DISEASES OF DENTAL PULP AND PERI RADICULAR TISSUES

2. DISEASES OF DENTAL PULP
AND
PERI RADICULAR TISSUES

3. DISEASES OF DENTAL PULP
• INTRODUCTION
• CAUSES OF PULPAL DISEASES
• PATHWAYS OF BACTERIAL INVASION
OF PULP
• REACTION OF PULP TO INVASION
• CLASSIFICATION OF PULPAL
DISEASES

4. INTRODUCTION
• Pulp is the formative organ of tooth
• The pulp responses to heat and cold stimuli
which are perceived as pain. Pulp can tolerate
temperatures between 60°f and 130°f.
• A normal pulp is asymptomatic within normal
limits and produces a mild to moderate transient
responses to thermal and electrical stimuli, when
stimulus is removed the pain subsides almost
immediately.
• Radiographs show an intact lamina dura.

5. PATHWAYS OF BACTERIAL
INVASION OF PULP
A) Direct invasion by way of the dentin such as
• Caries
• Fracture of crown or root
• Exposure during cavity preparation
• Attrition, abrasion ,erosion
• Crack in crown
B) Invasion through open blood vessels or lymphatics –
periodontal diseases, an accessory canal in furcation
area, gingival infection.
C) Invasion trough blood such as during infectious
diseases or transient bacteremia.

6. Tooth fracture Incisal notch

7. REVERSIBLE PULPITIS
• Definition:
Reversible pulpitis is a mild to
moderate inflammatory condition of pulp caused
by noxious stimuli in which the pulp is capable of
returning to un inflamed state following removal
of stimulus.
• Histopathology:
Reparative dentine, disruption of
odontoblastic layer, dilated blood vessels,
extravasations of oedema fluid ,chronic
inflammatory cells.

8. • Cause:
Trauma
Disturbed Occlusal relationship
Thermal shock
Overheating during polishing a filling
Excessive dehydration of a cavity
• Symptoms:
Sharp pain lasting for a moment which is
mainly caused by cold beverages than hot
foods.

9. • Diagnosis:
By the study of patients symptoms and
by clinical tests, pain is sharp, lasts for few
seconds and disappears when stimulus is
removed.
• Differential diagnosis:
Irreversible pulpitis.
• Treatment:
Periodic care to prevent development of
caries, early insertion of filling, desensitization of
necks of teeth, use of cavity varnish or base.

10. IRREVERSIBLE PULPITIS
• Definition:
Irreversible pulpitis is a persistent
inflammatory condition of pulp,
symptomatic or asymptomatic caused by a
noxious stimulus.
• Cause:
Caries
Chemical ,thermal or mechanical irritation

11. • Histopathology :
Microscopically we can see
Areas of abscesses
Zone of necrotic tissue
Micro organisms
Lymphocytes
Plasma cells
Macrophages

12. Symptoms:
• A paroxysm of pain is caused by sudden
temperature change, pressure from packing
foods into a cavity .
• Pain continues on removal of cause has been
removed.
• Pain comes spontaneously without apparent
cause.
• Pain is of sharp piercing type. it may be
continuous or intermittent.
• Change of position may increase intra pulpal
pressure which may exacerbate the pain.

13. Differential diagnosis:
Reversible pulpitis
Asymptomatic irreversible pulpitis.
Treatment:
Complete removal of pulp or
pulpectomy and the placement of an intra
canal medicament.

14. CHRONIC HYPERPLASTIC
PULPITIS
Definition:
Chronic hyperplastic pulpitis or pulp polyp is a
productive pulpal inflammation due to an extensive
carious exposure of a pulp.
Histopathology:
It consists of granulation tissue and is covered by
stratified squamous epithelium. Polymorphonuclear
neutrophils. lymphocytes, and plasma cells are also
seen.

15. Cause:
• Slow ,progressive carious exposure of the
pulp is the cause.
Symptoms:
• This condition is symptom less, except
during mastication when pressure of food
bolus may cause discomfort.

17. Diagnosis:
Fleshy reddish pulpal mass fills
most of pulp chamber or extends beyond
the confines of tooth .This is characteristic
feature of pulp polyp which is seen mostly
in teeth of children ad young adults .
Radiographs show a large open
cavity with direct access to pulp.
More current than normal is required
to elicit response by means of electric pulp
tester.

18. Differential diagnosis:
Proliferating gingival tissue.
Treatment:
Elimination of polypoid tissue followed
by extirpation of pulp.

19. INTERNAL RESORPTION
Definition:
Internal resorption is an idiopathic
slow or fast progressive resorptive process
occurring in the dentin of the pulp chamber
or root canals of the teeth.
Cause:
Cause is not known.
Often history of trauma present.

20. Histopathology:
Resorptive process leads to lacunae
formation which may be filled with
• Osteoid tissue
• Granulation tissue is present
• Multinucleated giant cells
• Metaplasia of the pulp is also seen.
Symptoms:
Internal resorption in root is asymptomatic.
In crown it is seen as pink spot.

21. .
Diagnosis:
Internal resorptions are usually diagnosed during
routine radiographic examination.
Radiographically there will be a change in the wall of
root canal or pulp chamber with a round or ovoid
radiolucent area .
Differential diagnosis:
External root resorption.
Treatment:
Extirpation of pulp.
Routine endodontic treatment.
Obturation with plasticized guttapercha technique.

23. PULP DEGENERATION
• It seen mostly in older people.
Symptoms:
• Early stages of pulpal degenerations are
clinically asymptomatic.
• In later stages tooth becomes discolored
and pulp will not respond to stimulation.

24. Cause:
• Persistent and mild irritation in the younger
people.
• The various pulpal degenerations are:
Calcific degeneration
Atrophic degeneration
Fibrous degeneration

25. • Calcific degeneration:
In calcific degeneration part of pulp tissue
is replaced by calcific material, that is pulp
stones or denticles are formed.
• Atrophic degeneration:
In atrophic degeneration fewer stellate
cells are present in pulp and intercellular fluid is
increased.
• Fibrous degeneration:
In this type of degeneration pulp is
characterized by replacement of cellular
elements y fibrous connective tissue

26. Pulp stone

27. NECROSIS OF PULP
Definition:
Necrosis is death of the pulp.
• It may be partial or total, depending on
whether part of or entire pulp is involved.
Cause:
Caused by any noxious insult injurious
to the pulp.

28. • Necrosis is of 3 types -
Coagulation necrosis
Liquefaction necrosis
Cessation necrosis
Symptoms:
• Discoloration of teeth-Greyish or brownish
discoloration.
• No painful symptoms.
• Partial necrosis responds to thermal changes.

29. Diagnosis:
• Radiograph shows thickening of periodontal
ligament.
• Necrosed pulp does not respond to thermal test
Histopathology:
• Necrotic pulp tissue
• Cellular debris
• Microorganisms
Treatment:
• Endodontic treatment

30. DISEASES OF
PERI RADICULAR TISSUES

31. INTRODUCTION
• Because of the relationship between the pulp and the
periradicular tissues, pulpal inflammation causes
inflammatory changes in the periodontal ligament even
before the pulp becomes totally necrotic.
• Bacteria and their toxins reach periradicular tissues from
pulp through various foramina of root canals and give
rise to inflammatory changes.
• Various other causes which lead to periradicular
diseases -
Neoplastic disorders
Periodontal conditions
Developmental factors
Trauma

32. CLASSIFICATION:
1)Acute periradicular disease
• Acute alveolar abscess
• Acute apical periodontitis
• Vital
• Non vital
2)Chronic periradicular diseases with areas of rarefaction
• Chronic alveolar abscess
• Granuloma
• Cyst
3)Condensing osteitis
4)External root resorption
5)Diseases of the periradicular tissues of non odontogenic
origin

33. ACUTE ALVEOLAR ABSCESS
• Synonyms:
Acute abscess, acute apical abscess, acute
dentoalveolar abscess, acute periapical
abscess, acute radicular abscess.
• Definition:
It is a localized collection of pus in the
alveolar bone at the apex of tooth following
death of pulp with extension of infection trough
the apical foramen into periradicular tissues.

34. • Cause:
Trauma
Chemical or mechanical irritation
Symptoms:
• First mere tenderness of tooth that may be
relieved by continued slight pressure on the
extruded tooth to push it back into alveolus.
• Later severe throbbing pain with swelling seen
on adjacent tissues near the affected tooth.
• Temperature raise will be present.

35. Diagnosis:
• By clinical examination and history given by
patient.
• Radiographs may show a cavity , defective
restoration .
• Thickened periodontal ligament
• Does not show any alveolar bone changes
• Evidence of breakdown of bone in the region of
root apex.
• Does not respond to electric or thermal test
• Tooth is not tender on percussion
• Tooth is mobile or extruded.

37. Differential diagnosis:
Periodontal abscess
Irreversible pulpitis
Histopathology:
Polymorphonuclear leukocytes
Microorganisms, Debris, Accumulation of
inflammatory exudates, suppuration spaces.
Treatment:
Establishing drainage.
Controlling systemic reaction.
After that endodontic treatment.

38. ACUTE APICAL PERIODONTITIS
Definition:
It is a painful inflammation of periodontium as a
result of trauma, irritation or infection through the root
canal ,regardless of whether the pulp is vital or non vital.
Cause:
Occlusal disturbance.
Restorations with high points.
Wedging of foreign object.
As a sequel of pulpal disease.
Forcing of bacteria or irritating medicaments into
periradicular area during endodontic treatment.
Over instrumentation

39. Symptoms:
• Pain and tenderness of tooth
• Tooth may be slightly to extremely painful during
percussion and chewing tests.
• If the tooth is vital ,a simple occlusal adjustment will
often relieve the pain. If the pulp is necrotic and left
untreated it may advances to acute periapical abscess.
Diagnosis:
• BY
-history given by the patient
- clinical examination
- Radiographs may show thickened periodontal
ligament.

41. • Differential diagnosis
Acute alveolar abscess.
• Histopathology:
Blood vessels are dilated
leukocytes
Accumulation of serous exudate
• Treatment:
Determining the cause and relieving
symptoms when the acute phase is subsided
toot is treated conservatively.

42. Acute exacerbation of chronic lesion
Synonyms:
• Phoenix abscess
Definition:
• Acute inflammatory reaction superimposed on an
existing chronic lesion, such as a cyst or granuloma.
Cause:
• Influx of necrotic products from diseased pulp may cause
dormant lesions to react and cause an acute
inflammatory response.

43. Symptoms:
• Tooth may be tender to touch.
• Tooth is elevated in its socket.
• Adjacent area become red and swollen.
Diagnosis:
• In asymptomatic tooth well defined periradicular lesion is
present.
• History of traumatic accident is present.
Differential diagnosis:
• Acute pulpitis.
• Acute alveolar abscess.

44. Histopathology:
In granuloma or cyst adjacent periradicular
tissues are areas of liquefaction necrosis with
Polymorphonuclear neutrophils and cellular
debris.
Treatment:
Establishing drainage.
Controlling systemic reaction.
Endodontic treatment.

45. CHRONIC PERIRADICULAR
DISEASE WITH AREAS OF
RAREFACTION

46. Chronic alveolar abscess
Synonyms:
Chronic suppurative apical periodontitis
Definition:
It is a long standing, low grade infection of
periradicular alveolar bone.
Cause:
Natural sequel of death of pulp.

47. Symptoms:
• Asymptomatic
• Sinus tract is present
• Large open cavities
Diagnosis:
• Radiographs show diffused rarefaction of bone
• Discoloration of tooth
• Does not react to electric pulp test
• Patient ha a sudden sharp pain tat subsided and
not recurred

48. Carious lesion

49. Sinus tract

51. Differential diagnosis:
• Abscess, Granuloma, Cyst
Histopathology:
• Destruction of periodontal fibers and cementum
• Lymphocytes and plasma cells are seen
• Polymorphonuclear neutrophils, mononuclear
cells, fibroblasts are present.
• Microorganisms.
Treatment:
• Elimination of infection in the root canal

52. GRANULOMA
[PERIAPICAL GRANULOMA]
Definition:
It is a growth of granulomatous tissue
continuous with the periodontal ligament
resulting from death of pulp and diffusion of
bacteria and bacterial toxins from root canal into
surrounding periradicular tissues through apical
and lateral foramina.
Cause:
• Death of pulp followed by a mild infection or
irritation of periapical tissue that stimulates a
productive cellular reaction.

54. Symptoms:
Asymptomatic
Diagnosis:
1)Routine radiographic examination –shows a well defined
area of rarefaction wit lack of continuity in the lamina
dura.
2) Sinus tract may be present .
3)Tooth does not respond to thermal or electric pulp tests.
Differential diagnosis:
Periapical cyst, Cementoma.

56. Histopathology:
• It consists of an outer, fibrous capsule which is
continuous with the periodontal ligament and an
inner , or central portion made up of looser
connective tissue and blood vessels and
characterized by presence of lymphocytes ,
plasma cells, leukocytes.
Treatment:
Root canal therapy
Resorption of granulomatous tissue and repair
with trabeculated bone.

57. RADICULAR CYST
Definition:
A cyst is a closed cavity or sac internally
lined with epithelium the center of which is filled
with fluid or semi solid material.
Symptoms:
• Initially asymptomatic.
• Once it becomes large it produces huge
swelling and causes movement of affected teeth.
• Teeth become mobile.
• If untreated cyst grow at expense of the root.

58. Cause:
• Physical chemical or bacterial injury.
Diagnosis:
• Tooth does not responds to thermal or electrical
pulp tests.
• Radiographs show loss of continuity in the
laminadura with an area of rarefaction which is a
well defined radiolucency. This area may round
or oval and is larger in size than granuloma.

60. Differential diagnosis:
Periapical abscess
Periapical granuloma
Histopathology:
Microscopically cyst is a granuloma
covered with stratified squamous epithelium and
is filled with eosinophilic material, debris.
Lymphocytes, leukocytes are also seen.
Treatment:
Enucleation of the cyst.

61. CHRONIC PERIRADICULAR DISEASE
WITH AREAS OF CONDENSATION
Condensing osteitis
Definition:
Condensing osteitis is the response to a low grade,
chronic inflammation of periradicular area as a result of a
mild irritation through the root canal.
Cause:
Mild irritation
Symptoms:
Asymptomatic

62. Diagnosis:
• Made from radiographs which is seen as
localized area of radiopacity surrounding the
affected tooth.
Histopathology:
• Areas of dense trabecular bone, Plasma cells,
lymphocytes.
Treatment:
• Endodontic treatment.

64. EXTERNAL ROOT RESORPTION
• Definition:
It is a lytic process occurring in the cementum
or cementum and dentin of the roots of teeth.
• Cause:
Trauma, excessive forces,
Granuloma, cyst, jaw tumors,
Replantation of teeth,
Bleaching and impaction of teeth,
Systemic diseases.
Idiopathic.

65. IDIOPATHIC ROOT RESORPTION

66. Histopathology:
• osteoclastic cells are seen which leads to areas
of resorption.
Symptoms:
• Asymptomatic.
• If the root is completely resorbed the tooth may
become mobile.

67. Diagnosis:
• By radiographs
Appears as concave or ragged areas on the
root surface or blunting of the apex is seen.
Differential diagnosis:
• Internal resorption
Treatment:
• Cause is removed and treated endodontically.

68. DISEASES OF PERIRADICULAR
TISSUE OF NON ODONTOGENIC
ORIGIN
• Such lesions may be manifestations of
A) Systemic diseases (NUERO FIBROMATOSIS)
B) Periodontal diseases
• In these type of lesions pulp is vital.
• E.g. Cementoma, cementoblastoma, Fissural
cysts, central giant cell granuloma.

69. BIBILOGRAPHY
• Path ways of Pulp - Cohen
• Endodontic practice - Grossman
• Oral Pathology - Shafer’s