Further Complications Flashcards by sophie rosen

Complicating Factors:
(3)

ENDO & PERIO
Fractures & Cracks
Resorption

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REGULARLY: ANY combination of multiple challenges to a tooth will
(3)

Increase the Difficulty *
*Reduce the Prognosis *
Limit the Outcome of TX *

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INVOLVEMENT of Endo and Perio in the same tooth :
(2)

LESSER PROGNOSIS than either disease ALONE
PERIO involvement is almost always the LIMITING FACTOR

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Now you need Endo Pulpal & Periapical Dx but ALSO

a Periodontal Dx
and some idea of the Periodontal Prognosis BEFORE you begin any Tx.
Helpful to know what came 1st (Endo or Perio)

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Remember: Periodontal health, function
& stability is one of the Basic
Requirements for any tooth being
considered for Endodontic Tx.
Also (2)

RESTORABILITY & ESTHETICS

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Dental Pulp intimately associated with
Periodontium and vice-versa:
(2)

Pulpal path. can infect periodontium
Periodontal path. can infect pulp

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nterchange occurs via multiple pathways or
following therapeutic procedures:

Apical foramen #1 (Natural or Procedural)
Accessory or lateral canals
Dentinal Tubules/Caries
Areas of cemental agenesis
Resorptive defects
Tooth Cracks or Fractures
Following SRP & other periodontal &
surgical procedures

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Lateral canals are
significant because they

allow pulpal disease to
extend directly to
periodontal tissues.

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Pathways of Communication:
#1: — : most
direct/common pathway*

Apical Foramen

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Irritants from involved pulp may pass
through apical foramina into
periradicular tissues via

inflammation or infection extension
or during endodontic procedures

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Irritants from periodontal
inflammation/injury /procedures may
pass through

apical foramina or
accessory (lateral) canals and directly
invade the dental pulp.

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Pathways of Communication
Lateral (accessory) Canals
Irritants from plaque that reach periodontal
tissues around lateral/accessory canals may
initiate
Lateral canals may be — + wide; bugs are @ —

inflammation in pulp followed by necrosis.

50um
.5-1um

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Lateral (accessory Canals)
– Irritants from diseased
pulp may pass through
lateral canals into
periodontal tissues
– This Lateral canal IS visible on XR
– Most often lateral (accessory) canals
are NOT visible radiographically but
are discovered following obturation.

(somewhat common) —% incidence In molars

23-76

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Other Pathways of Communication
* Areas of cemental agenesis or loss:
– Cementum is a natural
– —% may have a VOID @ CEJ)
– Any void of cementum (or enamel) via agenesis, injury or aggressive SRP will

protective barrier
18-25

expose dentinal tubules & pulp to attack from micro-organisms.

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Areas of cemental agenesis or loss:
– Cementum is a natural protective barrier
– 18-25% may have a VOID @ CEJ)
– Any void of cementum (or enamel) via agenesis,injury
or aggressive SRP will expose dentinal tubules
& pulp to attack from micro-organisms.

(6)

-Tooth brush Abrasion
- Erosion
- Bulemia & other destructive habits
- Bruxism
- Trauma
Toothbrush Abrasion

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Cementum is
thinnest or
missing at —

CEJ

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IATROGENIC Pathways of Communication

Problems we create as Endodontic Perforations or Post perforations

PROGNOSIS
SUFFERS

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Note the MULTIPLE EASY PATHWAYS
between pulp and periodontium.

You are NEVER dealing with PULP or
PERIODONTIUM alone. Both must be a
CONSIDERATION in ALL TREATMENT

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ny anomaly or injury providing access to the
dentinal tubules also provides noxious access to
the pulp.
If the anomaly or injury is apical to the
gingival attachment,

both the Pulp and
Periodontium are involved.
Prognosis decreases ***

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Why is it that prognosis
decreases significantly with
any perio involvement ?

We know that most
properly selected endo will
have 90+ percentage
success (largely regardless
of the cooperation of the
patient)
Perio success, on the other
hand, depends largely upon
the ability to motivate the
patient to take care of their
shortcomings which were
responsible for the perio
disease in the 1st place.

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BEST PROGNOSIS
of the 5 Categories*
(no Perio)

Pure Endo: Primary Endo Lesion

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Pure Endo: Primary Endo Lesion
Pulpal injury initiates forthcoming

A Drainage Tract originating from the apex or a lateral
canal may form along the root surface and exit via the
gingival sulcus. This is

LEO. Extension
of the pulpal inflammation procedes to the canals,
out the apex and irritates the periodontium (P/A
tissues) creating periodontal disease and loss of
bone.

NOT a true perio pocket. Also is
NOT a classic Draining Sinus Tract (DST) but it serves the
same purpose of draining the lesion (via the Sulcus)

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Pure Endo: Primary Endo Lesion
CLUES:
Clinical Pulpal DX indicates —
Often a — Onset + evidence of —
In molar teeth, the — area may appear to have significant bone loss.
Minimal to no — & no evidence of generalized or advanced —
Tooth mobile or exhibits a —
Swelling present in the — and tooth sore to (2)

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Necrotic Pulp
Rapid, pulpal damage (caries, trauma, etc.)
furcation
calculus, periodontitis
narrow channel sinus tract (perhaps via sulcus)
attached gingiva, biting or chewing.

Pure Endo: Primary Endo Lesion
With this Dx:

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RCT ONLY is
indicated.
Sinus tract & furca
should heal w/o Tx
following RCT
Do not curette
furcation region or
use caustic,
inflammatory
medications in the
pulp chamber.

3. Pure Perio: (Primary Perio lesion) Prognosis totally dependent upon

perio. Tx success and motivation of patient.

3. Pure Perio: (Primary Perio lesion) Clinical & radiographic assessments indicate

generalized, moderate to deep bony pockets (cone shaped and wide) Calculus present Diffuse inflammation Asymptomatic patient & pulp responds to sensibility testing WNL

3. Pure Perio: (Primary Perio lesion) CLUES: Clinical Pulpal Dx indicates --- No deep --- nor other significant pulpal injury Evidence for the presence of periodontal disease with (3) present.

Normal Pulp (VITAL) caries vertical bone loss, Inflamed soft tissue and calculus

3. Pure Perio: (Primary Perio lesion) When this Dx is determined:

TX is limited to Periodontal Therapy ONLY with the prognosis dependent upon the ability to remove the causative factors and the patient's ability to achieve meticulous self-care practices.

2. Endo-Perio: (Primary Endo with 2ndary Perio Involvement) prognosis

Guarded to poor prognosis due to perio.

2. Endo-Perio: (Primary Endo with 2ndary Perio Involvement) (3)

Look for some unusual deep pockets Little or no calculus in pockets No generalized perio condition

2. Endo-Perio: (Primary Endo with 2ndary Perio Involvement) CLUES: Clinical Pulpal Dx indicates Evidence for the presence of periodontal disease with (3) Radiographic changes in the pulpal space visible with ---

Necrotic Pulp vertical bone loss, Inflamed soft tissue and little or no calculus linear or isolated calcific changes

2. Endo-Perio: (Primary Endo with 2ndary Perio Involvement) When this Dx is determined:

Both RCT & Periodontal Tx are indicated. Simultaneous management of endo and perio is preferable. If pulp is necrotic, RCT is 1st, then perio. Prognosis for resolution is dependent upon ability to treat BOTH entities successfully

4. Perio - Endo: (Primary Perio lesion with 2ndary Endo Involvement) prognosis

Guarded to poor prognosis due to perio.

4. Perio - Endo: (Primary Perio lesion with 2ndary Endo Involvement) Clinical & radiographic assessments indicate

broad- based probings, vertical & possible apical or lateral bone loss. Infection from the deep perio pocket invades the pulpal tissue via the apical foramen & causes pulpitis Symptoms acute & history of previous extensive perio TX

4. Perio - Endo: (Primary Perio lesion with 2ndary Endo Involvement) CLUES: Clinical Pulpal Dx indicates --- Tooth often may have or needs --- Evidence for the presence of

SIP or Necrotic Pulp extensive restoration periodontal disease with vertical bone loss, Inflamed soft tissue and calculus present.

4. Perio - Endo: (Primary Perio lesion with 2ndary Endo Involvement) TX

Successful TX is RCT 1st followed by and dependent upon the ability to remove the causative factors for both periodontal disease and the patient's ability to achieve meticulous self- care practices once the RCT has been successfully performed.

5. “True” Combined Lesion: (RARE Combined or Concomitant Perio & Endo involvement) prognosis

Probably the poorest prognosis of all types (especially if associated with a VRF = hopeless)

5. “True” Combined Lesion: (RARE Combined or Concomitant Perio & Endo involvement) Clinical & radiographic assessments indicate... Communication with... Symptoms may be... Probing may reveal...

broad based probings & intraboney perio pocket an isolated peri-radicular lesion of pulpal origin (same as 4. but both lesions develop at the same time) acute or chronic (if present – due to pulpal inflammation) vertical fracture (generally TE)

5. “True” Combined Lesion: (RARE Combined or Concomitant Perio & Endo involvement) CLUES: Clinical Pulpal Dx indicates --- Tooth often has or needs --- or has suffered --- Evidence for the presence of...

Necrotic Pulp extensive restoration, trauma periodontal disease with vertical bone loss, Inflamed soft tissue and calculus present.

5. “True” Combined Lesion: (RARE Combined or Concomitant Perio & Endo involvement) TX

Perform RCT first to manage acute symptoms (if any). Treat periodontal concomitantly. Successful TX is dependent upon the ability to remove all causative factors for periodontal disease and the patient's ability to achieve meticulous self- care practices once the RCT has been performed

HINK ABOUT IT: * As a result of common pulpal-periodontal communications & interactions: (2)

– Given sufficient TIME & adequate NEGLECT, many endo infections can progress to develop a perio component. – Given sufficient TIME & adequate NEGLECT, many perio infections can progress to develop an endo component.

--- is one of the best means to differentiate endodontic from periodontal pathosis.

Pulp sensibility testing

The more time that passes; the more

difficult & confusing the Dx.

Pulpal Inflammation impact on Periodontium Acute or chronic? Symptoms? XR Pocket

* Process Rapid & Acute * Pulpal symptoms often present * Radiographic appearance of extension to the periodontium usually an Isolated Finding * Pocket narrow, drop-off, no calculus

Periodontal Inflammation impact on the Pulp Acute or chronic? Pulp undergoes.. Symptoms? Disease? Pocket

* Process Chronic * Pulp undergoes Slow Degeneration * Pulpal symptoms usually absent * Generalized periodontal disease usually present * Pockets Wide base,Cone- shaped, usually calculus present

DIFFERENTIAL Dx: Fractures (3)

VRF (Often invisible on XR) * HRF (Commonly visible on XR) * Developmental Groove (Dens en Dente)

DIFFERENTIAL Dx: Resorption 2

internal external

INTERNAL RESORPTION is routinely and successfully treated with

RCT (if NOT perforating)

Invasive EXTERNAL (of several types) resorption has been treated by several methods;

None have routinely predictable successful outcome . . . over time.

ENDO ONLY except perforating Think of IRR as a change in the nature of

PULPAL dendritic cells into clastic cells resulting in damage to the internal tooth structure (W/O PROPER REPAIR)

ENDO & PERIO Think of ERR as a change in the nature of

PDL cells which causes largely osteoblastic cells to activate –clastic cells resulting in damage to the external tooth structure (W/O PROPER REPAIR)

It’s IMPORTANT to determine if you are dealing with Internal or External Resorption* * IRR: (arises in the PULP cells) – Usually... – A --- & well circumscribed lesion arising in the pulp which... – --- defect: well-rounded with smooth borders, integral with pulp – Regardless of the angle exposed, radiographic lesion... – Unable to --- lesion on exterior of tooth (unless perforating) – Lamina dura and PDL...

asymptomatic VITAL PULP (found on XR) symmetrical, disrupts the normal architecture of the canal. Internal always remains centered on the root unless perforating to the facial or the lingual. probe intact around entire root surface(unless perforating)).

ERR: (arises in the PDL cells) Pulp is often --- A lesion which occurs on the --- surface of the root Often may be detected by... An irregular shaped lesion arising in the --- which... Lesion “MOVES” as the --- angulation of the X-ray is changed. Lamina dure and PDL ---.

Necrotic external an explorer on the exterior root surface PDL, does not alter the normal architecture of the canal horizontal disrupted

Other types of ERR (External Root Resorption): (3)

* Surface ERR (Self-limiting, Not discovered clinically) IGNORE * Chronic Apical Inflammatory ERR (Cratering of root apex – acknowledge, shorten prep and obturation) Expect good outcome. * Replacement ERR

* Replacement ERR

(Follows severe trauma (Avulsion/Intrusion), Resorption occurs, Loss replaced by Bone) Creates Ankylosed & Submerged teeth. Often unsuccessful; Consider as a “Temporary Measure” only.

Treatment of Resorptive Defects:: (3)

* All resorptive defects require CBCT for evaluation. REFER anything you are uncertain about Dx or Tx. REFER ALL RESORPTIONS at least for an Opinion

TAKE AWAY* RCT is difficult enough by itself: 42 ADD ANY OTHER ISSUE with the tooth or the patient . . . (AAE RCT difficulty form) --- INCREASES --- DECREASES

DIFFICULTY PROGNOSIS

Further Complications Flashcards

(57 cards)