Sindrom Endo-Parodontal Iasi.pdf

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UNIVERSITY OF MEDICINE AND PHARMACY

GR.T.POPA IAI FACULTY OF DENTAL MEDICINE

DOCTORATE THESIS

CLINICAL BIOLOGICAL RESEARCH IN MANAGEMENT

FOR ENDO-PERIODONTAL SINDROM

Abstract

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Aspirant Doctorate:

PETRONELA AGAFIEI

Iai 2011

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SUMMARY

SUMMARY ....................................................................... Error! Bookmark not defined.

KNOWLEDGE STAGE ...................................................................................................... 4

INTRODUCTION ............................................................................................................... 4

CHAPTER 1 ........................................................................................................................ 4

ENDO-PERIODONTAL MORPHOPHYSIOLOGY ....................................................... 4

CHAPTER II ....................................................................................................................... 4

ETIOLOGY OF ENDO-PERIODONTAL DIZORDERS .................................................. 4

MICROBIAL ETIOLOGY OF ENDODONTIC DISEASES ............................................. 4

CHAPTER III ..................................................................................................................... 5

PATHOPHYSIOLOGY OF ENDO-PERIODONTAL SYNDROME .............................. 5

PERSONAL PART ............................................................ Error! Bookmark not defined.

CHAPTER IV ...................................................................................................................... 5

CLINICAL BIOLOGICAL RESEARCH IN MANAGEMENT FOR ENDO-

PERIODONTAL SYNDROME .......................................................................................... 5

INTRODUCTION. THEME MOTIVATIONS ................................................................ 5 OBJECTIVES ...................................................................................................................... 5

RESEARCH DIRECTIONS ................................................................................................ 6

DATABASE CREATION AND STATISTICAL METHODS IN EVALUATION .......... 6

DISCUSSIONS .................................................................. Error! Bookmark not defined.

CHAPTER V ...................................................................................................................... 7

EVALUATION OF BACTERIAL PATTERN AND OF MICROBIAL

PATHOGENICITY LEVEL IN ENDO-PERIODONTAL SYNDROME.......................... 7

STUDY PURPOSE ........................................................... Error! Bookmark not defined.

MATERIAL AND METHOD ........................................... Error! Bookmark not defined.

RESULTS .......................................................................... Error! Bookmark not defined.


CHAPTER VI ................................................................................................................... 13

ANATOMOPATHOLOGICAL ASSESSMENT IN ENDO-PERIODONTAL

SYNDROME ..................................................................................................................... 13

STUDY PURPOSE ........................................................................................................... 13

MATERIAL AND METHOD ........................................................................................... 13



CHAPTER VII .................................................................................................................. 16

STUDY ON AGGRESSIVE POTENTIAL OF SCALING / SURFACING

TECHNIQUES IN ENDO-PERIODONTAL SYNDROME ............................................ 16

WORK PURPOSE. ........................................................... Error! Bookmark not defined.




CHAPTER VIII ................................................................................................................ 18

STUDY ON SCALING AND SURFACING EFFECTS AND IN CONJUNCTION

WITH SUBGINGIVAL APPLICATION OF CHLORHEXIDINE GEL IN

TREATMENT OF ENDO- PERIODONTAL SYNDROME ........................................... 18

STUDY PURPOSE ............................................................ Error! Bookmark not defined.



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CHAPTER IX ................................................................................................................... 23

RADIOLOGICAL ASSESSMENTS N ENDO--PERIODONTAL SYNDROME ........ 23 STUDY PURPOSE .......................................................... Error! Bookmark not defined.


RESULTS - CLINICAL CASES ...................................... Error! Bookmark not defined.


PROGNOSIS PRESERVATION OF TEETH EVALUATION ..... Error! Bookmark not

defined. CHAPTER X .................................................................................................................... 28

STUDY ON CLINICAL-COMPLEMENTARY EVALUATION AND TREATMENT

OF FACTORS INVOLVED IN ONSET OF ENDO-PERIODONTAL SYNDROME .... 28

STUDY PURPOSE .......................................................... Error! Bookmark not defined.

MATERIAL AND METHOD .......................................... Error! Bookmark not defined.

RESULTS DISCUSSION ................................................ Error! Bookmark not defined. THEORETICAL AND PRACTICAL CONTRIBUTIONS FOR DOMAIN

DEVELOPMENT .............................................................................................................. 30

GENERAL CONCLUSIONS ............................................................................................ 32

BIBLIOGRAPHY .............................................................................................................. 33

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KNOWLEDGE STAGE

INTRODUCTION

Between periodontal and endodontal space are closely interdependences, if one is

affected can determine the response from the other. This interrelation is given that the

tooth and periodontium is a functional unit.

Differential diagnosis of endodontic lesion (endodontic lesion is the term used to

describe an inflammatory process in periodontal tissue due to presence of toxic agents in

the tooth channel during infections) and periodontal lesions (periodontal lesion is the term

used for indicate an inflammatory process in periodontal tissue resulting from the

accumulation of dental plaque on surface) often can be difficult, because endodontal

lesions often have symptoms of apical periodontitis, while periodontal disease symptoms

often are present in the marginal periodontium.

CHAPTER I

ENDO-PERIODONTAL MORPHOPHYSIOLOGY

Between periodontal and endodontal space are closely interdependences, if one

is affected can determine the response from the other. This interrelation is done so, that

the tooth and periodontium is a functional unit.

The proper functioning depends on the status health of a tooth periodontium.

Disease status in this area may be the result of:

periodontal tissue illness expansion in pulp disease, apical progression to gum inflammation that can affect cement, ligament and

alveolar bone.

CHAPTER II

ETIOLOGY OF ENDO-PERIODONTAL DIZORDERS

MICROBIAL ETIOLOGY OF ENDODONTIC DISEASES

From the demonstration presence of bacterial forms in necrotic pulp tissue,

around 100 years ago, the effect of oral flora in the pathogenesis of pulp and periapicale

indigenous was obviously increased.

Is no less true that for many years, was missing direct relationship scientific

documentation on the cause - effect, mainly due to the ability of appropriate isolation and

identification of all bacteria involved.

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Endodontic microbiology recent surveys showed the role of Gram-negative

anaerobic and have demonstrated a link between symptomatic cases and certain types of

bacteria. These findings, coupled with the demonstration that the "invaders" unusual and

undiscovered enter in root system, strengthened the relationship between preclinical and

clinical disciplines.

CHAPTER III

PATHOPHYSIOLOGY OF ENDO-PERIODONTAL SYNDROME

As with other infections, in endo-periodontal syndrome, interactions between host

and bacteria determine the nature and extent of disease. Pathogenic microorganisms can

influence the infectious process progression by producing toxics that directly invade host

tissues and stimulate its response.

PERSONAL PART

CHAPTER IV

CLINICAL BIOLOGICAL RESEARCH IN MANAGEMENT FOR ENDO-PERIODONTAL

SYNDROME

INTRODUCTION - THEME MOTIVATIONS

Symptoms of inflammation common characteristics in periodontal diseases, which

are manifested by the presence of deep periodontal pockets with or without swelling and

suppuration at gingival marginal, increase mobility and dental angular defects bone, also

can be symptoms of a disease from the root channels system.

Following the concerns of both the current practice in the preparation and doctorate,

Ive proposed: o Data collection of documentary material to integrate data from the literature

on endo-periodontal relations and their treatment, conservative or surgical

o Endodontic and periodontal pathology study in patients trial, highlighting the complex program for evaluation and treatment of patients with severe

endo-periodontal syndrome including indications for choosing conservative

or surgical treatment

o Realisation of clinical and laboratory studies on a personal data concerning status health and endodontic / periodontal damage inpatients who referred

for dental treatment to my private dental office staff and in the

Periodontology Clinic - UMF Iasi.

OBJECTIVES

To achieve these goals, were named the following objectives:

o Developing a comprehensive assessment program that includes: o diagnosis correlated with evolutionary stage, o general and particular objectives of each clinical case,

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o case study database for processing statistical data, o basic pathogenic factors determination,

o Indication of clinical features, laboratory investigations, functional explorations and biological tests for the diagnosis and differential

diagnosis of certainty.

Database selection, examination and evaluation of cases we've realised in my

dental office at Tulcea and Periodontology Clinic at Faculty of Dental Medicine, Iai.

RESEARCH DIRECTIONS

The study was focused on the following:

o Evaluation of endodontic-periodontal status in determining therapeutic

options, surgical vs. conservative treatment.

o Evaluation of clinical indicators of periodontal disease (i.e., plaque index,

gingival inflammation indices - indices of bleeding, attachment loss, alveolar bone

lysis).

O Clinical and laboratory studies for identification of microbial flora isolated

from root channels and periodontal pockets.

O Assessment of iatrogenic potential of scaling / surfacing on pulp.

o Observation of clinical and microbiological effects of scaling / surfacing and

in conjunction with subgingival application of chlorhexidine gel in the treatment

of periodontal pockets, within the concept of total disinfection of the oral cavity.

o Evaluation of clinical, radiological and statistics for analysis and prognostic

assessment in periodontal surgery indication.

For assessing such various aspects of endo-periodontal syndrome, we approached

the multidimensional human cases included in our research using clinical

investigations, laboratory, statistics, microbiological.

DATABASE CREATION AND STATISTICAL METHODS IN EVALUATION

For performing this study I was beneficiary case trials from:

o Odontology- Periodontology Clinic, Faculty of Dental Medicine, UMF Iai in 2004-2007

o Private Dental Medicine Office - Tulcea I ve formed a group study of 151 patients who had periodontal symptoms,

manifested by changes in shape, colour or texture of the gums, swelling, spontaneous

bleeding or easily induced, pain and tenderness, or itching gingival gum, tooth mobility,

pockets with different depths , hyperplasias varying degrees. STATISTICS METHOD

Statistical analysis was performed using Microsoft Excel and statistical programs

NCSS / PASS, with applications in medical statistics.

Clinical cases

Next images are some of the most representative clinical cases included in this

study. Photographs are representing clinical modifications of patients and them

radiological aspects that determined the attitude of therapeutic choice.

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Patient C.V., 48 years

Fig.IV.1 Patient C.V., 48 years endo-periodontal syndrome 46, intraoral clinical

aspect

Fig. IV.2 Patient C.V., 48 years endo-periodontal syndrome 46, radiographic aspect

DISCUSSIONS

Diagnosis and control of endo-periodontal syndrome is based on clinical

parameters in a large extent. Clinical diagnosis affects directly decisions to initiate

treatment, to select methods and sketch the topography for treatment application.

CHAPTER V

EVALUATION OF BACTERIAL PATTERN AND OF MICROBIAL PATHOGENICITY LEVEL IN ENDO-

PERIODONTAL SYNDROME

STUDY PURPOSE

The purpose of this study was to investigate the composition of microbial flora in

infected channels and periodontal pockets in teeth with endo-periodontal syndrome, and

to determine associations frequency of bacteria found.

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MATERIAL AND METHOD

Content of 25 roots channel and 20 periodontal sites, with pockets 3-5 mm, from

20 patients, with clinical and radiographic diagnosis of endo-periodontal syndrome was

assessed by microbial analysis.

Identification of bacterial species was isolated by:

The appearance of growing colonies (colony morphology) pigment genesis, size, and shape.

Morpho-tinctory appearance of isolated colonies

RESULTS

A. DETERMINATION OF ENDODONTIC FLORA

The 25 samples contained microbial endodontic microorganisms cultivated. The

average number of CFU ml-1

was 8x104 per sample. Number of species in the channel

varies between 4 and 7 (average 5.1).

Table V. 1- Bacterial species of infected channels- Bacilli Gram negative

Bacterial species Number of samples

Fusobacterium spp 18

Prevotella oralis 9

Prevotella intermedia 19

Prevotella buccae 7

Prevotella melaninogenica 3

Peptostreptococcus prevotii 5

Bacteroides SPP 7

Capnocytophaga SPP 14

Fig.V.1. Bacterial species in infected channels: G-bacilli

Among G-bacilli were identified: Fusobacterium SPP, Prevotella SPP (P oralis, P

intermedia, P buccae, P melaninogenic), Peptostreptococcus prevotii, species of

Bacteroides and Capnocytophaga SPP. (table V.1, fig V.1)

Bacterial species Bacilli Gram -negative

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9

19 7 3

5

7 14

Fusobacterium spp P oralis P intermedia P buccae P melaninogenica P prevotii Bacteroides SPP Capnocytophaga SPP

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Table V.1- Bacterial species of infected channels- Gram positive

Bacterial species Number of samples

Eubacterium spp 15

Actinomyces SPP 9

Bifidiobacterium SPP 7

Propionibacterium spp 21

Fig V.2. Bacterial species in infected channels-bacilli Gram +

As the bacilli Gram +, were isolated following: Eubacterium SPP, Actinomyces

SPP, Bifidiobacterium SPP, Propionibacterium SPP (table V.2, fig V.2)

Table V.3 Bacterial species of infected channels - cocci Bacterial species Number of samples

Cocci g-

Veillonella SPP 7

Cocci g+

Peptostreptococus micros 25

Germella spp 3

Staphyilococcus spp 5

Fig.V.3 Distribution of bacterial species-cocci G + / -

From cocci G- were isolated Veillonella SPP, and from cocci G+, Staphylococcus

SPP, Peptostreptococus micros and Germella SPP (table V.3, fig V.3).

Bacterial species distribution Bacilli gram +

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9 7

21

Eubacterium spp Actinomyces spp Bifidiobacterium spp Propionibacterium spp

Distribution of bacterial species Cocci G+/-

7

25

3 5

Veillonella SPP Peptostreptococus micros

Germella SPP Staphilococcus SPP

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Table V.4 Bacterial species in infected channels

Microbial species Number of samples

G+Bacilli 63

G- Bacilli 52

G+Cocci 33

G-Cocci 7

Distribution of microbial samples from infected

canals

40%

34%

21%

5%

G+Bacilli

G-Bacilli

G+Cocci

G-Cocci

Fig. V.4. Distribution species in infected channels

As can be seen, overall, the species isolated, the highest proportion is the group

bacilli G - (40%), followed by the bacilli G + (34%), cocci representing 26% of the

species determined (cocci G - 5%, G + cocci 21%) (Fig. V.4.).

In gram negative bacilli group, the largest proportion was represented by

Prevotella intermedia and Fusobacterium in equal proportions (22%), followed by

Capnocytophaga SPP (17%) and Prevotella oralis (11%) (Fig.V. 4.)

Specii bacteriene

Bacili Gram -

22%

11%

22%9%4%

6%

9%

17%

Fusobacterium spp P oralisP intermedia P buccaeP melaninogenica P prevotiiBacteroides SPP Capnocytophaga SPP

Fig. V.5 Proportion of Bacteria G-

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Group Gram positive is the highest proportion Propionibacterium (41%),

followed by Eubacterium (29%), Actinomyces (17%) and Bifidiobacterium (13%) (Fig.

V.6).

Proportia speciilor bacteriene

Bacili gram +

29%

17%13%

41%Eubacterium spp

Actinomyces spp

Bifidiobacterium spp

Propionibacterium spp

Fig. V.6. The proportion of bacilli G +

As the proportion of cocci, the highest value was recorded for Peptostreptococus

micros (62%) followed by Veillonella (17%), Staphylococcus species (13%) and Gemelli

SPP (8%) (Fig .V.7).

Proportia speciilor microbiene

Cocci G+/-

17%

62%

8%

13%Veillonella spp

Peptostreptococus

micros

Germella spp

Staphilococcus spp

Fig.V.7 The proportion of microbial species cocci G-/ +

B. IDENTIFICATION OF MICROORGANISMS IN PERIODONTAL POCKETS

Identification was made according to the appearance of colony growth and

appearance morpho-tinctory. The 20 samples were positive for all anaerobic floras. We isolated 54 bacterial strains: 2-3 strains / sample. Of these, 50 species were

identified, 4 bacterial strains can not be identified. Isolated anaerobic species are Gram-

negative strains 33 (66%), Gram-positive bacilli 7 strains (14%), Gram-positive cocci 6

strains (12%), four unidentified strains (8%) (Fig.V.8). Anaerobic bacterial species

isolated types are shown in Table V.5.

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Predominant bacteria in gum pockets deposits of patients with chronic forms of

periodontal disease were as follows (Table V.5) (averages):

Table V.5 Types of microorganisms found in periodontal pockets

CATEGORY %of colonies

Bacteroides 2,83%

Bacilli G-anaerobes

P. melaninogenica 9,66%

Campylobacter 3,16%

Difteroizi anaerobes 16,5%

Difteroizi facultative 12%

Enterococus 8,1%

Fusobacterium 3,25%

Peptostreptococus 5,53%

Spirochete 1,26%

Staphylococci

B. G-facultative 1,08%

Streptococcus (70% mites) 26,16%

Veillonella 10,36%

2.83

9.66 3.16

16.5

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8.1

3.25

5.53

1.26

1.08

26.16

10.36

% din totalul coloniilor

Bacteroides Bacili G-anaerobi P. melaninogenica

Campylobacter Difteroizi anaerobi

Difteroizi facultativi Enterococus

Fusobacterium Peptostreptococus

Spirochete Stafilococi B. G-facultativi

Streptococus (70 mitis) Veillonella

Fig. V.8 Types of organisms identified in periodontal pockets

DISCUSSIONS

Bacterial invasion in necrotic pulp, often lead to periapicale inflammation.

The usual invasion of bacteria in the necrotic pulp is through the cavities, but from

the large number of species present on the surface of the tooth and gingival sulcus, a

small part will be developed in the environment provided by endodontic space. These

species, although they lack of pathogeneicity when are stationed in the oral cavity, in

infected channels plays an important role in inflammation and necrosis production.

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CHAPTER VI

ANATOMOPATHOLOGICAL ASSESSMENT IN ENDO-PARODONTAL SYNDROME

STUDY PURPOSE

In order to identify morphological aspects of various forms of periapicale

pathology in the endo-periodontal syndrome and their correlation with clinical

presentation, biopsies were performed in cases of periapicale granuloma, periapicale cysts

and chronic periapicale abscesses we studied.

MATERIAL AND METHOD

In all cases studied we selected a number of cases, based on clinical examination,

in conjunction with the X-ray, and were diagnosed with:

Periapicale granuloma 6 cases 7 cases periapicale cyst Chronic periapicale abscess 3 cases Biopsies were performed in cases of periapicale granuloma, periapicale cysts and

periapicale osteitis we studied.

They used conventional morphological methods (haematoxylin-eosin staining, HE),

Van Giemson staining and Immunohistochemistry.

RESULTS

PERIAPICALE GRANULOMA

Morphological aspects of periapicale granuloma cases evaluate were within the

patterns described in the literature. I found a granulomatos inflammatory process, with

mixed cellular, lymphocyte predominant, but there are also plasma cells and macrophages

Fig VI.1. Periapicale granuloma Col. HE, GB. x20, granulomatos

inflammatory process, with mixed cellular.

PERIAPICALE CYST S EPITHELIUM-COMPONENT

A true epithelial cyst does not communicate with the system. Canalled cyst is

recognized by epithelial tissue that separates formation. Treatment for this injury is only

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surgical and endodontic treatment has no effect because the cyst does not communicate

with the root channel.

This type of cyst formation occurs in a long period of time, about six months after

the channel becomes necrotic.

In preparations made by the main cysts, lesions were polymorphic. Cyst wall was

stratified squamous epithelium wallpaper, partly thickened, and partly eroded.

Fig. VI.2. Periapicale cyst col. HE, stratified squamous epithelium obx20se notes and

a polymorphous inflammatory infiltrate subjacent.

Also in this mass and collagen appeared Malassez epithelial rests.

Fig VI.3. Periapicale cyst col. V. Giemson, obx40, epithelial rest Malassez

RUSHTON HYALINE CORPUS

The sections examined were found included in epithelial thickness as subepiteliale

a series of round or oval structures consisting of damaged red blood cells (body Rushton

in formation) also found areas of necrosis and hemorrhagic fibrinous infiltration.

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Fig VI.4. Periapicale Cyst col. HE, obx40 corpora Rushton

Rushton hyaline corpora presence is a particular feature of odontogen cysts. Their

frequency ranges from 2.6% to 9.5% occurring in the epithelial or in the lumen of

morphological cysts. They have variety of forms.

Nature of this body is not well known, suggested that keratin are likely a product

of odontogen epithelium secret or degeneration of blood cells. Some authors have

suggested that there are materials left over after surgical interventions. Is unclear why

these children are mostly in the epithelium.

CHOLESTEROL

The presence of cholesterol crystals in apical periodontitis is a common

histopathological feature.

Fig VI.5. Periapicale cervical cyst obtain crystals of cholesterol col

H.E, ob x40,

DISCUSSIONS

Morphological aspects of the cases studied were within the patterns described in

the literature.

In periapicale granuloma there was a mixed cellularity with predominance of

lymphocytes. Immunohistochemistry, they were mainly B lymphocytes T lymphocytes

modest participation.

In periapicale cysts, wall coverings epithelium stratified squamous type was in

some bold, partly eroded, with sponginess and exocytose.

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We identified Rushton corps, and Malassez epithelial rests in the formation.

Infiltrate periapicale cell cysts were polymorphic, with predominance of lymphocytes,

immunohistochemistry identified as belonging to type B.

Fibrosis process was constantly on the periphery of lesions, either in lesion.

Investigation confirms our immune presumption granuloma and cysts from

periapicale.

Chronic periapicale abscess cases were classified as chronic fibrosis osteitis.

Before interpreting the results of morphological study performed by us, we shall

present interrelations periapicale infection, to see which is where in this three entities

studied.

CHAPTERVII

STUDY ON AGGRESSIVE POTENTIAL OF SCALING / SURFACING TECHNIQUES IN ENDO-PERIODONTAL

SYNDROME

WORK PURPOSE

Because it is difficult to clinically appreciate which is the value of a smooth root

surfaced and the level at which an involuntary surfaces can turn a dentin exposure, our

study aims to assess ex-vivo the effects of macro- and microscopic surfacing on

remaining tooth structure. The research was both ex-vivo to assess the surface appearance

and clinically, for assessing the effects due to surfacing

MATERIAL AND METHOD

In the study we used freshly extracted teeth 78, due to the evolution of different

forms of periodontal disease. Teeth were divided into 2 groups, and we proceed to scaling

and root surfaces as follows:

group A manual scaling, using Gracey curettes group B - ultrasonic scaling Sanitary safety, scaling was applied at one of the root surface, simulating the

clinical algorithm of scaling / surfacing until we obtained a smooth surface.

When labour was considered complete, teeth were placed in new dye bath.

Teeth were examined both macro and microscopically in terms of layout and intensity of

colour and surface appearance resulting from surfacing.

RESULTS

MACROSCOPIC EXAMINATION

Following examination of stained surfaces we observed the dye absence, mainly in

surfaced area, due to completely remove of all the fibbers attached to the cement surface,

which entitles us to believe that a "classic" surfacing remove not only infiltrated cement,

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but also is able to destroy and the elements necessary for re-attachment, cement and

fibber.

Fig. VII.1- Analysis of macroscopic samples evaluated

Areas examination additional revealed, all root cement removal with dentin

exposure in some areas, mostly prominent at 9 roots of the 78 teeth. We should mention

that, in terms of macroscopic. all surfaces surfaced seemed smooth, shiny.

MICROSCOPIC EXAMINATION

Lot A -manual scaling / surfacing: we observed striated appearance at the cement

surface, after Gracey curette and with, in some cases, exposure of dentinar surface.

Lot B -ultrasonic surface is smooth without dentin exposure, but have fine grooves

and defects due to the ultrasonic instrument tip action.

MICROSCOPIC EXAMINATION

Fig. VII.2 Striated appearance of the cementary surface after surfacing with Gracey

curettes

FigVII.3. Exposed dentine surface after manual scaling / surfacing

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Fig VII.4. Microscopic aspect of surfaces after ultrasonic scaling

DISCUSSIONS

"Classic" surfacing has a number of limitations that can be easily demonstrated.

Frequent repetition of the manoeuvres is especially detrimental in the long term

effects it produces.

Any practitioner must preoperative assess the need for manoeuvres, and take that:

however as motivation and awareness of patient stage is hard, it is preferable in all

respects, to avoid an unexpected intervention, often iatrogenic, as it is surfacing.

Cement may be subject to alterations in structure and composition of their

compounds both organic and inorganic, as a result of pathological changes in the

immediate vicinity.

Prolonged presence of inflammatory process on gingival connective tissue has as

results loss of collagen fibbers and destruction of gum.

Although the enzymatic destruction of collagen fibbers is evident in gingival

tissue, soft tissue extension of this process in much of the root with the loss of cross

collagen and dissolution of crystals of minerals was also described. However, this process

is rather limited to the surface with a diffuse transmission to unaffected underlying tissue.

CHAPTERVIII

STUDY ON SCALING AND SURFACING EFFECTS AND IN CONJUNCTION WITH SUBGINGIVAL

APPLICATION OF CHLORHEXIDINE GEL IN TREATMENT OF ENDO- PERIODONTAL SYNDROME

STUDY PURPOSE

The purpose of this study is to assess the effects of subgingival chlorhexidine gel

Periokine (Laboratorios Kin SA) in periodontal pockets as an adjunct to MS/ S.

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MATERIAL AND METHOD

In the present study were included 41 patients (22 women and 21 men with mean

age 45.9 (23-69 years) enrolled in the study group who received endodontic and / or

conservatory periodontal treatment.

They had no relevant medical history and have not received periodontal therapy or

antibiotic treatment at least six months before the study.

The following measurements were recorded at 60 and 90 days:

o plaque index (PI) Silness and Le o gingival index (GI), Le and Silness, o gingival recession (GR), o clinical attachment level (NAC), o probing depth of pockets (AP), o bleeding on probing (SS) as the absence or presence of bleeding by 30 seconds

after probing.

The type of treatment of each site was chosen by simply scaling distribution

following:

o lot 1- SM/S (11 patients); o lot 2 SM/S + irrigation with saline(13 patients); o lot 3 SM/S + irrigation chlorhexidine gel (17 patients).

For 4 weeks lot 2 and 3 subjects received weekly subgingival irrigation that began

with the first visit after SM / S (day 0, 7, 14, 21).

RESULTS

PLAQUE INDEX

There was a statistically significant reduction (p 0.05) between groups.

Fig VIII.1 Reduction of plaque index

GINGIVAL INDEX

The analysis of associated groups, statistically significant reduction was observed

(p

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group 3 had a statistically lower results (p

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Fig VIII.4 Reduction of probing depth in patients studied

Attachment level. We observed in all groups an increased clinical attachment.

Clinical attachment gain was statistically significant (p 0.05)

between them.

Fig VIII.5 Values of attachment gain

BLEEDING ON PROBING

11 patients in group 1 were analyzed in the initial period and 9 of them were

positive for bleeding on probing, among them eight persons became negative at T1. The

other two persons positive bleeding a patient was negative T1 to T2. 13 people have been

analyzed in group 2 and 10 of them were positive bleeding on probing and became

negative at T1 and T2 3 became positive. 17 people of Lot 3 were analyzed in the initial

period and 12 were positive and became negative bleeding T1. At this, all sites were

negative from T1 to T2

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Fig VIII.6. Reducing bleeding on probing index values in the three groups study

DISCUSSIONS

This study evaluated the effectiveness of local administration of chlorhexidine gel

as an adjunct to SM / S. Clinical improvement of all periodontal parameters of batches

tested were different from the original to a level of significance of 0.05.

Use the gel with chlorhexidine irrigation improved outcome SM / S in terms of

testing parameters.

These results can be linked with chlorhexidine action on microorganisms. The

group 1 reduced to a decrease in clinical parameters compared to group 3 by the end of

the study.

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CHAPTER IX

RADIOLOGICAL ASSESSMENTS N ENDO--PERIODONTAL SYNDROME

STUDY PURPOSE

Is to evaluate the usefulness of radiological studies in diagnosis and management of

patients with endo-periodontal syndrome.

MATERIAL AND METHOD

For radiographic assessment were taken in study patients with endo-periodontal

syndrome, who analyzed the quality of information brought by each imaging for areas of

interest, compared with clinical assessment. We considered the type of bone lysis,

location, severity and number of walls in vertical bone lesions twinning.

The types of radiological investigation were:

-X-ray retro-dental-alveolar

-OPT

-Computer tomography

Following the radio-visible elements, our examination said about:

- Spongy bone in the interdentally trabecular septum as furcation;

- Image cortical bon with contour increment to be net;

- Outline septal crest or top of the normal septum is located 1-2 mm apical to the

junction enamel - cement;

- Last lamina durra or cribriform lamina which corresponding to radiographic

image at ligament adjacent bone portion;

- Desmodontal space: space is black, may have occlusal aetiology but can be a

technique error;

- Furcation and their possible involvement;

- Images of the apical endo-periodontal lesions.

Radiographic assessment of bone was an indispensable element of diagnosis and

indication for choosing the method of treatment-conservative or surgical, allowing

assessment of interdentally and eventually interradiculare bone.

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RESULTS - CLINICAL CASES

Table IX.1 Analysis of clinical symptoms of periodontal disease

Symptoms of periodontal disease % of patients

Spontaneous bleeding 10%

Inflammation 90 %

Gingival recession 4 8%

Gingival hyperplasia 2%

Tooth Mobility 59%

Pockets false/true 42%

Table.IX.2 plaque index -averages (mm)

Wilcoxon test

Lot Study Control

Pre-treatment 1,87 1,7

Post-treatment 0,85 1,5

p 0,0001 0,0001

Difference 1,17 0,65

Ray examination

OPT advantages: is a global study, achieving in single film all system dental-

alveolar

Relatively easy due to its simplicity positioning without patient preparation, without the

vomit reflexes, associated with rapid execution, low radiation and price is a

recommended as initial dental examination

Figure IX.1 Radiographic examination in endo-periodontal syndrome

Computer tomography CT

Volumetric computerized tomography used - NewTom QR - DVT 9000

Using computerized tomography was performed dental volume due to the fact that

the minimum radiation dose to the patient is 5 times lower than for conventional

tomography, the actual time of patient exposure is minimal, avoid any error in positioning

the patient, geometric measurements are accurate to 1:1, the reports are available on CDs

or photo paper.

Software program uses a special algorithm that reduces the influence of the metal.

In dental volumetric tomography to look so few "mm" extra bone in comparison with

conventional tomography.

With panoramic tomography images we obtained, axial sections, cross sections

and three-dimensional images.

25

Patient S.S., 54 years,

Fig. IX.2 Clinical aspects intraoral

INDEX 1:

o D = tooth position (e.g. D16) o R = right) o L= left

Measurements:

o Yellow - vertical (length) o Green - horizontal (width) o red point - mandible canal (applied on cross sections) o red line - mandible canal (applied to the Panoramic section) o a orange line - mandible canal (applied to the Panoramic section

Fig. IX.3 Panoramic evaluation

Fig. IX.4 Panoramic evaluation

26

Fig. IX.5 Infra-osseous pocket of on the distal 25; ratings in the decision to treat

bone capital conservator vs. surgical

Fig. IX.6 Endo-periodontal syndrome; infra-osseous pocket on the distal of 25;

evaluation of treatment decision

27

Fig. IX.7 - Evaluation of bone density

Fig. IX.8. 3D- Modelling

DISCUSSIONS

Periapicale radiographs and ortopantomographics may under-or overestimate the

present line of the alveolar bone. Alveolar bone may be unclear, especially in vertical

faults. However, if diagnostic methods detect only 1% (ortopantomographics) or 4%

(apical scan) of the initial vertical lesions, unradiographic method may be preferred by

others, despite the existence of significant statistical differences between methods.

The need for 3D CT has led to the appreciation of the characteristics of the

alveolar bone. CT uses a rotating X-ray fascicule to record an image section of the

patient, generally in the axial direction. Modern CT apparatus use a continuously moving

table so that obtains the spiral or helical images of the patient. After image acquisition,

using a computer program can simulate 3D.

Simplified concept of CBCT devices lead to significant reductions in operating

costs compared with traditional CT. One of the major disadvantages is reduced image

sharpness and image playback inability best of soft parts, which makes this method

particularly indicated for bone structures.

PROGNOSIS PRESERVATION OF TEETH EVALUATION

It should be considered two aspects: overall outcome and prognosis of individual teeth.

In many cases, after radiographic examination, it is preferable to establish a

provisional prognosis until after the initial phase of treatment evaluation. Following

28

initial therapy, active lesions can be converted temporarily inactive why a final prognosis

will be evaluated only after completing the first phase of treatment.

CHAPTER X

STUDY ON CLINICAL-COMPLEMENTARY EVALUATION AND TREATMENT OF FACTORS

INVOLVED IN ONSET OF ENDO-PERIODONTAL SYNDROME

STUDY PURPOSE

It is assessing the incidence and response to conservative treatment of the factors

involved in endo-periodontal syndrome

MATERIAL AND METHOD

The study included all patients in the research groups who conducted conservative

treatment

RESULTS DISCUSSION

Table X.1 Distribution of endo-periodontal syndrome cases, symptoms and

radiographic appearance

Type of

lesion

Nr

teeth

Vitality Pain Swelling Periodontal

pocket

Rx

Aspect

Primary

endodontic

lesion

32 - moderate to

severe

+/- Absent /

Possible

fistula

Rx T +/-

Primary

endodontic

lesions,

periodontal

secondary

31 - moderate to

severe

unsteady present pocket

fistula

trajectory

Rx apex to

sulcus,

crestal

bone

height

reduction

Primary

periodontal

lesion

31 + Absent-

moderate

possible Pocket 4

mm

bone loss

to near

apex

True

combined

lesions

28 - moderate to

severe

unsteady periapicale

communicates

with deep

pockets

loss to

apex bone

loss

29

INCORRECT ENDODONTIC TREATMENT

A properly performed endodontic treatment is the key factor of successful

treatment. It is very important to clean, shape and clog the system channels for successful

treatment.

INCORRECT RESTORATION

Coronary leaching is an important cause of failure in the treatment of endo-

periodontal. Root channels system can recontaminate with microorganisms by delaying

their implementation restorations or crown fracture or broken tooth.

TRAUMA

Alveolar bone trauma or at tooth pulp and periodontal ligament may affect directly or

indirectly.

RESORPTION

Root resorption is a condition that is associated with a physiological or pathological

phenomenon which is manifested by loss of dentine, cement and / or alveolar bone.

PERFORATION

False paths are root unwanted complications that can lead to a failure of endo-

periodontal syndrome treatment because they establish communication between the

system and periodontal tissue channels the oral cavity in which case the prognosis is false

reserved. Carious lesions ways may occur due to extensive iatrogenic or after absorption

DEVELOPMENTAL ABNORMALITIES

Teeth with developmental abnormalities such as invaginations or vertical grooves

root teeth do not respond normally to such treatment. This grooves start from the central

fissures in molars and occlusal face supracingular to front and continue along to the apical

root-distance variables

Fig. X.1 Anomaly of lateral incisor palatal groove

30

THEORETICAL AND PRACTICAL CONTRIBUTIONS FOR DOMAIN

DEVELOPMENT

In our research we started from the observation that the periodontium is

anatomically in relation to pulp in the apical foramen and lateral channels of

communication which creates ways in which pathogens can move from side to side if one

or both types of tissue are affected.

Resorption processes from root level and therapeutic measures used in the treatment

of periodontal disease with dentinal tubules exposure establishes another communication

channel with pulp.

Not only that there may be interactions between periodontal and dental pulp that can

aggravate or extend the lesion, but these interactions put the clinician in difficulty in the

sense that it must determine the cause periodontal disease directly.

Following in the preparation doctorate, I proposed:

o data collection of scientific research to integrate data from the literature on endo-periodontal relations and their treatment, conservative or surgical

endodontic and periodontal

o study of endodontic and periodontal pathology in patients of our study, highlighting the complex program for evaluation and treatment in patients

with severe endo-periodontal syndrome and indication of conservative or

surgical treatments

o performance of clinical and laboratory studies on a personal data concerning health and damage endodontic / periodontal in patients who

were referred to my private dental office for dental treatment and to the

Clinic of Periodontology UMF Iai.

The study was focused on the following:

o Evaluation of endodontic-periodontal status in determining therapeutic options,

surgical vs. conservative treatment.

o Evaluation of clinical indicators of periodontal disease (i.e., plaque index, gingival

inflammation indices - indices of bleeding, attachment loss, alveolar bone lysis).

o Studies on the identification of clinical and laboratory microbial flora isolated

from root canals and periodontal pockets.

o Assessment of iatrogenic potential of scaling / surfasajului on pulp.

o Observation of clinical and microbiological effects of scaling/surfacing and in

conjunction with subgingival application of chlorhexidine gel in the treatment of

periodontal pockets, within the concept of total disinfection of the oral cavity.

31

o Evaluation of clinical, radiological and statistical analysis and prognostic

evaluation in conservative or surgical treatment indication.

As an element of originality we introduced for the first time, after our knowledge,

the study of diseases simultaneously and the periodontal-endodontic, emphasizing two-

way relationship that exists between them.

Ive tried to demonstrate the microbiological assessment that anaerobic bacterial flora involved in the emergence of endodontic disease and periodontal have similarities;

they are influencing and mouldings each other.

Also as an original contribution we introduced complementary evaluation of

radiographic- Computer tomography in the study of endo-periodontal syndrome as an

instrument of high precision in assessing therapeutic options, conservative or surgical

treatment.

32

GENERAL CONCLUSIONS

Results indicate that endodontic pathogens do not occur randomly but are found in specific combinations that may contribute to the development of clinical signs

and symptoms.

Diseases of endodontic and periodontal edges are clearly related to the existence of Gram-negative microbial species in subgingival level.

The microbiological tests aimed to isolate and identify anaerobic gram-negative bacterial species known to be involved in diseases such as endodontic and

periodontal disease.

Microbiological testing provides important data for targeted antibiotic treatment choice by performing sensitivity testing, working with microbiology laboratory is

essential.

Control board subgingival bacterial load supragingival reduce to some extent. Mechanical treatment is relatively effective in suppressing periodontal pathogens and improvements in clinical status.

Conventional mechanical treatment is a necessary step in periodontal treatment, but always fails to completely eliminate periodontal pathogens, particularly

furcation, deep periodontal pockets and other intraoral niches.

In view of the complex ecosystem of periodontal pockets, there is need for antimicrobial agents in conjunction with scaling and surfacing, to eliminate the

pathogenic flora in some cases of periodontitis.

Antimicrobial agents are effective in removing potential periodontal pathogens process such inaccessible sites, such as implications furcation, the convex surface

root deep soft tissues and tubular dentine.

Surfacing in "classic" manner has a number of limitations that can be easily demonstrated.

Frequent repetition of the manoeuvres is especially detrimental in the long term effects it produces.

Every practitioner should evaluate endo-periodontal syndrome by preoperative needs for scaling / surfacing, and regarding that as hard motivation and awareness

for patients, it is preferable in all respects, an unexpected intervention, often

iatrogenic, and surfacing

Loss of substance: surfacing repeated regularly every 3 months, as recommended in the textbooks of Periodontology, causes loss of substances which give eroded

appearances, characteristically, as evident in the third cervical roots thinned and

constitute the possible iatrogenic factors pulp involvement

Compliance with mechanical approach of hardened during periodontal lesions resulting in a lower frequency of these types of problems.

Our research demonstrates the importance of aggressive attitude changings on cement as the defining role in obtaining tissue reinsertion of periodontal ligament

collagen fibbers and fibber-growth over the root surfaces.

We detected many factors that contribute to the onset of endo-periodontal which I grouped as follows:

- Incorrect endodontic treatment over/under restorations

- Incorrect conservative operative procedures

- Trauma to teeth or alveolar bone

- Developmental abnormalities

- Iatrogenic endodontic-Perforations / false root paths

33

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