Endoperio lesions

happiness yes this is dr srikanth from team mds conquer now i'm going to discuss the topic endo period lesions so first of all when you're talking about an infection infection may start at one place okay and may enter at different places this is what regularly seen in the human body so the entry of the infection from the entry point that is the focus of infection okay it spreads to different areas or different systems similarly when you're talking about a dental heart tissue which contains enamel you have your tent in you have your pulp over here and this yellow area inside the gingiva which attaches is called as cementum and all this area is called as very periodontal tissue okay so particularly this area is called as periapical periodontal tissue so this is water the structures that are present in the dental heart tissue that is the truth so now we are talking about the relationship of pulp and periapical okay here you have pulp and you have your periapical tissue or periodontium okay so first of all we need to talk about what are the communications that are present so whenever you have a communication okay then only the infection from one area that is the pulp will spread to periapical or periodontium or periodontium will spread to the pulp so that is the relationship between the pulp and periodontal tissue we are going to talk about okay so when you are talking about this particular content the main important aspect that you have to make a note is what are the communications the communication number one is apical foramen so apical foramin is one communication where the pulp is going to communicate with the paradox and the second communication you can see here this is the whenever whenever there is a gingival recession you will lose cementum over that particular area the local cementum is lost and your dental tubules will be exposed so the first route is apical foramen the second route is dentinal tubules and sometimes apart from the apical foramen you will have your accessory canals you will have your lateral canals you will have your fertile canals so all the extra canals okay so the one communication between the pulp and periapical is apical foramin the second communication is the dentinal tubules and third communication are the canals so these are the communications by which the infections from one area will spread to other area means pulpal infection can be spreaded to the periodontium periodontal infection can be spreaded to the pulp because they have communication so these communications are prime reasons for the spread of infection so according to kohen okay the classification according to kohen says the classification of endoperial lesions can be categorized into primary endodontic lesion means which has only endodontic origin primary endodontic secondary periodontal means it started as an endo but with all the communications with any of these communications three communications we have learned it has spread it to the periodontia but initially it has started in end of then primary periodontium only periodontal and primary periodontal secondary means initially it started in the period aspect but spread it to the endodontic creation and the last one this is very very important a case which you cannot judge whether it is primary endo or primary perio but has endocrine relations means two separate lesions you are not in a position to conclude it as whether it is primary endo or primary period such lesions will be comes under the true combined lesions that is endo plus period so this classification is very very important because in recent aims and recent need we have seen a decent number of questions by just giving the clinical scenario and asking you to identify which type of lesion it is like the diagnosis of endopedia the first important aspect that you have to make a note is primary endodontic lesion i'm clearly stressing it primary endodontic lesion okay so primary endodontic lesion means that can be a deep caries okay so that can be you can see in this radiograph you will have you have a kerys which is approaching to the pulp and there is pulpitis okay so there is pulpit is the pulp is inflamed then from the pulpal with all the chances what are the chances one communication is by the dentinal root dentinal sheals the second communication is can be by the fertile canals the third communication can be by the apical foramen it spreads to the periodontium it damages the predomination it can damage the peritoneum also right so so such cases are called as primary endodontic origin so if this case has periodontal pathology also then it is going to then we can call it as primary endo and secondary period if it has only endodontic origin then it is called as primary endodontic relation the second one is primary periodontal okay so there is a deep pocket here you can see there is a deep pocket you have a bone loss here you can clearly appreciate on the radiograph you have a bone loss here so by which you have a pocket and the infection starts from the periodontia okay if this infection start from the periodontium and if in future if it is going to hit the pulp also pulp also means you don't have a dental caries you don't have any signs of or any ethiology for the pulpal infection on the radiograph or on the clinical scenario but the pulp is damaged because it has a deep pocket which indirectly gives means it is started as a primary it has started as a primary periodontal periodontal lesion but further it has caused endodontic problems also means some purple disease so it is called as primary perio and secondary endo then i have discussed a combined lesion okay means it has the problem from both the sides it has a pulpal problem and it has a periodontal problem which does not have a communication which they are not coordinated to each other in the clinical scenario because you can see a deep pocket over here okay and you can see a pulpal infection over here but it's not communicated right so it's a palpably it is different and periodontally it is different you cannot come to your conclusion that whether it is primary perio or primary under such lesions are called as combined lesions so as already discussed what are the communications between the pulp and the periapical the pulp and periapical communications are either by the dentinal tubules okay or either by the lateral and axillary canals or either by the apical foramen so these are the three communications which causes the pulpal infection to spread to the periapical and the periapical infection to spread the pulpal areas so now we learn some integrated way of handling this so there are some ethological factors for the causation of the primary i mean endocrine lesions and similarly you have some contributing factors so what are the contributing factors if you have a poor endodontic treatment your endodontic treatment is not great okay so it may lead to primary endo it may lead to end of variation in the future okay it contributes to and coronal leakage coronal leakage is the most common cause for the failure of endodontic treatment because uh as we know that we give a temporary registration once the bmp is done before the obturation and the minimum thickness of the registration that is required is 3.5 millimeters okay the cabinet whatever we give okay so cabot or imr we give that's right so that that that that holds the coronal registration right that's the coronal registration and the minimum thickness that is required is 3.5 millimeters and it is the same reason why uh your when whenever you whenever you are planning for post endodontic treatment make sure your cutter patches should be sealed up to the up to the uh canal orifice levels okay so by which you can provide a proper coronal seal so coronal seal is mandatory because if there is any damage of the coronal sill there are high chances that your endodontic treatment is going to fail okay so similarly the other contributing factors are the trauma you have your root resorptions you have your perforations developmental anomalies particularly like grooves palette or ginger grooves grooves which are extended onto the root surface because whenever a groove that is extending onto the root surface is going to provide a pathway for the bacteria to move easily okay so whenever the things are going on the root what is root area called us that is per periodontium right so there are high chances that the endopaerial lesion can form similarly a crack tooth syndrome all these are contributing factors but coming to the ecological factors the major ecological factor of the organisms that is bacteria bacteria is the most common cause for the pulpit is and similarly bacteria is the most common cause of endopaeria lesion here we have some important things that you have to make or not so among the list of the bacteria the anaerobic bacteria causes 90 percentage of of infections okay and similarly you can make a note that spirochetes are associated with both endo and periolicions okay your spirochetes are associated with both endo and uh perio lesions and uh when when you compare with the number of spirochetes the spirochetes will be more in the case of your sub gingival plaque when compared with the endodontic origin okay and make a note that l forms okay l forms of bacteria will learn about what are these different forms of bacteria so all forms of bacteria are present more in endo when compared with the perio okay you have your fungal infections okay that is candy asses you have your viral infections that is hepa simplex cytomegaly epstein-barr virus type 1 are associated with both indo-imperial lesions and similarly there are few other non-living organisms non-living pathogens that can cause this okay that can be a foreign body or your dentin or cementum chip or your improperly removed amalgam registration or your root canal filling material so all these are the materials okay extrinsic materials and similarly you have some intrinsic agents like these are the different uh crystals different types of bodies and which can be seen in the histological sessions we'll i'll show that i'll show you the diagrams which are very very important as a diagram based question so as already discussed you have some live pathogens you have some non-living pathogens so it's already discussed bacteria is a live pathogen you make a note about your fungus candy assist is the most common your bacteria you'll talk more about spirochetes when you want to differentiate endoletion from periolation because uh your imperial agents your spirochetes will be more that is about your treponomia denticola okay which is a spirochete which is most commonly seen in the periodontal lesions when compared with the endodontic region so whenever you have a communication between endoperio so these bacteria which are present in the periodontism will go through the passages okay and will reach the pulpal so by which you can you can you can diagnosis by using some microbiological tests you can diagnosis roughly as endopedial lesions similarly you have your viruses okay the viruses can be herpes simplex virus or cytomegaly virus or epsingbar virus so all these viruses can be seen in the case of your endopedia lesions so as already discussed okay these are the non-living pathogens which are going to cause the endoperial lesion okay so these are the foreign bodies okay it's already discussed like uh i mean the leftover gingival retraction cord will cause inflammation will leads to the bone loss and will will cause the bone loss leading to the periodontal problems okay so you can make a note okay this is a well-known histological slide uh epithelial rests of malice okay so please do please do identify this i i think like uh arrow based questions i think they're very rare to ask like marking by pointing a particular area and asking you to identify this regularly they are going to give astrological slide that is given the recent neet 2020 which has given on general astrology but of course your oral histology is nowhere an exception so i just want you to make a note about these diagrams and please try to identify them okay these are the cholesterol crystals okay which can be seen in the periapical uh radicular cyst okay radicular periapical cyst uh these are russell's bodies okay so please do try to identify this this unique russell body and these are rust and highland bodies okay so you can you can identify them so please do that i mean these are the questions which are commonly seen in your oral pathology but please do make a note about the histological slide too because there are high chances that they can throw a histological slide and ask you to identify it okay so these are lead and crystals okay and i have discussed about all the contributing factors your poor endodontic therapy poor restoration that is due to the coronal leakage your trauma resorption which can be internal or external development and anomalies particularly we need to talk about pallet or gingival or any sort of grooves which are extending onto the root surface perforations and the root factors so all these are going to be the contributing factors means most of these contributing factors they provide a gateway for the bacteria to move from one place to other place regularly you have uh you have a gateway which moves from pulp to periapical you have three gateways which we have learned so these are these are the contributing factors which are going to provide other gateways or which are going to provide an easy access for the infection from one area to move to other other areas okay so you can see a poorly poor endodontic treatment so here you don't have your proper observation the observation is not good so you have so much of space for the bacteria which is in the peridontium to enter into this particular area or for the bacteria which is present here to enter into this particular area so the communications has increased well similarly similarly the condition here okay your restoration your poor endodontic treatment okay these are the reasons and coming here this is a poor registration i was talking about like sealing of your gut apache is very very important once you seal the gatta patch if you take like your system so this is this is where you're going to obturate right so you're going to keep gutta pacha here until this area so these are the orifices make sure you keep gutta pacha but the new concept says that the world concept says that your orifice should be filled with gada bache entirely what new concept says that your rfi should be filled two millimeters below the gutta patch and this two millimeters you have to seal with a good sealant okay most probably how to use gic so you will get a seal here so once you get a seal here however that you are going to do your post and advantage treatment okay so in most of these cases here you can see your gatapatch is not sealed well okay your post enantic restoration was not proper okay so this is a coronal leakage you can see a resorption here okay you can see an internal resolution over here you can see this internal resorption mostly these internal resolutions are due to trauma okay and you can see some external resorption over this particular area maybe this external resolutions can be maybe maybe one of the one of the ethology for this external resumptions can be your orthodontic treat treatments okay so this is an external resorption case and this is an internal resorption case so you can see a perforation okay improperly paste i was talking like whenever you treat uh your mora molars lucky make sure that your post length should not be more than this particular area but this is the long axis how you have to keep the post right so but the post was kept in a different direction okay which leads to perforation it's almost the case is almost the similar okay so whenever you're keeping a perforation you're giving a chance for the bacteria to move from one area to other area so that's these are again contributing factors your fractures in the similar way you're giving your bacteria to chance to move okay so development elements i was talking about the palatal gingival group you can see this the palette of gingival groups extending means normally you don't have any communication for the bacteria but when you have a deep pocket and a paratha ginger okay then the bacteria has the easy passes okay so all these are going to be contributing factors and make sure you have a decent coverage or the diagram based questions so whenever a radiograph or a clinical photograph is given like by seeing the options you need to get some findings get some analysis get some ideology or the diagnosis and the treatment plans like for example in this palette or ginger will grow okay so what you have to do is uh apart from like you have to see whether whether it is going to cause the pulpal disease or periapical disease if it's not causing anything make sure you provide access for this and you seal it seal it with gic so the passes can be overcome okay so such a case like you have to find a way to overcome this contributing factor so what are the different things that are used for for this particular diagnosis okay so diagnosis is very very important one is visual examination that is clinical photographs clinical photographs and the second one is palpation okay it is tender on vertical or tender on horizontal okay you have to see both okay so your palpation will will give some idea about the inflammation areas your percussion vertical percussion is going to give is going to like it's going to help in checking the periapical inflammation okay so your mobility will helps in testing the periodontium your radiographs may give some clue about the extent of dental caries approaching the pulp whether it is a pulpitis or it can give you an idea about the bone loss your pulp vitality is going to give the viability of the pulp okay and your probing is going to give the viability of pedentium your crack tooth test your tooth slot all these all these things are useful in finding out is there any chance of fracture the fistula tracing is generally done by the cut apache mostly you you use a and like whenever you see a fistula or whenever you see a sinus tract opening make sure you insert some gutta pacha in it okay preferably uh 25 number gatapacha is inserted in it and you have to take a multiple series of radiographs from different angles by which you can conclude that this infection is from this particular tip okay so there is one more classification which is based upon the treatment okay so the classification says requires only endodontic treatment means it is only endodontic lesion requires periodontal treatment only a periodontal relation requires both treatments so it's going to be endoperiolation so like whenever you have to go you know the cases where you have to go for only endodontic treatment for example i am going to give an example you have a teeth okay and it has a sinus opening into the gingival sulcus so what you have to do you have a you have your two one with sinus opening in the sulcus so what you have to do uh you you have to trace the sinus opening so take the take a cut apache keep in the sinus opening and you can trace it like if it is going towards the periapical area then you have to check the vitality of the teeth so white mostly the vitality will be non-vital right so it's an endodontic lesion okay it's an endodontic condition so what is the treatment of this case you have to do root canal treatment so do root do root canal treatment in most of the cases the treatment the root canal treatment is going to be the permanent treatment for this case and what about the sinus tag when the root canal treatment is done when the infection is removed so sinus tract will heal by its own the healing of sinus tract will be done by its own okay so this is the case where only endodontic treatment is required right and the second one is periodontal treatment like when whenever whenever you diagnose a periodontium periodontitis or some periodontal pocket on a particular teeth then you do only period treatment okay so and you have to check the vitality in most of the cases in this particular case the vitality will be positive okay the pulp is normal but you have the periodontal problem so so treat the periodontium it's the only predomination and the next one is uh a combination of both okay it's already discussed like you have your primary endo and secondary period or primary perio and secondary indus all these cases you have to do a combined treatment you have to do a treatment which is of combination and preferably what most of the studies say that when you have an endoperiolation make sure you complete the endotreatment first because the prognosis for the endotreatment will be fast so root canal can be done in single appointment or in one or two appointments but when you have a bone loss uh your periodontism to regenerate or or reversal the bone loss it's going to take lots of time right so so endodontic treatment has to be done first followed by the periodontal treatment in most of the cases so this is a basic difference uh i mean you're well versed with this i'm just going to make a note so so the theology for endodontic lesion is the necrosis of pulp and the ethiology of periodontal adhesion is the infection in the inflammation of the pulp when you're talking about the nature of the pain it is acute and spontaneous most of your periodontal pains are dull and chronic and coming to the swelling the swelling uh regularly occurs in the periapical abscess which is diffused which is diffused and this is a curse in the attached gingiva which is a localized one so when i'm talking about percussion the percussion will be like it will be positive in vertical direction it will be mild in lateral direction okay so and the probing depth is is going to be normal is going to be more than the normal here okay so how do you diagnose the sinus opening the sinus opening the gut apache pointing leading to the effects of the teeth that is involved it it may move towards the sulcus of the teeth that is involved okay so the mobility is localized in nature and it's going to be very very rare in the endodontic lesions but it is more generalized in the nature your junction epithelium is normal your gingiva is normal the treatment is root canal your junctional epithelium will shows apical migration your gingiva will be inflamed in recession and here it's a paragraph relation sometimes because of the communications it can be primary under to secondary period and and say primary period to secondary end so as already discussed the primary thing that you have to do is endodontic therapy treat endo first followed by you're going to do all the periodontal things so sometimes there are a few other extraordinary things that you have to do that is the hemi session radiation bicuspidization all these things i'm just going to post the you can just check the photographs okay so this is an endodontic surgery okay uh which is done here you can see a big periapical lesion with lots of bone loss okay the endodontic lesion was the endodontic surgery periapical surgery was done so of course whenever you have only periodontal problems you have to do your periapical surgery that is the deep screening scaling or the root planning and these are the extraordinary cases where you can clearly see here you have a bone loss or a particular two okay particular root of a teeth okay so it's very difficult to save the entire thing so what better you can do is you can save this half that is called as hemi session okay so this is a section case okay where you can save the half you can you can remove the half of the teeth you can say you can see an edgeless area and a bridge or a bridge is placed so when you can do a hemi session okay hemi session is uh i mean the indications of humiliations are very simple uh so whenever you have uh a bone loss okay severe bone loss on a on a route on one road on a route okay or we have a fractured road fractured road or you have a blocked route means where your endodontic treatment you are not able to do an treatment because of some calcification or something or you have a perforated root okay so all these cases it's better to remove one root okay so save the one and remove the other okay so these are the things that you have to regularly do so here it's it's a one more case that is called as bicuspidization where one molar okay because you have your your fertile bone loss okay so you cut it you got like this and make it into two premolars okay so one molar is broken into two premolars by going through the forcation the best indication is whenever you have a a focal perforation or whenever you have uh you have you have a severe bone loss in the furcation okay in such cases you can go for this hemisection or you can go for this bicuspidation or bisection okay so i'm done for now signing off dr shrikant from team mds concur learning with mds concur