7. Cracked Tooth Perio-Endo Flashcards Preview

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Flashcards in 7. Cracked Tooth Perio-Endo Deck (29)
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1
Q

Pathways: Perforations

Prognosis
____ > Old
____ > Large
____> Crestal

  • We see a lot in clinic when people put posts in teeth w/ out rubber dam
  • Posts are over dimensional in terms of size of the RC space
  • This is how a post comes out in the middle of a palatal root
  • Post on D root with the post coming out of the RC space and perforating a root
  • surgical repair when the post was cut back and filling material was placed over to make sure it doesn’t continue w/ inflammation.
A

fresh
small
coronal, apical

2
Q

Pathways: fractures

Structure Loss: Any tooth that has a rct is more susceptible to fractures
b/c there is one connecting link b/t tooth structure loss and it fractures
all the teeth that req rct have ____ that goes to the pulp so they’ve lost tooth structure
• weaker in general to ____ forces
when we talk about restoring endodontically treated teeth most ppl recommend putting ____ on teeth in posterior area after the tooth has had endo treatment.
Less so b/c of any ____ deficiency you get from doing access prep and rct
More so b/c by the time you’ve done rct you’ve lost ____
• that overall loss is really what leads to increase risk of fracture.

A
decay
mastication
crowns
structural
tooth structure
3
Q

Pathways: Fractures

  1. Large Taper Instruments: A lot of ppl have in the past instrumented very large tapers
    • Area below the CEJ in the roots “peri-cervical” area – ____ third of root canal system and roots is particularly susceptible to fracture if ppl instrument w/ old tools that have large taper
    • Bio Race system has 4 taper prep
    • XP shaper you also kind of get 4 taper in MD directions
    • In the past when ppl used hand instruments they used gates-glidden
    burs to aggressively open up in coronal third of RC that causes a lot of taper prep
    • Why? They had to use stainless steel instruments to get around curvature
    • you had to open up in very ____ in the coronal third into the middle and weaken the tooth structure extensively.
    • We believe w/ old style instrumentation and rct you get a lot of fracture in the root they are fractured out b/c of the large ____
A

cervical
wide
taper

4
Q

Pathways: Fractures

  1. Big Ass Posts: Ppl placing posts that are too large in the teeth - you can cause a lot of fracture as well
    a. Over dimensional size of the tooth: post is too ____ to put in RC
    b. Metal posts have a diff ____ than denjn (composite reinforced posts are used more now to bond into rc)
    • every jme you bite on tooth it flexes, parjcularly if you already have a restorajon on the tooth w/ margins - buccal cusps and walls that are filled w/ regular fillings
    • When metal post is placed in tooth it works like a crowbar
    • The metal doesn’t ____ in the same way of the denjn
    • Diff b/c elasjcity modulus ____ the risk of fracture over jme
    • We want ppl to go to ____ post b/c they have a similar elasjcity modulus as denjn plus they are bonded to root canal system a
    • if we have to remove one of them they are ____ to remove in comparison to a metal jtanium or gold build up post
A
big
elasticity modulus
flex
increases
composite reinforced
easy
5
Q
  • Fracture associated w/ extremely ____ root canal prep
  • you see that it’s tapered and is gates-gliden
  • looks like a boQle neck
  • weakens quite a bit
  • ____ shaped lesion around the root
  • shows what fracture looks like aSer it has split the root
  • Fairly large ____, retreatment of exisTng rct that was instrumented larger than it was before
  • Fracture in palatal aspect of the palatal root

• They explored w a raised flat to look at the root, you can see it stained with ____, in this case the pic isn’t stained but you can see the fracture line that goes
down the root

A

tapered
C
instrumentation
methylene blue

6
Q

Periodontal effects on the pulp

Majority of studies do not suggest a correlation between the ____ status and that of the ____.

A

periodontal

pulp

7
Q

NO:
• Protective Action of Dentinal Fluid Flow: remember when we said if we have ____ pulp we have a pulp tissue pressure
• this will create a continuous ____ of dentinal fluid in the tubule
• if it is opened from the outer aspect of the root.
• Bacteria have a hard time getting into the tubules if there is
a ____ pulp tissue that continuously provides the outward dental fluid that they have to swim upstream to say they can’t get into the tubule.

• Immune Response of the Pulp: there is an immune system that protects the pulp if there is only a very ____ number of bugs going into the tubule.
• We know the tubules are large enough to let bugs get through but
that’s why these ppl say it protects from perio pockets and disease to affect the endo rc space and pulp going through tubules even if you have cemento-enamel defects.

A

vital
outflow
vital

small

8
Q

YES:
But if you have pulp that is compromised (this is where the YES group
comes in) there can be an affect form perio system to root canal system

Inflammation/Resorption:
• If these take place from outside it destroys the ____ and allows easier access into root canal system
• b/c you don’t have tubules anymore and
• have destruction that gets from outside to inside.
• the more probable reason for this if you have a pulp that
isn’t ____ anymore
• Ex pulp already affected by another disease like
some irreversible pulpitis going into pulpal necrosis
to pulp dying off - the immune system is ____
• Ex or if you have an aging pulp (more calcifications
and aprofic areas - ____ immune system
• the pulp may not be able to provide consistent dentinal
outflow through the tubules, bugs can get in and take over resistance of pulp.

Each of these aspects have some ____ to it

A
dentin
healthy
weaker
diminished
truth
9
Q

Pathways: developmental anomalies

Developmental grooves
Max incisors:
____ > central

Enamel projections
32.6% in ____

____ (51.0%)
> ____ (45.6%)
> ____ (13.6%)

A
lateral
molars
ma 2nd
max 2nd
max 1st
10
Q

Pathways: developmental anomalies

• Palatal grooves
• we see these once in a while and can’t do anything about
them

• Deep longitudinal groove
• ____ in lateral incisors in maxilla (they most often occur
here)
• ____ probing seen and it appears there is a vertical fracture
• it is narrow w/ probing
• Not typical generalized perio disease where we would have sloped craters,
• it might look narrow and deep
• Might mimic root fracture

• How do you find out if this is perio disease or if it’s something related
to endo disease?
• Student answer:
• ____ testing
• ____ testing
• make sure the pulp tissue in the pulp is alive
• Put cold test and see if it reacts
• In degenerating pulp in old pt if you don’t get a response what would you do?
• ____! - if cold doesn’t help try EPT it picks up more issues

• Enamel projections
• sometimes they have spawns coming out from enamel
• might be pearls or projections but they are anatomical variations that can cause perio disease
• Why? b/c it’s ____ for pt
• might continue to progress perio disease down into apical
portion of root
• you may think it’s endo-perio related disease but in reality it’s
pure perio if you did histology

A
vertically
deep
vitality
sensitivity
EPT
uncleanable
11
Q

Classification: Simon 1972

Endodontic Lesion
- (periodontal involvement) ->
Endodontic Lesion with Secondary ____ Involvement

Periodontal Lesion
- (periodontal involvement) -> Periodontal Lesion with Secondary ____ Involvement

  • We may often mistake cases where you have deep ____ and pulp ____ for a combination of both diseases
  • BUT…in reality you only have endo disease that has ____ associated that goes through perio ligament space.
  • Lots of ppl shooting from hip (Joanna: meaning they are guessing and making shit up) and call it endo/perio lesion
  • that is the most common reaction to get if you have deep probing on tooth or negative pulp vitality or pulp necrosis or you would have an existing rct when you go to restorative department

• Might be just endo disease w/ a drainage pathway not in form of a sinus tract going through the buccal mucosa but actually going through ____ space, and that’s why you have a deep probing
But we still have to teach this crap b/c its coming on the boards

A

periodontal
endodontic

probing
necrosis
sinus tract

perio ligament

12
Q

• Idea is you have isolated endodontic lesions
• very distinct from true periodontic lesions
• Then remember you have pathways that might connect the endo and
periodontium, you have endo lesions plus a perio involvement that gets you to an endo lesion w/ a secondary perio involvement

• Most of the time this is really just a tooth w/ an endo disease and a ____ going through ____ space and not true perio involvement
• What might be and indication where you have endo disease on tooth plus perio disease if you have deep probing on tooth (other than just gently sloped craters)?
____

  • If you can visualize that there is concrements + plaque which are another indication for perio disease then you have true perio involvement
  • But when you just have a deep probing and the diagnosis of endo disease then you actually probably just have ____ disease
  • we commonly mislabel them as “endodontic disease w/ secondary perio involvement” b/c that’s how this ancient classification was actually going about
  • Then you have the other way around, perio disease w/ the idea now that the pulp can be affected by microorganisms in perio ligament space and you get a perio lesion w/ secondary endo involvement.
A

sinus tract
perio ligament
calculus and plaque
endo

13
Q

Endodontic Lesion

Characteristics

Tooth \_\_\_\_
\_\_\_\_ pulp/ Hx of root canal treatment
\_\_\_\_
Radiolucency at the apex
\_\_\_\_ sensitivity 
\_\_\_\_ of pulpal origin
!Gingival Sulcus or Fistula
  1. TRUE ENDO LESION
    take an xray and you see apical periodontitis located around the apex of the root

Tooth Mobility:
• Typically a tooth mobility should be ____ if pt doesn’t have any other perio disease
• In the end perio will lead to tooth mobility
• If you have mobility of 0-1 it’s low, not typically a hint that you have true perio involvement other than having one pocket

Necrotic pulp/Swelling/Radiolucency:
• something has been going on for you to assume that the ____ seen on xray is truly coming from root canal system.
• Might be a ____, radiolucency apex.

A

mobility
swelling
percussion
sinus tract

little
radiolucency
swelling

14
Q
  1. True Endo Lesion

Percussion Sensitivity:
• Could be the case for perio abscess will typically be located more in the cervical area of the root
• In this case it’s apically - if the tooth has percussion sensitivity that goes w/ ____ disease.

Sinus Tract:
• You night have ____ of origin
• that might be the deep pocket going down into the tooth or
• you might even see it coming out of the gingival sulcus or “fistula” < we
shouldn’t use this it should be sinus tract.
• The trick is that you should have ____ pulp vitality.

Is there is a scenario where you might have positive response to pulp test and you still have endo disease and it would be endo not perio?
• YES - ____!!!
• Vitality in one root and the other root might have apical periodontitis
• the decay might have been located in distal or mesial roots.
• Now the D is necrotic and M still has vital pulp tissue
• so you might have to explore more in terms of diagnostic means to
figure out if it’s endo or perio
• Then it becomes more important if you see generalized bone loss on pt or if you have calculus etc.
• these scenarios exist but this (pic on slide) is clear b/c you have a one
rooted tooth.

A

endo
sinus tract
negative
multi rooted tooth

15
Q

Periodontal Lesion

Characteristics
Chronic periodontitis 
Wide \_\_\_\_
Radiographic bone loss \_\_\_\_ pulp
Plaque / calculus
Previous \_\_\_\_ treatment
  1. TRUE PERIO LESION
    • Striking reason number one: Wide Probing
    • ____ bone loss all over the place for that pt not just an isolated
    pocket
    • furcation is something in this area which - might not be all the time for
    perio disease (this could also be endo origin)
    • ____:
    • then you have calculus that’s a typical sign.
    • Not everybody w/ perio disease has calculus b/c they may have just
    come from ____ appointment
    • important to talk to pt to see if they have these
A

probing
vital
periodontal

generalized
calculus
hygiene

16
Q
  1. TRUE PERIO LESION

• Chronic perio, wide probing, xray bone loss, ____ pulp!
• But of course there can be teeth that have been ____ treated that have perio disease.
• This is a gray area, most important hardest thing for something moving from lecture to clinic b/c it’s the art of diagnosis
• Over time you have to make use of all the info at hand to come to diagnosis what’s the truth of the symptoms to figure out the disease the pt is presenting
w/

A

vital

root canal

17
Q
  1. TRUE PERIO LESION

• This might not always be conclusive: he saw a pt that was in pain since 2 weeks someone prepped a crown
• they have symptoms that don’t make sense
• they have ____ pain indicating tooth grinding
• might have some idiopathic neuro pain, some endo disease, irreversible pulpitis
• after the crown was prepared and the tooth going through mechanical
inflammation from the trauma
• Then they tell Setzer 4 yrs ago I had same treatment on the right side
and I was in pain for 4 weeks and then it was just gone
• Hard to come to conclusion and sometimes only helps if you see them
twice
• he’s gonna see tomorrow if it’s truly irreversible pulpitis in 19 or just grinding from TMJ
• Plaque, calc previous perio all needs to go into information but…
• ____ Pulp: the top issue is pulp vitality
• Perio Lesion will have ____ pulp - unless ____ - one root would show
apical periodontitis and the others may be vital (from a couple slides back)

A

tmj
vital
vital
multirooted

18
Q

Endodontic Lesion

Endodontic Lesion with Secondary Periodontal Involvement

Characteristics
____-standing pulpal pathosis
- Periapical drainage becomes ____
Superimposition of ____ ____ periodontal defect

A

long
chronic
plaque/calculus
localized

19
Q
  1. ENDO LESION W/ SECONDARY PERIO
    • This is a typical tooth that’s gonna be labeled this primary endo secondary perio (or endo/perio lesion - they call it this in restorative dept)
    • He saw this pt 15 years ago
    • She came from restorative and wanted to
    keep it longer b/c they wanted to take 18 out and also 21 out and place implants
    • but the pt was running out of money b/c they already took teeth out in the other 3 quads so she couldn’t afford anymore treatment
    • Everyone thought it was true endo/perio lesion but in reality what we see is ____ loss from true ____ disease from pulp necrosis that happened in that situation.
    • Very often this might be something that’s associated w/ long standing ____ pathosis that took a long time to develop and it was necrotic for quite awhile
    • Then you see establishment of this type of ____
    through this sulcus like we have over here
    • Saying localized perio disease might be the wrong word (it
    could be if this was truly secondary perio involvement might add to it in the end) but we’d rather call it concomitant lesion
A

bone
endo
pulpal
sinus tract

20
Q

Periodontal lesion

with secondary endodontic involvement

Characteristics
History of extensive ____ disease
Plaque ____
Pulp may be ____

A

periodontal
formation
necrotic

21
Q
  1. CONCOMITANT LESIONS

• But there is definitely cases where someone has pulp necrosis and apical periodontitis AND perio disease
• that’s not uncommon
• it’s a situation where one doesn’t effect the
other
• Just means you have tooth where pt has
____ perio disease and perio disease on
the one tooth and…
• now that tooth also gets pulp ____
• If you have that situation its concomitant lesions
• At the same time you have marginal breakdown of ____ tissues PLUS you have ____
that’s related to endo disease.
• 5th category of Simon’s classification, concomitant
lesion existing at the same time.

A

generalized
necrosis
perio
apical periodontitis

22
Q

Marginal periodontitis
____ debris
bacterial ____
____ irritants

____ periodontitis

• So you have microbes moving in here
• perio disease and you have microbes coming out
b/c of the endo disease.

A

necrotic
byproducts
roxic
retrograrde

23
Q

Concomitant lesions

Characteristics
Endodontic disease + periodontal pocket
\_\_\_\_ pulp
Endodontic &amp; Periodontal conventional &amp; surgical treatment
Prognosis \_\_\_\_
  1. CONCOMITANT LESIONS
    • So you have both entities present:
    • endo (necrotic pulp) + perio pocket
    • This would be a fair prognosis b/c there is a lot of things going on w/ the tooth at the same time
    • Most of the time the issue w/ actually keeping the tooth for a long time is due to the ____ aspect of the tooth
    • Rct has a very high chance to heal the apical periodontitis - at least for ____ - even if the lesion doesn’t go away 100%.
    • The chance someone keeps tooth after endo is like 97% for 10 years – ooo baby!
    • But if you have someone w/ generalized perio (so already pockets of 6+ mm) it’s more difficult to control
    • especially if pt has risk factors:
    • ____
    • genetic predisposition to ____
    • if they aren’t following up w/ hygiene and
    not removing plaque that’s building up
    • There are things that have a much bigger impact on
A

necrotic
fair
perio
functionality

24
Q

And now we have #6 in Simon’s classifications, it’s a true combined lesion, and this is essentially when you have an endodontic disease with a larger ____ and at one point, the existing ____ disease is truly connected together with an apical periodontitis

Essentially, apical periodontitis gets so large that periodontal pocket gets so deep that at one point it just happily moves in ____.

So now we have a real problem because now you have an infection coming from the periodontal space going down into the apical region, or the infection comes up from the apical periodontitis

A

apical periodontitis
periodontal disease
together

25
Q

True combined lesion

characteristics

  • endodontic disease + deep periodontal pocket
  • pulp may be ____
  • endodontic -> periodontal
  • ____ & surgical treatment
  • prognosis guarded

Before we move on, for the concomitant lesion, the only time we can diagnose that is radiographically if you can see distinct separation between them. Well it’s more than just radiographically, you would do a cold test, probings around the tooth, etc, everything goes together and you’ll make a ____-fold diagnosis, one for endo and one for perio for the tooth.

But you wouldn’t see something like a a J-shaped connected lesion? ____ that’s not at this point. At this point, you cannot probe this. If it’s one lesion that truly exists at the same time, aka a true combined lesion but it’s now connected, you can take a perio explorer and go all the way down to the ____.

It’s a good point to say, if you have a perio and endo concomitant lesion, you ____ be able to probe down to the apex of the tooth because they’re not connected at this point.

A

necrotic
conventional
No

root tip
won’t

26
Q

Diagnosis and Treatment
Periodontal Probing

Probing
____ discrimination of the level of the epithelial attachment

Sounding (+ local ____)
penetrating through the attachment to define the most ____ level of the alveolar bone

So sometimes it’s difficult to see if they’re connected when you do periodontal probing, and the reason for this is because it’s painful if you have a deep pocket and you want to probe this on the patient

When you can do is that you can anesthetize the pt and probe under anesthesia. Typically when you do a probing with the pt, you are actually just probing to the ____ and this already is not pleasant particularly if you have slight or severe inflammation on the tooth and soft tissues.

If you really wanted to probe down and see if there is a true connection between the perio lesions and the apical periodontitis, you would really have to put some ____ behind that probe and see if you can get to the apical portion, and because this is painful you need ____ the pt, then you can do what is called sounding.

A

tactile
anesthesia
coronal

epithelial attachment
apical portion
anesthetize

27
Q

Endodontic lesion

Vitality Test (____)
Probing (____) Percussion/Palpation (____) Minimal to no ____ (Tracing of a ____)
Radiolucency confined within ____
Root canal treatment ____ Prognosis

A
-
narrow
\+/-
calculus
sinus tract
bone
excellent
28
Q

Periodontal lesion

Vitality Test (____)
Probing (____) Percussion/Palpation (____) Plaque/ calculus
____ evidence of
crestal/ generalized bone loss
Periodontal treatment ____/RP or surgery or extraction

A
\+
wide
plaque/calculus
radiographic
scaling
29
Q

Sounding is when you go beyond the ____ and probe or sound down to the bone level and the bone crest that you have, and this something that is impossible to do without anesthesia because otherwise the pt
will feel too much pain.

Don’t do this as your first test bc if you numb up the patient and think oh I should have done the cold test, it’s too late, so this would be one of the ____ things you want to do. One of the things that people sometime forget in restorative clinic, they sent the pt over and said “oh we numbed up the pt because they were in pain” k thanks because now all of our tests don’t work, we can’t do a cold test, there might not be percussion, etc if the pt is numb.

All of these tests should be done before the pt is ____, If you have to do a sounding, it has to be the last test because you have to numb the pt and make it so you can’t do any of the other tests.

A

epithelial attachment
last
numb