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CONTENTS
INTRODUCTION DEFINITION CLASSIFICATION ETIOLOGY CONTROVERSIES REGARDING THE COMBINED LESION PATHWAYS OF SPREAD COMPARISION OF CLINICAL PRESENTATION B/W APICAL & MARGINAL PERIODONTITIS DIFFERENTIAL DIAGNOSIS EFFECT OF PULP & ITS TREATMENT ON PERIODONTIUM EFFECT OF PERIO. DISEASE & TREATMENT ON PULP PERIODONTAL EVALUATION LESIONS DIAGNOSIS TREATMENT REFERENCES CONCLUSION www.indiandentalacademy.com
DEFINITION
•An isolated, usually narrow, deep probing depth of pulpal or periodontal origin. •Lesion with sub marginal or intrabony periradicular bone loss of pulpal and/or periodontal origin that communicates with the oral cavity via probing defect.
•A localized periodontal probing depth of pulpal or periodontal origin. www.indiandentalacademy.com
STOCK
COHEN •
Primary endodontic lesion
•
Primary endodontic lesion with secondary periodontal involvement
•
Primary periodontal lesion
•
Primary periodontal lesion with secondary endodontic involvement
•
True combined lesion
•
Concomitant pulpal & periodontal lesion
DIA PG 654 www.indiandentalacademy.com
WEINE
Tooth in which symptoms clinically and radiographically simulate periodontal disease but are due to pulpal inflammation
Tooth that has both pulpal and periodontal disease concomitantly
Tooth has no pulpal problem but require endodontic therapy plus root amputation to gain periodontal healing
Tooth that clinically and radiographically simulated pulpal or periapical disease but infact has periodontal disease
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LESIONS REQUIRING ENDODONTIC TREATMENT ONLY necrotic pulp and apical granulomatous tissue replacing periodontium with or without sinous tract Chronic periapical abscess with sinus tract Longitudinal and horizontal root fractures Pathologic and iatrogenic root perforations Teeth with incomplete apical root development Endodontic implants Teeth that require hemisection Root submergence
GROSSMAN www.indiandentalacademy.com
LESIONS REQUIRING PERIODONTAL TREATMENT ONLY
Occlusal trauma causing reversible pulpitis Occlusal trauma plus gingival inflammation resulting in pocket formation and reversible pulpitis Suprabony or infrabony pocket formation treated with overzealous root planning and curettage leading to pulpal sensitivity Extensive infrabony pocket formation extending beyond the root apex and sometimes coupled with lateral or apical resorption yet with pulp that responds with in normal limits to clinical testing
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LESIONS REQUIRING COMBINED ENDO – PERIO TREATMENT
Any lesion in Group I That results in irreversible reactions in the attachment apparatus and requires periodontal treatment
Any lesion in Group II that results in irreversible reactions to the pulp tissue and also requires endodontic treatment
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ATYPICAL ANATOMIC FACTORS Malaligned tooth Multirooted teeth / additional root Additional canal Cervical enamel projection Large lateral / accessory canal TRAUMA
With gingival inflammation Tooth fracture Pulp / perio involvement + sinus tract Cellular changes - resorption
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MISCELLANEOUS Iatrogenic systemic
SINUS TRACT
INFRABONY POCKET
•From canal
•From gingival crevice
•Narrow
•wide
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CONTROVERSIAL ASPECT CONCERNING THE COMBINED LESION PULPAL PERIODONTAL Chacker Massler Czarnecki & Schilder
PERIODONTAL PULPAL ? Venous blood flow outward
Drawback Lateral / accesory canal - flow bothways Seltzer & bender Stahl
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Physiologic : • Apical foramen • Lateral canals • Dentinal tubules • Periodontal ligament • Alveolar bone • Neural pathways • Vasculolymphatic pathway
Iatrogenic : • Palatogingival grooves • Cementum defect • Vertical root fractures • Perforations www.indiandentalacademy.com
COMPARISION MARGINAL PERIODONTITIS
APICAL PERIODONTITIS
Cervical
Apex
Plaque
Pulpal inflammation
Horizontal / Vertical bone loss - Seldom bone loss – localized generalized & deep Open
Contained
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Attachment loss asso. with Anatomic defect on root Nature of pathogenic flora Necrotic & infected pulp Host defense mechanism defect.
Aggresiveness asso with Lateral & apical foramen Nature of flora Apical host defense
Periodontal probing & radiographic examination
Radiographic examination
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DIFFERENTIAL DIAGNOSIS PULPAL
PERIODONTAL
Cause
pulp infection
periodontal
Vitality
non vital
vital
Restorative
deep or extensive
not related
Plaque /calculus
not related
primary cause
Inflammation
acute
chronic
Pockets
single and narrow
multiple and wide
pH value
acidic
alkaline
Trauma
primary or secondary
contributing factor
Microbial
few
CLINICAL
coronally
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complex
RADIOGRAPHIC Pattern Bone loss Periapical Vertical bone loss:
localized wider apically radiolucent no
generalized wider coronally not related yes
HISTOPATHOLOGY Junctional epithelium Granulation tissues Gingival
no apical migration apical (minimal) normal
present coronal (larger) recession
TREATMENT Therapy
RCT
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Periodontal therapy
Problems in diagnosis : Vertical root fracture: varied radiographic picture Different angulations Surgical exposure lateral condensation excessive Post placement Cause Extensive restorations Older patients Gingival sulcus & pocket area Single rooted teeth multirooted teeth Developmental grooves In doubt ? – Biopsy / Histological analysis Systemic diseases mimic lesion on radiograph : Scleroderma Metastatic carcinoma Osteosarcoma www.indiandentalacademy.com
EFFECT OF PULP AND ITS TREATMENT ON PERIODONTIUM Periodontal inflammation & bone loss Sub marginal bone loss Horizontal bone loss Vertical intrabony pockets Furcation involvement Periodontal wound healing Traumatized necrotic pulp RC infection – compromised healing Gingival tissue thickness Alveolar bone level Surgical trauma to flap Effective flap repositioning Root canal treatment Doubtful pulpal status Iatrogenic problems
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EFFECT OF PERIODONTAL DISEASE & ITS TREATMENT ON PULP Periodontal disease & pulp •Limited •Channels closed + dystrophic calcification- chronic •Sufficient viurlence – pulpal disease •Poor prognosis •Extraction / Root resection Periodontal treatment & pulp •Scaling & root planing – excessive cementum removal •Compromised pulp
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