EndoPerio Inter relation Presentation
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Transcript of EndoPerio Inter relation Presentation
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Endodontic Periodontic
Considerationspresent
ed by:
Mashael Foudah
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Endodontic Periodontic
Considerations
presented by:
Mashael Foudah
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Relationship between endodontics &periodontics
Effect of endodontics on
periodontics
Effect of periodontics onendodntics
Classification of endo-perio lesionsDiagnosis
Treatment & prognosis
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Endodontic–periodontallesions present challenges to
the clinician as far asdiagnosis, prognosis and
treatment.
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The dentalpulp and
periodontaltissues are
closely related.three main
avenues forexchange ofinfectiouselements
between thetwo
compartmentsare created by :
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De Deus 1975Vertucci 2005
(1) dentinal tubules(2) lateral and accessory canals(3) the apical foramina
+ Non-physiologic
Pathways
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Endodontic disease and theperiodontium
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Developmental Trauma Iatrogenic
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Developmental
Trauma
Iatrogenic
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-4- Inadequate endodontic treatment
- 3- Coronal leakage
- 2- Trauma
- 6- ResorptionsNon-infective infective
- 5- Perforations
- 1- Developmental malformations
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-4- Inadequate endodontic treatment
- 3- Coronal leakage- 2- Trauma
- 6- ResorptionsNon-infective infective
Transient
Pressure-induced Chemical-induced
Replacement
Extracanal invasive
- 5- Perforations
- 1- Developmental malformations
Internal
External
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PIRR EIRR
Andreasen (1981) classification:
* Replacement resorption* Surface resorption
* Inflammatory resorption
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PIRR
EIRR
= Transient
= Extracanal invasive
* Surface resorption
= External
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-1-Provide a nidus for accumulationof bacterial biofilm and an avenue
for the progression of periodontaldisease that may also affect thepulp.
PGG
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concussion
SubluxtionluxationAvulsion
Intrusion
-2-Trauma
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Vertical root fracture
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1. loss of tooth structure and loss of fracture resistanceafter overzealous root canal preparation and subsequent
restorative procedures leaving thin dentin walls.
2. Notches, ledges, and cracks induced by root canalpreparation, root canal filling procedures, and seating
of threaded pins and posts.
3. teeth serving as terminal abutments in cantilever
bridges
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Molars and premolars appear moreoften affected than incisors and canines
Clinical signs and symptoms
associated with vertical rootfractures vary hugely
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- pronounced pain and abscess
formationtenderness on mastication with
mild dull pain and discomfort
- Sinus tracts may emerge- narrow, local deep periodontal
or
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Radiographic signs:
- Lateral radiolucency along oneor both of the lateral root surfaces
- Thin halo-like apical radiolucency
- Widening of the PDL
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Often the diagnosis of a verticalroot fracture has to be confirmed
by surgical exposure
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Treatment:
- There are reports of successful management offractured teeth by re-attaching the fragments after
extraction followed by re-implantation.
- Fractured teeth are normally candidates forextraction.
- In multi-rooted teeth a treatment alternative ishemisection.
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-3-Root canals may become
recontaminated by microorganismsdue to delay in placement of acoronal restoration and fracture
of the coronal restoration and/orthe tooth
Leakage
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-4-Poor endodontic treatment allowscanal re-infection and treatment
failure. Endodontic failures can betreated either by orthograde orretrograde retreatment techniques.
Poor RCT
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-5-Root perforations may resultfrom:
extensive carious lesions
resorptionduring RCT or post preparation
Perforations
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prognosis of root perforationsdepends on:
*size
*location*time of diagnosis and treatment*degree of periodontal damage
*sealing ability and biocompatibility of the repairmaterial
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MTA, Super EBA, Cavit , IRM,glass ionomer cements,composites, and amalgam
*controlled root extrusion*
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Transient (Remodeling) rootresorption:
is a reparative process that
occurs in response to minor
trauma to the normal functioningteeth.
-6-
Resorptions
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Pressure-induced
. Succedaneous teeth
. Impacted teeth. Expanding lesions. Iatrogenic pressure, such as
excessive orthodontic movements
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Chmeical-induced:
intracoronal bleaching withhighly concentrated oxiding
agents.
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Replacement root resorption:
occurs following extensive necrosisof the periodontal ligament with
formation of bone onto a denuded area of the root surface.
This condition is most often seenas a complication of luxation and
avulsion injuries.
E t l i i
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Extracanal invasive:
uncommon form of rootresorption.characterized by its cervical
location, and invasive nature.There may be no signs or symptoms
unless the resorption is associated with pulpal or periodontal infection.
Heithersay GS. 1999
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The etiology of invasive cervicalresorption is not fully understood.
but, predisposing factors like
traumatic injuries, orthodontictreatment, and intracoronalbleaching may be associated.
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- Surgical exposure and removal of
the granulation tissue, filling thedefect followed by re-suturing theflap.
"apically"
- Orthodontic extrusion of the tooth.
- GTR has also been advocated
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External Resorption
caused by stimuli such as:
pulpal and/or sulcular infection
traumatic displacement injuries
tumors
cysts
certain systemic diseases
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It can usually be stopped byfocusing the treatment on the
endodontic infection
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Internal Resorption
The etiology of this type of rootresorption is usually trauma.
Extreme heat was suggested as apossible cause.
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Removal of the inflammed pulpaltissue and obturation of the rootcanal system is the treatment of
choice
P i d t l di d th l
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The effect of periodontal inflammation on the pulp iscontroversial. It has been suggested that periodontaldisease has no effect on the pulp before it involves
the apex. On the other hand, several studies suggested
that the effect of periodontal disease on the pulp isdegenerative.
Periodontal disease and the pulp
Teeth with caries or restorations that also haveperiodontal disease have more atrophic pulps thanteeth with caries or restorations but no periodontal
disease.
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scaling, curettage as well as periodontal surgery
may not induce severe inflammatory changes ofthe pulp
Bergenholtz G and Lindhe J. 1978
The effect of periodontal treatment on the
pulp
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Pathogenesis
Living pathogens
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Pathogenesis
Living pathogensNon- living pathogenes
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BacteriaFungiViruses
Biofilm
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A.a
T.f
E.corrodens
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~ HSV~ CMV
~ EBV
C. albicans
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Foreign bodies(food,calculus, resto.)
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Classification
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Acute exacerbation of achronic AP on a tooth with a
necrotic pulp to drain throughthe PDL into sulcus mimickinga periodontal abscess, a deep
periodontal pocket or aGrade III furcation in multi-rooted teeth
Primary Endo
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Primary Perio
It is the result of progressionof chronic periodontitis
apically along the rootsurface with wide generalized pockets.
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Primary Endo withsecondary Perio
When primary endodontic diseaseremains untreated.
Plaque forms at the gingival
margin of the sinus tract and leads to plaque-induced periodontitis in the area
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Apical progression of
a periodontal pocketcontinues until theapical tissues are
involved via theapical foramen
Primary Perio withsecondary Endo
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Concomitant Lesion
Concomitant endo-perio lesionis an additional classification
that has been proposed todescribe the presence of endoand perio disease as two
separate and distinct entities
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True Combined Lesion
True combined endo/perio diseaseoccurs less frequently than other
endo/perio problems
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Diagnosis
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"Swelling, erythema, sinus/fistula,fracture & any etiologic orcontributing factors"
Inspection
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Swelling caused by endodontic
infections often occurs in themucobuccal fold or spreads to thefascial planes.
Swelling associated with periodontal
problems is found in the KAG and rarely spreads beyond themucogingival line.
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Palpation
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Percussion
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When a periodontal abscess is
present, these clinical entities may bepositive.
A tooth with an endodontic problemusually produces tenderness and pain
on percussion and palpation.
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Mobility
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In the acute stage of anendodontic infection,mobilityinvolves a single tooth.
Generalized mobility suggests
periodontal or occlusal origin.
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Ice test
Heat test
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Hot gutta-percha applied to the tooth coated with
petroleum jelly to preventsticking to the tooth
surface.
If a crown is present, a
rotating rubberprophylaxis cup can berun on a dried tooth to
create heat.
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EPT
f
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e.g: Laser Doppler Flowmetry
Blood flow test
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Cavity test
Preparation of a test cavity should be done without anesthesia.
A small access preparation ismade through a crown or through
the enamel to determine whethervitality is present in the pulp.
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Probing
S t
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Sinus tracing
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Dx:- Endodontic lesion
-Periodontitis
- Vertical root fracture- Perforation
C k & f t
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Craks & fractures
Aided inspection
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Transillumination
dyes
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y
Bite test
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Radiographs
Periodontal and endodontic problems canradiographically mimic
each other;therefore pulptesting and periodontalprobing must be used
along with the radiograph.
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Treatment&Prognosis
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1ry endo 1ry perio
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y y
sequelae-Necrotic pulp with a chronic AP-Draining sinus tract
-Swelling in the mucobuccal fold is pathognomonic.
-Chronic in nature and oftenobserved on other teeth
-Minimal or no pain
Dx
-Negative pulp vitality tests
-Periodontal probing is withinnormal limits
-sinus tracing
-Probing
-Plaque & calculus-Vital pulp
Tx NSRCT Peiodontal Tx
Px Excellent Dependent on the CAL
1ry endo\2ry perio 1ry perio\2ry endo
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sequelae plaque and calculus often form
in the draining sinus tract
-Retro infection of the pulptissue may occur
- severe pain
Dx
-Pulp vitality tests are negative
-plaque and calculus in the pocket
-Probing "generalized
periodontitis'-Pulp vitality test results can be
mixed
Tx-NSRCT
-Perio.Tx
Perio. Tx + RCT
PxExcellent for endo.
case dependent for perio.
Depends on the periodontal
condition & Tx
True combined Concomitant
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sequelea-Pulpal and periodontal pathoses develop
independently and unite
-Significant periodontalinvolvement
Pulpal lesion separate from the
periodontal lesion BUT occurring at the
same time
Dx
-Different Diagnostic methods for pulp &
periodontium
D.D:vertical root fracture
perforationsresorption
Thorough clinical and radiographicexamination
Tx
-Good conservative NSRCT.
- Periodontal therapy can be performed
before, during, or immediately after the
endodontic treatment.
-Hemisection or root resection.
-SRCT
-Good conservative NSRCT.
- Periodontal therapy can be performed
before, during, or immediately after the
endodontic treatment.
-Hemisection or root resection.
-SRCT
Px Dependent on the periodontal condition. Dependent on the periodontal condition.
References
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- Periodontics: Medicine, Surgery and Implants, 1eLouis F. Rose , Brian Mealey , Robert Genco
- Clinical Periodontology and Implant Dentistry, 5eJan Lindhe, Niklaus P. Lang, Thorkild Karring
- Diagnosis, prognosis and decision-making in the
treatmentof combined periodontal-endodontic lesionsby Ilan Rotstein & James H. S. Simon "2000"
- The endo-perio lesion: a criticalappraisal of the
disease condition by ILAN ROTSTEIN & JAMES H. SIMON"2006"
Refere es
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