Transcribed by Anam Khalid Wednesday, October 15

th
, 2014

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Perio-Endo Relationships by Dr. Foran/ DecisionRCT 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 dont 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 youre confused, shout it
out. Im here to help you. Okay, so basically what were going to discuss is the
relationship between endodontic and periodontal disease and how that impacts
your diagnosis and your treatment for your patients when youre entering the clinic.
Its 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, were 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 highabout 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
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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.

[Slide #7] [Diagnosis]
[Dr. Foran] When youre 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 havent
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 youre treating a patient with a chief
complain or a problem and youre 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 lesionand 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 were
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 its localized in the entire region or just predominantly on
one tooth in one area.

[Slide #9] [Sensitivity Testing]
[Dr. Foran] Okay. So, thats a sensitivity tester. Its 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 its necrotic. Just four to remember. And the way that
you determine that is if theres a yes or a no to a stimulus. If youre placing ice on the
tooth or an electric stimulus and the patient feels pain, that is an indication that you
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have either a normal pulp, or a pulpitis. But for sure the positive test rules out
necrosis. Okay, so thats very important. When you have a positive test to
temperature, youre ruling out infection of the pulp tissue. So if any area of the
mouth around that tooth appears to be infected, youre 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 beforepatients 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 theres 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 youre not sure, your second line would
be electric pulp testing. False negatives. Why would a tooth respond? Im 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 youre checking
and you see no decay. See no evidence of bone loss. No mobility. And youre looking
clinically and honestly, you dont 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 theres 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 theres 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 sidenormal 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, youll come up and show someone an x-ray and say, well the patient
has pain and I see this line do you think that theres 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 its 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 youll need to doperiodontal probing. All six surfaces.
Youll 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 its near the apex of the rootits endo. If its above, its
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.

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[Slide #16] [Treatment]
[Dr. Foran] So youve done all these tests. You have your sensitivity testing. You
have your percussions. Youre 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 its coming from is key.

[Slide #17] [Classifications of Perio-Endo]
[Dr. Foran] I dont care if you remember these word for word in terms of type I,
type II, type II but Id like you to know what primary endodontic lesions are. I
dont care about classification numbers. Whats 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. Its 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 youre tracing ones at the apex,
that its an endodontic problem. But what I also mentioned to you, in your response,
was that you can trace a lesion thats not to the apex, and its 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
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that the bacteria will travel down the root surface and cause periapical pathology,
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. Its not in the peri-apex. Its in an area where bacteria
can leak through. And those canals can typically be quite large enoughalmost as
large as where the apex would be, the apical foramen and lateral canalsto 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? Lets forget about
the lecture for a second. Youd want to scale. Right. And thats normal and people
practicing for 20 years still want to do that. Thats 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; youre 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 thats a very, very large communication. Its
anatomic, theres nothing wrong. Its not a crack. But it can happen. Yes?

[Student]So whats 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 thats 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
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beyond the confines of the periapical area. And what that bacteria will start to do is
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 youre 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 its very big and youll actually form this
radiolucency anywhere that is big enough for bacteria to leak through. So whatever
youre 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. Its probing pretty isolated. Everywhere else seems to be about
4s, 3s. 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, youre 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 youve 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 theres 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 youve 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 youre 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 dont 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 wisebecause 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. 8s, 7s, 6s. 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 Im not spending time on itis 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
theres more chance of bacteria to contaminate so the theory is that advanced
periodontal disease can in fact cause necrosis of the pulp. But its the flipside. Its not
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starting from the decay in the crown. Its starting from the bacteria up onto the root
surface. Not spending a lot of time on it. Dont worry too much about it.

[Slide #33] [Primary Periodontal Lesion with Secondary Endodontic Involvement]
[Dr. Foran] This, you do. Sorry. This is an exampleadvanced bone loss here.
Maybe its who came first, who really knows because its 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
its 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 doesnt have much to travel because theres 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 its 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 heres 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 its
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 Ill
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 dont know if youve been exposed to it. I
dont know what kind of perio lectures youve had but I think its coming after this?
Essentially its 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, dont 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? Its
sometimes iatrogenic, by us. And so, if were restoring teeth we have to be really
cognizant of leakage. Its 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 youre 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]its 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 dont care that
you know that its called mineral trioxide aggregate. All I want you to know is its an
ideal sealing material because it has a very high pH, very strong, and its very very
biocompatible. The problem is that its very very hard to work with because its
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 didnt
do these. Patient is coming for a post and core, piezo [?] drill, bleeding, outside the
root clean it. Place MTA here. Hopefully youll 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 Im 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, lets 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 dont 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 theres 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 dont 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 pocketyou want to investigate possibility of a vertical root fracture
which is the cornerstone of a perio-endo lesion. Its frank communication, through
and through, center of the canal, right through. Its difficult to diagnose at first at
early stages because theres 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 its
going to be down this way. Okay? Now, keeping in mind that this is a pictureits a
two-dimensional picture of a three-dimensional object. So, if Im 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, youll 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 Im 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 youll be encountering in the
university are not the patients youll be encountering out in private practice. And
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13
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. Im 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 dont dismiss it as a good treatment option. Patients have a lot of
medical history now not a lot of time thats 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 youll 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, its like comparing apples and oranges.
Its not the same. An implant is usually successful. It could have a little bone loss
around it but its solid great. In root canal, its 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 youre dealing with a pulpitis. And in that case a patient will
come in with a chief complaint. So its to tell you necrosis or vital, so to speak. Its
your first test. The only time the electric pulp test I would bring in is if my cold
sensitivity test is inconclusive and Im just not sure so I would like a back up. Heat is
a whole other thing and I dont want to confuse you too much with the heat but the
sensitivity and what were talking about with the pulp fibers that respond to heat
are not there. Those are deep pulpal fibers, C fibers in the root but theyre not the
a-delta, sensitivity that were looking for in our diagnosis for the endo-perio. Thats
it? Okay. Alright. Thank you.

DecisionRCT 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. Im going to get started. So you all are D2s. Okay, so I am Dr.
Gerber. I am junior faculty at the Endodontics Department and Im also the director
of the Honors Program so Im sure Ill 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.
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You know, looking at so many faculty that are now my colleagues and I also did my
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 lets get started.

[Slide #2] [Natural teeth Vs. Implants]
[Dr. Gopinathan] If you have any questions please raise your hand. I dont have any
kind of rules except that theres too many questions Id 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. Theres no nerve fibers in the PDL that detect pain. Thats 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. Theyre made out of titanium. They do
not have proprioceptive periodontal ligament fibers. Theyre 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 forcesheavy 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 thats the correct answer. It is only through histological examination
can you ever be able to see that theres osseointegration that takes place between
the bone and the implant.

[Slide #3] [N/A]
[Dr. Gopinathan] So, lets say youre doing your treatment planning for an
endodontic case. You know what? Im 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
its not restorable. So what are your treatment options then? Okay, so lets 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.
Lets say hes a diabetic or hes a smoker or shes a smoker. What would be your
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treatment plan? It would be basically an extraction because its not really restorable.
However, if you have a healthy periodontium, the tooth can be restored. You want to
now be able to look atwell, 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? Lets
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
surgerywhich is an apicoectomy. Alright, so then your treatment plan would be
according to that retreatment or apicoectomy.

If the canals are obstructed, lets say theyre calcified, theyre non-negotiable
meaning, lets 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
thats how you would basically make your flowchart in your mind.

[Slide # we dont have this slide in the version she gave uscheck 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 its poor prognosis if the tooth, again, unrestorable
periodontially involved. But the issues you want to really consider when youre
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? Thats also
important. Patient factorspatient 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. Thats 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? Thats another consideration. Okay, so now. Lets 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 dont 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 its 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, lets 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 whats 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. Its a non-vital or a
necrotic pulp. So the infection basically has eaten away and Im using non-
technical terms and its invaded the entire root canal system and its 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 dont feel anything and its 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 . Im 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 its 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, youll
find neutrophils which are the PMNs or the first defense cells.

[Slide #11] [N/A]
[Dr. Gopinathan] Okay, so whats going on in this case? Yeah, its failed root canal
therapy and its also you have external resorption. So, basically youve lost this
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whole apical portion due to the infection thats 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 theres open apices and external
resorption. And then by the time you remove the post youll probably thin out these
walls of dentin thats 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. Theres 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. Its 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. Thats what you see on the histological slides previously. Yeah,
youd find bacteria in here and PMNs 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 thats necrotic thats an infection or you can have a very much vital pulp
but youll see irreversible pulpitis because anything with an itis in the ending it
means inflammation which is totally different from infection. Whats the difference
between inflammation and infectionat least for a root canal? From a root canal
point of view? You know I think Ive 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, its non-vital. Its already dead. And its
an infection. So, in terms of inflammation though, between the reversible and
irreversible, how would you distinguish it?

[Student] I would say with inflammation its more reversible like thats yea I
dont know if Im understanding

[Dr. Gopinathan] Okay, so youre almost close so, yes?

[Student]--The more infection there is the more damage the more irreversible it is so
the longer time youve 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 dont 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 youre removing that stimulus of inflammation.
Irreversible pulpitis is where you do have inflammation but unfortunately its
already crossed over that barrier of dentin and the pulp so its the pulp dentinal
junction that its crossed over and its already gotten into the pulp tissue and you
have a lot of inflammation thats 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, youre dealing with bacteria. Inflammation, no bacteria. So thats 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] Im 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 dont have bacteria, no. No. its only in
infection. Because infection is something where its already its 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 its still
inflammation. Its 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. Thats for inflammation too. The infection is
where you now have bacteria thats 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. Youre going to have different type of a
nerve that reacts to the inflammation and youre going to have very short-lasting
once you remove the stimulus the pain is no longer there. Okay, so its a short
duration, sharp-shooting pain and its 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, whats going on there is you have a dull throbbing pain, keeps you up
at night. You dont 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,
whats going to happen, youre not going to feel anything. So its 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 isnt going to be any
inflammatory response?

[Dr. Gopinathan]There isnt going to be an inflammatory response, per se, in the
pulp but youll see it in the remember how I told you youll have PMNs coming in
to cause a peri-apical granuloma? But its not inflammation per se. Its just more of
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dead tissue and bacterial byproducts that are causing it. The difference is its
bacteria thats 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 thats 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 its going to be its going to look like, wow,
theres no more bacteria inside. Well, guess what, in this little developmental
grooves you may have bacteria and thats still going to cause failure of your root
canal treatment.

[Slide #19] [N/A]
[Dr. Gopinathan] Okay, Im not going to go too much into that because Im 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? Thats 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 lets 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 answers 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 thats a 6 month
recall. So you can see that most of the time, give the tooth a chance. You know, dont
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. Its 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 its the surgical to another surgical, meaning youre 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 lets say you didnt do proper cleaning and shaping. You
gave a very poor obturation or poor fill on the case meaning youre short of the
apex, you have voids in the root canal. Lets say for a non-vital tooth where you need
to put calcium hydroxide as your medicament, you didnt. You did it one step instead
and the infection was still there. Because remember, when youre doing root canal,
youre not sterilizing the root canal. Youre just basically creating an environment so
that the bacteria thats 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 theres 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 were 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 lets say you did
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coronal surgery on a case but the patient didnt 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 youre 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 youre 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 dont use amalgam anymore but this is the old-fashioned way of doing it. And
heres 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 heres 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 its financial
problems, you can put a removable. However, the best-case scenario would be an
implant depending that you have the right quantity of bonethe 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, youre not going to have
those PDL fibers. What you do however is the interface of the implant to the bone
thats going to be osseointegration. So thats 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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placementthey dont 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 its 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 dont 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, youre 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 thats 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, its 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 dont look at
success. All they want to know is is the implant still in your mouth? Thats it. So,
here root form implants have the best amount of survivability, which to them is
success. And thats due to solid osseointegration and it can be up to or beyond 97%,
wther its in depends where in the arch it is and the bone density. So of course
youre going to have type I and type II bone that are going to be much more dense
and its going to be better in the mandible than you have in the maxilla. And it also
depends upon how many roots you havesingle 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 thats due to surgical trauma. Some sort of
wound healing especially if they have a medical issue thats underlying. Insufficient
primary stability so when you put the implant in its 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. Overloadingtoo 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 weve removed the PFM. So you can
see the extensive damagecoronal damage. So what we decided to do was
atraumatic extractions which technically is not how can I put it, I mean its not
exactly that everyones able to do atraumatic extraction even in this case
because youre 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 thats 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 its 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 youre
starting to see that soft tissue architecture. And the papilla its not really shrinking
badly. Because youre 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. Its 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
dont see any black triangles or shrinkage anywhere. It looks the same as the other
teeth.

[Slide #94] [THANK YOU!!!]
[Dr. Gopinathan] And thats it! Because I didnt want to bore you guys too much but
any questions? Any tomatoes? Ha ha.