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Diseases of the Pulp

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Diseases of the Pulp

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Diseases of the Pulp

  1. 1. 1
  2. 2. Diseases of the Pulp Dr. Nithin Mathew
  3. 3. Diseases of the Pulp – Dr. Nithin Mathew CONTENTS • Introduction • Pathophysiology • Classification • Etiological Agents • Mechanical • Thermal • Electrical • Bacterial • Diseases of the pulp • Reversible Pulpitis • Irreversible Pulpitis • Chronic Hyperplastic Pulpitis • Internal Resorption • Pulp Degeneration • Pulp Necrosis • Conclusion • References D i s e a s e s o f t h e P u l p 3
  4. 4. Introduction
  5. 5. Diseases of the Pulp – Dr. Nithin Mathew • Dental pulp – formative organ of the tooth which produces • Primary dentin during development of the tooth • Secondary dentin after the tooth eruption • Reparative dentin in response to stimulation as long as the odontoblasts remain intact. • Pulp consists of • Tiny blood vessels • Lymph • Myelinated and unmyelinated nerve fibres, etc.. D i s e a s e s o f t h e P u l p 5
  6. 6. Diseases of the Pulp – Dr. Nithin Mathew • Reacts to bacterial infection or other stimuli by an inflammatory response. • Inflammatory response of the pulp is altered by some unique features of the pulp: • Encased by a hard tissue (enamel/dentin) • Does not allow for usual swelling associated with exudate of acute inflammatory response. • Lack of collateral circulation • To maintain the vitality when primary circulation is compromised. • Response to any stimuli only as pain • Temp. of 16-55°C is well tolerated by the pulp • Temp. above this is perceived as pain D i s e a s e s o f t h e P u l p 6
  7. 7. Diseases of the Pulp – Dr. Nithin Mathew • Referred pain • Localizing affected tooth is difficult as proprioceptive nerve fibres are absent in the pulp. • Relating clinical status of the tooth to histopathology is very difficult as there are no signs or tests that correlate the two. D i s e a s e s o f t h e P u l p 7
  8. 8. Pathophysiology of Pulpal Disease
  9. 9. Diseases of the Pulp – Dr. Nithin Mathew 9 External Noxious Stimuli Pulp Mast Cells Vasculature Cells Release of Inflammatory Mediators (Histamine, Prostaglandins, Bradykinins) Degranulation Decreased Blood Flow Cellular Damage
  10. 10. Diseases of the Pulp – Dr. Nithin Mathew 10 Release of Inflammatory Mediators (Histamine, Prostaglandins, Bradykinins) Dilatation of Arterioles Increased Pulpal Pressure & Secondary Compression of Venous Return Vessel Damage, Pulpal Inflammation, Tissue Necrosis Localized pulpal damage will spread to involve the entire pulp
  11. 11. Diseases of the Pulp – Dr. Nithin Mathew 11 Irritation to Clinical Crown Localized Pulpal Inflammation Increased Local Tissue Pressure Venous Collapse – Ichemia – Local Necrosis Release of Intercellular Inflammatory Agents Circumferential Vascular Disturbances Increases Tissue Pressure Necrosis of Additional Tissue Total Pulpitis Initial Insult Localized Effect Mechanism Spread
  12. 12. Classification of Pulpal Diseases
  13. 13. Diseases of the Pulp – Dr. Nithin Mathew Grossman’s Classification 1. Pulpitis (Inflammatory Diseases) i. Reversible a. Acute (symptomatic) b. Chronic (asymptomatic) ii. Irreversible a. Acute i. Abnormally responsive to cold ii. Abnormally responsive to heat b. Chronic a. Asymptomatic with pulp exposure b. Hyperplastic pulpitis c. Internal resorption 2. Pulp Degeneration i. Calcific ii. Atrophic iii. Fibrous 3. Pulp Necrosis D i s e a s e s o f t h e P u l p 13
  14. 14. Diseases of the Pulp – Dr. Nithin Mathew Seltzer & Bender’s Classification • Found little correlation between clinical symptoms and histologic appearance. • They correlated the results of clinical tests of the pulp with the histologic diagnosis: Treatable: • Intact uninflammed pulp • Transitional stage • Atrophic pulp • Acute pulpitis • Chronic partial pulpitis without necrosis Untreatable: • Chronic partial pulpitis with necrosis • Chronic total pulpitis • Total pulp necrosis D i s e a s e s o f t h e P u l p 14
  15. 15. Diseases of the Pulp – Dr. Nithin Mathew Baume’s Classification • Found no direct correlation between clinical symptoms and histologic findings. • Based on clinical symptoms : 1. The symptomless, vital pulp which has been injured or involved by deep caries, for which pulp capping may be done 2. Pulps with a history of pain which are amenable to pharmacotherapy 3. Pulps indicated for extirpation and immediate root filling 4. Necrosed pulps involving infection of radicular dentin accessible to antiseptic root canal therapy D i s e a s e s o f t h e P u l p 15
  16. 16. Diseases of the Pulp – Dr. Nithin Mathew F.J. Harty’s Classification • Clinicians have rejected previous complex histopathological classification and has developed a simple classification of the state of the pulp. 1. Normal pulp 2. Reversible pulpitis 3. Irreversible pulpitis 4. Pulp necrosis D i s e a s e s o f t h e P u l p 16
  17. 17. Diseases of the Pulp – Dr. Nithin Mathew Cohen’s Classification 1. Reversible Pulpitis 2. Irreversible Pulpitis 3. Asymptomatic Irreversible Pulpitis 4. Hyperplastic Pulpitis 5. Internal Resorption 6. Symptomatic Irreversible Pulpitis 7. Pulp Necrosis D i s e a s e s o f t h e P u l p 17
  18. 18. Diseases of the Pulp – Dr. Nithin Mathew WHO Classification K04.0 : Pulpitis/pulpal hyperemia/pulpal abscess/pulp polyp, acute/chronic hyperplastic/ulcerative pulpitis K04.1 : Necrosed pulp/pulp gangrene K04.2 : Pulp degeneration, Denticles/pulp calcification K04.3 : Abnormal hard tissue formation in pulp secondary or irregular dentin. D i s e a s e s o f t h e P u l p 18
  19. 19. Diseases of the Pulp – Dr. Nithin Mathew Classification by Morse et al (1977) • Vital asymptomatic • Hypersensitive dentin • Inflamed – reversible • Inflamed/degenerating without radiolucent periapical area - irreversible • Inflamed/degenerating with radiolucent periapical area - irreversible • Necrotic without radiolucent periapical area • Necrotic with radiolucent periapical area D i s e a s e s o f t h e P u l p 19
  20. 20. Etiology
  21. 21. Diseases of the Pulp – Dr. Nithin Mathew According to Grossman Physical I. Mechanical 1. Trauma i. Accidental ii. Iatrogenic 2. Pathologic Wear 3. Crack tooth syndrome 4. Barodontalgia D i s e a s e s o f t h e P u l p 21 II. Thermal 1. Heat from cavity preparation 2. Exothermic heat from setting of cement 3. Conduction of heat & cold through deep filling without a protective base 4. Frictional heat caused due to polishing of restoration
  22. 22. Diseases of the Pulp – Dr. Nithin Mathew Chemical 1. Phosphoric acid, acrylic monomer, etc 2. Erosion (acids) Bacterial 1. Toxins associated with caries 2. Direct invasion of pulp from caries/trauma 3. Microbial colonization in the pulp by blood borne micro-organisms (Anachoresis) D i s e a s e s o f t h e P u l p 22
  23. 23. Diseases of the Pulp – Dr. Nithin Mathew According to Ingle Bacterial • Coronal Ingress: 1. Caries 2. Fracture – complete and incomplete 3. Non fracture trauma 4. Anomalies of tooth development. • Radicular Ingress: 1. Caries 2. Retrogenic infection – periodontal pocket and infection 3. Hematogenic D i s e a s e s o f t h e P u l p 23 Traumatic • Acute : 1. Coronal fracture 2. Radicular fracture 3. Vascular stasis 4. Luxation 5. Avulsion • Chronic : 1. Attrition 2. Abrasion 3. Erosion
  24. 24. Diseases of the Pulp – Dr. Nithin Mathew Iatrogenic 1. Cavity preparation: Heat of preparation, depth of preparation, dehydration, pulp horn extensions, pulp exposure, haemorrhage etc. 2. Restorations: Insertion, fracture – complete and incomplete forces of cementing, heat of polishing etc. 3. Intentional extirpation 4. Periodontal curettage 5. Orthodontic movement 6. Electrosurgery 7. Laser burn 8. Rhinoplasty 9. Osteotomy 10. Intubation D i s e a s e s o f t h e P u l p 24
  25. 25. Diseases of the Pulp – Dr. Nithin Mathew Chemical • Filling materials – cements, etching agents, bonding agents etc. • Disinfectants – silver nitrate, phenol, sodium fluorides • Desiccants – alcohol, ether and others Idiopathic • Aging • Internal resorption • External resorption • Hereditary hypophosphataemia • Sickle cell anaemia • Herpes zoster infection • HIV and AIDS D i s e a s e s o f t h e P u l p 25
  26. 26. Diseases of the Pulp – Dr. Nithin Mathew According to Nicholl • Nicholl’s has given the causes of pulpal diseases as: • Causes unassociated with dental procedures • Causes associated with dental procedures D i s e a s e s o f t h e P u l p 26
  27. 27. Diseases of the Pulp – Dr. Nithin Mathew Physical Causes – Mechanical Injuries Trauma • May or may not be accompanied by fracture of the crown or root • Injury may be Accidental / Iatrogenic • Accidental • Violent blow during a fight, sports, automobile accident or household accident. • Habits like bruxism, nail and thread biting. • Iatrogenic • During cavity preparation or excavation of caries. • Rapid orthodontic tooth movement. • Pins used to retain amalgam restorations. D i s e a s e s o f t h e P u l p 27
  28. 28. Diseases of the Pulp – Dr. Nithin Mathew Pathologic Wear • Pulp may also become exposed or nearly exposed by pathologic wear of the teeth • Attrition • Abrasion • Bruxism • Abfraction • Occlusal trauma may also injure the pulp because of repeated irritation to the neurovascular bundle in the periradicular area. D i s e a s e s o f t h e P u l p 28
  29. 29. Diseases of the Pulp – Dr. Nithin Mathew Cracked Tooth Syndrome • Incomplete fractures - body of the tooth - pain of idiopathic origin. • Pain ranging from mild to excruciating at the irritation or release of the biting pressure. • Diagnosis - made by reproducing the pain by asking the patient to bite on a rubber wheel or a tooth sloth. • Cracked enamel is visualized using a dye or by transilluminating the tooth with fiberoptic light. D i s e a s e s o f t h e P u l p 29
  30. 30. Diseases of the Pulp – Dr. Nithin Mathew Barodontalgia • Pain experienced in the tooth due to low atmospheric pressure • Irreversible Pulpitis • Symptomless at ground level • Pain at high altitude due to reduced pressure D i s e a s e s o f t h e P u l p 30 During ascent, trapped gases may expand and enter the dentinal tubules which stimulate the nociceptors in the pulp. Movement of the contents of the pulp chamber through the apex of the tooth causes pain
  31. 31. Diseases of the Pulp – Dr. Nithin Mathew Physical Causes – Thermal Injuries Heat from Cavity Preparation • Temp. changes produced during cavity preparation • Increase of 20°C in temperature 1mm from the pulp • Increase of 30°C, 0.5mm from the pulp during dry cavity preparation • High speed tungsten carbide/diamond bur – reduce operating time but accelerates pulpal death if used without a coolant. • Heat generated is sufficient to cause irreparable pulp damage. D i s e a s e s o f t h e P u l p 31
  32. 32. Diseases of the Pulp – Dr. Nithin Mathew • Degree of pulpal response is inversely proportional to Remaining Dentin Thickness (RDT) • RDT – key factor – determining if the changes are reversible or irreversible. • Pulp horn extensions must be considered during cavity preparation • Constant drying can also cause pulpal inflammation and necrosis. D i s e a s e s o f t h e P u l p 32
  33. 33. Diseases of the Pulp – Dr. Nithin Mathew Heat Conduction by fillings • Metallic fillings close to the pulp without an intermediate base may conduct the temperature changes rapidly to the pulp and may destroy the pulp. Frictional Heat during Polishing • Enough heat may be generated during polishing of a restoration or during setting of a cement. – Transient Pulpal Injury • Usually Reversible in nature D i s e a s e s o f t h e P u l p 33
  34. 34. Diseases of the Pulp – Dr. Nithin Mathew Physical Causes – Electrical Agents • Galvanic current produced from dissimilar metallic restoration may generate heat and cause pulpal damage. D i s e a s e s o f t h e P u l p 34
  35. 35. Diseases of the Pulp – Dr. Nithin Mathew Chemical Agents • Pulpal damage arise as a result of chemical irritation of pulp caused by • Erosion or use of acidic restorative materials • Key factors determining pulpal reaction to a restorative material : • Acidity (pH of the material) • Heat generated during setting reaction • Remaining dentin thickness • Absorption of water during setting reaction • Poor marginal adaptation of the material which contributes to bacterial leakage. • Long term prognosis of a restorative material – determined by its ability to inhibit micro- leakage and pulpal bacterial contamination D i s e a s e s o f t h e P u l p 35
  36. 36. Diseases of the Pulp – Dr. Nithin Mathew Bacterial Agents • Most common cause of pulpal injury. • Bacteria enter the pulp through: • Break in the dentin (caries/accidental exposure) • From developmental grooves • From percolation around a restoration • From extension of infection • Through open blood vessels/lymphatics during infections diseases/bacteremia • From gingiva • Presence or absence of bacterial irritation is the determining factor in pulp survival once the pulp has been mechanically exposed. D i s e a s e s o f t h e P u l p 36
  37. 37. Diseases of the Pulp – Dr. Nithin Mathew Anachoresis • Microbial contamination of the pulp by blood borne micro-organisms • Bacteria circulating in blood stream tend to accumulate at sites of pulpal inflammation (following a mechanical / chemical injury to the pulp) • One probable cause for this phenomenon is increased capillary permeability in this area D i s e a s e s o f t h e P u l p 37
  38. 38. Diseases of Dental Pulp
  39. 39. Diseases of the Pulp – Dr. Nithin Mathew Sequelae of Pulpal Disesaes 39 Normal Pulp Reversible Pulpitis Irreversible Pulpitis Chronic Hyperplastic Pulpitis Symptomatic Irreversible Pulpitis Asymptomatic Irreversible Pulpitis Internal Resorption Pulpal Necrosis Calcific Degeneration/ Calcific Metamorphosis Stimuli Causing Degenerating pulpal changes Noxius Stimuli
  40. 40. Diseases of the Pulp – Dr. Nithin Mathew Reversible Pulpitis Mild to moderate inflammatory condition of the pulp caused by noxious stimuli in which the pulp is capable of returning to the uninflamed state following removal of the stimuli. Etiology • Trauma – blow / disturbed occlusal relation • Thermal shock • Excessive dehydration • Chemical irritation – sweet/sour food • Galvanism • Excessive orthodontic forces D i s e a s e s o f t h e P u l p 40 R e v e r s i b l e P u l p i t i s
  41. 41. Diseases of the Pulp – Dr. Nithin Mathew • Slow progressive chronic lesion • Local vascular congestion • Circulatory disturbances • Irritant that causes hyperaemic or mild inflammation in one pulp may produce secondary dentin in another, if the irritant is mild enough or if the pulp is vigorous enough to protect itself. D i s e a s e s o f t h e P u l p 41 R e v e r s i b l e P u l p i t i s
  42. 42. Diseases of the Pulp – Dr. Nithin Mathew Symptoms • Short sharp pain lasting for a moment • Does not occur spontaneously and does not continue when the cause has been removed. • Most often brought on by cold than hot food or beverages and by cold air. D i s e a s e s o f t h e P u l p 42 R e v e r s i b l e P u l p i t i s
  43. 43. Diseases of the Pulp – Dr. Nithin Mathew Diagnosis Diagnosis is by a study of the patients symptoms and by clinical tests. • Pain: • Pain is sharp, lasts for a few seconds and generally disappears when the stimulus is removed. • Cold, sweet or sour usually causes the pain. • Sometimes, the pain may become chronic and may continue for weeks or even months. • Visual examination and history: • Examine for caries, restorations, fractures or traumatic occlusion. • A history of past dental treatment and history of subjective symptoms. D i s e a s e s o f t h e P u l p 43 R e v e r s i b l e P u l p i t i s
  44. 44. Diseases of the Pulp – Dr. Nithin Mathew • Percussion: • Reacts normally to percussion, palpation and mobility • Radiograph: • Periapical tissue is normal on radiographic examination. • Vitality test: • Hyperalgesic pulp responds more readily to cold stimulation than normal teeth. • Electric pulp testing requires minimal current to initiate positive response, due to increased excitability of Aδ- fibres. D i s e a s e s o f t h e P u l p 44 R e v e r s i b l e P u l p i t i s
  45. 45. Diseases of the Pulp – Dr. Nithin Mathew Histopathology Reversible pulpitis may range from hyperaemia to mild to moderate inflammatory changes limited to the area of the involved dentinal tubules. Histological changes: • Reparative dentin • Disruption of odontoblasts • Dilated blood vessels • Extravasation of edema fluid • Chronic inflammatory cells D i s e a s e s o f t h e P u l p 45 R e v e r s i b l e P u l p i t i s
  46. 46. Diseases of the Pulp – Dr. Nithin Mathew Differential Diagnosis • Can be differentiated from irreversible pulpitis because of its characteristic symptoms of sharp onset of pain lasting for a few seconds. • Thermal tests are useful in locating the affected tooth as reversible pulpitis responds readily to cold. • Electric pulp test is an excellent corroborating test. D i s e a s e s o f t h e P u l p 46 R e v e r s i b l e P u l p i t i s
  47. 47. Diseases of the Pulp – Dr. Nithin Mathew Treatment • Prevention is the best treatment for reversible pulpitis. • Periodic care to prevent the development of caries • Early restoration if a cavity has developed • Use of a cavity varnish or a cement base before insertion of a restoration • Care in cavity preparation and polishing • Once the symptoms has subsided, tooth must be tested for vitality to make sure that pulp necrosis hasn’t occurred. D i s e a s e s o f t h e P u l p 47 R e v e r s i b l e P u l p i t i s
  48. 48. Diseases of the Pulp – Dr. Nithin Mathew Prognosis • Favourableif the irritant is removed early enough. • Otherwise, the condition may develop into irreversible pulpitis. D i s e a s e s o f t h e P u l p 48 R e v e r s i b l e P u l p i t i s
  49. 49. Diseases of the Pulp – Dr. Nithin Mathew Irreversible Pulpitis Persistent inflammatory condition of the pulp, symptomatic or asymptomatic in nature with the pulp becoming incapable of healing. Types: • Symptomatic • Asymptomatic Etiology • Most common - bacterial involvement of the pulp • Chemical, thermal or mechanical injuries • Reversible pulpitis, if not treated may deteriorate into irreversible pulpitis. D i s e a s e s o f t h e P u l p 49 I r r e v e r s i b l e P u l p i t i s
  50. 50. Diseases of the Pulp – Dr. Nithin Mathew Symptoms • Early stages, a paroxysm of pain may be caused by • sudden temperature changes, particularly cold, sweet or acid food stuffs • pressure from packing food into a cavity and on lying down, which results in congestion of the blood vessels of the pulp. • Pain persists for several minutes to lingering after the removal of the stimulus. • Pain is described as sharp, piercing or shooting and it is generally severe. • Changes in position that is on bending or lying down exacerbates the pain because of changes in intrapulpal pressure. D i s e a s e s o f t h e P u l p 50 I r r e v e r s i b l e P u l p i t i s
  51. 51. Diseases of the Pulp – Dr. Nithin Mathew • Referred pain to the adjacent teeth, to the temple or sinuses when an upper posterior tooth is involved or to the ear when a lower posterior tooth is affected. • Later stages, pain is severe, described as boring, gnawing or throbbing. • Nocturnal pain, which is intolerable despite their efforts at analgesia. • Apical periodontitis is absent except in the later stages, when inflammation or infection extends to the periodontal ligament. D i s e a s e s o f t h e P u l p 51 I r r e v e r s i b l e P u l p i t i s
  52. 52. Diseases of the Pulp – Dr. Nithin Mathew Diagnosis Diagnosis is by a study of the patients symptoms and by clinical tests. • Pain: • Pain may be mild to severe or even excruciating throbbing. • Is generally diffuse and readily not localized by the patient. • Pain lingers after the primary irritant has been removed. • Pain may be referred to other areas. • Visual examination and history: • Deep cavity extending to the pulp. • Decay under a restoration. D i s e a s e s o f t h e P u l p 52 I r r e v e r s i b l e P u l p i t i s
  53. 53. Diseases of the Pulp – Dr. Nithin Mathew • Percussion: • Tenderness implies an increased intrapulpal pressure, as a result of hyperactive exudative (acute) inflammatory tissue. • Widening of the periodontal ligament space without percussion tenderness implies a non-painful state. • Radiograph: • May not show anything of significance. • May disclose an interproximal cavity or caries under a filling threatening the integrity of the pulp. D i s e a s e s o f t h e P u l p 53 I r r e v e r s i b l e P u l p i t i s
  54. 54. Diseases of the Pulp – Dr. Nithin Mathew • Vitality test: • Thermal test: • May respond in the same as reversible pulpitis, but pain may persist after the stimulus is removed. • As pulpal inflammation progresses, heat will intensify the responses because it has an expansive effect on the blood vessels, tissue and gaseous products of proteolysis. • Cold will tend to relieve the pain in advanced stages of pulpits, because, it has a contractile effect on the remaining central or apical functional vascular bed, reducing the intrapulpal pressure. D i s e a s e s o f t h e P u l p 54 I r r e v e r s i b l e P u l p i t i s
  55. 55. Diseases of the Pulp – Dr. Nithin Mathew • Electric Pulp test: • A response to less current may be expected in early stages because of low threshold of peripheral Aδ-fibres. • As the tissue becomes more necrotic, more current is required. • This test may not be diagnostic in advanced cases of acute pulpalgia, because of mixed responses, particulary multirootd teeth. D i s e a s e s o f t h e P u l p 55 I r r e v e r s i b l e P u l p i t i s
  56. 56. Diseases of the Pulp – Dr. Nithin Mathew Histopathology • Has both acute and chronic inflammatory changes. • Continuous vasodilatation • Accumulation of edema fluid in the connective tissue surrounding the tiny tissue • White blood cell collection may be found beneath the area of carious penetration • Odontoblasts are destroyed • Localized destruction of the pulp by polymorphonuclear leucocyte cells and formation of micro-abscess. D i s e a s e s o f t h e P u l p 56 I r r e v e r s i b l e P u l p i t i s
  57. 57. Diseases of the Pulp – Dr. Nithin Mathew Differential Diagnosis • One must differentiate between reversible and irreversible pulpitis. • Asymptomatic Stage: • Exposed pulp exhibits little/no pain except when food in packed. • Hence more current is required to elicit a response to EPT than in control tooth. • Early symptomatic Stage: • Less current is required to elicit a response in EPT than normal. • Pulp is abnormally responsive to cold • Induced/spontaneous pain that occurs is sharp and piercing. D i s e a s e s o f t h e P u l p 57 I r r e v e r s i b l e P u l p i t i s
  58. 58. Diseases of the Pulp – Dr. Nithin Mathew • Later Stages: • Symptoms may simulate those of acute alveolar abscess. • Abscess is differentiated from irreversible pulpitis, such that abscess will have: • Swelling • Tenderness on percussion • Mobility • Lack of response to vitality tests • Systemic symptoms: fever or nausea D i s e a s e s o f t h e P u l p 58 I r r e v e r s i b l e P u l p i t i s
  59. 59. Diseases of the Pulp – Dr. Nithin Mathew Treatment • Complete removal of the pulp or pulpectomy and the placement of an intracanal medicament to act as a disinfectant or obtundent • Extraction should be considered if the tooth is unrestorable. D i s e a s e s o f t h e P u l p 59 I r r e v e r s i b l e P u l p i t i s
  60. 60. Diseases of the Pulp – Dr. Nithin Mathew Prognosis • Favourable if the pulp is removed and the tooth undergoes proper endodontic therapy and restoration. D i s e a s e s o f t h e P u l p 60 I r r e v e r s i b l e P u l p i t i s
  61. 61. Diseases of the Pulp – Dr. Nithin Mathew Chronic Hyperplastic Pulpitis Productive pulpal inflammation due to an extensive carious exposure of a young pulp. • Characterized by the development of granulation tissue, covered at times with epithelium and resulting from long standing, low grade irritation. Etiology • Slow, progressive carious exposure. • For the development of pulp polyp, a large, open cavity, a young resistant pulp and a chronic low grade stimulus are necessary. • Mechanical irritation from chewing and bacterial infection often provide the stimulus. D i s e a s e s o f t h e P u l p 61 C h r o n i c H y p e r p l a s t i c P u l p i t i s
  62. 62. Diseases of the Pulp – Dr. Nithin Mathew Symptoms • Symptomless, except during mastication, when pressure from the food bolus may cause discomfort. D i s e a s e s o f t h e P u l p 62 C h r o n i c H y p e r p l a s t i c P u l p i t i s
  63. 63. Diseases of the Pulp – Dr. Nithin Mathew Diagnosis • Generally seen only in the teeth of children and young adults. • Polyp tissue is clinically characteristic as a fleshy, reddish, pulpal mass which fills most of the pulp chamber or cavity or extends beyond the confines of the tooth. • At times, the mass is large enough to interfere with the comfortable closure of the tooth. • Cutting of this tissue does not cause pain but pressure thereby transmitted to the apical end of the pulp does cause pain. • Differentiated from gingival overgrowth by tracing the stalk of the polypoid tissue. D i s e a s e s o f t h e P u l p 63 C h r o n i c H y p e r p l a s t i c P u l p i t i s
  64. 64. Diseases of the Pulp – Dr. Nithin Mathew • Radiograph: • Show a large open cavity with direct access to the pulp chamber. • Vitality test: • Thermal test: • Tooth may respond feebly or not at all to the thermal tests unless extreme cold such as ethyl chloride spray is used. D i s e a s e s o f t h e P u l p 64 C h r o n i c H y p e r p l a s t i c P u l p i t i s
  65. 65. Diseases of the Pulp – Dr. Nithin Mathew Histopathology • Surface is covered by stratified squamous epithelium. • Tissue in the pulp chamber is transformed into granulation tissue. • Granulation tissue is young vascular connective tissue containing polymorphonuclear neutrophils, lymphocytes and plasma cells. • Pulp tissue is chronically inflamed. D i s e a s e s o f t h e P u l p 65 C h r o n i c H y p e r p l a s t i c P u l p i t i s
  66. 66. Diseases of the Pulp – Dr. Nithin Mathew Differential Diagnosis • Appearance of hyperplastic pulpitis is characteristic and should be easily recognized. • The disorder must be distinguished from proliferating gingival tissue. D i s e a s e s o f t h e P u l p 66 C h r o n i c H y p e r p l a s t i c P u l p i t i s
  67. 67. Diseases of the Pulp – Dr. Nithin Mathew Treatment • Hyperplastic pulpal mass is removed with a periodontal curette or spoon excavator and the bleeding can be controlled with pressure. • Pulp tissue of the chamber is then completely removed and a dressing of formocresol is sealed in contact with the radicular pulp tissues. • The radicular pulp is extirpated at a later visit. • If time permits, the entire procedure of pulpectomy can be completed in a single visit. D i s e a s e s o f t h e P u l p 67 C h r o n i c H y p e r p l a s t i c P u l p i t i s
  68. 68. Diseases of the Pulp – Dr. Nithin Mathew Prognosis • Prognosis of the pulp is unfavourable but the prognosis of the tooth is favourable after endodontic treatment and adequate restoration. D i s e a s e s o f t h e P u l p 68 C h r o n i c H y p e r p l a s t i c P u l p i t i s
  69. 69. Diseases of the Pulp – Dr. Nithin Mathew Internal Resorption It is an idiopathic, slow or fast progressive resorptive process occuring in the dentin of the pulp chamber or root canals of teeth. Etiology • The cause of internal resorption is not known, but such patients often have a history of trauma. D i s e a s e s o f t h e P u l p 69 I n t e r n a l R e s o r p t i o n
  70. 70. Diseases of the Pulp – Dr. Nithin Mathew Symptoms • Internal resorption in the root of a tooth is asymptomatic. • Crown, it may be manifested as a reddish area called “pink spot” - Pink tooth of Mummery • Reddish area represents the granulation tissue showing through the resorbed area of the crown. D i s e a s e s o f t h e P u l p 70 I n t e r n a l R e s o r p t i o n
  71. 71. Diseases of the Pulp – Dr. Nithin Mathew Histopathology • Internal resorption is the result of osteoclastic activity. • Resorptive process is characterized by lacunae which may be filled in by osteoid tissue which is regarded as an attempt at repair. • Presence of granulation tissue accounts for the profuse bleeding when the pulp is removed. • Multinucleated giant cells or dentinoclasts are present. • Pulp is usually chronically inflamed. • Metaplasia of the pulp that is transformation to another type of tissue such as bone or cementum, sometimes occurs. D i s e a s e s o f t h e P u l p 71 I n t e r n a l R e s o r p t i o n
  72. 72. Diseases of the Pulp – Dr. Nithin Mathew Diagnosis • May affect either the crown or the root of the tooth or it may be extensive enough to involve both. • May be slow, progressive extending over 1-2 years or it may develop rapidly and perforate the tooth within a matter of months. • Most readily seen in the maxillary anterior teeth. • Radiograph: • Radiographs show changes in the appearance of the walls in the root canal or pulp chamber with a round or ovoid radiolucent area. D i s e a s e s o f t h e P u l p 72 I n t e r n a l R e s o r p t i o n
  73. 73. Diseases of the Pulp – Dr. Nithin Mathew Differential Diagnosis • When internal resorption progresses into the periodontal space and a perforation of the root occurs, it is difficult to differentiate from external resorption. • Resorptive defect is more extensive in the pulpal wall than on the root surface. D i s e a s e s o f t h e P u l p 73 I n t e r n a l R e s o r p t i o n
  74. 74. Diseases of the Pulp – Dr. Nithin Mathew Treatment • Extirpation of the pulp stops the internal resorptive process. • Routine endodontic treatment is indicated, but obturation of the defect requires a special effort, preferably with a plasticized gutta percha method. • In many patients, however, the conditions progresses unobserved because it is painless, until the root is perforated. • In such a case, calcium hydroxide paste is sealed in the root canal and is periodically renewed until the defect is repaired. • Repair is completed when the calcific barrier is present, following which the canal with its defect is obturated with plasticized gutta percha. D i s e a s e s o f t h e P u l p 74 I n t e r n a l R e s o r p t i o n
  75. 75. Diseases of the Pulp – Dr. Nithin Mathew Prognosis • Prognosis is best before perforation of the root or crown occurs. • If perforation occurs, prognosis is guarded and depends on the formation of a calcific barrier or access to the perforation that permits surgical repair. D i s e a s e s o f t h e P u l p 75 I n t e r n a l R e s o r p t i o n
  76. 76. Diseases of the Pulp – Dr. Nithin Mathew Pulp Degeneration • Generally present in the teeth of older people. • May also be seen in teeth of younger people as a the result of persistent mild irritation. • Early stages of pulp degeneration shows no signs or symptoms. • But as the degeneration progresses, the tooth may discolour and the pulp will not respond to stimulation. Types: • Calcific degeneration • Atrophic degeneration • Fibrous degeneration D i s e a s e s o f t h e P u l p 76 P u l p D e g e n e r a t i o n
  77. 77. Diseases of the Pulp – Dr. Nithin Mathew Calcific Degeneration • Part of the pulp tissue is replaced by calcific material (pulp stones or denticles). • Calcification may occur either within the pulp chamber or root canal, but it is generally present in the pulp chamber. • Calcified material has a laminated structure, and lies unattached within the body of the pulp / even attached to the wall of the pulp chamber. • It is not possible to distinguish one type from another on a radiograph. D i s e a s e s o f t h e P u l p 77 P u l p D e g e n e r a t i o n
  78. 78. Diseases of the Pulp – Dr. Nithin Mathew • Classified according to : • Position: • Free: pulp stones lie freely in the pulp tissue • Attached: pulp stones are attached to the dentinal walls • Embedded: pulp stones are encircled by dentin • Structure: • True: pulp stones are similar to dentin having dentinal tubules and odontoblasts. • False: calcified masses arranged in lamellar fashion around a nidus and do not contain dentinal tubules D i s e a s e s o f t h e P u l p 78 P u l p D e g e n e r a t i o n
  79. 79. Diseases of the Pulp – Dr. Nithin Mathew • Degeneration of complete pulp space may occur as a sequelae to a traumatic injury - Calcific Metamorphosis. • Such response to trauma is characterised by rapid deposition of hard tissue within the canal space. • Teeth remains asymptomatic and may exhibit discoloration of crown. • Obliteration is evident radiographically as an intracanal radio- opacity similar to surrounding dentin. D i s e a s e s o f t h e P u l p 79 P u l p D e g e n e r a t i o n
  80. 80. Diseases of the Pulp – Dr. Nithin Mathew Atrophic Degeneration • Observed histopathologically in pulps of older people. • Fewer stellate cells are present and intercellular fluid is increased. • The pulp tissue is less sensitive than normal. • No clinical diagnosis exists. D i s e a s e s o f t h e P u l p 80 P u l p D e g e n e r a t i o n
  81. 81. Diseases of the Pulp – Dr. Nithin Mathew Fibrous Degeneration • Characterized by replacement of the cellular elements by fibrous connective tissue. • Pulp has the characteristic appearance of a leathery fiber. • No distinguishing clinical symptoms to aid in diagnosis. D i s e a s e s o f t h e P u l p 81 P u l p D e g e n e r a t i o n
  82. 82. Diseases of the Pulp – Dr. Nithin Mathew Necrosis of Pulp • Necrosis is death of the pulp. • May be partial or total, depending on whether part of or the entire pulp is involved. • Necrosis can be caused • As the sequel to inflammation • Following a traumatic injury in which the pulp is destroyed before an inflammatory reaction can take place. Etiology: • Can be caused by any noxious insult injurious to the pulp such as bacteria, trauma and chemical irritation. D i s e a s e s o f t h e P u l p 82 N e c r o s i s o f P u l p
  83. 83. Diseases of the Pulp – Dr. Nithin Mathew Types • Coagulation Necrosis: • Soluble portion of tissue is precipitated or is converted into a solid mass. • Caseation is a form of coagulation necrosis in which the tissue is converted into a cheesy mass consisting chiefly of coagulation proteins, fats and water. • Liquefaction Necrosis: • Necrosis which results when proteolytic enzymes convert the tissue into a softened mass, a liquid, or amorphous debris. D i s e a s e s o f t h e P u l p 83 N e c r o s i s o f P u l p
  84. 84. Diseases of the Pulp – Dr. Nithin Mathew • End Products of Pulp Decomposition: • Hydrogen Sulfide • Ammonia • Fatty Substances • Indicam • Water • Carbon Dioxide D i s e a s e s o f t h e P u l p 84 • Intermediate Products of Pulp Decomposition: • Indole • Skatole • Putriciene • Cadaverine N e c r o s i s o f P u l p
  85. 85. Diseases of the Pulp – Dr. Nithin Mathew Symptoms • Necrotic pulp causes no painful symptoms. • Discolouration of the tooth is the first indication that the pulp is dead. • Toothlacks its usual brilliance, lustre and translucency. • Presence of a necrotic pulp may be discovered only by chance, because such a tooth is asymptomatic. • Teeth with partial necrosis can respond to thermal changes, owing to the presence of vital nerve fibres passing through the adjacent inflamed tissue. D i s e a s e s o f t h e P u l p 85 N e c r o s i s o f P u l p
  86. 86. Diseases of the Pulp – Dr. Nithin Mathew Diagnosis • Pain is absent in a tooth with total necrosis. • Radiographs: • Thickened PDL space • Swelling, mobility and response to percussion and palpation are negative. • There is no response to vitality tests as well. • Teeth with partial necrosis can respond to thermal changes, owing to the presence of vital nerve fibres passing through the adjacent inflamed tissue. D i s e a s e s o f t h e P u l p 86 N e c r o s i s o f P u l p
  87. 87. Diseases of the Pulp – Dr. Nithin Mathew Histopathology • Necrotic pulp tissue, cellular debris and microorganisms may be seen in the pulp cavity. • Periapical tissue may be normal or slight evidence of inflammation of the apical periodontal ligament may be present. D i s e a s e s o f t h e P u l p 87 N e c r o s i s o f P u l p
  88. 88. Diseases of the Pulp – Dr. Nithin Mathew Treatment • Proper treatment of necrosis is the thorough canal debridement. • Obturation of the root canals. D i s e a s e s o f t h e P u l p 88 N e c r o s i s o f P u l p
  89. 89. Diseases of the Pulp – Dr. Nithin Mathew Prognosis • Prognosis of the tooth is favourable if proper endodontic therapy is done. D i s e a s e s o f t h e P u l p 89 N e c r o s i s o f P u l p
  90. 90. Features Reversible Pulpitis Acute Pulpitis Chronic Pulpitis Hyperplastic Pulpitis Pulp Necrosis Pain & Stimulus Mild pain lasting for a moment Constant to severe pain caused by hot/cold stimuli Mild and intermittent • No Pain • Bleeds profusely due to rich vascularity Not Present Stimulus Heat, Cold or sugar Hot/cold/ spontaneous Spontaneous Pulp Test • Thermal Readily responds to cold Acute pain to hot stimuli No response No response No response • Electric Normal response Normal to elevated response More current is required More current is required In Liquefaction necrosis – positive response with EPT Radiograph • Deep caries • Defective restoration • Deep caries • Defective restoration • Chronic apical periodontitis • Local condensing osteitis • Chronic apical periodontitis • Local condensing osteitis Sometimes Apical Periodontitis or Condensing osteitis Treatment • Removal of Decay • Restn with Pulp protection • Pulpotomy • RCT • RCT • Extraction of non- restorable tooth • Removal of polypoid tissue followed by RCT
  91. 91. Diseases of the Pulp – Dr. Nithin Mathew Conclusion • Pulp is also a formative and highly resistant organ of the tooth. • Pulp is among the most densely innervated and vascularised tissues in the human body. • The microcirculatory system serves several essential roles in maintaining the vitality of the pulp. • Both these systems are critically important in maintaining the homeostasis of the dental pulp. • The value of the pulp as an integral part of the tooth, both anatomic and functional should be recognised and every effort must be made to conserve it. D i s e a s e s o f t h e P u l p 91
  92. 92. Diseases of the Pulp – Dr. Nithin Mathew References • Dental Pulp – Seltzer & Bender (2nd Edition) • Endodontic Practice – Grossman (13th Edition) • Endodontics – Ingle (6th Edition) • Pathways of the Pulp – Stephen Cohen • Endodontic Therapy – Franklin S. Weine (6th Edition) • Textbook– Nageshwar Rao (1st Edition) • Textbookof Endodontics – Nisha Garg D i s e a s e s o f t h e P u l p 92
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