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Introduction CONTENTS
Definition
Extent and shape
Development
Structure
Principle fibers
Functions of pdl
Age changes in pdl
Endo-perio relationships
EFFECTS OF PULPAL DISEASE ON PERIODONTIUM
INFLUENCE OF ENDODONTIC PROCEDURES ON PERIODONTIUM
Clinical aspects of PDL
PDL injection
Conclusion
References
INTRODUCTION
The normal periodontium is a unique and a complex
dynamic structure; each of its components having distinct
functions that are capable of adaptation during the life of
the structure.
PDL has the shape of an hour glass and is narrowest at the mid root level.
Once the Hertwig Epithelial root sheath disintegrates leaving behind the Epithelial rests
of Malassez, cells of the dental follicle come close to the surface of newly formed
dentin.
The dental follicle cells then differentiate into cementoblasts & lay down cementum on
dentin on the developing root.
The other cells of the dental follicle differentiate into fibroblast & lay down fibers &
ground substance of the periodontal ligament.
As the crown approaches the oral mucosa during tooth eruption, these
fibroblast become active & start producing collagen fibrils. They initially lack
orientation, but they soon acquire an orientation oblique to the tooth.(4)
The first collagen bundles appear in the region immediately apical to the
cemento enamel junction & give rise to gingivodental fiber groups. As tooth
eruption progresses, additional oblique fibers appear & become attached to the
newly formed cementum & bone.
STRUCTURE
CELLULAR ELEMENTS
a. Connective tissue cells
Synthetic Resorptive
-Fibroblasts - Fibroblasts
-Cementoblasts - Cementoclasts
-Osteoblasts - Osteoclasts
b. Epithelial cell rests
c. Neuro-vascular elements
PERIODONTAL FIBERS
GROUND SUBSTANCE
CONNECTIVE TISSUE CELLS
FIBROBLASTS:
Most predominant cell type of periodontal ligament.
-> found between the fibers of the periodontal ligament, where they are
surrounded by fibers & ground substance.
Ovoid or elongated cells oriented along the principal fibres.
Large cells with an extensive cytoplasm
Associated with protein synthesis & secretion (e.g. RER, several Golgi
complex, & many secretary vesicles)
Because of exceptionally high rate of turnover of collagen in the ligament,
any interference in the fibroblast function by disease rapidly produces a loss
of the tooths supporting tissue.
OSTEOBLASTS
These are the cells responsible for secreting the organic matrix (mainly
collagen) of cementum.
As distinct layer of cells on the root surface, similar to osteoblastic layer but
not regular in arrangement.
osteoclasts
cementoclasts
Both are rich in acid phosphatase
activity.
RESORPTIVE CELLS
OSTEOCLASTS
Bone resorbing cells.
Present on the surface of bone where it is removed. At such locations the cells
occupy pits called Resorption bays or lacunae of howship.
Large cells : 20 100 m diameters.
Numerous nucleus : upto 20 or more
Cytoplasm : Numerous mitochondria lysosomes
Osteoclasts are formed by fusion of mononuclear cells arising from bone marrow.
They do not cover the whole of resorbing surface at any one time, rather they service
a much larger area by demonstrating considerable motility.
Inhibitor->Osteoprotegrin(16)
CEMENTOCLASTS
Resemble Osteoclasts.
Lymphatic drainage
A. Lymph vessels - Follow the course of
blood vessels.
Course apically - pass through the fundus
of the socket or they may pass through
the cribriform plate to empty into larger
channels pursuing intraosseous paths.
FUNCTIONS OF PDL:
FORMATIVE AND REMODELING FUNCTION : Cells of the PDL participate in the formation and
resorption of cementum and bone, which occur in - physiologic tooth movement, -
accommodation of the periodontium to occlusal forces - in the repair of injures. Remodeling :
The 3-D organization of the fiber meshwork is adapted to accommodate for positional changes
of the tooth in its socket or changes in functional state (such as hypofunction). It relates to
adaptability of PDL tissues. Both these processes can occur simultaneously and may therefore
be indistinguishable
NUTRITIONAL: PDL supplies nutrients to the cementum , bone, and gingiva by way of blood
vessels and provides lymphatic drainage. The PDL contains blood vessels, which provide
anabolites and other substance to the cementum, bone and gingiva. & removes catabolites. IV.
HOMEOSTATIC: Adaptability to rapidly changing applied forces and its capacity to maintain its
width at constant diameter throughout life. Its is evident that the cells of PDL have the ability
to resorb and synthesize the extracellular substance of the connective tissue of the ligament ,
alveolar bone and cementum
SENSORY FUNCTION The PDL is abundantly supplied with sensory nerve fibers capable of the
repair of transmitting tactile, pressure and pain sensations by the trigeminal pathway. The PDL
provides a most efficient proprioceptive mechanism. 4 types of neural terminations are seen
1. Free nerve endings pain(at regular intervals along the length of the root. 2. Ruffini like
mechanoreceptors (apical area) 3. Meissners corpuscles - mechanoreceptors (middle 3rd) 4.
Spindle like pressure and vibration endings (apex)
. PHYSICAL FUNCTION : 1) Provision of a soft tissue casing to protect the vessels and nerves
from injury by mechanical forces. 2) Transmission of occlusal forces to the bone. 3) Attachment
of the teeth to the bone. 4) Maintainence of the gingival tissues in their proper relationship to
the teeth. 5) Resistance to the impact of occlusal forces (Shock absorption).
EFFECTS OF AGING ON THE
PERIODONTAL LIGAMENT
Reduction in vascularity, elasticity.
Decreased number of fibroblasts with more irregular structure is
seen.
Decreased Collagen synthesis with increasing age.
Decrease in no. of periodontal fibers. The fiber bundles were
thicker, broader and more highly organized.
Areas of hyalinization were present.
Decreased organic matrix production & epithelial cell rests.
Increased amount of elastic fibers.
The surfaces of the periodontal alveolar bone were jagged &
uneven & an irregular insertion of fibers were seen.
CLINICAL CONSIDERATIONS
The primary role of the periodontal socket is to support the
tooth in the bony socket .
Inflammatory diseases of the pulp progress to the apical
periodontal ligament and replace its fiber bundles with
granulation tissue .
This lesion is called a periapical granuloma may contain
epithelial cells that undergo proliferation and produce a cyst .
Various surgical techniques like Guided Tissue regeneration
are being used for correction of Periodontal destruction .
Guided Tissue regeneration is based on principle that specific
cells contribute to formation of specific tissues.
ENDO PERIO RELATIONSHIP
Introduction
The relationship between the periodontium and the pulp
was first discovered by Simring and Goldberg in 1964
Anatomical pathways:
Apical foramen
Lateral and accessory canals
Dentinal tubules
Non-physiological pathways:
Iatrogenic root canal perforations
Vertical root fractures
CLASSIFICATION OF ENDO- PERIO
LESIONS
I. Based on etiology, diagnosis, treatment and prognosis
(by Simon, 1972)
The apical progression of a periodontal pocket may continue until the apical
tissues are involved. In this case, the pulp may become necrotic as a result of
infection entering through lateral canals or the apical foramen. In single-rooted
teeth, the prognosis is usually poor. In molar teeth, the prognosis may be better.
Since not all the roots may suffer the same loss of supporting tissue, root resection
can be considered as a treatment alternative.
TRUE COMBINED LESION
True combined endodontic periodontal disease occurs less frequently than other
endodontic-periodontal problems. It is formed when an endodontic lesion
progressing coronally joins an infected periodontal pocket progressing apically.The
degree of attachment loss in this type of lesion is invariably large and the prognosis
guarded. This is particularly true in single-rooted teeth. In molar teeth, root
resection can be an alternative treatment. The radiographic appearance of
combined endodontic periodontal disease may be similar to that of a vertically
fractured tooth. If a sinus tract is present, it may be necessary to raise a flap to
determine the etiology of the lesion.
PRIMARY PERIODONTAL
PRIMARY ENDODONTIC LESION LESION WITH SECONDARY
ENDO LESION:
conventional endodontic RCT
therapy
Periodontal therapy
PRIMARY ENDODONTIC LESION
WITH SECONDORY Root amputation
PERIODONTAL INVOLVEMENT GTR
endo-perio therapy TRUE COMBINED LESION
PRIMARY PERIODONTAL Endo therapy
LESION -
Perio therapy
Guided tissue regeneration
hemisection
Root amputation and
bicuspidization
hemisection
Root amputation
EFFECT OF PERIODONTITIS ON THE PULP
Clinical Features
Smooth, shiny swelling of the gingiva
Painful, tender to palpation
Purulent exudate
Radiographic features: Radiographs taken with gutta percha cones gently guided
in to the periodontal pocket to site of abscess may provide an ideal regarding the origin
of abscess.
Radioluceny on lateral surface of the root .
widening of pdl
Treatment
Incision and drainage
Extraction
PERIAPICAL ABSCESS
Also known as Dento-alveolar
Abscess;develops from acute
periodontitis,periapical granuloma
acute or chronic suppurative process
of dental periapical region
Causes: irritation of periapical tissues
{endo procedures}
Clinical Feature
1.acute inflammation of
apical peridontium
2.tooth is extremely painful
3.slightly extruded from its
socket
Radiographic Feature
Thickening of pdl space
Radiolucent area at apex
Treatment
Drainage must be established
Extract the tooth
Root canal therapy
Acute apical abscess
An acute apical abscess is a severe inflammatory
response to microorganisms or their irritants that have
leached out into the periradicular tissues.
Radiographic changes
There is a well-defined radiolucent area, as in many
situations an acute apical abscess is an acute
exacerbation of a chronic situation
periodontal ligament space is widened .
Treatment: Initial treatment of an acute apical abscess
involves removal of the cause as soon as possible.
Drainage should be established either by opening
the tooth or incision into a related swelling.
An antibiotic may need to be prescribed,
depending on the patients condition.
Once the acute symptoms have subsided, then root
canal therapy or extraction may be performed.
CHRONIC APICAL ABSCESS
The chronic apical abscess is some times so painless that is may go undetected form
years until revealed by an x-ray .It is an inflammatory reaction to pulpal infection
and necrosis characterized by gradual onset,little or no discomfort , and the
intermittent discharge of pus through an associated sinus tract.The chronic abscess
may be differentiated from cysts and granulomas by the fact that both cysts and
granulomas have well defined radiolucencies associated with them. The treatment
is Conventional Root canal treatment.
PERIAPICAL GRANULOMA
A periapical granuloma is defined as a
growth of granulomatous tissue
continuous with the periodontal
ligament resulting from pulpal death
with diffusion of toxic products in to the
periapical area .In most cases, a
granuloma is symptomless
Radiographically one sees a well defined
area of rarefaction with some
irregularities , A massive invasion of
pulpal contaminants will result in the
formation of an acute abscess{phoenix
abscess}.