What are some of communication pathways between the pulp and periodontium?
- Apical foremen
- Dentinal tubules
- Accessory canals
- Lateral canals
What is the primary aetiology factors of endo-perio lesions?
- Endo or perio infection
- Trauma an/or iatriogenic trauma - like perforation during root canal treatment or root fracture or crack post RCT or root resorption
What is an endo-perio lesion?
An EPL (endo-perio lesion) is a pathological communication between the pulpal and periodontal tissues at a given tooth accompanied by a deep periodontal pocket and altered pulp sensitivity test that may occur in (symptomatic) acute or chronic (asymptomatic) form.
What is the endo-perio aetiology?
- Primary endo infection - carious lesions affect the pulp and secondarily affect the periodontium
- Inflamed pulp exerts little or no effect on the periodontium
- Necrotic pulp cause bone resorption
- Sinus tract drain through PDL into gingival sulcus
- Isolated periodontal defect
What are some of the diagnostic hints that might lead us to see that the lesion is a primary endo secondary perio lesion?
- Pulp test negative
- Compromised coronal integrity
- Isolated deep narrow peridontal pocket - might need to use a guttapercha and take a PA
What is the treatment of primary endo secondary perio lesion?
- RCT
- No immediate scaling and root instrumentation - please await healing first - 3-6 months should be enough for healing and reassessment
What are some of the diagnostic hints that might lead us to see that the lesion is a primary perio secondary endo lesion?
- Sever periodontitis
- Pathological changes occur in pulp
- Retrograde pulpitis - acute pain for long duration
- Pulp test incoclusive
- Coronal integrity intact
- Deep periodontal pockets around the tooth
What is the treatment of primary perio secondary endo lesion?
- Scaling and root instrumentation needs to be done together with the root canal treatment
or
- Extraction depending on prognosis
What is the diagnostic clues of a combination endo-perio lesion?
- Pup test is negative
- Deep peridotnal pockets on multiple sites
What is the treatment for a combination endo-perio lesion?
- Scaling and root instrumentation needs to be done together with the root canal treatment
- Possible resective surgery
What is the treatment of fractures teeth?
- Do nothing
- Extraction
What is usually associated with hopeless prognosis of EPL?
EPLs that are related to aitriogenic damage.
How to write a diagnostic statement for a endo-perio lesion?
- Write that it is a endo perio lesiom
- Root damage extent
- Perio status of the patient
- Grade of the problem
What are the classifications of periodontal pockets associated with an endo-perio lesion associated with periodontitis patients?
Grade 1 - narrow and deep periodontal pocket in 1 tooth surface
Grade 2 - wide deep periodontal pocket in 1 tooth surface
Grade 3 - wide deep periodontal pocket in more than 1 tooth surface
What are the classifications of periodontal pockets associated with an endo-perio lesion associated with non-periodontitis patients?
Grade 1 - narrow deep periodontal pocket in 1 tooth surface
Grade 2 - wide deep periodontal pocket in 1 tooth surface
Grade 3 - deep periodontal pockets in more than 1 tooth surface
What are the difference between the periodontium in children comparing to adults?
- Gingival colour more reddish because of the thinness
- Rounded gingval margins
- Looser consistency
- Smoother surface
- Increase in attached gingiva
- Sulcus depth shallower
- Wider PDL space
- Prominent lamina dura
- Distance between CEJ to alveolar crest is less
What decreases the susceptibility to gingivitis in children?
- Thicker junctional epithelium
- T-cell dominated response
- Few B lymphocytes
- Less calculus build up thus less niches for bacteria to propagate
Why is there around 100% occurrence rate of gingivitis in kids going through puberty?
There is a theory that during puberty when tooth exfoliation occurs, due to some discomfort that may occure during the process - the brushing habit worsen in kids thus resulting in gingivitis.
Also fixed and removable orthodontic appliances contirute to this.
What are some of the other systemic factors that may contribute to development of gingivitis in young patients?
- Smoking
- Hyperglycemia
- Nutritional factors
- Pharmacological factors
- Sex steroid hormones
- Hematological factors like leukemia
How do we treat primary herpetic gingivostomatitis?
Primary herpetic gingivostomatitis is a disease that occurs after primary infection with herpes simplex virus
Treatment:
10-14 day duration
Control fever, pain and hydration
DO NOT TOUCH THE ULCERS
What do we classify any fast-progression periodontitis in young patients?
Grade C and we look at the underlying systemic conditions or genetic factors.
What is the BPE and how do we use it for paediatric patients?
BPE stands for basic periodontal examination and we use it as a code system similar to PSI!
Children with codes 0,1,2 should just have routine exams
While children with codes 3 & 4 should be undergoing consistent periodontal care to improve their condition
Note that some times Code 3 in a mixed dentition could be just erupting teeth so please be considerate.
What caution should we have in terms of perio and orthodontics?
The actual orthodontic process do not cause attachment loss but:
There needs to be cautious approach for patient with with thin periodontium phenotype as labial orthodontic movement in thin periodontal phenotype may result in bone dehiscence.
And presents of gingival inflammation or trauma may result in CAL.
What is pathological tooth migration (PTM)?
In significant periodontitis, the arch integrity may be compromised due to destruction of Sharpay fibres thus resulting in migration of the teeth.
The symptoms may be increase diastemas, drifting of teeth or collapsing of occlusal vertical dimension
