Sindrom Endo-Parodontal Iasi PDF

UNIVERSITY OF MEDICINE AND PHARMACY
GR.T.POPA IAI
FACULTY OF DENTAL MEDICINE
DOCTORATE THESIS
CLINICAL BIOLOGICAL RESEARCH IN MANAGEMENT
FOR ENDO-PERIODONTAL SINDROM
Abstract
Scientific Coordinator:
PROF. DR. SILVIA MRU
Aspirant Doctorate:
PETRONELA AGAFIEI
Iai 2011
SUMMARY
SUMMARY ....................................................................... Error! Bookmark not defined.
KNOWLEDGE STAGE ...................................................................................................... 4
INTRODUCTION ............................................................................................................... 4
CHAPTER 1 ........................................................................................................................ 4
ENDO-PERIODONTAL MORPHOPHYSIOLOGY ....................................................... 4
CHAPTER II....................................................................................................................... 4
ETIOLOGY OF ENDO-PERIODONTAL DIZORDERS .................................................. 4
MICROBIAL ETIOLOGY OF ENDODONTIC DISEASES ............................................. 4
CHAPTER III ..................................................................................................................... 5
PATHOPHYSIOLOGY OF ENDO-PERIODONTAL SYNDROME .............................. 5
PERSONAL PART ............................................................ Error! Bookmark not defined.
CHAPTER IV ...................................................................................................................... 5
CLINICAL BIOLOGICAL RESEARCH IN MANAGEMENT FOR ENDOPERIODONTAL SYNDROME .......................................................................................... 5
INTRODUCTION. THEME MOTIVATIONS ................................................................ 5
OBJECTIVES ...................................................................................................................... 5
RESEARCH DIRECTIONS ................................................................................................ 6
DATABASE CREATION AND STATISTICAL METHODS IN EVALUATION .......... 6
DISCUSSIONS .................................................................. Error! Bookmark not defined.
CHAPTER V ...................................................................................................................... 7
EVALUATION OF BACTERIAL PATTERN AND OF MICROBIAL
PATHOGENICITY LEVEL IN ENDO-PERIODONTAL SYNDROME.......................... 7
STUDY PURPOSE........................................................... Error! Bookmark not defined.
MATERIAL AND METHOD ........................................... Error! Bookmark not defined.
RESULTS .......................................................................... Error! Bookmark not defined.
CHAPTER VI ................................................................................................................... 13
ANATOMOPATHOLOGICAL ASSESSMENT IN ENDO-PERIODONTAL
SYNDROME ..................................................................................................................... 13
STUDY PURPOSE........................................................................................................... 13
MATERIAL AND METHOD ........................................................................................... 13
CHAPTER VII .................................................................................................................. 16
STUDY ON AGGRESSIVE POTENTIAL OF SCALING / SURFACING
TECHNIQUES IN ENDO-PERIODONTAL SYNDROME ............................................ 16
WORK PURPOSE. ........................................................... Error! Bookmark not defined.
CHAPTER VIII ................................................................................................................ 18
STUDY ON SCALING AND SURFACING EFFECTS AND IN CONJUNCTION
WITH SUBGINGIVAL APPLICATION OF CHLORHEXIDINE GEL IN
TREATMENT OF ENDO- PERIODONTAL SYNDROME ........................................... 18
STUDY PURPOSE............................................................ Error! Bookmark not defined.
2
CHAPTER IX ................................................................................................................... 23
RADIOLOGICAL ASSESSMENTS N ENDO--PERIODONTAL SYNDROME ........ 23
STUDY PURPOSE.......................................................... Error! Bookmark not defined.
RESULTS - CLINICAL CASES ...................................... Error! Bookmark not defined.
PROGNOSIS PRESERVATION OF TEETH EVALUATION ..... Error! Bookmark not
defined.
CHAPTER X .................................................................................................................... 28
STUDY ON CLINICAL-COMPLEMENTARY EVALUATION AND TREATMENT
OF FACTORS INVOLVED IN ONSET OF ENDO-PERIODONTAL SYNDROME .... 28
STUDY PURPOSE.......................................................... Error! Bookmark not defined.
MATERIAL AND METHOD .......................................... Error! Bookmark not defined.
RESULTS DISCUSSION................................................ Error! Bookmark not defined.
THEORETICAL AND PRACTICAL CONTRIBUTIONS FOR DOMAIN
DEVELOPMENT .............................................................................................................. 30
GENERAL CONCLUSIONS ............................................................................................ 32
BIBLIOGRAPHY .............................................................................................................. 33
KNOWLEDGE STAGE
INTRODUCTION
Between periodontal and endodontal space are closely interdependences, if one is
affected can determine the response from the other. This interrelation is given that the
tooth and periodontium is a functional unit.
Differential diagnosis of endodontic lesion (endodontic lesion is the term used to
describe an inflammatory process in periodontal tissue due to presence of toxic agents in
the tooth channel during infections) and periodontal lesions (periodontal lesion is the term
used for indicate an inflammatory process in periodontal tissue resulting from the
accumulation of dental plaque on surface) often can be difficult, because endodontal
lesions often have symptoms of apical periodontitis, while periodontal disease symptoms
often are present in the marginal periodontium.
CHAPTER I
ENDO-PERIODONTAL MORPHOPHYSIOLOGY
Between periodontal and endodontal space are closely interdependences, if one
is affected can determine the response from the other. This interrelation is done so, that
the tooth and periodontium is a functional unit.
The proper functioning depends on the status health of a tooth periodontium.
Disease status in this area may be the result of:
periodontal tissue illness expansion in pulp disease,
apical progression to gum inflammation that can affect cement, ligament and
alveolar bone.
CHAPTER II
ETIOLOGY OF ENDO-PERIODONTAL DIZORDERS
MICROBIAL ETIOLOGY OF ENDODONTIC DISEASES

From the demonstration presence of bacterial forms in necrotic pulp tissue,
around 100 years ago, the effect of oral flora in the pathogenesis of pulp and periapicale
indigenous was obviously increased.
Is no less true that for many years, was missing direct relationship scientific
documentation on the cause - effect, mainly due to the ability of appropriate isolation and
identification of all bacteria involved.
Endodontic microbiology recent surveys showed the role of Gram-negative

anaerobic and have demonstrated a link between symptomatic cases and certain types of
bacteria. These findings, coupled with the demonstration that the "invaders" unusual and
undiscovered enter in root system, strengthened the relationship between preclinical and
clinical disciplines.
CHAPTER III
PATHOPHYSIOLOGY OF ENDO-PERIODONTAL
SYNDROME
As with other infections, in endo-periodontal syndrome, interactions between host
and bacteria determine the nature and extent of disease. Pathogenic microorganisms can
influence the infectious process progression by producing toxics that directly invade host
tissues and stimulate its response.
PERSONAL PART
CHAPTER IV
CLINICAL BIOLOGICAL RESEARCH IN

MANAGEMENT FOR ENDO-PERIODONTAL
SYNDROME
INTRODUCTION - THEME MOTIVATIONS
Symptoms of inflammation common characteristics in periodontal diseases, which
are manifested by the presence of deep periodontal pockets with or without swelling and
suppuration at gingival marginal, increase mobility and dental angular defects bone, also
can be symptoms of a disease from the root channels system.
Following the concerns of both the current practice in the preparation and doctorate,
Ive proposed:
o Data collection of documentary material to integrate data from the literature
on endo-periodontal relations and their treatment, conservative or surgical
o Endodontic and periodontal pathology study in patients trial, highlighting
the complex program for evaluation and treatment of patients with severe
endo-periodontal syndrome including indications for choosing conservative
or surgical treatment
o Realisation of clinical and laboratory studies on a personal data concerning
status health and endodontic / periodontal damage inpatients who referred
for dental treatment to my private dental office staff and in the
Periodontology Clinic - UMF Iasi.
OBJECTIVES
To achieve these goals, were named the following objectives:
o Developing a comprehensive assessment program that includes:
o diagnosis correlated with evolutionary stage,
o general and particular objectives of each clinical case,
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o case study database for processing statistical data,

o basic pathogenic factors determination,
o Indication of clinical features, laboratory investigations, functional
explorations and biological tests for the diagnosis and differential
diagnosis of certainty.
Database selection, examination and evaluation of cases we've realised in my
dental office at Tulcea and Periodontology Clinic at Faculty of Dental Medicine, Iai.
RESEARCH DIRECTIONS
The study was focused on the following:
o Evaluation of endodontic-periodontal status in determining therapeutic
options, surgical vs. conservative treatment.
o Evaluation of clinical indicators of periodontal disease (i.e., plaque index,
gingival inflammation indices - indices of bleeding, attachment loss, alveolar bone
lysis).
O Clinical and laboratory studies for identification of microbial flora isolated
from root channels and periodontal pockets.
O Assessment of iatrogenic potential of scaling / surfacing on pulp.
o Observation of clinical and microbiological effects of scaling / surfacing and
in conjunction with subgingival application of chlorhexidine gel in the treatment
of periodontal pockets, within the concept of total disinfection of the oral cavity.
o Evaluation of clinical, radiological and statistics for analysis and prognostic
assessment in periodontal surgery indication.
For assessing such various aspects of endo-periodontal syndrome, we approached
the multidimensional human cases included in our research using clinical
investigations, laboratory, statistics, microbiological.
DATABASE CREATION AND STATISTICAL METHODS IN

EVALUATION
For performing this study I was beneficiary case trials from:
o Odontology- Periodontology Clinic, Faculty of Dental Medicine, UMF Iai
in 2004-2007
o Private Dental Medicine Office - Tulcea
I ve formed a group study of 151 patients who had periodontal symptoms,
manifested by changes in shape, colour or texture of the gums, swelling, spontaneous
bleeding or easily induced, pain and tenderness, or itching gingival gum, tooth mobility,
pockets with different depths , hyperplasias varying degrees.
STATISTICS METHOD
Statistical analysis was performed using Microsoft Excel and statistical programs
NCSS / PASS, with applications in medical statistics.
Clinical cases
Next images are some of the most representative clinical cases included in this
study. Photographs are representing clinical modifications of patients and them
radiological aspects that determined the attitude of therapeutic choice.
Patient C.V., 48 years
Fig.IV.1 Patient C.V., 48 years endo-periodontal syndrome 46, intraoral clinical

aspect
Fig. IV.2 Patient C.V., 48 years endo-periodontal syndrome 46, radiographic aspect
DISCUSSIONS
Diagnosis and control of endo-periodontal syndrome is based on clinical
parameters in a large extent. Clinical diagnosis affects directly decisions to initiate
treatment, to select methods and sketch the topography for treatment application.
CHAPTER V
EVALUATION OF BACTERIAL PATTERN AND OF

MICROBIAL PATHOGENICITY LEVEL IN ENDOPERIODONTAL SYNDROME
STUDY PURPOSE
The purpose of this study was to investigate the composition of microbial flora in
infected channels and periodontal pockets in teeth with endo-periodontal syndrome, and
to determine associations frequency of bacteria found.
MATERIAL AND METHOD

Content of 25 roots channel and 20 periodontal sites, with pockets 3-5 mm, from
20 patients, with clinical and radiographic diagnosis of endo-periodontal syndrome was
assessed by microbial analysis.
Identification of bacterial species was isolated by:
The appearance of growing colonies (colony morphology) pigment genesis, size,
and shape.
Morpho-tinctory appearance of isolated colonies
RESULTS
A. DETERMINATION OF ENDODONTIC FLORA
The 25 samples contained microbial endodontic microorganisms cultivated. The
average number of CFU ml-1 was 8x104 per sample. Number of species in the channel
varies between 4 and 7 (average 5.1).
Table V. 1- Bacterial species of infected channels- Bacilli Gram negative
Bacterial species
Fusobacterium spp
Prevotella oralis
Prevotella intermedia
Prevotella buccae
Prevotella melaninogenica
Number of samples
18
9
19
7
3
Peptostreptococcus prevotii
Bacteroides SPP
Capnocytophaga SPP
5
7
14
Bacterial species
Bacilli Gram -negative
14
18
7
5
9
7
19
Fusobacterium spp
P oralis
P intermedia
P buccae
P melaninogenica
P prevotii
Bacteroides SPP
Capnocytophaga SPP
Fig.V.1. Bacterial species in infected channels: G-bacilli

Among G-bacilli were identified: Fusobacterium SPP, Prevotella SPP (P oralis, P
intermedia, P buccae, P melaninogenic), Peptostreptococcus prevotii, species of
Bacteroides and Capnocytophaga SPP. (table V.1, fig V.1)
Table V.1- Bacterial species of infected channels- Gram positive

Bacterial species
Number of samples
Eubacterium spp
15
Actinomyces SPP
9
Bifidiobacterium SPP
7
Propionibacterium spp
21
Bacterial species distribution
Bacilli gram +
15
21
7
Eubacterium spp
Actinomyces spp
Bifidiobacterium spp Propionibacterium spp
Fig V.2. Bacterial species in infected channels-bacilli Gram +

As the bacilli Gram +, were isolated following: Eubacterium SPP, Actinomyces
SPP, Bifidiobacterium SPP, Propionibacterium SPP (table V.2, fig V.2)
Table V.3 Bacterial species of infected channels - cocci
Bacterial species
Number of samples
Cocci gVeillonella SPP
7
Cocci g+
Peptostreptococus micros
25
Germella spp
3
Staphyilococcus spp
5
Distribution of bacterial species
Cocci G+/-
25
Veillonella SPP
Peptostreptococus micros
Germella SPP
Staphilococcus SPP
Fig.V.3 Distribution of bacterial species-cocci G + / From cocci G- were isolated Veillonella SPP, and from cocci G+, Staphylococcus
SPP, Peptostreptococus micros and Germella SPP (table V.3, fig V.3).
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Table V.4 Bacterial species in infected channels

Microbial species
Number of samples
G+Bacilli
63
G- Bacilli
52
G+Cocci
Distribution
of microbial samples33
from infected
G-Cocci
7
canals
5%
21%
40%
G+Bacilli
G-Bacilli
G+Cocci
G-Cocci
34%
Fig. V.4. Distribution species in infected channels

As can be seen, overall, the species isolated, the highest proportion is the group
bacilli G - (40%), followed by the bacilli G + (34%), cocci representing 26% of the
species determined (cocci G - 5%, G + cocci 21%) (Fig. V.4.).
In gram negative bacilli group, the largest proportion was represented by
Prevotella intermedia and Fusobacterium in equal proportions (22%), followed by
Capnocytophaga SPP (17%) and Prevotella oralis (11%) (Fig.V. 4.)
Specii bacteriene
Bacili Gram Fusobacterium spp
P intermedia
P melaninogenica
Bacteroides SPP
P oralis
P buccae
P prevotii
Capnocytophaga SPP
17%
22%
9%
6%
4%
11%
9%
22%
Fig. V.5 Proportion of Bacteria G-
10
Group Gram positive is the highest proportion Propionibacterium (41%),

followed by Eubacterium (29%), Actinomyces (17%) and Bifidiobacterium (13%) (Fig.
V.6).
Proportia speciilor bacteriene

Bacili gram +
29%
41%
Eubacterium spp
Actinomyces spp
Bifidiobacterium spp
Propionibacterium spp
17%
13%
Fig. V.6. The proportion of bacilli G +

As the proportion of cocci, the highest value was recorded for Peptostreptococus
micros (62%) followed by Veillonella (17%), Staphylococcus species (13%) and Gemelli
SPP (8%) (Fig .V.7).
Proportia speciilor microbiene
Cocci G+/-
Veillonella spp
Peptostreptococus
micros
13%
17%
8%
Germella spp
Staphilococcus spp
62%
Fig.V.7 The proportion of microbial species cocci G-/ +

B. IDENTIFICATION OF MICROORGANISMS IN PERIODONTAL POCKETS
Identification was made according to the appearance of colony growth and
appearance morpho-tinctory. The 20 samples were positive for all anaerobic floras.
We isolated 54 bacterial strains: 2-3 strains / sample. Of these, 50 species were
identified, 4 bacterial strains can not be identified. Isolated anaerobic species are Gramnegative strains 33 (66%), Gram-positive bacilli 7 strains (14%), Gram-positive cocci 6
strains (12%), four unidentified strains (8%) (Fig.V.8). Anaerobic bacterial species
isolated types are shown in Table V.5.
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Predominant bacteria in gum pockets deposits of patients with chronic forms of

periodontal disease were as follows (Table V.5) (averages):
Table V.5 Types of microorganisms found in periodontal pockets
CATEGORY
%of colonies
Bacteroides
Bacilli G-anaerobes
P. melaninogenica
Campylobacter
Difteroizi anaerobes
Difteroizi facultative
Enterococus
Fusobacterium
Peptostreptococus
Spirochete
Staphylococci
B. G-facultative
Streptococcus (70% mites)
Veillonella
2,83%
9,66%
3,16%
16,5%
12%
8,1%
3,25%
5,53%
1,26%
1,08%
26,16%
10,36%
% din totalul coloniilor

2.83
10.36
9.66
3.16
26.16
16.5
12
5.53
8.1
1.08
1.26
3.25
Bacteroides
Campylobacter
Difteroizi facultativi
Fusobacterium
Spirochete
Streptococus (70 mitis)
Bacili G-anaerobi P. melaninogenica

Difteroizi anaerobi
Enterococus
Peptostreptococus
Stafilococi B. G-facultativi
Veillonella
Fig. V.8 Types of organisms identified in periodontal pockets
DISCUSSIONS
Bacterial invasion in necrotic pulp, often lead to periapicale inflammation.
The usual invasion of bacteria in the necrotic pulp is through the cavities, but from
the large number of species present on the surface of the tooth and gingival sulcus, a
small part will be developed in the environment provided by endodontic space. These
species, although they lack of pathogeneicity when are stationed in the oral cavity, in
infected channels plays an important role in inflammation and necrosis production.
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CHAPTER VI
ANATOMOPATHOLOGICAL ASSESSMENT IN ENDOPARODONTAL SYNDROME

STUDY PURPOSE
In order to identify morphological aspects of various forms of periapicale
pathology in the endo-periodontal syndrome and their correlation with clinical
presentation, biopsies were performed in cases of periapicale granuloma, periapicale cysts
and chronic periapicale abscesses we studied.
MATERIAL AND METHOD

In all cases studied we selected a number of cases, based on clinical examination,
in conjunction with the X-ray, and were diagnosed with:
Periapicale granuloma 6 cases
7 cases periapicale cyst
Chronic periapicale abscess 3 cases
Biopsies were performed in cases of periapicale granuloma, periapicale cysts and
periapicale osteitis we studied.
They used conventional morphological methods (haematoxylin-eosin staining, HE),
Van Giemson staining and Immunohistochemistry.
RESULTS
PERIAPICALE GRANULOMA
Morphological aspects of periapicale granuloma cases evaluate were within the
patterns described in the literature. I found a granulomatos inflammatory process, with
mixed cellular, lymphocyte predominant, but there are also plasma cells and macrophages
Fig VI.1. Periapicale granuloma Col. HE, GB. x20, granulomatos

inflammatory process, with mixed cellular.
PERIAPICALE CYST S EPITHELIUM-COMPONENT
A true epithelial cyst does not communicate with the system. Canalled cyst is
recognized by epithelial tissue that separates formation. Treatment for this injury is only
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surgical and endodontic treatment has no effect because the cyst does not communicate
with the root channel.
This type of cyst formation occurs in a long period of time, about six months after
the channel becomes necrotic.
In preparations made by the main cysts, lesions were polymorphic. Cyst wall was
stratified squamous epithelium wallpaper, partly thickened, and partly eroded.
Fig. VI.2. Periapicale cyst col. HE, stratified squamous epithelium obx20se notes and
a polymorphous inflammatory infiltrate subjacent.
Also in this mass and collagen appeared Malassez epithelial rests.
Fig VI.3. Periapicale cyst col. V. Giemson, obx40, epithelial rest Malassez
RUSHTON HYALINE CORPUS
The sections examined were found included in epithelial thickness as subepiteliale
a series of round or oval structures consisting of damaged red blood cells (body Rushton
in formation) also found areas of necrosis and hemorrhagic fibrinous infiltration.
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Fig VI.4. Periapicale Cyst col. HE, obx40 corpora Rushton

Rushton hyaline corpora presence is a particular feature of odontogen cysts. Their
frequency ranges from 2.6% to 9.5% occurring in the epithelial or in the lumen of
morphological cysts. They have variety of forms.
Nature of this body is not well known, suggested that keratin are likely a product
of odontogen epithelium secret or degeneration of blood cells. Some authors have
suggested that there are materials left over after surgical interventions. Is unclear why
these children are mostly in the epithelium.
CHOLESTEROL
The presence of cholesterol crystals in apical periodontitis is a common
histopathological feature.
Fig VI.5. Periapicale cervical cyst obtain crystals of cholesterol col

H.E, ob x40,
DISCUSSIONS
Morphological aspects of the cases studied were within the patterns described in
the literature.
In periapicale granuloma there was a mixed cellularity with predominance of
lymphocytes. Immunohistochemistry, they were mainly B lymphocytes T lymphocytes
modest participation.
In periapicale cysts, wall coverings epithelium stratified squamous type was in
some bold, partly eroded, with sponginess and exocytose.
15
We identified Rushton corps, and Malassez epithelial rests in the formation.

Infiltrate periapicale cell cysts were polymorphic, with predominance of lymphocytes,
immunohistochemistry identified as belonging to type B.
Fibrosis process was constantly on the periphery of lesions, either in lesion.
Investigation confirms our immune presumption granuloma and cysts from
periapicale.
Chronic periapicale abscess cases were classified as chronic fibrosis osteitis.
Before interpreting the results of morphological study performed by us, we shall
present interrelations periapicale infection, to see which is where in this three entities
studied.
CHAPTERVII
STUDY ON AGGRESSIVE POTENTIAL OF SCALING /

SURFACING TECHNIQUES IN ENDO-PERIODONTAL
SYNDROME
WORK PURPOSE
Because it is difficult to clinically appreciate which is the value of a smooth root
surfaced and the level at which an involuntary surfaces can turn a dentin exposure, our
study aims to assess ex-vivo the effects of macro- and microscopic surfacing on
remaining tooth structure. The research was both ex-vivo to assess the surface appearance
and clinically, for assessing the effects due to surfacing
MATERIAL AND METHOD

In the study we used freshly extracted teeth 78, due to the evolution of different
forms of periodontal disease. Teeth were divided into 2 groups, and we proceed to scaling
and root surfaces as follows:
group A manual scaling, using Gracey curettes
group B - ultrasonic scaling
Sanitary safety, scaling was applied at one of the root surface, simulating the
clinical algorithm of scaling / surfacing until we obtained a smooth surface.
When labour was considered complete, teeth were placed in new dye bath.
Teeth were examined both macro and microscopically in terms of layout and intensity of
colour and surface appearance resulting from surfacing.
RESULTS
MACROSCOPIC EXAMINATION
Following examination of stained surfaces we observed the dye absence, mainly in
surfaced area, due to completely remove of all the fibbers attached to the cement surface,
which entitles us to believe that a "classic" surfacing remove not only infiltrated cement,
16
but also is able to destroy and the elements necessary for re-attachment, cement and
fibber.
Fig. VII.1- Analysis of macroscopic samples evaluated

Areas examination additional revealed, all root cement removal with dentin
exposure in some areas, mostly prominent at 9 roots of the 78 teeth. We should mention
that, in terms of macroscopic. all surfaces surfaced seemed smooth, shiny.
MICROSCOPIC EXAMINATION
Lot A -manual scaling / surfacing: we observed striated appearance at the cement
surface, after Gracey curette and with, in some cases, exposure of dentinar surface.
Lot B -ultrasonic surface is smooth without dentin exposure, but have fine grooves
and defects due to the ultrasonic instrument tip action.
MICROSCOPIC EXAMINATION
Fig. VII.2 Striated appearance of the cementary surface after surfacing with Gracey
curettes
FigVII.3. Exposed dentine surface after manual scaling / surfacing
17
Fig VII.4. Microscopic aspect of surfaces after ultrasonic scaling
DISCUSSIONS
"Classic" surfacing has a number of limitations that can be easily demonstrated.
Frequent repetition of the manoeuvres is especially detrimental in the long term
effects it produces.
Any practitioner must preoperative assess the need for manoeuvres, and take that:
however as motivation and awareness of patient stage is hard, it is preferable in all
respects, to avoid an unexpected intervention, often iatrogenic, as it is surfacing.
Cement may be subject to alterations in structure and composition of their
compounds both organic and inorganic, as a result of pathological changes in the
immediate vicinity.
Prolonged presence of inflammatory process on gingival connective tissue has as
results loss of collagen fibbers and destruction of gum.
Although the enzymatic destruction of collagen fibbers is evident in gingival
tissue, soft tissue extension of this process in much of the root with the loss of cross
collagen and dissolution of crystals of minerals was also described. However, this process
is rather limited to the surface with a diffuse transmission to unaffected underlying tissue.
CHAPTERVIII
STUDY ON SCALING AND SURFACING EFFECTS AND

IN CONJUNCTION WITH SUBGINGIVAL
APPLICATION OF CHLORHEXIDINE GEL IN
TREATMENT OF ENDO- PERIODONTAL SYNDROME
STUDY PURPOSE
The purpose of this study is to assess the effects of subgingival chlorhexidine gel
Periokine (Laboratorios Kin SA) in periodontal pockets as an adjunct to MS/ S.
18
MATERIAL AND METHOD

In the present study were included 41 patients (22 women and 21 men with mean
age 45.9 (23-69 years) enrolled in the study group who received endodontic and / or
conservatory periodontal treatment.
They had no relevant medical history and have not received periodontal therapy or
antibiotic treatment at least six months before the study.
The following measurements were recorded at 60 and 90 days:
o
o
o
o
o
o
plaque index (PI) Silness and Le

gingival index (GI), Le and Silness,
gingival recession (GR),
clinical attachment level (NAC),
probing depth of pockets (AP),
bleeding on probing (SS) as the absence or presence of bleeding by 30 seconds
after probing.
The type of treatment of each site was chosen by simply scaling distribution
following:
o lot 1- SM/S (11 patients);
o lot 2 SM/S + irrigation with saline(13 patients);
o lot 3 SM/S + irrigation chlorhexidine gel (17 patients).
For 4 weeks lot 2 and 3 subjects received weekly subgingival irrigation that began
with the first visit after SM / S (day 0, 7, 14, 21).
RESULTS
PLAQUE INDEX
There was a statistically significant reduction (p <0.05) in all groups from T1 to
T2 initial period. T1 to T2 reduction from was not significant. There were no significant
differences (p> 0.05) between groups.
Fig VIII.1 Reduction of plaque index

GINGIVAL INDEX
The analysis of associated groups, statistically significant reduction was observed

(p <0.05) from the period T1 and a further increase to T2. It appeared for each group, but
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group 3 had a statistically lower results (p <0.05) compared to groups 1 and 2 in which no
special statistical differences were observed.
Fig VIII.2 Reduction of gingival index values

GINGIVAL RECESSION
There was a result of the initial stable until the end of the study. Lot 3 showed a
greater recession than other groups at T1 and T2.
Fig VIII.3 Plots studied in gingival recession values

DEPTH PROBING
A significant decrease (p <0.05) in all groups from T0 to T1 was observed, was
stable between T1 and T2. There were no significant differences between groups
20
Fig VIII.4 Reduction of probing depth in patients studied

Attachment level. We observed in all groups an increased clinical attachment.
Clinical attachment gain was statistically significant (p <0.05) between T0 and T1 and T2
constant up before. It appeared for each group but no significant differences (p> 0.05)
between them.
Fig VIII.5 Values of attachment gain

BLEEDING ON PROBING
11 patients in group 1 were analyzed in the initial period and 9 of them were
positive for bleeding on probing, among them eight persons became negative at T1. The
other two persons positive bleeding a patient was negative T1 to T2. 13 people have been
analyzed in group 2 and 10 of them were positive bleeding on probing and became
negative at T1 and T2 3 became positive. 17 people of Lot 3 were analyzed in the initial
period and 12 were positive and became negative bleeding T1. At this, all sites were
negative from T1 to T2
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Fig VIII.6. Reducing bleeding on probing index values in the three groups study
DISCUSSIONS
This study evaluated the effectiveness of local administration of chlorhexidine gel
as an adjunct to SM / S. Clinical improvement of all periodontal parameters of batches
tested were different from the original to a level of significance of 0.05.
Use the gel with chlorhexidine irrigation improved outcome SM / S in terms of
testing parameters.
These results can be linked with chlorhexidine action on microorganisms. The
group 1 reduced to a decrease in clinical parameters compared to group 3 by the end of
the study.
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CHAPTER IX
RADIOLOGICAL ASSESSMENTS N ENDO-PERIODONTAL SYNDROME

STUDY PURPOSE
Is to evaluate the usefulness of radiological studies in diagnosis and management of
patients with endo-periodontal syndrome.
MATERIAL AND METHOD
For radiographic assessment were taken in study patients with endo-periodontal
syndrome, who analyzed the quality of information brought by each imaging for areas of
interest, compared with clinical assessment. We considered the type of bone lysis,
location, severity and number of walls in vertical bone lesions twinning.
The types of radiological investigation were:
-X-ray retro-dental-alveolar
-OPT
-Computer tomography
Following the radio-visible elements, our examination said about:
- Spongy bone in the interdentally trabecular septum as furcation;
- Image cortical bon with contour increment to be net;
- Outline septal crest or top of the normal septum is located 1-2 mm apical to the
junction enamel - cement;
- Last lamina durra or cribriform lamina which corresponding to radiographic
image at ligament adjacent bone portion;
- Desmodontal space: space is black, may have occlusal aetiology but can be a
technique error;
- Furcation and their possible involvement;
- Images of the apical endo-periodontal lesions.
Radiographic assessment of bone was an indispensable element of diagnosis and
indication for choosing the method of treatment-conservative or surgical, allowing
assessment of interdentally and eventually interradiculare bone.
23
RESULTS - CLINICAL CASES

Table IX.1 Analysis of clinical symptoms of periodontal disease
Symptoms of periodontal disease
% of patients
Spontaneous bleeding
10%
Inflammation
90 %
Gingival recession
4 8%
Gingival hyperplasia
2%
Tooth Mobility
59%
Pockets false/true
42%
Table.IX.2 plaque index -averages (mm)
Wilcoxon test
Lot
Pre-treatment
Post-treatment
p
Difference
Study
1,87
0,85
0,0001
1,17
Control
1,7
1,5
0,0001
0,65
Ray examination
OPT advantages: is a global study, achieving in single film all system dentalalveolar
Relatively easy due to its simplicity positioning without patient preparation, without the
vomit reflexes, associated with rapid execution, low radiation and price is a
recommended as initial dental examination
Figure IX.1 Radiographic examination in endo-periodontal syndrome
Computer tomography CT
Volumetric computerized tomography used - NewTom QR - DVT 9000
Using computerized tomography was performed dental volume due to the fact that
the minimum radiation dose to the patient is 5 times lower than for conventional
tomography, the actual time of patient exposure is minimal, avoid any error in positioning
the patient, geometric measurements are accurate to 1:1, the reports are available on CDs
or photo paper.
Software program uses a special algorithm that reduces the influence of the metal.
In dental volumetric tomography to look so few "mm" extra bone in comparison with
conventional tomography.
With panoramic tomography images we obtained, axial sections, cross sections
and three-dimensional images.
24
Patient S.S., 54 years,
Fig. IX.2 Clinical aspects intraoral

INDEX 1:
o D = tooth position (e.g. D16)
o R = right)
o L= left
Measurements:
o Yellow - vertical (length)
o Green - horizontal (width)
o red point - mandible canal (applied on cross sections)
o red line - mandible canal (applied to the Panoramic section)
o a orange line - mandible canal (applied to the Panoramic section
Fig. IX.3 Panoramic evaluation
Fig. IX.4 Panoramic evaluation
25
Fig. IX.5 Infra-osseous pocket of on the distal 25; ratings in the decision to treat
bone capital conservator vs. surgical
Fig. IX.6 Endo-periodontal syndrome; infra-osseous pocket on the distal of 25;

evaluation of treatment decision
26
Fig. IX.7 - Evaluation of bone density
Fig. IX.8. 3D- Modelling
DISCUSSIONS
Periapicale radiographs and ortopantomographics may under-or overestimate the
present line of the alveolar bone. Alveolar bone may be unclear, especially in vertical
faults. However, if diagnostic methods detect only 1% (ortopantomographics) or 4%
(apical scan) of the initial vertical lesions, unradiographic method may be preferred by
others, despite the existence of significant statistical differences between methods.
The need for 3D CT has led to the appreciation of the characteristics of the
alveolar bone. CT uses a rotating X-ray fascicule to record an image section of the
patient, generally in the axial direction. Modern CT apparatus use a continuously moving
table so that obtains the spiral or helical images of the patient. After image acquisition,
using a computer program can simulate 3D.
Simplified concept of CBCT devices lead to significant reductions in operating
costs compared with traditional CT. One of the major disadvantages is reduced image
sharpness and image playback inability best of soft parts, which makes this method
particularly indicated for bone structures.
PROGNOSIS PRESERVATION OF TEETH EVALUATION
It should be considered two aspects: overall outcome and prognosis of individual teeth.
In many cases, after radiographic examination, it is preferable to establish a
provisional prognosis until after the initial phase of treatment evaluation. Following
27
initial therapy, active lesions can be converted temporarily inactive why a final prognosis
will be evaluated only after completing the first phase of treatment.
CHAPTER X
STUDY ON CLINICAL-COMPLEMENTARY
EVALUATION AND TREATMENT OF FACTORS
INVOLVED IN ONSET OF ENDO-PERIODONTAL
SYNDROME
STUDY PURPOSE
It is assessing the incidence and response to conservative treatment of the factors
involved in endo-periodontal syndrome
MATERIAL AND METHOD

The study included all patients in the research groups who conducted conservative
treatment
RESULTS DISCUSSION
Table X.1 Distribution of endo-periodontal syndrome cases, symptoms and
radiographic appearance
Type of
Nr
Vitality
Pain
Swelling
Periodontal
Rx
lesion
teeth
pocket
Aspect
Primary
32
moderate to +/Absent /
Rx T +/endodontic
severe
Possible
lesion
fistula
Primary
31
moderate to unsteady
present pocket Rx apex to
endodontic
severe
fistula
sulcus,
lesions,
trajectory
crestal
periodontal
bone
secondary
height
reduction
Primary
31
+
Absentpossible
Pocket <3crestal
periodontal
moderate
4mm
bone
lesion
height
reduction
Periodontal 19
+
Absent
possible
Pocket > 4 bone loss
lesion
Present if
mm
to near
primary,
possible
apex
secondary
endodontic
endodontic
involvement
True
28
moderate to unsteady
periapicale
loss to
combined
severe
communicates apex bone
lesions
with deep
loss
pockets
28
INCORRECT ENDODONTIC TREATMENT

A properly performed endodontic treatment is the key factor of successful
treatment. It is very important to clean, shape and clog the system channels for successful
treatment.
INCORRECT RESTORATION
Coronary leaching is an important cause of failure in the treatment of endoperiodontal. Root channels system can recontaminate with microorganisms by delaying
their implementation restorations or crown fracture or broken tooth.
TRAUMA
Alveolar bone trauma or at tooth pulp and periodontal ligament may affect directly or
indirectly.
RESORPTION
Root resorption is a condition that is associated with a physiological or pathological
phenomenon which is manifested by loss of dentine, cement and / or alveolar bone.
PERFORATION
False paths are root unwanted complications that can lead to a failure of endoperiodontal syndrome treatment because they establish communication between the
system and periodontal tissue channels the oral cavity in which case the prognosis is false
reserved. Carious lesions ways may occur due to extensive iatrogenic or after absorption
DEVELOPMENTAL ABNORMALITIES
Teeth with developmental abnormalities such as invaginations or vertical grooves
root teeth do not respond normally to such treatment. This grooves start from the central
fissures in molars and occlusal face supracingular to front and continue along to the apical
root-distance variables
Fig. X.1 Anomaly of lateral incisor palatal groove
29
THEORETICAL AND PRACTICAL CONTRIBUTIONS FOR DOMAIN

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

anatomically in relation to pulp in the apical foramen and lateral channels of
communication which creates ways in which pathogens can move from side to side if one
or both types of tissue are affected.
Resorption processes from root level and therapeutic measures used in the treatment
of periodontal disease with dentinal tubules exposure establishes another communication
channel with pulp.
Not only that there may be interactions between periodontal and dental pulp that can
aggravate or extend the lesion, but these interactions put the clinician in difficulty in the
sense that it must determine the cause periodontal disease directly.
Following in the preparation doctorate, I proposed:
o data collection of scientific research to integrate data from the literature on
endo-periodontal relations and their treatment, conservative or surgical
endodontic and periodontal
o
study of endodontic and periodontal pathology in patients of our study,

highlighting the complex program for evaluation and treatment in patients
with severe endo-periodontal syndrome and indication of conservative or
surgical treatments
performance of clinical and laboratory studies on a personal data

concerning health and damage endodontic / periodontal in patients who
were referred to my private dental office for dental treatment and to the
Clinic of Periodontology UMF Iai.
The study was focused on the following:

o Evaluation of endodontic-periodontal status in determining therapeutic options,
surgical vs. conservative treatment.
o Evaluation of clinical indicators of periodontal disease (i.e., plaque index, gingival
inflammation indices - indices of bleeding, attachment loss, alveolar bone lysis).
o Studies on the identification of clinical and laboratory microbial flora isolated
from root canals and periodontal pockets.
o
Assessment of iatrogenic potential of scaling / surfasajului on pulp.
o Observation of clinical and microbiological effects of scaling/surfacing and in

conjunction with subgingival application of chlorhexidine gel in the treatment of
periodontal pockets, within the concept of total disinfection of the oral cavity.
30
o Evaluation of clinical, radiological and statistical analysis and prognostic

evaluation in conservative or surgical treatment indication.
As an element of originality we introduced for the first time, after our knowledge,
the study of diseases simultaneously and the periodontal-endodontic, emphasizing twoway relationship that exists between them.
Ive tried to demonstrate the microbiological assessment that anaerobic bacterial
flora involved in the emergence of endodontic disease and periodontal have similarities;
they are influencing and mouldings each other.
Also as an original contribution we introduced complementary evaluation of
radiographic- Computer tomography in the study of endo-periodontal syndrome as an
instrument of high precision in assessing therapeutic options, conservative or surgical
treatment.
31
GENERAL CONCLUSIONS
Results indicate that endodontic pathogens do not occur randomly but are found
in specific combinations that may contribute to the development of clinical signs
and symptoms.
Diseases of endodontic and periodontal edges are clearly related to the existence
of Gram-negative microbial species in subgingival level.
The microbiological tests aimed to isolate and identify anaerobic gram-negative
bacterial species known to be involved in diseases such as endodontic and
periodontal disease.
Microbiological testing provides important data for targeted antibiotic treatment
choice by performing sensitivity testing, working with microbiology laboratory is
essential.
Control board subgingival bacterial load supragingival reduce to some extent.
Mechanical treatment is relatively effective in suppressing periodontal pathogens
and improvements in clinical status.
Conventional mechanical treatment is a necessary step in periodontal treatment,
but always fails to completely eliminate periodontal pathogens, particularly
furcation, deep periodontal pockets and other intraoral niches.
In view of the complex ecosystem of periodontal pockets, there is need for
antimicrobial agents in conjunction with scaling and surfacing, to eliminate the
pathogenic flora in some cases of periodontitis.
Antimicrobial agents are effective in removing potential periodontal pathogens
process such inaccessible sites, such as implications furcation, the convex surface
root deep soft tissues and tubular dentine.
Surfacing in "classic" manner has a number of limitations that can be easily
demonstrated.
Frequent repetition of the manoeuvres is especially detrimental in the long term
effects it produces.
Every practitioner should evaluate endo-periodontal syndrome by preoperative
needs for scaling / surfacing, and regarding that as hard motivation and awareness
for patients, it is preferable in all respects, an unexpected intervention, often
iatrogenic, and surfacing
Loss of substance: surfacing repeated regularly every 3 months, as recommended
in the textbooks of Periodontology, causes loss of substances which give eroded
appearances, characteristically, as evident in the third cervical roots thinned and
constitute the possible iatrogenic factors pulp involvement
Compliance with mechanical approach of hardened during periodontal lesions
resulting in a lower frequency of these types of problems.
Our research demonstrates the importance of aggressive attitude changings on
cement as the defining role in obtaining tissue reinsertion of periodontal ligament
collagen fibbers and fibber-growth over the root surfaces.
We detected many factors that contribute to the onset of endo-periodontal which
I grouped as follows:
- Incorrect endodontic treatment over/under restorations
- Incorrect conservative operative procedures
- Trauma to teeth or alveolar bone
- Developmental abnormalities
- Iatrogenic endodontic-Perforations / false root paths
32
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UNIVERSITY OF MEDICINE AND PHARMACY

ETIOLOGY OF ENDO-PERIODONTAL DIZORDERS

MICROBIAL ETIOLOGY OF ENDODONTIC DISEASES

Endodontic microbiology recent surveys showed the role of Gram-negative

CLINICAL BIOLOGICAL RESEARCH IN

o case study database for processing statistical data,

DATABASE CREATION AND STATISTICAL METHODS IN

Patient C.V., 48 years

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

EVALUATION OF BACTERIAL PATTERN AND OF

MATERIAL AND METHOD

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

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

Bifidiobacterium spp Propionibacterium spp

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

Table V.4 Bacterial species in infected channels

Fig. V.4. Distribution species in infected channels

Fig. V.5 Proportion of Bacteria G-

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

Proportia speciilor bacteriene

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

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

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

% din totalul coloniilor

Bacili G-anaerobi P. melaninogenica

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

ANATOMOPATHOLOGICAL ASSESSMENT IN ENDOPARODONTAL SYNDROME

MATERIAL AND METHOD

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

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

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

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

STUDY ON AGGRESSIVE POTENTIAL OF SCALING /

MATERIAL AND METHOD

Fig. VII.1- Analysis of macroscopic samples evaluated

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

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

STUDY ON SCALING AND SURFACING EFFECTS AND

MATERIAL AND METHOD

plaque index (PI) Silness and Le

Fig VIII.1 Reduction of plaque index

The analysis of associated groups, statistically significant reduction was observed

Fig VIII.2 Reduction of gingival index values

Fig VIII.3 Plots studied in gingival recession values

Fig VIII.4 Reduction of probing depth in patients studied

Fig VIII.5 Values of attachment gain

RADIOLOGICAL ASSESSMENTS N ENDO-PERIODONTAL SYNDROME

RESULTS - CLINICAL CASES

Figure IX.1 Radiographic examination in endo-periodontal syndrome

Patient S.S., 54 years,

Fig. IX.2 Clinical aspects intraoral

Fig. IX.3 Panoramic evaluation

Fig. IX.4 Panoramic evaluation

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

Fig. IX.7 - Evaluation of bone density

Fig. IX.8. 3D- Modelling

MATERIAL AND METHOD

INCORRECT ENDODONTIC TREATMENT

Fig. X.1 Anomaly of lateral incisor palatal groove

THEORETICAL AND PRACTICAL CONTRIBUTIONS FOR DOMAIN

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

study of endodontic and periodontal pathology in patients of our study,

performance of clinical and laboratory studies on a personal data