牙周病學(xué)課件：Concomitant Lesions of Periodontitis

1、Concomitant Lesions of PeriodontitisPathological changes of PeriodontitisGingival inflammationPocket formationBone resorptionContents Furcation involvementPeriodontitis associated with endodontic lesionPeriodontal abscessGingiva recessionHypersensitivity and caries of rootFurcation InvolvementThe pr

2、ogress of inflammatory periodontal disease, if unabated, ultimately results in attachment loss sufficient enough to affect the bifurcation or trifurcation of multirooted teeth.Etiologic factorsBacterial plaque primary factorAnatomic featuresCervical enamel projectionsOcclusal traumaPulp pathosisprom

3、oting factorsDental plaqueInitial factorOcclusal traumaImportant promoting factorFurcation area is sensitive to occlusal forceFactors leading to occlusal traumaInappropriate occlusal force大小、分布、方向、頻率、持續(xù)時間咬合力方向垂直壓力側(cè)向壓力扭轉(zhuǎn)力咬合力分布不均：早接觸Less periodontal support The root trunk represents the undivided regi

4、on of the rootAnatomic features 1Root trunk lengthmisialbaccaldistal上頜第一磨牙上頜第一雙尖牙 Furcation entranceAnatomic features 2ConcavityAnatomic features 3enamel projectionPulpal infectionExamination & Diagnosis probing radiographClassificationBase on horizontal attachment loss in the furcationGlickmen grad

5、eGrade Grade Grade Grade Hamps gradeGrade Grade Grade Glickmen grade Grade :Furcation involvement is the incipient or early stage of furcation involvement. Pocket is suprabony and primarily affects the soft tissue.Grade The furcation lesion is essentially a cul-de-sac with a definite horizontal comp

6、onent. If multiple defects are present, they do not communicate with each otherGlickmen grade Grade The bone is not attached to the dome of the furcation. The opening may be filled with soft tissue and may not be visibleGlickmen gradeGrade The interdental bone is destroyed and the soft tissue have r

7、eceded apically so that the furcation opening is clinically visibleGlickmen gradeHamp gradeAttaching a millimeter measurement to separate the extent of horizontal attachment Treatment Objectives of furcation therapyFacilitate maintenancePrevent further attachment lossObliterate the furcation defects

8、 as a periodontal maintenance problemGrade : OHI, scaling and root planningEliminate enamel projections, facial grooves, overhangingOdontoplasty, recontouring and replacementResolution of inflammatory lesions after scaling and rootplanningFlap operation with odontoplasty and osteoplastyGrade : Flap

9、operation with odontoplasty and osteoplasty GTRAPF+ osteoplastyBone graftguided tissue regeneration ,GTRGTR GTR+bone graftGrade - :Combination of endodontics, periodontal surgery and restorationTunnel preparationRoot amputationHemisectionExtraction Tunnel preparation root resectionroot separationroo

10、t separationroot separationhemisectionBuccalLingual手術(shù)中全冠修復(fù)后手術(shù)后1年P(guān)eriodontitis associated with endodontic lesionA lesion involving both periodontal and pulpal tissues can be of primary endodontic, primary periodontal or stem from separate originsClassification (1999)VII. Periodontitis Associated With

11、 Endodontic Lesions A. Combined periodontic-endodontic lesions Primary endodontic disease with secondary periodontal involvement Primary periodontal disease with secondary endodontic involvement Combined periodontal and endodontic diseases Pathways connecting pulpal and periodontal tissues Apical fo

12、ramenLateral and accessory canalsDentinal tubule1.6%8.8%17%Principal and most direct pathwaysPocket PulpApical foramen Fig. 1 Fig. 2Bacterial & inflammatory byproductsPathwaysLateral and accessory canalsPrevalence : 23% to 76%Where? anywhere Majority: apical third Pathways1.6%8.8%17%Dentinal tubules

13、 Dentin exposure at the CEJ:10% of teeth 25% of anterior teeth Periodontal disease and surgical procedures cause cementum denuded and dentinal tubules exposurePathwaysPrimary endodontic disease with secondary periodontal involvementImpact of pulp to periodontiumVital pulp, although significantly inf

14、lamed or scarred, is unlikely to cause breakdown of the periodontium, occasionally, widening periodontal ligament space may occurSterile necrotic pulps have little effect to the periodontiumNecrotic pulp is frequently associated with the inflammatory involvement of the periodontal tissuePulp necrosi

15、sThrough apical foramen Through lateral or accessory canalsDentinal tubulesThrough apical foramenAbscess may drain off inA sinus tract along the periodontal ligament spaceAn extraosseous fistulation into gingival sulcus/pocketby lateral and accessory canalsHowever, endodontic infection leads to peri

16、odontal tissue breakdownNot frequently occurs Bacteria in infected root canals can come into dentinEndodontic pathogens can stimulate epithelial downgrowth along denuded dentin surfaces. by dentinal tubules Primary periodontal disease with secondary endodontic involvementPeriodontal inflammation and

17、 bacteria may directly extend to the pulp through apical foramen, lateral canals or dentinal tubules, cause retrograde pulpitisBut it is rarely occuredPeriodontal inflammation and bacteria usually just cause local pulpal responsecommon reaction - hypersensitivityDegenerative changes of the pulp calc

18、ifications, infarctions and internal resorptions periodontal disease long-standingPeriodontal lesionEndodontic lesionCombinedTrue combined lesionDiagnosis HistoryPulp testingPeriodontal probingRadiographsCriteria to establish a diagnosis1 Perio - 2 Endo1 Endo - 2 PerioHistory Periodontal disease Per

19、iodontal treatment Caries, Fracture, Restorative treatment Endodontic treatmentClinical findings Pus/bleedinding on probing Periodontal disease experienceCalculus present Pulp responses vital /nonvitalAdvanced caries, toothwear, large restorations, discolored tooth Questionable or non-responsive to

20、pulp test Narrow and deep probing pocketX-rayAlveolar bone lossFurcation involvement Apical radiolucency Endodontic therapy Endodontic or post perforation(s) Differences between periodontal and endodontic originDiagnosisTreatmentPrimary endodontic disease with secondary periodontal involvementAfter

21、proper endodontic therapy, periodontal lesions frequently heal without a persistent periodontal defect. RCTOne yearEndodontic therapy first Plus periodontal treatment Evaluate treatment result after 2-3 monthsRCT3-month Primary periodontal disease with secondary endodontic involvementBoth endodontic

22、 and periodontal treatments are necessary.RCTTrue combined diseaseEvaluate value of the toothInitiate endodontic therapy firstPeriodontal treatmentRCT3 months2 years Bone graftPeriodontal abscessDefinition:A localized accumulation of pus within the gingival wall of a periodontal pocket.Periodontal a

23、bscessAbscess of periodontiumGingival abscessPeriodontal abscessPericoronal abscessClassification of Periodontal Abscess :Acute/chronicSingle/multipleCauses of periodontal abscessExtension of infection from a periodontal pocket deeply into the supporting periodontal tissues and locallization of the

24、suppurative inflammatory process along the lateral aspect of the rootLateral extension of inflammation from the inner surface of a periodontal pocket into the connective tissue of the pocket wall. Locallization of the abscess results when drainage into the pocket space is impairedIn a pocket that de

25、scribes a tortuous course around the root, a periodontal abscess may form in the cul-de-sac, the deep end of which is shut off from the surface.Causes of periodontal abscessIncomplete removal of calculus during treatment of periodontal pocket. In this instance, the gingival wall shrinks, occluding t

26、he pocket orifice, and a periodontal abscess occurs in the sealed-off portion of the pocket.A periodontal abscess may occur in the absence of periodontal disease after trauma to the tooth or perforation of the lateral wall of the root in endodontic therapyCracked toothClinical featureAn ovoid elevat

27、ion of the gingiva along the lateral aspect of the root.The gingiva is edematous and red, with smooth, shiny surface.Accompanying symptoms:Acute abscess throbbing, radiating painExquisite tenderness of the gingiva to palpationSensitivity of the tooth to palpationTooth mobilityLymphadenitisSystemic e

28、ffects: fever, leukocytosis and malaiseChronic abscessHave a history of intermittent exudationSinus, may be covered by a mass of granulation tissueUsually asymptomEpisodes of dull gnawing painSlight elevation of the toothDesire to bite down and grind the toothDiagnosis of periodontal abscess Patient

29、s chief complaintClinical findingsRadiographic findingsDifferential diagnosisPeriodontal abscessGingival abscessDestructive periodontitisForeign objectPeriodontal pocketDisease-free areaPeriodontal supporting tissuesMarginal or interdental gingivaDifferential diagnosisPeriodontal abscessPeriapical a

30、bscesspreexistingPeriodontal pocketDeep restoration, cariesPulp testvitalnonvitalSwelling localizedgeneralizedLocation Gingiva marginApical areaPainDull, constant, less severeThrobbing, lasting, more severemobilityMovement before and after treatmentMovement, but release after treatmentpercussionLess

31、 severeMore severeRadiograph of bone loss alveolar crestApical areaTreatment Rationale of treatment :Alleviate the painControl the spread of infectionEstablish drainageTreatmentDrainage:Through the pocket Through an external incisionLocal anesthesiaBy probe, curette or bladeAntibiotics AnalgesicsCop

32、ious fluid diet, bed rest if necessaryGingival recessionRecession is exposure of the root surface by an apical shift in the position of the gingivaPosition of gingivaSeverity of recession is determined by the actual position of the gingivaRecession refers to the location of the gingiva, not its cond

33、itions.Gingival recessionEtiologic factorsFaulty toothbrushing techniqueTooth malpositionFriction from soft tissueGingival inflammtionAbnormal frenum attachmentTrauma from occlusionOrthodontic movementClinical significanceSusceptible to cariesDentin hypersensitivityHyperemia of pulp and associated s

34、ymptomsCreate oral hygiene problemTreatment Eliminate the etiologic factorsmucogingival surgeryCoronally displaced flapLaterally positioned flapSubepithelial connective tissue autograftFrenotomy or frenectomyGTRSingle tooth free gingival graft Connective tissue graftRoot coverage with resorbable mem

35、brane -GTRRoot hypersensitivityCausesRoot exposure as gingival recession or pocket formationAfter scaling, root planning or periodontal surgeryHydrodynamic mechanism ManifestationPain induced by cold or hot temperature; by citrus fruits or sweets; or by contact with a toothbrush or a dental instrumentDiagnosisLocated by gentle exploration with a probe or cold airPointed out directly by patientTreatment Adequate plaque co