UNIDAD FORMATIVA 2
4. Seguimiento y control de indicadores de gestión de stock
WHAT ARE DIFFERENT PATHWAYS OF COMMUNICATION BETWEEN PULP AND PERIODONTIUM?
Dentinal Tubules
• Traverse from pulpodentinal junction to cemento- dentinal or dentinoenamel junction.
• Congenital absence of cementum, cemental exposure by periodontal disease, caries, root surface instrumen- tation–exposes dentinal tubules.
Lateral or Accessory Canals
• Most common in apical third of posterior teeth. • Difficult to identify on radiographs.
• Identified by isolated defects on the lateral surface of roots or by postobturation radiographs showing sealer puffs.
Apical Foramen
• Major pathway of communication.
• Inflammatory factors exit through apical foramen and irritate periodontium.
Perforation of the Root
Perforation creates an artificial communication between the root canal system and the periodontium.
Vertical Root Fracture
Vertical root fracture can form a communication between root canal system and the periodontium.
WHAT IS ETIOLOGY OF ENDODONTIC- PERIODONTAL PROBLEMS?
Pulpal diseases can result in the periodontal problems and vice versa. It is the length of time that the etiological factor persists in the susceptible environment which is
directly related to the probability of occurrence of combined lesions.
Predisposing Factors Resulting in Combined Endodontic Periodontal Lesions
• Malpositioned teeth causing trauma. • Presence of additional canals in teeth.
• Large number of accessory and the lateral canals. • Trauma combined with gingival inflammation. • Vertical root fracture.
• Crown fracture. • Root resorption. • Perforations
• Systemic factors such as diabetes.
HOW WILL YOU DIAGNOSE A CASE OF ENDODONTIC-PERIODONTAL LESIONS? Clinical Tests
Different signs and symptoms can be assessed by visual examination, palpation and percussion.
Radiographs
Radiographs are of great help in diagnosing caries, extensive restorations, root resorption, root fracture, thickened periodontal ligament space and any changes in the alveolar bone.
Pulp Vitality Tests
Determination of pulp vitality is essential for accurate differential diagnosis of the lesions.
Tracking Sinus or Fistula
Tracking the fistula may aid the clinician to differentiate the source.
Pocket Probing
Pocket probing helps in knowing location and extent of the pockets.
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Microbiological Examination
Occasionally the microbiological analysis can provide an important information regarding the main source of the problem.
CLASSIFY ENDODONTIC PERIODONTAL LESIONS
Simon et al have classified the lesions based on the primary source of the infection. It is:
1. Primary endodontic lesion.
2. Primary endodontic lesion with secondary periodontal involvement.
3. Primary periodontal lesions.
4. Primary periodontal lesions with secondary endodontic involvement.
Primary Endodontic Lesions (Fig. 22.1)
• Sometimes an acute exacerbation of chronic apical lesion in a nonvital tooth may drain coronally through periodontal ligament into the gingival sulcus, thus mimic clinically the presence of periodontal abscess. • Tooth is associated with necrotic pulp, pulp does not
show response to vitality tests.
• Sinus tract may be seen from apical foramen, lateral canals or the furcation area.
• Probing shows true pockets. Pocket is associated with minimal plaque or calculus. The significant sign of
this lesion is that patient does not have periodontal disease in other areas of oral cavity.
Treatment
• Root canal therapy. • Good prognosis.
Primary Endodontic Lesion with Secondary Periodontal Involvement (Fig. 22.2)
These lesions appear if primary endodontic lesion is not treated. The endodontic disease will continue, resulting in destruction of periapical alveolar bone, progression into the interradicular area, and finally causing break down of surrounding hard and soft tissues.
Treatment
• Root canal treatment to remove irritants from pulp space.
• Concomitant periodontal therapy.
Fig. 22.1: Spread of infection can occur (A) from apical foramen
to gingival sulcus via periodontium (B) from lateral canal to pocket (C) from lateral canal to furcation (D) from apex to furcation
• Extraction of teeth with vertical root fracture if prognosis is poor.
Primary Periodontal Lesions (Fig. 22.3)
• Primarily these lesions are produced by the periodontal disease. In these lesions periodontal
Fig. 22.2: Primary endodontic lesion with secondary
break down slowly advances down to the root surface until the apex is reached. Pulp may be normal in most of the cases but as the disease progress, pulp may become affected.
• Periodontal probing may show presence of plaque and calculus within the periodontal pocket.
• Usually generalized periodontal involvement is present.
Treatment
• Oral prophylaxis and oral hygiene instructions. • Scaling and root planning.
• Periodontal surgery, root amputation.
Primary Periodontal Lesions with Secondary Endodontic Involvement (Fig. 22.4)
• Periodontal disease may have effect on the pulp through lateral and accessory canals, apical foramen, dentinal tubules or during iatrogenic errors. Once the pulp gets secondarily affected, it can in turn affect the primary periodontal lesion.
• Oral examination of patient reveals presence of generalized periodontal disease.
Treatment
• Root canal treatment
• Periodontal surgery in some cases.
Independent Endodontic and Periodontal /Lesions which do not Communicate
• One may commonly see a tooth associated with pulpal and periodontal disease as separate and distinct entities. Both the disease states exist but with different etiological factors and with no evidence that either of disease has impact on the other.
• Periodontal examination may show periodontal pocket associated with plaque or calculus.
• Tooth is usually nonvital.
• Root canal treatment is needed for treating pulp space infection.
• Periodontal therapy is required for periodontal pro- blem.
True Combined Endo-Perio Lesions (Fig. 22.5)
• The true combined lesions are produced when one of these lesion (pulpal or periodontal) which are present in and around the same tooth coalesce and become clinically indistinguishable. These are difficult to diagnose and treat.
• After completion of endodontic therapy, periodontal therapy is started which may include scaling, root planning, surgery along with oral hygiene instruc- tions.
Fig. 22.3: Primary periodontal lesion Fig. 22.4: Spread of periodontal lesion into endodontic
Endodontic Periodontic Interrelationship 99
HOW IS DIFFERENTIAL DIAGNOSIS BETWEEN PULPAL AND PERIODONTAL DISEASE MADE?
Features Periodontal Pulpal
Etiology Periodontal Pulpal
infection infection
Plaque and calculus Commonly seen No relation
Tooth vitality Tooth is vital Non vital
Periodontal Usually present, If present
destruction and generalized single, isolated
Pattern of disease Generalized Localized
Radiolucency Usually not Periapical
related radiolucency
Treatment Periodontal Root canal
therapy therapy