47/48: Perio Endo Relationships, RCT, and Implants

Transcribed by Anam Khalid Wednesday, October 15th, 2014

Perio-Endo Relationships by Dr. Foran/ Decision RCT or Implants– Diagnosis ‐and Treatment of Oral Diseases by Dr. Gopinathan

[Slide #1] – [The Endo-Perio Relationship: Diagnosis and Decision Making][Dr. Foran] – For those of you who do not know me, my name is Dr. Foran. I am teaching in the D3 and D4 clinic on the floor with you and your patients. This is actually my first lecture with you. I don’t know exactly where most of you are coming from in terms of the didactic knowledge of endodontics and perio so if anything is not clear to you, feel free to shout it out. If anything is something different where you thought something was true and now you’re confused, shout it out. I’m here to help you. Okay, so basically what we’re going to discuss is the relationship between endodontic and periodontal disease and how that impacts your diagnosis and your treatment for your patients when you’re entering the clinic. It’s not an easy topic. It can be very confusing but there are basic premises that if you follow routinely you will likely be able to form a very appropriate diagnosis.

[Slide #2] – [Anatomical Relationship][Dr. Foran] – So to start, we’re just going to talk about the anatomical relationships of the root canal system and the periodontium. So, there are five locations where the pulp and the periodontal ligament communicate. Okay, they are dentinal tubules, lateral canals and secondary canals, which the names are not as important that you remember. Just as long as you know they are branches of the main root canal system. Accessory canals which are found in the furcation of molars and also at the root apex.

[Slide #3] – [Lateral and Accessory Canals][Dr. Foran] – Lateral and accessory canals are very important because they are avenues for bacteria to travel through the pulp into the periodontal ligament space. The incidence of this is pretty high—about 30-40% of molars. And also they are predominantly in the apical third of either molars or single rooted teeth. In the multi-rooted teeth, again, you can have furcation and or in the apex, anywhere from 25% to 75%.

[Slide #5] – [Pulpal and Periodontal Vasculature][Dr. Foran] – This is basically just a slide to give you an idea, with India ink, of how that intimate relationship is formed. And so, internally and outside you can see on the root surface and the bone in here is the nerve canal, intertwined, and these jutting out are communications to the PDL.

[Slide #6] – [Etiology][Dr. Foran] – The etiology of all these lesions is bacteria. Now, whether or not that bacteria is coming from inside the pulp or outside in the periodontium is what you need to determine in order to come up with the correct diagnosis of lesions. Regardless of where they come from, the system is the same. The chain of events are the same. You have a source of bacteria. You have a mode of entry and then you have a susceptible host to which the pathogen can then cause disease.

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[Slide #7] – [Diagnosis][Dr. Foran] – When you’re seeing your patients clinically, there are certain steps that you will want to follow. I know a lot of this may seem strange because you haven’t really been active in patient care yet, am I right about that? Okay. But you just keep this in mind; later on it may come back to you and make sense. So everything is a systematic approach. First and foremost, when you’re treating a patient with a chief complain or a problem and you’re suspecting that this might be either root canal problems, sensitivity, decay, periodontal disease … these steps can always be employed to come up with the correct answer. The first step is to do a clinical hard tissue examination of the tooth. Sensitivity testing is to give you basically the information about the pulp status. And that sensitivity testing can be done with either temperature, thermal stimuli, hot or cold, predominantly cold, and/or electric. The cold test is the more appropriate first-line test, better than the electric pulp test and then I will go into the reasons, if you want, more of that later on. Look for any kind of cracks in the teeth. Very often, patients will come in with a complaint and you can localize on the mesial marginal ridges of teeth certain small little dark lines. Those can be indications of cracks in which bacteria from the outside can leak through into the pulp. Percussion, tapping, basically, with the bottom part of the mirror to see if the patient has pain. Palpation of the root apices and also noting any mobility. So those are your hard tissue examinations. Things you want to look for.

[Slide #8] – [Diagnosis][Dr. Foran] – Radiographic exams. Likely you will always want to take a bitewing and a periapical radiograph because these two x-rays will give you two different types of information. Bitewing x-rays are very good for locating decay, locating how far the crestal bone would be from either a deep carious lesion—and a periapical radiograph obviously will be able to give you a visual of what might be happening at the root apex. The presence and size of any sorts of lesions, predominantly we’re speaking about periapical lesions and/or furcation involvements, any radiolucencies which might point to a perio, bone loss or an endodontic pathosis, you want to know exactly where they are on this x-ray relative to the root surface. Any kind of size abnormalities, are they round, are they oblique. The location and type of bone losses are going to be important as well. You want to determine whether or not you have vertical or crestal and if it’s localized in the entire region or just predominantly on one tooth in one area.

[Slide #9] – [Sensitivity Testing][Dr. Foran] – Okay. So, that’s a sensitivity tester. It’s just a schematic of how to do it. What your goal here is to find out the diagnosis of the pulp. You only have primarily four choices for a pulpal diagnosis. The pulp can be normal, it can have a pulpitis (reversible or irreversible), or it’s necrotic. Just four to remember. And the way that you determine that is if there’s a yes or a no to a stimulus. If you’re placing ice on the tooth or an electric stimulus and the patient feels pain, that is an indication that you have either a normal pulp, or a pulpitis. But for sure the positive test rules out necrosis. Okay, so that’s very important. When you have a positive test to

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temperature, you’re ruling out infection of the pulp tissue. So if any area of the mouth around that tooth appears to be infected, you’re pretty certain that that infection is not coming from an endodontic problem. Okay. False positives. Why would you put cold on a tooth and the patient feels it? Well, again, back to what I was saying before—patients can sometimes feel pain where there is somewhat of a degeneration of the tissue, but still you have a very strong neural response. Neural tissue dies relatively last in the game. So even though there’s no vasculature, the nerve supply may still be vital enough to elicit a response. But the cold test usually is the one that will give you that indication. If you’re not sure, your second line would be electric pulp testing. False negatives. Why would a tooth respond? I’m sorry why would a tooth not respond but is still considered normal? And that could be in a case where you have very very small tiny canal system, either from a trauma, or elderly person with excessive grinding, that canal will shrink. And as it shrinks, it reduces the transmission of that cold temperature through the tooth to the nerve. So in actuality, you might not be getting a strong response but that tissue there is still viable.

[Slide #10] – [Cracked Tooth Testing: Transillumination][Dr. Foran] – Okay, so cracked tooth testing. Clinically I told you to check for cracks. Sometimes patients will come in just having pain with biting. And you’re checking and you see no decay. See no evidence of bone loss. No mobility. And you’re looking clinically and honestly, you don’t see any kind of frank marking of a crack or a fracture. And so the transilluminator is very useful. What the transilluminator can do for you is to basically illuminate this tooth from the cervical portion and light it up, almost as if there’s a microscope underneath it. And if that light gets cut or does not transmit through to the entire tooth and you cannot see this tooth illuminated all the way, then likelihood is that there’s a crack. What happens is that crack comes down vertically through the crown and it deflects the light. So one side beyond the crack will look dark and the other will look light. So this is just a clinical example of what that may look like.

[Slide #11] – [Cracked Tooth Testing: Transillumination][Dr. Foran] – On the left hand side—normal intact tooth without any cracks. Transilluminator is there. Tooth lights up from the buccal straight to the lingual. On the other side, light would not be transmitted through if there is a crack line underneath. This is very important because teeth with large restorations may have those cracks underneath those fillings, which will not be visible to the eye, nor will they be visible on a radiograph. So usually, sometimes, and you will encounter this I can guarantee, you’ll come up and show someone an x-ray and say, well the patient has pain and I see this line do you think that there’s a crack or a fracture? 99.9% of the time you will not see these on radiographs because in order to line up an x-ray in the exact plane of a very small, thin crack line is very, very unlikely. So the cracks are more of a clinical diagnosis based on percussion, biting, and transillumination or if it’s an old crack you may see the actual black line along the marginal ridges.

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[Slide #12] – [Cracked Tooth Testing: Methylene Blue][Dr. Foran] – Another way but as practical is caries indicator or methylene blue dye. Basically wash the tooth, chamber inside and rinse it. And anywhere that you see these dark lines indicates where the dye is penetrating. So that could be another useful way to do it.

[Slide #13] – [Diagnosis][Dr. Foran] – So that is part of the hard tissue examinations. Moving forward to the soft tissue exam. What you’ll need to do—periodontal probing. All six surfaces. You’ll need to notice that there is any location of abscess, where is the abscess? Is it fluctuant? Is it indurated? Is it draining? Is there a stoma or a draining sinus tract? And all of these must be present in order to diagnose if you want to trace and find out exactly where it is. So can anyone tell me why you need to trace stomas? If I come to you and I tell you that a patient has periodontal disease, and the patient also has a history of many root canals, and I tell you that this patient is now presenting with a tooth and next to one of these teeth there is a draining stoma, like a fistula. Why is it important to trace that stoma? Yes?

[Student]— Because if it’s near the apex of the root—it’s endo. If it’s above, it’s probably because of perio, because of infection near bone. Bone loss.

[Dr. Foran] – Okay, very good. True. You want to determine the source of the infection.

[Slide #14] – [Diagnosis][Dr. Foran] – Now, if is a stoma is tracing towards the apex and there is periapical pathosis, that is an endodontic problem. If you trace a stoma to the midroot and take an x-ray, as shown there, this could be either or. This could have been an endodontic problem that perforated through to the outer root surface. Or it could have been the result of an injury, where the PDL was damaged and bacteria got through the sulcus and started to cause an external resorption. So, you are right. You need to trace in order to determine the source of the infection but keep in mind that the sensitivity testings really need to go along with that because you can have situations where traces do not trace to the apex but they still are endodontic problems and I will show you an example of that.

[Slide #15] – [Diagnosis][Dr. Foran] – This is not it. This is just another example of a pure endodontic lesion. Now you can see how long this root is and yet the stoma is not very high. So they can drain at any area. You can have a stoma on tooth #7 and the problem is actually tooth #10. Believe it or not, it can happen. So you really need to trace these when possible.

[Slide #16] – [Treatment]

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[Dr. Foran] – So you’ve done all these tests. You have your sensitivity testing. You have your percussions. You’re tracing stomas if you need to. Now how do you decide what to do? Shall you just proceed with endo? Should you proceed with perio? Should you proceed with both if you see that the whole tooth has a problem? And determining where it’s coming from is key.

[Slide #17] – [Classifications of Perio-Endo][Dr. Foran] – I don’t care if you remember these word for word in terms of type I, type II, type II— but I’d like you to know what primary endodontic lesions are. I don’t care about classification numbers. What’s important is that you know that there are these categories. There are five major. Starting from an endodontic lesion. Then an endodontic lesion which has some periodontal component to it. Then we move to purely purely periodontal problems. Then we move to endo and perio problems that are existent but have nothing to do with each other. And then the true combined.

[Slide #18] – [Primary Endodontic Lesion][Dr. Foran] – So I would like for you just to go through these slides. If there is any question, please stop me because this is really what you need to know. Alright. So, primary endodontic lesion is your garden-variety root canal, necrotic pulp. The source is in the pulp. It’s infected. The bacteria will travel through that canal space from the coronal portion down towards the apex. May or may not form periapical pathosis and the treatment for this would be conventional endodontics and the prognosis is excellent, 95+% success rate.

[Slide #19] – [Primary Endodontic Lesion][Dr. Foran] –These are visual examples of endo lesions. Deep restorations, PAPs, sensitivity testings are negative. Same with the lowers and then the treatment and then the healing.

[Slide #20] – [Primary Endodontic Lesion][Dr. Foran] –Again, you have a very large restoration. The tooth was treated. These heal. They heal well with primary, regular, conventional therapy.

[Slide #21] – [Primary Endodontic Lesion][Dr. Foran] –Another example.

[Slide #22] – [Primary Endodontic Lesion: “Furcal Blowout”][Dr. Foran] –Okay, back to what I had mentioned before. I told you that tracing stomas are very important. And I also told you that if you’re tracing ones at the apex, that it’s an endodontic problem. But what I also mentioned to you, in your response, was that you can trace a lesion that’s not to the apex, and it’s still an endodontic problem. And that would be in a situation that we term furcal blowout. These happen in multi-rooted teeth. The pathogenesis of this is such: tooth with a large restoration, lower molar, becomes infected. Nerve becomes necrotic. Pathogenesis is that the bacteria will travel down the root surface and cause periapical pathology,

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which we know. But keep in mind, that as I told you before, there are five areas where the pulp communicates with the PDL and one of those is the dentinal tubules. In a molar with a furcation, you have dentin tubules in the furcation so that necrotic pulp toxins leak through those tubules as well and can cause a pseudoperiapical pathosis but in the furcation. It’s not in the peri-apex. It’s in an area where bacteria can leak through. And those canals can typically be quite large enough—almost as large as where the apex would be, the apical foramen and lateral canals—to cause radiolucencies in the furca. You will come across this hundreds of time in practice and in clinic and your first gut instinct would be to what? Someone showed you this x-ray. Forget about the root canal portion. Someone showed you this x-ray and that the patient has some swelling on the gingiva. What would be your first gut reaction to do?

[Student]—To test to see if the tooth is vital?

[Dr. Foran]—Would that really be your first gut reaction to do? Let’s forget about the lecture for a second. You’d want to scale. Right. And that’s normal and people practicing for 20 years still want to do that. That’s what we want to do. We want to physically remove things. But this will never heal by doing that because the problem is not external. If you do not remove that necrotic pulp that will never heal. In fact, you can actually prevent healing by doing that because whatever cells you may have there that are healthy; you’re basically just scraping them out and removing them. So scaling is not what you want to do in an area with a furcation involvement unless you are certain that that pulp is not infected. Does that make sense to everyone? Because this is a very important concept. Okay.

[Slide #23] – [Treatment][Dr. Foran] – Just an example of how these furcation canals can look. In the center there may be a necrotic pulp and that’s a very, very large communication. It’s anatomic, there’s nothing wrong. It’s not a crack. But it can happen. Yes?

[Student]—So what’s your recommendation for the previous case? So what should you do, again?

[Slide #22] – [Primary Endodontic Lesion: “Furcal Blowout”][Dr. Foran] – Okay, so if this were to be presented to you radiographically and clinically there is a swelling … localized, gingival swelling, maybe a stoma, maybe not. And this pulp is testing necrotic, you initiate root canal therapy. And you wait. Period. Within a week or two weeks, it should start to resolve. So that’s what you would do.

[Slide #24] – [Primary Endodontic Lesion with Secondary Periodontal Involvement][Dr. Foran] – Okay. So primary endo lesion, which is your basic root canal with a secondary periodontal involvement, means that this necrotic pulp has migrated down and has advanced somewhat beyond its confines of the root system and beyond the confines of the periapical area. And what that bacteria will start to do is

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to migrate through the least path of resistance which is along periodontal ligament space. And that infection will travel down the root. It will exist and then it will start to migrate coronally along the PDL. The result is a thin isolated narrow pocket. This pocket is an endodontic problem. This pocket is not a periodontal problem. So, again, if you have a pocket, which is isolated on a tooth, do not grab the scaler and start root palning until you have confirmed the pulpal diagnosis. It may present with a sinus tract, or it may not. That is why part of the probing, part of the clinical exam is important. You may not know, you may not have any visual reason to probe the area. But if you’re suspecting that you do want to do that. The gutta percha will trace to the apex or any exit along the root surface, meaning just as though in a molar you can have these big furcation canals or communications where you start to see a PAP, you may sometimes have those canals on a single rooted tooth on the lateral root surface maybe of a central incisor. And it’s very big and you’ll actually form this radiolucency anywhere that is big enough for bacteria to leak through. So whatever you’re seeing radiographically I want you to envision where is this coming from? Why is it manifesting? And why is it manifesting in this particular area? Okay.

[Slide #25] – [Primary Endodontic Lesion with Secondary Periodontal Involvement][Dr. Foran] – Here is an example of a primary endo with secondary perio. Clinically, patient has a full gold crown. There is gingival inflammation, some suppuration. You take a perio probe. It’s probing pretty isolated. Everywhere else seems to be about 4’s, 3’s. And you take an x-ray and your gutta percha point is going down to the apex. The treatment for this tooth would be what? Root canal and anything else? You want to do anything any other treatment here? How many people think you would do just a root canal? Good, you’re all wrong. You just do the endo. This is a primary endodontic problem. The source is the necrotic pulp. Remove the necrotic pulp. This will heal. This pocket will close.

[Slide #26] – [Case Report: Visit 1][Dr. Foran] – Case reports. Yes?

[Student]—So once you’ve done the RCT to address the narrow pocket along the lesion, and then you wait and the patient comes back on recall a couple months later ... if there’s inflammation at that area, do you try to do SRP? Or do you suspect that the root canal treatment has failed?

[Dr. Foran]—It depends. Good question. If the presentation is exactly the same … in other words, you have a 10 mm, 11 mm pocket … you’ve done the endo and that 11 mm pocket is still there, your differential will be that you did a very poor job, which is unlikely. Maybe there are two distal canals. Maybe you missed one. Or there could be a vertical root fracture. If the pocket has been unchanged. If you’re getting some resolution but not a complete resolution, then that is the point where you start considering there may be a periodontal component as well. In which case, you can either refer to the periodontist or open a flap and take a look. But initial therapy—root canal only.

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Okay, and so here are just some examples that I gathered to show you. This was a patient who was referred to the office for an evaluation and the patient had been told to have the tooth extracted. So, what I did was basically … oh, clinically there was similar situation clinically here … trace the gutta percha down to the distal root. Removed all the gutta percha. Two canals. Calcium hydroxide.

[Slide #27] – [Case Report 1: Visit 1][Dr. Foran] – Final x-ray. Two and a half years. No pocket. Complete resolution of the lesion.

[Slide #28] – [Case Report: Visit 1][Dr. Foran] – And that was without any periodontal therapy. No SRP, no cleaning, nothing. Second case, sort of same scenario. Patient did not want to lose the tooth.

[Slide #29] – [Case Report 2:][Dr. Foran] – Go ahead. Treat the tooth. Endo. Three year recall. No pocketing. Healed.

[Slide #30] – [Primary Periodontal Lesion][Dr. Foran] – So those are examples … good examples, because I don’t show you my failures … of how this is possible and this is the correct approach to treatment. So moving along to the opposite end are the primary periodontal lesions. The source of the bacteria in any kind of clinical visual infection here is the periodontal space. The source is periodontal disease. There are wide, broad pocketing associated with crestal bone loss here. These are not the narrow isolated pockets that I have mentioned before. We have actual attachment loss here, starting from the crestal bone down, either from the interproximals or from the furcations. There is usually a general presence, overall, comprehensively, of perio problems with the patient. And the pulp response is positive. So, the prognosis of these types of lesions strictly depends on the feasibility of the periodontal therapy. Can you fix this tooth with SRP? With apically repositioned flaps? With any sort of regenerative procedures periodontal wise—because a root canal here is out of the equation. Root canal is not a problem. So anything you do from here on will depend on perio.

[Slide #31] – [Primary Periodontal Lesion][Dr. Foran] – Examples. Wide pocketing. 8’s, 7’s, 6’s. All around the facial root surfaces. Here you can notice you have two components. You have a vertical and a horizontal bone loss. The tooth will test with cold to be positive.

[Slide #32] – [Primary Periodontal Lesion with Secondary Endodontic Involvement][Dr. Foran] – Primary perios with secondary endo. Very rare. This is a situation—and I’m not spending time on it—is a tooth that has just been so grossly compromised periodontally that as the bone loss continues and bacteria adhere to that root surface, we know that the communications are higher in the apical third … there’s more chance of bacteria to contaminate so the theory is that advanced periodontal disease can in fact cause necrosis of the pulp. But it’s the flipside. It’s not

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starting from the decay in the crown. It’s starting from the bacteria up onto the root surface. Not spending a lot of time on it. Don’t worry too much about it.

[Slide #33] – [Primary Periodontal Lesion with Secondary Endodontic Involvement][Dr. Foran] – This, you do. Sorry. This is an example—advanced bone loss here. Maybe it’s … who came first, who really knows because it’s such an advanced problem. This could have been a trauma. Maybe the nerve was dead for a hundred years and then later on they developed perio problem. So who really knows and so it’s … not very very important.

[Slide #34] – [True Combined Lesion][Dr. Foran] – The true combined lesions are important because these teeth have two separate entities going on simultaneously but one is not the cause of the effect. They just coexist as independent problems. And so both sources of bacteria would be necrotic pulp and perio pocket. And they can form and they can coalesce to join each other. So you can imagine a patient with moderate periodontitis and bone loss involving furcations of all teeth. And coincidentally, a very large restoration cuasing necrosis of a pulp. And that PAP, periapical pathosis, gets larger and instead of migrating up to form a pocket, it doesn’t have much to travel because there’s already a crestal bone loss existing from the periodontal disease. So these are problems that exist independently of each other but at the end they both must be treated in order to save the tooth. And, again, the prognosis of these depend on perio. Because, not to simplify endodontics, but the endodontics can always be done. Periodontal surgery may not always be possible. So your prognosis will depend on how well you think the periodontal surgery will go.

[Slide #35] – [True Combined Lesion][Dr. Foran] – So here is an example of what can be done. I am not advocating either way that this is how you would treat it but it’s to give you an idea of what can be done instead of extracting teeth and placing implants because maybe your patient may not be a candidate for such. So here’s a tooth that presents with some crestal bone loss and some vertical bone loss as well as some necrotic pulp. And so the tooth was treated endodontically and then restored with a crown.

[Slide #36] – [True Combined Lesion][Dr. Foran] – But about six months later, the patient returns with a fistula which is traced around the distobuccal root through the furca and back around in between palatal. And so, for argument sake, our endodontic therapy was relatively successful but still we had a mechanical problem here with the fistula. So, instead of extraction, we basically eliminate the source of the infection and eliminate the pocket by removing the distobuccal root. That will 1, create and solve the fistula problem and 2, it will almost eliminate the pocket because there is no more root left there for bacteria to gather around. And the periodontal bone loss will still be there but it will not have as much as a vertical component. So this is just for you. Just to visualize that you can save teeth this way.

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[Slide #38] – [Developmental Malformations][Dr. Foran] – So what else can form perio-endo? Genetics. Developmental abnormalities. Lateral incisors primarily can have a developmental groove. That developmental groove is a source where there is no attachment. Period. And so it’s very susceptible to having bacteria develop and pocket formation. How can we solve it? You can take it out or you can elevate a flap and basically clean out … which I’ll just explain here. As the palatal flap is elevated, that groove can be cleaned as best you can and you can place in that area different materials.

[Slide #39] – [Emdogain][Dr. Foran] – One material, Emdogain, I don’t know if you’ve been exposed to it. I don’t know what kind of perio lectures you’ve had but I think it’s coming after this? Essentially it’s just an enamel matrix protein, which helps to keep the surface free of epithelial attachment so that cells regenerating the normal attachment can enter and be filled and inhibits the epithelium from coming back in and forming the pocket again. Again, for your information, don’t get crazy about it. I just wanted to show you.

[Slide #40] – [Coronal Leakage][Dr. Foran] – How do the bacteria get in? Other than neglect or decay or caries? It’s sometimes iatrogenic, by us. And so, if we’re restoring teeth we have to be really cognizant of leakage. It’s the biggest point of failure. Delaying restorations. Keeping people on temporaries too long. Having open margins. Post-spaces that are just left open and get contaminated. But one of the good ways to prevent that sometimes is if a patient needs to be on a temporary after endo, you can just put a little sealant over the chamber. This way, if it falls out, at least it gives you some sort of barrier for saliva.

[Slide #41] – [Root Perforation][Dr. Foran] – Root perforations. So a perio-endo lesion created by us, practitioners. Results in a direct communication with the root canal system and the periodontium. The prognosis depends on the size, location, when you found it, the degree of damage and the material you’re going to use to repair it. As an educated guess, based on the exposure to bacteria, which part of the root will have the best prognosis in a perforation repair? The apical third, middle, coronal of the root?

[Student]—Coronal.

[Dr. Foran]—why?

[Student]—Less anaerobic bacteria and …

[Other student]—I would say the apical.

[Dr. Foran]—why?

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[Student]—it’s further away.

[Dr. Foran]—from?

[Student]—From the bacteria contaminants.

[Dr. Foran]—Correct. Correct. The better prognosis is in the apical third. How much bacteria innately do you have in bone? None. Or else we would have major problems if we had inherent bacteria in our bone. The perforation, you would like it, as further away from the coronal areas, further away from the sulcus and furthest away from the furcation. So the apical third, they have the best prognosis.

[Slide #42] – [Post Perforation Repair: MTA][Dr. Foran] – The most common material used right now is MTA. I don’t care that you know that it’s called mineral trioxide aggregate. All I want you to know is it’s an ideal sealing material because it has a very high pH, very strong, and it’s very very biocompatible. The problem is that it’s very very hard to work with because it’s essentially concrete.

[Slide #43] – [Post Perforations][Dr. Foran] – And here are just some visuals of some beautiful dentistry. I did not do these. But they are pictures of what can happen. And I have done them. But I didn’t do these. Patient is coming for a post and core, piezo [?] drill, bleeding, outside the root … clean it. Place MTA here. Hopefully you’ll get healing. This one did.

[Slide #44] – [Post Perforation][Dr. Foran] – Same problem. Patient comes in. Post taken out. Post put back in. then we have to go ahead and repair that root surface.

[Slide #45] – [Furcal Perforation Repair][Dr. Foran] – Same here. Can happen in a furcation. And this one obviously is going to have less of a chance … I’m frozen. Sorry. This will have less of a chance of success as opposed to …

[Slide #43] – [Post Perforations][Dr. Foran] – … that one … or opposed to one which just transported, let’s say, a hook on the mesial root. Yes?

[Student]— [unintelligible].

[Dr. Foran]—Oh, yeah. Sure. So right here … okay. Or maybe I can draw. Hey, look at that. Okay. So this here is the post. And this is the point at which the post went through the distal root surface. And by the looks of this x-ray and I don’t have dates, this probably was not repaired immediately because the periodontal ligament is a lot thicker and this lucency is not as strong as it was here. So time went by and this got sort of contaminated. So the MTA is placed here and once the bacteria is

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removed and there’s no longer the communication, then hopefully you get regeneration of the normal tissue which is bone.

[Slide #44] – [Post Perforation][Dr. Foran] – Here, same thing. You cannot notice the perforation, per se, because it happened more on the palatal or facial surface but caused this enormous lesion. This here, when was taken out, we can notice that it was attempted to be retreated. Because this filling material does not look the same. And during retreatment, another instrument went through. So this was packed with MTA and this was actually the post-op. So a lot of improvement there.

[Slide #45] – [Furcal Perforation Repair][Dr. Foran] – And the perforation here was in the furca, right down … bur came here and then was filled in. This is not MTA. I don’t know what this is. Material but this here is. Might have been maybe some bone grafting, which is not necessary.

[Slide #46] – [Vertical Root Fracture][Dr. Foran] –And lastly, coming back to your initial question about what to do if you still have that pocket—you want to investigate possibility of a vertical root fracture which is the cornerstone of a perio-endo lesion. It’s frank communication, through and through, center of the canal, right through. It’s difficult to diagnose at first at early stages because there’s no clinical finding but later on you start to develop this sort of J-shaped lesion and why does it develop like this? I will try to explain it as best as I can by drawing. The mesiobuccal root here if it had a vertical root fracture, the fracture is going to be likely along the mesial marginal ridge which means it’s going to be down this way. Okay? Now, keeping in mind that this is a picture—it’s a two-dimensional picture of a three-dimensional object. So, if I’m standing and looking at this red line head-on from the mesial, that crack is going to become infected on both sides of it, almost like a heart. And so, the bone loss will come around the front and around the back. And so very often times, you’ll have very steep probing depths on both the mesiobuccal and the mesiolingual of the root because that bacteria is circumferentially causing the pocket. So, late stage vertical fractures usually have two very advanced probings on both. Endo will not save this. Nor will perio. So those need to be extracted.

[Slide #47] – [Vertical Root Fracture][Dr. Foran] – Most likely tooth for this to happen to is maxillary premolar basically because of the anatomy of the concavity and occlusion.

[Slide #48] – [Dental Implants][Dr. Foran] – And you are going to get … your next lecture is going to be on I think more implant and decision making but I’m not here to advocate either or because every situation is case-specific. But what I will tell you is that if you are thinking to extract a tooth and place an implant, these factors should be taken into consideration very seriously because the patients you’ll be encountering in the university are not the patients you’ll be encountering out in private practice. And

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there will not be incentive programs for patients in private practice. So if you can save their tooth and their insurance will help them a little more to save their tooth, at least you understand what is reasonable and what is not. I’m not telling you to try to save a tooth with a vertical root fracture or advanced perio. What I am telling you is that if a tooth does present with needing endo and maybe some minor perio procedure, please don’t dismiss it as a good treatment option. Patients have a lot of medical history now … not a lot of time … that’s wise to start extracting teeth and placing implants. And patients are getting older and they are taking a lot more medication and they have a lot more problems. So just be very smart and use your common sense and your treatment plans. The last thing that I will just say about this … success and survival. And you’ll know as you come reading on your papers and I will make a comment on it but … the criteria for success … survival of endo-treated teeth and implants … if you look at the criteria, they are very different and so when someone does approach you that success rates are 99% and necrotic teeth root canal are only 80. If you look at the criteria, it’s like comparing apples and oranges. It’s not the same. An implant is usually successful. It could have a little bone loss around it but it’s solid … great. In root canal, it’s not like that. You still have the presence of a small area even if it were ten times that size, it could be considered to be a failure in the literature. So just keep that in mind and that is all I have to say unless any of you need clarification on anything that was said today. Questions? Yes?

[Student]—Can you explain more about the sensitivity for hot and cold, the difference in …

[Dr. Foran]—Cold sensitivity is really to tell you if a tooth is infected or normal/inflamed. So it is a qualitative test. It does not necessarily give you the degree of vitality unless you’re dealing with a pulpitis. And in that case a patient will come in with a chief complaint. So it’s to tell you necrosis or vital, so to speak. It’s your first test. The only time the electric pulp test I would bring in is if my cold sensitivity test is inconclusive and I’m just not sure so I would like a back up. Heat is a whole other thing and I don’t want to confuse you too much with the heat but the sensitivity and what we’re talking about with the pulp … fibers that respond to heat are not there. Those are deep pulpal fibers, C fibers in the root … but they’re not the a-delta, sensitivity that we’re looking for in our diagnosis for the endo-perio. That’s it? Okay. Alright. Thank you.

Decision RCT or Implants– Diagnosis and Treatment of Oral Diseases by Dr. ‐Gopinathan

[Slide #1] – [Decision Making: Root Canal Treatment vs. Placing an Implant][Dr. Gopinathan] –Hello. I’m going to get started. So you all are D2s. Okay, so I am Dr. Gerber. I am junior faculty at the Endodontics Department and I’m also the director of the Honors Program so I’m sure I’ll be seeing you guys next year in clinic when you guys start applying and everything for the honors program. A little bit about myself is I went to dental school here too so I was one of you guys sitting out there. You know, looking at so many faculty that are now my colleagues and I also did my

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endodontic residency here and I did an implant residency here too. So, my topic today is about decision making of either doing your root canal treatment versus placing an implant. Okay, so let’s get started.

[Slide #2] – [Natural teeth Vs. Implants][Dr. Gopinathan] – If you have any questions please raise your hand. I don’t have any kind of rules except that there’s too many questions I’d like to get the lecture going. Alright, so how do you distinguish between a natural tooth versus an implant? Natural teeth usually have a PDL for proprioception and proprioception is usually felt by beta fibers. There’s no nerve fibers in the PDL that detect pain. That’s only in the pulp as well know. And failure of any sort of … for a natural tooth or a root canal tooth is due to some sort of infection. Natural tooth, of course, also are able to withstand heavy occlusal forces.

Implants, on the other hand, are man-made. They’re made out of titanium. They do not have proprioceptive periodontal ligament fibers. They’re very much more geared towards light occlusal forces. Failure is due to some sort of inflammation, which is like peri-implantitis which causes a lot of bone resorption and mobility of the implant. Or some kind of biomechanical forces—heavy occlusal load for example that disrupts the osseointegration. Osseointegration is defined as the fusion of the implant to the bone but what distinguishes that? Like how are you going to be able to tell that an implant has fused to the bone? Can you tell that on a radiograph? Who said yes? Okay, so we have a couple yeses. Who thinks they can be able to see that clinically? Okay, another yes for clinical. Not for osseointegration. Peri-implantitis, yes. What about through histology? Anyone for histology? Okay, so majority for histology. So that’s the correct answer. It is only through histological examination can you ever be able to see that there’s osseointegration that takes place between the bone and the implant.

[Slide #3] – [N/A][Dr. Gopinathan] –So, let’s say you’re doing your treatment planning for an endodontic case. You know what? I’m going to take my clicker or pointer I should say … okay. Alright. So the first thing you want to do is of course your diagnosis. What is your periapical and pulpal diagnosis? That will give you the status of the condition of the tooth. Does it need endo or not? Then you also want to look at your periodontal assessment. So do you have a healthy periodontium? Or do you have something with pockets and your perio lesions? Excessive bone loss? And poor periodontal prognosis. And of course you also have to keep in mind the medical issues that the patient has and also any of their habits, like smoking. Okay, restorability is the next thing you want to look at. Is the tooth restorable or maybe it’s not restorable. So what are your treatment options then? Okay, so let’s say you have a case where you have pulpal disease in a tooth. You have deep periodontal pockets also. Endo-perio lesion could be there that Dr. Foran just discussed with you. You could have excessive bone loss. And you have poor periodontal prognosis. Let’s say he’s a diabetic or he’s a smoker or she’s a smoker. What would be your treatment plan? It would be basically an extraction because it’s not really restorable.

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However, if you have a healthy periodontium, the tooth can be restored. You want to now be able to look at—well, okay, if I do the root canal, are the root canals going to be negotiable? And are they also unobstructed? Is it something that I could do myself as a general dentist? Or do I have to refer the case out to a specialist? Let’s just say you also have a case where you have a previous inadequate or a failing root canal, then you want to be able to know, well do I have to do a non-surgical retreatment or is it more successful for the patient and for the tooth itself to do surgery—which is an apicoectomy. Alright, so then your treatment plan would be according to that retreatment or apicoectomy.

If the canals are obstructed, let’s say they’re calcified, they’re non-negotiable—meaning, let’s say you also have some sort of mishap that happened like a separated instrument or a perforation that occurred, you can still be able to know if you want to do surgery on the tooth or would you have to refer the case to a specialist? And that’s how you would basically make your flowchart in your mind.

[Slide # we don’t have this slide in the version she gave us—check podcast] – [N/A][Dr. Gopinathan] –Okay, and this is just another way of looking at it too. This is another flowchart of the treatment plan. You want to confirm your pulpal and periradicular diagnosis. You want to be able to provide pain relief as needed. And that could also be antibiotics included or your pain medications along with therapy itself … incision and drainage. Those are all part of pain relief. Consider all of your treatment options. So here it’s poor prognosis if the tooth, again, unrestorable … periodontially involved. But the issues you want to really consider when you’re making the treatment plan is what is the strategic value of the tooth. Is it an abutment tooth? Is it a tooth that you need to have for a occlusion? Or for asthetic concerns? What are your periodontal factors that are involved? That’s also important. Patient factors—patient factors deals with their habits, either willing to modify any changes … control their medications, their medical issues, oral hygiene factors. That all comes into play also. And their financial. That’s a big big thing is finances.

Restorability options you have to also look at. Is it going to be good with a crown? Or a removable prosthesis? That’s another consideration. Okay, so now. Let’s say that you have decided that the tooth is deemed unrestorable. You want to do extraction. You can place a prosthetic replacement, whether it be fixed or removable or just leave it alone in the extraction site. But most of the time, you want to be able to put either a bridge or you want to be able to put an implant. You don’t just want to leave an edentulous area open to bone loss.

Alright, now the level of difficulty or skill of the case is also, you know, dependent on the dentist himself or herself. So, either it’s a routine case where you could do a straightforward root canal and you can do a complete restoration. Unfortunately there are situations where you have a mishap or some sort of procedural error and then you want to be able to refer to the endodontist. If you have a complex or

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difficult case including retreatment, then of course you want to refer also to a specialist.

[Slide #4] – [N/A][Dr. Gopinathan] –So this in a case like this where you have an anterior lateral incisor that has a radiolucent lesion and what is the correct terminology for this? Pulpal and periradicular diagnosis … anyone? Um … okay. But the correct term would be? Okay, let’s start with the pulp. So, what would cause the pulp … what would cause this radiolucency? Okay, so bacteria. Right. Bacteria is the biggest thing. So what’s going on with the pulp? Is it healthy? Are the nerves alive? Okay, who said necrotic? Okay, so yes. That would be your pulpal diagnosis. It’s a non-vital or a necrotic pulp. So the infection basically has eaten away … and I’m using non-technical terms … and it’s invaded the entire root canal system and it’s also invaded the dentinal tubules that surround the walls of the root canal leading to the foramen and then into the peri-radicular space or peri-radicular tissue and most of the time when it breaks through the soft tissue and the bone, what is that you see? Like either a pimple or an abscess .. okay? So does anyone know now what the peri-radicular diagnosis would be? Have you guys had lecture on this yet or no? Okay, so it would be basically apical periodontitis. Okay? So it either … the apical periodontitis can be acute if the patient is still symptomatic or it could be chronic … that means they don’t feel anything and it’s been there for a very long amount of time. And of course, you have bacteria. Bacterial byproducts. Not only do you have that but you also have your human immune response cells like your neutrophils, macrophages.

[Slide #5] – [N/A][Dr. Gopinathan] –Okay, and this is what I was talking about in the dentinal tubules which surround the walls of dentin …. I’m sorry, it surrounds the canal. Okay, so you find bacteria, basically, that has invaded the tubules.

[Slide #6] – [N/A][Dr. Gopinathan] – And this is what you find on histological slide. So here you have the main root canal, which is all necrotic tissue, and then this is your foramen. This is where you have periapical granuloma where it’s just a killing field of cells … of bacteria, bacterial byproduct, and human immune response cells.

[Slide #10] – [N/A][Dr. Gopinathan] – And this is just a different microscopic view of the same exact thing and this is again, the apical foramen … parts of dentin you see here. This is the main root canal. The BA stands for bacteria that you find. These are little tiny blood vessels. But these are the … if you see a more close-up view of the bacteria, you’ll find neutrophils which are the PMN’s or the first defense cells.

[Slide #11] – [N/A][Dr. Gopinathan] –Okay, so what’s going on in this case? Yeah, it’s failed root canal therapy and it’s also … you have external resorption. So, basically you’ve lost this

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whole apical portion due to the infection that’s there. So you basically have a very open, wide apex of the root. So in a case like this, is this something even worth doing the retreat? Yes or no? Who says yes? Okay, one brave soul. And who says no? Oh, two brave souls. Okay, so what will be your reasoning? Okay, but what about … anything else on the x-ray that you see? Right, so restorability would be an issue. And then what about being able to remove the post and then … I mean you can always do root canal or retreat any teeth … you know. But you always have to think about these considerations, you know, besides just the tooth itself. So the amount of bone loss right here and then the fact that there’s open apices and external resorption. And then by the time you remove the post you’ll probably thin out these walls of dentin that’s probably going to fracture … cause some sort of fracture to occur. So best in all … this is the type of case where you would want to extract the tooth and place an implant.

[Slide #8] – [N/A][Dr. Gopinathan] – Okay, this looks real delicious, right? So here you have basically a molar that had extensive decay. There’s a small vertical root fracture line right here and then you have this huge area that comes out with it. Anyone know what that is? That was your apical periodontitis lesion that you see on a radiograph as a radiolucency. It’s very soft.

[Slide #9] – [Bone remodeling][Dr. Gopinathan] –Okay, so let me just go to the next slide for a moment.

[Slide #14] – [N/A][Dr. Gopinathan] –So, here, basically, you had … for pulpitis cases or anything that ends in –itis ... okay, yes? Which slide? This one? Yeah …

[Slide #8] – [N/A][Dr. Gopinathan] –Yeah, this is not a cyst but this is the peri-apical periodontitis lesion. Oh, yeah. That’s what you see on the histological slides previously. Yeah, you’d find bacteria in here and PMN’s … all of that that I showed you the histological slide in.

[Slide #14] – [N/A][Dr. Gopinathan] –Okay, so in terms of apical periodontitis you can either have something that’s necrotic that’s an infection or you can have a very much vital pulp but you’ll see irreversible pulpitis because anything with an –itis in the ending it means inflammation which is totally different from infection. What’s the difference between inflammation and infection—at least for a root canal? From a root canal point of view? You know I think I’ve had blind dates better than this. Yeah? Okay that was a good try. I mean, your body does try to isolate, you know, the bacteria in an infection. Yes?

[Student]—Inflammation would be reversible whereas infection would not be.

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[Dr. Gopinathan] –Okay, and what about for irreversible pulpitis?

[Student]—Well, what do you mean?

[Dr. Gopinathan]—Okay, so you can have … with the pulp you can either have reversible versus irreversible pulpitis where you have a vital inflamed pulp. But reversible, like you said, is reversible. It can go, you know, back to health, in a sense. And for an infection, like a non-vital necrotic, it’s non-vital. It’s already dead. And it’s an infection. So, in terms of inflammation though, between the reversible and irreversible, how would you distinguish it?

[Student] –I would say with inflammation it’s more reversible … like that’s … yea … I don’t know if I’m understanding …

[Dr. Gopinathan] –Okay, so you’re almost close so, yes?

[Student]--The more infection there is the more damage the more irreversible it is so the longer time you’ve had it, longer … [unintelligible].

[Dr. Gopinathan]—Alright, so you have reversible or … are you sure you never had any lectures on this with the endo? Okay, so you have two types of vital inflamed pulp tissue. You have reversible which means you don’t need to do root canal because the pulp can revert back itself to health and you just do like some sort of operative procedure where you’re removing that stimulus of inflammation. Irreversible pulpitis is where you do have inflammation but unfortunately it’s already crossed over that barrier of dentin and the pulp so it’s the pulp dentinal junction that it’s crossed over and it’s already gotten into the pulp tissue and you have a lot of inflammation that’s there. If you have a lot of inflammation, you have a lot of blood vessels that form and it causes a lot of pain, obviously, to the patient. But in infection, you’re dealing with bacteria. Inflammation, no bacteria. So that’s the thing. Infection yu need to have bacteria to cause the infection, to make it a non-vital tooth. Okay? So does that make any sense? Okay.

[Slide #15] – [N/A][Dr. Gopinathan] –I’m sorry if that was like pulling teeth … that moment. Okay, so … did someone say something over here?

[Student] –Okay, so in inflammation you …

[Dr. Gopinathan] –Inflammation, you don’t have bacteria, no. No. it’s only in infection. Because infection is something where it’s already … it’s becoming non-vital so your nerve tissues are dying. Your connective tissue in the pulp is going to die. You have less amount of oxygen because of that. And you have less amount of blood vessels that are able to supply oxygen to the tissues because of the infection. Yes?

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[Student]—Okay, so can you tell me if this is right? So you have … [unintelligible].

[Dr. Gopinathan] –For reversible.

[Student] –And then irreversible …

[Dr. Gopinathan] –… is where you need to get root canal therapy but it’s still inflammation. It’s not infection. So it has not gone through the entire root canal system and caused a lesion to occur.

[Student]—Okay, and then when you said it cracks the pulpal …

[Dr. Gopinathan] – Dentin junction, yes. That’s for inflammation too. The infection is where you now have bacteria that’s crossed.

[Student]—[unintelligible]

[Dr. Gopinathan]—Yes, when you have infection, yes, you have to have root canal therapy. Yeah. Yes?

[Student]—So, the symptoms are the same? …

[Dr. Gopinathan]—Ah, okay so the symptoms are going to be a little different. So the symptoms for reversible pulpitis is … anyone remember the hydrodynamic theory? Okay, that is exactly reversible pulpitis. You’re going to have different type of a nerve that reacts to the inflammation and you’re going to have very short-lasting … once you remove the stimulus the pain is no longer there. Okay, so it’s a short duration, sharp-shooting pain and it’s all due to hydrodynamic theory of the dentinal tubules. The fluid in the dentinal tubules.

Irreversible pulpitis, where you do need to get root canal but you still have inflammation, what’s going on there is you have a dull throbbing pain, keeps you up at night. You don’t need to have a stimulus present. It would just cause pain. And the pain lasts for over 10 to 15 seconds.

And a non-vital tooth because you no longer have a functioning nerve supply there, what’s going to happen, you’re not going to feel anything. So it’s not going to respond to any sort of test, especially vitality tests. So does that make more sense? Yes?

[Student]—So if you have an infection, are you saying there isn’t going to be any inflammatory response?

[Dr. Gopinathan]—There isn’t going to be an inflammatory response, per se, in the pulp but you’ll see it in the … remember how I told you you’ll have PMNs coming in to cause a peri-apical granuloma? But it’s not inflammation per se. It’s just more of

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dead tissue and bacterial byproducts that are causing it. The difference is it’s bacteria that’s present. Okay? Yeah?

[Student]—Inflammation is mainly caused by trauma to the tooth and some …

[Dr. Gopinathan]—Inflammation can be because of trauma. It can be because of a small amount of caries that’s there. It can be because of the way you bite or you chew. It can … anything can happen with that. Okay.

[Slide #18] – [N/A][Dr. Gopinathan] –This is another infection where you have … this is a mandibular molar, the mesial root. And here you have the mesial … buccal and mesiolingual. What you see here is the developmental groove and what these little things here are bacteria. So, what I wanted to show you guys was, even though you may be able to clean out the canals really well and it’s going to be … it’s going to look like, wow, there’s no more bacteria inside. Well, guess what, in this little developmental grooves you may have bacteria and that’s still going to cause failure of your root canal treatment.

[Slide #19] – [N/A][Dr. Gopinathan] –Okay, I’m not going to go too much into that because I’m going way into endo.

[Slide #21] – [N/A][Dr. Gopinathan] – So, here, you have another anterior tooth that has a custom cast post with an obturation fill … and a large area. So who thinks they would want to extract this tooth and put an implant in? Or would they do the treatment or retreatment? No implant. Or would you want to do surgery? That’s another option too. Remember I was saying you can do non-surgical or surgical. So, you said … so you want to see what the results would be?

[Slide #22] – [N/A][Dr. Gopinathan] –So, so far, they did an apicoectomy. They put a retrograde filling in and the lesion healed. So good choice there, doctor. Does anyone else have any questions so far? Okay.

[Slide #23] – [N/A][Dr. Gopinathan] –What about this one? Retreatment or pull it? Who said that? Okay. And you say that too or you just have a question? Okay … maybe. But let’s say the probing would only give you levels of 3 millimeters.

[Student]—Retreatment.

[Dr. Gopinathan]—Okay.

[Slide #24] – [N/A]

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[Dr. Gopinathan] –Very good.

[Slide #25] – [N/A][Dr. Gopinathan] –Okay, now what about this one? … Okay.

[Slide #27] – [N/A][Dr. Gopinathan] – Oh, well look at that the answer’s already there. Okay.

[Slide #28] – [Pre-Op and WL X-Rays][Dr. Gopinathan] –Alright this is a case where, you know, a patient had orthodontic treatment. So you can see the external resorption that occur, blunted apices.

[Slide #29] – [Final and 6 month Recall X-Rays][Dr. Gopinathan] –And they ended up obturating the case and then that’s a 6 month recall. So you can see that most of the time, give the tooth a chance. You know, don’t be so quick to just put an implant in there.

[Slide #30] – [RCT Success Rates][Dr. Gopinathan] –So, for root canal success. Conventional root canal therapy usually is 95-97% for vital cases, meaning without bacteria present. It’s a little bit lower in the high 80s or mid-80s for non-vital teeth. Retreatments are even lower success rates. And for apicoectomies, you do have a good success rate but maybe it could be in the 60s or so but it’s the surgical to another surgical, meaning you’re doing surgery for the second time. I would just say forget that. You might as well go ahead and place the implant because the success rate is like in the 30s. Yeah?

[Student]—What can cause a root canal to be less successful?

[Dr. Gopinathan]—Okay, so let’s say you didn’t do proper cleaning and shaping. You gave a very poor obturation or poor fill on the case meaning you’re short of the apex, you have voids in the root canal. Let’s say for a non-vital tooth where you need to put calcium hydroxide as your medicament, you didn’t. You did it one step instead and the infection was still there. Because remember, when you’re doing root canal, you’re not sterilizing the root canal. You’re just basically creating an environment so that the bacteria that’s left over and present is not going to have a certain type of threshold to cause an infection again. Alright, so root canal success is defined as absence of clinical symptoms, intact PDL, apical PDL, and a decrease in the size of the periapical radiolucency over time. And like I said there’s lower success rate for retreatments.

[Slide #31] – [Factors affecting the Prognosis of Periapical surgery:][Dr. Gopinathan] –So what are the factors that affect the periapical surgery prognosis? Okay, if we’re dealing with second molars or mandibular molars, even maxillary molars, accessibility in the molar region is very poor. You can have a persistent lesion despite a satisfactory retrograde filling. The size of lesion is greater than 5 or equal to 5 millimeters. You have coronal leakage. So let’s say you did

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coronal surgery on a case but the patient didn’t want to spend money to get a new crown, well guess what the same reasons are going to cause that apicoectomy to fail because again, you have that microleakage. Periodontial involvement of the respective tooth that you’re doing this surgery on and also the buccal fenestration which is the window where the opening that gains access to the periapical area may not heal with an intact bony plate. So you’re compromising that whole area.

[Slide #32] – [N/A][Dr. Gopinathan] –Okay, now what about this? To treat or retreat? Or extract? Or surgery? Those are posts. Yeah, I guess they really wanted that crown to be retained, you know?

[Student]—Extract.

[Dr. Gopinathan]—Right.

[Slide #33] – [N/A][Dr. Gopinathan] –What about this one? The patient came in with a little pimple in the anterior portion and you traced it with a gutta percha point to see where it was coming from. Now, this patient went through apicoectomy already using amalgam. They don’t use amalgam anymore but this is the old-fashioned way of doing it. And here’s a little bit of the pieces of amalgam that are just there. Post. What would you want to do? Extract.

[Slide #34] – [N/A][Dr. Gopinathan] –And then here’s another case where you definitely want to extract because this is a comlete vertical root fracture on this case.

[Slide #35] – [N/A][Dr. Gopinathan] –And then when you open it, there we go.

[Slide #36] – [N/A][Dr. Gopinathan] –Okay, so now since we discussed the cases to extract, what are you going to do? You can either put, like I said, a fixed prosthesis. If it’s financial problems, you can put a removable. However, the best-case scenario would be an implant depending that you have the right quantity of bone—the amount of bone that you have is very important. So, here you have the difference between a natural tooth and an artificial tooth, which is the crown. Here you have the implant abutment. This is your PDL fibers that are holding the gingiva to the tooth and anchoring it to the alveolar bone. Here, with the implant, you’re not going to have those PDL fibers. What you do however is the interface of the implant to the bone that’s going to be osseointegration. So that’s the difference between that.

[Slide #37] – [N/A][Dr. Gopinathan]—Okay, so how would you place an implant? So now usually everyone does it in one step procedures and they do an immediate implant

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placement—they don’t wait anymore. Unless the bone is so far gone that you need to place a bone graft. So you make an incision in the gingiva and it’s usually flapless surgery sometimes and sometimes you can do a surgery with a flap. The gingival tissue is then lifted away from the bone just like you would do for an apicoectomy. You do have a small drill that you place in the bone to make a window. And then from here through the socket, you place the implant using different types of drills. Okay. And then the gingiva is then replaced and stitched for stage two. However, people don’t usually do this anymore unless you have a lot of bone loss and you want to do a graft. Usually if you have a good bone height or width, you’re going to be able to place the implant into the prepared bone. And then you place the abutment a little bit later.

[Slide #38] – [N/A][Dr. Gopinathan] –And that’s like in this case. And then you can put like immediate prosthesis on there.

[Slide #39] – [N/A][Dr. Gopinathan] –And this is just shows the type of fibers that you have for natural tooth and what you would have with the implant. Again, it’s all … the implant is adhereing to the bone itself and of course for a natural tooth you have all of these gingival collagen fibers.

[Slide #40] – [N/A][Dr. Gopinathan] – Okay, so. Implant success rate is completely different than an endodontic success rate. Why? Because they look at survivability. They don’t look at success. All they want to know is is the implant still in your mouth? That’s it. So, here root form implants have the best amount of survivability, which to them is success. And that’s due to solid osseointegration and it can be up to or beyond 97%, wther it’s in … depends where in the arch it is and the bone density. So of course you’re going to have type I and type II bone that are going to be much more dense and it’s going to be better in the mandible than you have in the maxilla. And it also depends upon how many roots you have—single rooted teeth are a little bit more successful than areas where you have multi-rooted teeth. Success is also dependent on the presence of periapical radiolucency with the adjacent tooth. You always want to be able to get rid of periapical radiolucency before you put an implant in.

[Slide #41] – [ Implant success can be further compromised by several biological and technical complications ] [Dr. Gopinathan] –Okay, so now. Implant success can be compromised by further several biological and technical complications. So here you have mechanical damage of the implant itself. Maybe when the hygienist is cleaning like sometimes that happens when you scrape a little bit too much or you can also have damage to the components of the implant and that can be an abutment, an occlusal screw, a fracturing of the veneer or the framework, loss in the cement restoration retention.

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[Slide #42] – [Early implant failures occur mainly during the first weeks or months after implant placement and are related to:][Dr. Gopinathan] –Okay, early implant failures are usually due to the first few weeks or months after implant placement and that’s due to surgical trauma. Some sort of wound healing especially if they have a medical issue that’s underlying. Insufficient primary stability so when you put the implant in it’s not very stable initially. And initial overload. You never want to overload the implant with too much force. Late stage implant losses are due to microbial infection. Overloading—too much occlusal load. And toxic reactions from implant surface contamination. So, for example, if people use citric acid or any sort of acid remnants on an implant to make sure it adheres to the bone even better.

[Slide #59] – [Implant Clinical Case 1][Dr. Gopinathan] –Alright. So this was my case that I had when I was in the plant residency program. It was a 24-year-old female that came in for a consult for a PFM #9. She said she had a tooth infection. In her medical history there was nothing significant. No allergies. In her dental history, she was previously treated #9 with PFM. And extraoral exam: no swelling anywhere so she was within normal limits. However, in her intraoral exam, she was very tender to palpation, extremely tender to percussion. The probing around the PFM #9 was 5-6 mm and there was class I mobility.

[Slide #60] – [Pre-Operative (PFM #9)][Dr. Gopinathan] –This is the pre-operative photograph.

[Slide #61] – [Occlusal view][Dr. Gopinathan] –This is the occlusal view.

[Slide #62] – [Pre-op Radiograph][Dr. Gopinathan] –And here is the radiograph. So as you can see, it was a lot of resorption that has occurred here. Due to that and because the bone loss it was mobile.

[Slide #63] – [Exposure of tooth #9][Dr. Gopinathan] –And this is what we did after we’ve removed the PFM. So you can see the extensive damage—coronal damage. So what we decided to do was atraumatic extractions which technically is not … how can I put it, I mean … it’s not exactly that everyone’s able to do … atraumatic extraction … even in this case because you’re always going to have some sort of trauma to the gingival tissue or to the papilla. Yes? [inaudible] Where was the fracture? Yeah. There was decay that was underneath the crown that caused that.

[Slide #64] – [Atraumatic extraction of # 9][Dr. Gopinathan] –So, here is the atraumatic extraction of tooth #9.

[Slide #65] – [Chronic Apical Periodontitis of # 9]

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[Dr. Gopinathan] –And, remember how I was showing you in the other picture about the chronic apical periodontitis lesion. So that’s where that was, right there, that was causing the radiolucency.

[Slide #66] – [Extraction Socket][Dr. Gopinathan] –Okay, so here is the extraction socket. So what you want to go in is debride and irrigate with saline and make sure that all the walls are present. However, in this case all the walls were not present because remember we saw the radiolucency and it was on the buccal plate.

[Slide #67] – [N/A][Dr. Gopinathan] –So, what I had to do here was basically have to do a bone graft. So, I did have to put a bone graft and a resorbable membrane over the bone graft to hold the graft together. And suture it. Have the patient come back in six months.

[Slide #68] – [N/A][Dr. Gopinathan] –So this is what the bone graft looks like.

[Slide #75] – [Occlusal view][Dr. Gopinathan] –And this is the pretty picture. And because we also had to put a resorbable membrane, suture it, unfortunately because it is in the anterior area in the aesthetic zone and we wanted to make sure that there was no black triangles and papilla shrinkage, we had to get a gingival graft tissue also from the hard palate area and place it onto this so that everything would be looking aesthetically pleasing for the patient.

[Slide #76] – [Immediate loading of provisional #9][Dr. Gopinathan] –Then we did immediate loading but remember it’s not going to be super strong. So it was just basically to make sure the papilla was going to be able to withhold the shape.

[Slide #77] – [Post-op radiograph][Dr. Gopinathan] –And this was the radiograph and here you can see the bone graft that we filled in into the socket.

[Slide #78] – [Soft Tissue Architecture][Dr. Gopinathan] –And then a month later she came back. Well she came back a week later … two weeks later and then this was a month later where basically now you’re starting to see that soft tissue architecture. And the papilla it’s not really shrinking badly. Because you’re going to have some bone loss when you place the implant and you usually have up to 2 mm to the first thread of the implant.

[Slide #79] – [Temporization of #9][Dr. Gopinathan] –Then we temporized it.

[Slide #80] – [Implant placement after 6 months]

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[Dr. Gopinathan] –And then six months later we placed the implant because the graft has now become the bone. It’s taken very well.

[Slide #81] – [Bone Remodeling][Dr. Gopinathan] –And, as I said, you always lose like up to 2 mm of bone loss to the first thread of the implant, only because you have bone remodeling that occurs.

[Slide #82] – [Follow-up][Dr. Gopinathan] –And this was from my patient again. This was the follow-up. I think three months later with the temporary. So you can see the soft tissue. You don’t see any black triangles or shrinkage anywhere. It looks the same as the other teeth.

[Slide #94] – [THANK YOU!!!][Dr. Gopinathan] –And that’s it! Because I didn’t want to bore you guys too much but any questions? Any tomatoes? Ha ha.

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Documents

47/48: Perio Endo Relationships, RCT, and Implants