CC BY
121MEDICAL SCIENCES
УДК 616.31-003
Микляев С. В.
Леонова О.М.
1. Тамбовский государственный университет им. Г.Р. Державина 2. Тамбовская областная клиническая стоматологическая поликлиника
DOI: 10.24411/2520-6990-2019-10066 ЭНДОДОНТО-ПАРОДОНТАЛЬНЫЕ ПОРАЖЕНИЯ (обзор литературы)
Miklyaev S. V.
Leonova O. M.
1. Tambov state University. G. R. Derzhavin 2. Tambov regional clinical dental clinic
ENDODONTAL-PERIODONTAL LESIONS (literature review)
Аннотация:
Эндодонто-пародонтальное поражение - это совокупность поражения пульпы и тканей пародонта. В современной стоматологии данное поражение является серьезной проблемой, так как требует от врача-стоматолога определенных знаний не только в области эндодонтии, но и в области пародонтоло-гии[4,5]. Взаимосвязь пульпы и пародонта определяется эмбриональным, анатомическим и функциональным сходством.
Abstract:
Endodontal-periodontal lesion is the combination of lesions of the pulp and periodontal tissues. In modern dentistry, this lesion is a serious problem, since it requires certain knowledge from the dentist not only in the field of endodontics, but also in the field ofperiodontics[4,5]. The relationship between the pulp and the periodontium is determined by embryonic, anatomical and functional similarity.
Ключевые слова: эндодонто-пародонтальные поражения, эндодонтия, пародонтологическое лечение, биопленка, бактериальная микрофлора.
Keywords: endodontal-periodontal lesions, root canal treatment, periodontal treatment, biofilm, bacterial microflora.
Introduction. Currently, dentistry is increasingly gaining relevance in the diagnosis and treatment of patients at the initial stage of the disease, in order to prevent its further progression, the least dental intervention and preservation of the tooth both anatomically and functionally[7]. Of great importance in this problem are the knowledge of the dentist, modern technologies and materials, and most importantly, observing the principles of deontology, to inform the patient about his disease and offer all possible options for further treatment, which is aimed at preserving the tooth[10].
Literature review. Modern dentistry does not stand still, which used to be the cause of tooth extraction, now it is not difficult to treat and preserve it as an organ. Such diseases include a combination of lesions of the pulp and periodontal tissues - endodontal-perio-dontal lesion.
According to the generalized data of independent who experts, based on the latest results of epidemiological studies, intact periodontal occurs only in 2-10% of cases, inflammatory periodontal diseases are detected in 90-95% of the adult population. Already by the age of 25-30, more than 50% of the population have a variety of clinical manifestations of periodontal disease and often aggressive nature of the flow of a process which may lead to a change in the reactivity of the organism of the patient and to the complete loss of teeth. A particularly high level of periodontal disease falls on the age of 35-44 years (from 65% to 98%) and 15-19 years (from 55% to 89%).
Thus, according to the who, severe periodontal disease occurs in 5-25% of the adult population, the average degree-30-45% of the adult population and only 2-8% of people have intact periodontal at the age of 3545 years. The prevalence of periodontal disease at the age of 40 years, in General, is 94.3%. Periodontitis is one of the most common diseases of the maxillofacial region, in recent years, it shows a clear trend towards an increase in morbidity among the population.
The main reason for the development of periodon-titis is improper individual hygiene of the oral cavity, as well as visits to the dentist at least once a year. Improper personal hygiene of the oral cavity includes: improper use of the toothbrush, not timely replacement of the brush, not proper use of dental floss and toothpicks, as well as ignoring the use of rinses. If used improperly toothbrush the formation of dental plaque is initially soft plaque, then formed dental plaque, then the mineralization and formation of supra - and subgingival stones. Untimely changing of toothbrush or the nozzle leads to the growth of pathogenic microorganisms on the brush, also during this time, the bristles lose their flexibility and may injure the gums. In case of violation of the technique of using dental floss instead of cleaning the interdental spaces from food residues, thanks to which the carious process can develop, patients get injured gums and there is a risk of bringing the infection into the wound. A similar situation may arise when using toothpicks due to improper use, the patient injures the gums and pushes the remnants of food into the
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wound. As a result, inflammation occurs. The use of mouthwashes is an additional means of cleaning teeth and preventing gum disease.
The main etiological factor in the development of both periodontitis and complications of the carious process is bacterial microflora. In both diseases, mixed anaerobic flora prevails.
Microbiological studies have revealed that non-hemolytic Streptococcus, gram-negative Bacillus, Candida fungi, epidermal Staphylococcus predominate in the root canal and periodontal pocket. At the same time, the relationship between the content of the periodontal pocket and the root canal is not important.
However, there is evidence of severe microbial contamination of the root canal and periodontal pocket by microorganisms Bacteroides vulgaris and Entero-cocus faecalis. In this case, the intact teeth is recommended to remove the pulp in patients with chronic generalized periodontitis. All this is proved by the presence of irreversible changes in the pulp in this pathology.
To determine the etiology and pathogenesis of the disease, a classification of periodontal microbial complexes was created, each complex has a role. These include: red, orange, green, yellow and purple microbial complexes.
The representatives of the red complex are: Por-phyromonas gingivalis, Treponema denticola, Tan-nerella forsythia (Bacteroides forsythus). The interrelation between bacteria of this complex and deepening of periodontal pocket is noticed. Active participation of these bacteria in periodontal destruction was also noted.
The orange complex (Fusobacterium nucleatum, Prevotella intermedia, Prevotella nigrescens) contains potential pathogens for periodontal tissues. These microorganisms are present in small concentrations in the oral cavity. They begin to actively multiply with pathological changes. This complex is interconnected with the red complex.
The green complex is represented by: Capno-cytophaga spp., Campylobacter concisus, Eikenella corrodens. These microorganisms are found in diseases of periodontal tissues with severe destructive changes. The complex plays an important role in the development of diseases of the mucosa of the oral cavity and resorption of the cement of the tooth root[8,9].
Yellow (Streptococcus oralis, Streptococcus mitis, Streptococcus sanguinis) and purple (Actinomyces odontolyticus, Veillonella parvula) complexes perform a protective role, entering into antagonism with perio-dontal pathogens.
All mentioned microbial complexes, in the presence of periodontal pocket, are part of the dental plaque. However, within the periodontal pocket the species composition of individual microbial complexes may differ[2].
Pulp and periodontium are of mesenchymal nature, the cells that proliferate in the formation of the tooth to form the tooth papilla and dental SAC, which are respectively precursors of pulp and periodontium.
The main way of communication of the tooth and periodontal is the apical opening, it is through it that the closest relationship between them is achieved. Studies have shown that in periodontal disease, in the formation of pathological pockets, the pulp is not involved in the process until the infection reaches the apical opening. Also, this process involves the entire branched system
of the root canal, due to the lateral and additional channels^]. They can be present everywhere along the root. The study revealed that 17% of teeth have additional channels in the apical part, 9% in the middle and 2% in the upper third. There are relatively few destructive changes in the periodontium associated with lateral channels. Additional channels in the area of furcation of molars are also ways of communication of pulp and periodontal. The distribution of additional channels in this area is quite large and is 76%, but not all of these channels extend to the entire thickness of the dentin to the bottom of the furcation[3,4].
Another way of infection is through dentine tubes. Dentin tubes-a thin, tapering outward tubules, radially penetrating the dentin from the pulp to the enamel (in the crown) or cement (in the root). Closer to the enamel, they give lateral V-shaped branches, in the area of the top of the root there are no branches. The tubules of the crown Are s-shaped curved, and almost straight at the root[9,11]. Due to the radial orientation of the tubules, their density is greater from the pulp side than in the outer layers of dentin. The contents of dentin tubes are odontoblasts and nerve fibers surrounded by tissue (dentin) fluid. In case of carious lesions, dentine tubes serve as pathways for the spread of microorganisms[5].
Currently, when a diagnosis of endodontal-perio-dontal lesions using a classification proposed by Simon Glik and Frank in 1972., based on the etiology, diagnosis, prognosis and treatment of this pathology[1,2].
Classification:
* primary endodontic disease;
* primary endodontic disease with secondary per-iodontal disease;
* primary periodontal disease;
* primary periodontal disease with secondary en-dodontic disease;
* true combined lesion.
In primary endodontic disease, the pulp is primarily affected, when communicating through the apical opening or additional channels, healthy periodontal tissues are affected. In this clinical case, it is necessary to study the area of furcation, if there are no defects in this area, then this is exclusively an endodontic lesion. For the patient, this situation means that a favorable prognosis is possible[3].
Endodontic lesion with secondary involvement of periodontium is characterized by pulp lesion due to complications of carious process with defeat of initially healthy marginal periodontium. The formation of periodontal pockets[12]. Most often, this type of lesion is observed in the Palatine roots of the upper molars, which is accompanied by a bone defect of the type of cleft. In this case, a combined treatment. First performed endodontic treatment, after 2-3months evaluate the treatment, then begin to plan periodontal treatment. This time is necessary for the periodontal to be able to regenerate itself after the elimination of the main source of infection.
Primary periodontal disease is characterized by the formation of periodontal pockets, and there is resorption of the alveolar bone. The diagnostic feature is the preservation of the viability of the pulp. In this case, only periodontal treatment is required[10].
Periodontal lesion with secondary involvement of endodontic lesion is characterized by the progression of periodontal disease, which leads to the deepening of the periodontal pocket and pulp lesion. The inflammatory
process of the pulp can be at different stages - from focal to necrosis[2,6,8]. The depth of the periodontal pocket, at which infection of the pulp occurs, is also diverse and depends on the anatomical features of the tooth. For single-rooted teeth, the prognosis is worse than for multi-rooted teeth, due to the fact that the destruction of the supporting tissues can occur non-identical at different roots. Treatment begins with endodon-tic manipulations, but they do not change the clinical situation, so periodontal treatment is necessary[13,14].
The truly combined lesions include clinical cases where endodontic pathology and periodontal pathology develop independently of each other in the area of one tooth. Naturally, this process takes place up to a certain point, in the end, both pathologies merge into one. Harrington identified 3 criteria for this lesion: a devital tooth with a periodontal pocket, communicating either with the lateral canal or with the apical opening. The treatment is carried out sequentially, first endodontic, periodontal and then.
Summary. Thus, when endodontal-periodontal lesions observed relationship between bacterial microflora of the dental pulp and periodontal tissues. In most cases, the tissue of the pulp is inseminated with perio-dontal flora, which leads to irreversible processes in the pulp and the further progression of periodontal diseases. This is why the prognosis of a tooth with-perio lesion depends on the state of periodontal tissues. This explains the low efficiency of treatment of patients with this pathology and the high risk of recurrence of the disease. Effective treatment, first of all, should be aimed at eliminating the microbial factor from the periodontal pocket and root canal system, and then to restore the supporting structures of the tooth. Also, efforts should be directed not only to the elimination of the pathogenic factor, but also to the activation of local mechanisms for the protection and regeneration of periodontal tissues.
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