibly lateral canals
How does a primary endodontic lesion present? (3)
Necrotic pulp with CAP and sinus tract that drains through the sulcus
Radiograph reveals isolated perio defect around individual tooth
no associated generalized perio
Investigations for primary endodontic lesion (2)
Negative pulp vitality test
Tracing tract with GP (leads to apex or mid root if lateral canal)
Treatment of primary endo lesions? Prognosis?
No debridement needed
RCT
Great prognosis → rapid and complete healing (3-6 months)
How does a primary periodontal lesion present? (3)
May mimic an endodontic problem clinically and radiographically
Minimal - no pain with perio lesions
If it is painful, there may be coronal fracture that extends into PDL
Clinical tests for primary periodontal lesions (2)
Periodontal pocket reaches apex
pulp testing is within normal limits (vital)?
Treatment of primary periodontal lesions (3)
Periodontal therapy
RCT NOT INDICATED (unless pulp vitality changes)
Reevaluation after therapy to check for possible retrograde endodontic lesion
Prognosis of primary periodontal lesions after treatment
Depends on quality of periodontal therapy
- Teeth with perio attachment loss to the apex = not favourable prognosis
Differential diagnosis of true combined lesion
Vertical Root Fracture
Clinical tests for True Combined Lesion (3)
tooth not vital
Deep perio pockets at multiple sites around tooth
Radiograph with multiple gp points into sulcus tracing to apex
Tooth is necrotic
primary endodontic lesion
- note the isolated perio problem and sinus tract
36 pocket extends to apex
primary periodontal lesion
What is a Primary endodontic lesion with primary periodontal involvement?
Vitality?
Features?
Tx / prognosis?
Primary endodontic lesion with an independent periodontal lesion
- Perio pocket does not extend up to the PA lesion
- Tooth not vital
Tx: endo AND perio therapy
Prognosis of endodontic component is excellent but most be done with periodontal treatment otherwise limited healing of attachment apparatus
What is primary periodontal lesion with secondary endodontic involvement? Symptoms?
- Periodontal involvement extends to apex of tooth and causes retroinfection of pulp
- Possibility of severe pain
2 causes of primary periodontal lesion with secondary endodontic involvement?
infection of pulp from lateral canal exposure due to periodontal pocket
Dental abrasions from debridement causes exposure of tubules which may contribute to pulp death
primary periodontal lesion with secondary endodontic involvement
Perio status?
Vitality?
Tx?
Prognosis?
Pt will have generalised periodontitis
Vitality will be mixed depending on severity - may be sensitive to cold
Tx: perio therapy in conjunction with RCT
Prognosis depends on perio therapy → favourable endodontic prognosis will only be obtained when tooth is in a closed/protected environment. Thus the PA lesion healing response is unpredictable
What is a True Combined Lesion?
Lesion that forms when separate pulpal and periodontal pathoses develop independently and unite
True combined lesion
Perio status
Vitality
Features
Radiographic appearance
significant periodontal involvement
Non vital
Tooth will have deep perio probing depths at multiple sites
radiograph to be taken with multiple gutta percha points in sulcus tracing them to apex
Treatment of True Combined Lesion (3)
RCT
Perio therapy (initiated before, during or immediately after endo tx)
Possibly hemi-section or Root resection
Prognosis of True Combined Lesion?
dependent on the perio therapy
- the greater the periodontal involvement, the poorer the prognosis
How long after endo treatment (EPL) should you review tooth for and decide if you need graft?
6 months
Pic is of primary endo lesion that healed with endo tx only
what are three alternative treatment modalities if EPL treatment is unsuccessful?
(ex. file fracture)
Root amputation in maxillary molars
Hemi section for mandibular molars
Extraction
What treatment should be done first in EPL
ENDO
- Must decide if tooth has good restorability first → otherwise extract
