Pulp and Periapical Lesions: Classifications & Treatment

Pulp Lesions and Periapical Lesions

• Include all classifications, diagnostic terminology, and treatments

Classification of Lesions

• Pulp lesions classified (Cohen 1999) include pulp normal, reversible pulpitis, irreversible pulpitis (symptomatic or asymptomatic), internal resorption, calcific metamorphosis, and necrosis.
• Periapical disease classification (Cohen 1999) includes acute apical periodontitis, acute apical abscess, phoenix abscess, periapical osteitis, granulomas, and cysts
• AAE consensus conference recommended diagnostic terminology is used to manage universal language to describe condition; established by American Association of Endodontics to describe pulpal and apical pathologies.
• Pulp lesions are categorized as pulpal (normal pulp, reversible pulpitis, symptomatic irreversible pulpitis, asymptomatic reversible pulpitis, pulpal necrosis, previously treated tooth, tooth with initiated treatment) and apical (normal apical tissues, asymptomatic apical periodontitis, symptomatic apical periodontitis, acute apical abscess, chronic apical abscess), and condensing osteitis

Classification of Pulp Lesions

• Normal pulp is asymptomatic; has transient response to thermal and electric stimuli that disappears immediately after stimulus removal.
• There is no response to percussion and palpation, with a normal radiographic image
• Reversible pulpitis occurs with inflamed dental pulp able to return to its original state, caused by shallow cavities or defective restorations; symptoms resolve with the removal of stimuli.
  • Little to no symptoms; rapid, acute hypersensitivity to thermal stimuli, but normal response to percussion and palpation, as periodontal ligament is not inflamed; pain is only provoked, never spontaneous; radiographically, periapical region is normal
  • Key differentiation from irreversible pulpitis is how pain manifests, especially duration and spontaneity
• Irreversible pulpitis occurs with pulp inflammation that cannot return to original state, needing more invasive treatments; etiology includes deep cavities near pulp or exposure to pulp chamber; recent crowns, deep restorations, or restorations can also cause it (radiographically observed).
  • Symptomatic involves intense pain provoked by thermal stimuli, persisting for some time, becoming spontaneous; patient may describe throbbing due to lack of drainage; vertical percussion may cause pain due to inflammation transmitting to periodontal ligament; analgesics needed for pain relief
    • Heat may cause pain, while cold may not respond or may relieve pain, generating heat; caries removal may expose pulp, or enamel and dentin may fracture due to trauma
  • Asymptomatic is known as pulp polyp or hyperplastic pulpitis; exophytic proliferation of pulpal tissue into carious cavity, a pinkish-red granulomatous mass, fibrous cauliflower-like, and painless on exploration
    • Mainly in children/adolescents in molar region of permanent teeth; more exposed to oral environment, greater chance of draining; depends on content, may bleed if vascularized or cause slight discomfort if fibrous
• Pulpitis cannot be diagnosed radiographically; radiograph reveals pulp space only
• Necrosis occurs when bacteria exceeds blood vessel capacity to allow leukocytes to destroy bacteria upon entering pulp; basically the death of the pulp.
  • Totally asymptomatic; thermal/electrical tests are negative.
  • Cavity or mechanical tests aid diagnosis in doubtful cases; crown color change indicates pulp loss, often gray or black due to pulp darkening; translucency loss and radiographs may reveal caries or inadequate restoration
  • Increased periodontal ligament space possible

Internal Dentin Resorption

• Refers to dentin loss inside; etiology not well-defined, but may be due to trauma, caries, orthodontics, or bruxism.
  • Painless and detectable via radiograph; root canal treatment should be initiated immediately due to irreversible inflammatory process; inactive mesenchymal cells can become dentinoclasts (destroy dentin)
  • Can occur radicularly or coronally; if unidentified, can perforate root; clinically, it appears as pink spot.
  • Depending on destruction, extraction is indicated

Calcific Metamorphosis

• Idiopathic etiology; various causal factors, such as trauma, caries, cavity preparation, hypofunction, traumatic occlusion, periodontal/gingival inflammations.
  • Reduced pulp chamber and diminished nerves/blood vessels in coronal pulp from structures’ calcification; narrow pulp, crown is less translucent, has yellowish hue; no thermal/electrical response; palpating/percussion is within normal limits

Periapical Pathologies

• Starts as apical periodontitis, the body’s defensive response to dental pulp destruction; microorganisms and host defenses destroy periapical tissue, resulting in lesions
• Infection stimulates inflammatory, primarily involving dental pulp, highly vulnerable due to rigid dentin walls and terminal circulation prohibiting revascularization
• Less intense irritants entering pulp stimulate tertiary dentin, greater intensity irritants cause pulp death; inflammation extends to the area if untreated

Periapical Lesion Classifications

• Acute apical periodontitis is an acute inflammatory process that occurs around apex before bone resorbs.
  • Caused by pulpal pathology, trauma, overinstrumentation, occlusal trauma; percussion pain is pathognomonic, ranging from mild to intense on contact or simple grazing with tongue; can react to vitality tests
  • Tooth may be slightly extruded/mobile; differs from chronic by not being radiographically observed; extremely painful
• Chronic apical periodontitis inflammation and periodontal destruction, presents usually without clinical symptoms
  • Negative pulp vitality tests and is asymptomatic; palpation sensitivity may occur
  • Any radiolucent apical image must be drafted as "chronic apical periodontitis" because to know if its a cyst or abcess a biopsy would need to be done after the extraction of the lesion
• Acute periapical abscess cannot be radiographically seen, but can be clinically seen through volume increase, pus accumilation, reddened tissue and fever.
  • Strong pain on palpitation and percussion test, slight increase in mobility; radiographically, normal or little widened periodontal ligament; may quickly spread to muscle without destroying bone
• Chronic periapical abscess forms a purulent exudate with drainage through fistulous tract.
  • Is generally asymptomatic; tooth involved responds negatively to diagnostic vitality test and palpable
• Condensing osteitis or periapical osteosclerosis is observed radiographically as a radiopaque image, bone mass increase.
  • During inflammatory/infectious process, osteoblastic cells become activated, causing excessive bone production apically; commonly seen in young individuals and apices of mandibular molars with deep carious lesions and chronic pulps; has sensitivity to mastication and percussion
• Apical or radicular cyst is a continuously growing cavity, internally lined by epithelial tissue and externally by connective tissue, contains liquid or semisolid substance.
  • Always associated with necrotic pulp tooth, vitality tests are negative; apical palpation may be negative; neighbouring teeth can be displaced, show mobility, apices separate radiographically
  • Radiographically, appears as radiolucent image surrounded by intense radiopaque line; histologically, lesion wall formed by a stratified squamous epithelium

Diagnosis and Case Selection

• Diagnosis determines disease's nature/condition; recognizes patient, determines ailment, and diagnoses it for effective treatment.
• Case selection and treatment starts after clinician diagnoses endodontic issue. Factors are:
  • Patient and environment knowledge, in-depth disease knowledge (etiopathogenesis, location, type), health questionnaire (systemic data), pulp sensitivity, painful history (provoked/spontaneous sensation, cold/heat stimulus), examination/palpation/percussion data, radiograph, diagnosis.
• Diagnosis classes are: etiologic, anatomy-morphological, provisional and definitive.
• Prior case selection factors: equipment and skills availability, professional-patient relationship, and economic factor.

General Factors

• Endodontics performed due to surgery contraindications: blood dyscrasias, patients who received radiation therapy, anticoagulant medication, hyperthyroid patients, and cancer
• Heart problems: Recent myocardial infarction (6 months); do not use vasoconstrictor or antibiotic for patients not well-controlled; use antibiotics; is the patient pregnant, perform treatment with medical permission, needing to be treated, and the second trimester; allergy to latex

Local Factors

• Tooth anatomy must be radiographically difficult, must be able to make the procedure; the sond tells you the condition of the peridontal

Pulp Considerations

• Pulp Protection is to maintain the pulp in a good condition
• Pulp Expiration if total because the treatment consist in removing all

Procedure Considerations

• There needs to be pre-surgery to isolate correctly

Isolation

• The AAE states the that disinfection is important

Isolation

• Introduced in 1864 by dentist from NY
• Advantages are protection to the patient from anything you could drop, cleaner field, protection to the soft tissue, and better view
• Some instrument include rubber dam, punch, forceps