endo

1. Pulp &
Periapical
Pathosis
Dr. Hadil Abdallah Altilbani
BDS Santiago de Compostela University Spain.
MSc. University of Valencia Spain.
Department of Endodontics University of Palestine .

2. CLASSIFCATION
OF
DISEASES
OF THE PULP

3. according to:
❑ Severity & duration:
i) Acute
ii) Chronic
iii)Subacute
❑ Presence or absence of symptoms:
i)Symptomatic
ii)Asymptomatic
❑ Ability to heal:
i)Reversible
ii) Non reversible
❑ Another classification of acute & chronic based on presence or absence of direct communication
between pulp & oral environment:
- Open pulpitis (pulpitis aperta) communicated exist.
- Closed pulpitis (pulpitis clausa) no communication exist.
❑ Based on extend
• Focal /Partial pulpitis
• Total /Generalized pulpitis
Inflammatory Diseases
Of The Pulp

4. CLASSIFICATION OF PULPAL DISEASES
According to Grossman
I] PULPITIS
a) REVERSIBLE
1. Acute (symptomatic)
2. Chronic (asymptomatic)
b) IRREVERSIBLE
1. Acute
- Abnormally responsive to cold
- Abnormally responsive to heat
2. Chronic
- Asymptomatic with pulp exposure
- Hyperplastic pulpitis
- Internal resorption
• II] PULP DEGENERATION
• Calcific (Radiographic diagnosis)
• Others (Histopathologic diagnosis)
• III] PULP NECROSIS
ACCORDING TO F.J. HARTY
A simple classification based on the
state of the pulp.
◦ Normal pulp.
◦ Reversible pulpitis.
◦ Irreversible pulpitis.
◦ Pulp necrosis.
SHAFER’S Classification
1.According to involvement
a) Partial
b) Total
2. According to severity
a) Acute
b) Chronic
3. According to presence or absence of direct communication between the dental pulp
and oral environment
a) Pulpitis aperta
b) Pulpitis Clausa

5. According toWeine
A) INFLAMMATORY CHANGES
HYPERALGIA
 Hypersensitive dentin.
 Hyperemia.
PAINFUL PULPITIS
 Acute pulpalgia (acute pulpitis)
 Chronic pulpalgia (subacute pulpitis)
NON PAINFUL PULPITIS
 Cronic Ulcerative Pulpitis
 Chronic Pulpitis
 Hyperplastic pulpitis.
B) ADDITIONAL PULP CHANGES
 Necrosis
 Retrogressive changes
 Internal Resorption
According to Cohen:
 Reversible pulpitis
 Irreversible pulpitis
 Asymptomatic Irreversible pulpitis
 Symptomatic irreversible
 Hyperplastic pulpitis
 Internal resorption
 Pulp necrosis
According to SELTZER (HISTOLOGIC CLASSIFICATION)
• Intact - uninflammed pulp
• Atrophic pulp
• Acute pulpitis
• Intact pulp with scattered chronic inflammatory cells (transitional stage)
• Chronic partial pulpitis
- with partial liqufeaction necrosis
-with partial coagulation necrosis
• Chronic total pulpitis
- with partial liqufeaction necrosis
• Total pulp necrosis

6. 1-Inflammatory diseases of the pulp
(Pulpitis)
❑ A- HYPERALGESIA- HYPERSENSITIVITY- REVERSIBLE PULPITIS HYPERSENSITIVE-DENTIN-HYPEREMIA-
HYPERACTVE PULPALGIA
❑ B – IRREVERSBLE PULPITIS
a) SYMPTOMATIC PULPITIS :PAINFUL PULPITIS: ACUTE PULPITIS
b) ASYMPTOMATIC PULPITIS: NON PAINFUL PULPITIS:
CHRONIC PULPITIS
✓ i.CHRONIC ULCERATIVE PULPITIS
✓ ii. CHRONIC HYPERPLASTIC PULPITIS
✓ iii. CLOSED FORM OF CHRONIC PULPITIS

7. Histopathology: Range from hyperaemia to mild to moderate
inflammatory changes limited to the are a of involved D.T., V.D.→
↑I.P.P. → Oedema → W.B.C.s infiltration →followed by odontoblast
differentiation and reparative dentin formation
Slowing of blood flow & hemoconcentration due to transudation
can cause thrombosis.
REVERSIBLE PULPITIS
A mild to moderate inflammatory condition of pulp caused by noxious stimuli in which pulp is capable of
returning to the uninflamed state following removal of the stimuli. Also, referred as “PULP HYPERAEMIA”.
A- Hypersensitivity- Reversible Pulpitis- Hypersensitive
Dentin-hyperemia- Hyperactve Pulpalgia
Focal Reversible Pulpitis
ETIOLOGY
1. Trauma
2. Thermal shock
3. Excessive dehydration
4. Galvanism
5. Chemical stimulus
6. Bacteria
7. Circulatory disturbances
8. Local vascular congestion

11. Symptoms
 Sharp pain lasting for a moment
 More often brought on by cold than hot food
 Does not occur spontaneously
 Does not continue when stimulus has been
removed
 Teeth are not tender on percussion
 Teeth usually show deep caries, metallic
restoration with defective margins.
This will cause pain, in addition to inflammatory
mediators that will cause lowering of pain
threshold and the sensation of pain as a
result.(onset)

12. DIAGNOSIS
1. Pain: Sharp pain, lasts for a few seconds Cold, sweet or sour
causes pain
2. Visual examination & history:
Examine for caries, restorations, fractures or traumatic
occlusion
History of past dental treatment
3. Clinical tests:
Cold test is excellent way to locate pain
Normal to percussion, palpation and mobility
4. Radiographically : No changes
5. Vitality test:
More readily response to cold stimulation than
normal teeth Treatment
- Prevention
- Removal of the noxious stimuli
- Check for vitality
- Periodic care to prevent caries
- Proper insulation of the restoration
- Desensitization
Prognosis
 Good - if irritant is removed earlier
 Otherwise condition may develop to Irreversible pulpitis

16. Irreversible Pulpitis
A persistent inflammatory condition of the pulp, symptomatic or asymptomatic, caused by noxious
stimulus.
❑ May be Acute or chronic
ETIOLOGY
 Caries
 Chemical, thermal and mechanical injuries
 Sequelae of reversible pulpitis
B – Irreversble Pulpitis
Symptomatic Irreversble Pulpitis :
Painful Pulpitis: Acute Pulpitis
Definition: A clinical diagnosis based on subjective and objective findings indicating that
the vital inflamed pulp is incapable of healing.

17. Acute Pulpitis
Irreversible condition characterized by acute, intense inflammatory response in pulp.
CLINICAL FEATURES:
• Teeth extremely sensitive to thermal changes.
• Hot or cold stimuli cause increase in pain intensity & persists. As pulpal inflammation progresses, heat will
intensify the responses.
• Cold will tend to relieve the pain in advanced stages of pulpits.
• Pain can be spontaneous in nature which is sharp, piercing, intermittent or continuous in nature.
• Pain - poorly localized.
• lancinating or throbbing type. (10 – 15mins)
• Intensity of pain can increase when patient lies down.
HISTOLOGIC FEATURES:
• Edema in pulp with vasodilation.
• Destruction of odontoblasts at pulp dentin border.
• Rise in pressure due to inflammatory exudate local collapse of venous part of circulation Tissue hypoxia & anoxia
Destruction of pulp & abscess formation.
• Numerous abscess formation cause pulp liquefaction & necrosis. (acute suppurative pulpitis)

18. Acute pulpitis with
Intrapulpal abscess

19. Irreversible Pulpitis: EARLY STAGE
•Sharp, severe pain upon thermal stimulation, especially cold
•Spontaneous or continuous pain
•Exacerbated by lying down
•Pain can be localized to a specific tooth.
Irreversible Pulpitis: LATE STAGE. S/s?
•Throbbing pain keeps patient awake at night; dull prolonged
pain
•Cold may produce relief; heat makes it worse
•Pain often referred - not localized
•Responds to percussion and palpation
•Radiographic periapical changes often evident

20. Irreversible Pulpitis
Hot Tooth

21. Diagnosis
• Deep cavity extending to the pulp.
• Decay under filling.
• Greyish scum like layer.
• An odor of decomposition.
• Probing into the area is not painful.
• Deep probing will result in pain & haemorrhage.
History-
-May reveal previous symptoms or a traumatic experience
Radiographic examination:
-May not show anything of significance.
-It may disclose an interproximal cavity or caries under a filling
Percussion:
-Tenderness
Pulpal pain is due to:
- pressure built up due to lack of exudate escape.
- pain producing substances from inflammation.
✓ Pain subsides when drainage is established or when pulp undergoes complete necrosis.
✓ The tooth is not tendered to percussion unless the pulpal inflammation has spread beyond the root apex into the periapical region.

22. POTENTIALLY REVERSIBLE PROBABLY IRREVERSIBLE
Pain Sharp, Momentary : dissipates readily after removal of
stimulus
Continuous, throbbing : Persists minutes to
hours
Stimulus Requires external stimulus
(cold, heat, sweet)
Spontaneous : dead or injured tissue in
chambers or canal.
Intermittent : Spontaneous pain of short
duration.
History Recent dental procedure, cervical abrasion Extensive restoration, pulp capping, deep caries,
trauma
Referred pain Negative Common
Lying down Negative Increases pain
Color Negative May be present due to tissue lysis & intrapulpal
haemorrhage.
Radiograph Restoration ,caries, periodontal pocket, cupping of
alveolar crest
Deep restoration, caries
Periapex - Normal Periapex – widening of PDL
Endodontic Therapy Franklin S. Wein 6th edition