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PRDM 135 | ORAL PATHOLOGY | LECTURE MODULE: 1st Topic for Midterms LESSON: Abnormalities of the Pulp 1st SEMESTER | S.Y. 2024-2025 Lecture notes typewritten by: Rhein Feniza...
PRDM 135 | ORAL PATHOLOGY | LECTURE MODULE: 1st Topic for Midterms LESSON: Abnormalities of the Pulp 1st SEMESTER | S.Y. 2024-2025 Lecture notes typewritten by: Rhein Feniza ABNORMALITIES OF THE PULP PULP CALCIFICATION Dentin-Pulp Complex Various forms of pulp calcification may represent a pathologic state or o Dentin – Forms the main bulk of the tooth merely an occurrence within the range of biologic variation o Pulp – Occupies the central portion of the tooth These calcifications may be located in any portion of the pulp tissue Pulp o Is a specialized soft connective tissue Chief Morphologic Forms of Calcification o Well vascularized 1. Discrete pulp stones (denticles, 2. Diffuse (linear) – paralleling o Consists of lymphatics and nervous tissue that occupies the center of the tooth pulp nodules) the blood vessels and nerves o Every person normally has 52 pulp organs ▪ 32 in permanent ▪ 20 in deciduous o Each pulp has a shape that conforms the respective tooth o Each pulp resides in a pulp chamber surrounded by dentin containing the peripheral extensions of the cells that formed it o Pulp cavity is the center space housing the pulp tissue o 2 parts of the pulp 1. Pulp chamber – Pulp cavity located - crown portion Classification of Pulp Stones 2. Pulp canal – On the crown portion - root portion 1. According to True Denticle – Are made up of localized Pulp Chamber Coronal Pulp histological structure masses of calcified tissue that resemble The pulp chamber follows Located centrally in the dentin because of their tubular structure the outline of the crown False Denticle – Composed of localized dentino-enamel junction Coronal pulp of young masses of calcified material or consists (DEJ) individuals resembles the only of concentric lamellae of calcified Extensions of pulp shape of the outer surface tissues and do not exhibit dentinal chamber under the cusps of the crown dentin tubules. and incisal edges are the Cervical region of the of pulp horns the pulp organs constricts May occur commonly in the pulp as the contour of the chamber crown Larger than the true denticle The continuous Mixed Type – Combination of true and deposition of dentin false makes the pulp smaller Concentric – Denoting circles with age (makes the teeth yellow when getting Lamella – Thin plate older) 2. According to location Free Denticle – Denticles lying entirely to Radicular Pulp Apical Foramen in relation to dentinal the pulp tissue Known as root pulp Where the root canal wall Attached Denticle – Denticles that are Extends from the cervical terminates continuously attached to the dentinal region of the crown to the Average size of the apical walls root apex foramen in the adult Embedded Denticle – Pulp stone is Not always straight maxillary teeth is 0.4mm Vary in size, shape and Average size of the apical entirely surrounded by dentin number foramen in the adult 3. According to Form Nodular – Rounded mass of irregular Continuous with the mandibular teeth is shape periapical connective 0.3mm Amorphous – Indefinite form tissues through apical Pulp communicates with Fibrillar (diffused) – Elongated foramen or foramina the periodontal ligament calcification following course of the at the root apex through the apical foramen as blood vessels and nerves well as accessory canals Periodontal ligament – A Etiology system of collagenous 1. Unknown connective tissue 2. Appears to increase with the age of the person In older teeth, with 3. No significant relation to: completed apex formation, the foramen Pulpal irritation are narrow and often Bacteria delta-shaped Age or sex Accessory Canal Traumatic operative procedure Accessory canals or lateral canals or secondary canals or apical ramifications Clinical Significance May be seen anywhere along the root but most numerous on the apical third of the root 1. No clinical significance May also occur where the developing root encounters a 2. Difficulty may be encountered in extirpating the pulp during root canal blood vessel therapy Clinically significant in the spread of infection either from the pulp to periodontal ligament or from the PDL to the pulp Structural Features The central region of the pulp contains large nerve trunk and blood vessels pg. 1 ROOT RESOPTION Tumor and Benign and malignant tumors may cause root resorption cysts Root resorption is the breakdown or destruction, and subsequent loss, of the root structure of a tooth due to living body cell attacking Classification o Physiologic – Occurs in the cementum during shedding o Pathologic – Following pathological conditions Types of root resorption Tumor – Swelling or enlargement; new growth of tissue o External – Arising as a result of tissue reaction in the periodontal Cyst – Closed sac in or under the skin, line with epithelium or pericoronal tissues containing fluid or semisolid material o Internal – Form pulpal tissue reaction Clinical Feature 1. Apical periodontal cyst exert pressure on the apex of the involved or adjacent tooth Impacted teeth Completely impacted or embedded teeth in bone occasionally will undergo crown or root resorption Impacted – Physical barrier in erupted path Embedded – Lack of eruptive force External Root Resorption Internal Root Resorption Tooth resorption that starts and progresses from the periodontal ligament; generally seen at the apex or lateral surface Clinical Features 1. Pink-hued area on the crown which represent the hyperplastic vascular pulp tissue 2. No significant findings if the resorption begins in the root 3. Unusual for more than one tooth is involved in any given patient Periapical Resorption of calcified dental tissues similar to resorption of Inflammation bone Example is the presence of periapical granuloma due to trauma may cause root resorption if the inflammatory lesion persists for a period of time Clinical Features Roentgenographic 1. Round, ovoid radiolucent area in the central portion of 1. Slight burning of the root apex in early stages proceeding Features the tooth associated with pulp but no the external surface of the tooth unless the condition of the perforation occurred 2. Complete perforation occurs if the tooth is untreated 2. Tooth that had root canal treated and filled but with periapical inflammation permits, resorption may ultimately leave only the root canal filling projecting out of a shortened root Histologic 1. Degree of resorption of the Features inner of pulpal surface of dentin 2. Proliferation of pulp tissue filling the defect 3. Resorption of an irregular lacunar variety occasional osteoclasts or odontoclasts knowns as odontoclastoma 4. Chronic inflammatory reaction of pulp tissue Granuloma – Chronic inflammatory lesion, may resolve spontaneously, remain static, become gangrenous, spread or act as focal or infection Resorption – The loss of substance Enamel Hypoplasia Reimplanted Non-vital tissue expect when the vascular supply of the Enamel hypoplasia due to local infection or trauma teeth or developing tooth may be reestablished during o Common in permanent maxillary incisors or maxillary or mandibular transplantation transplantation premolars of tooth Root is replaced by bone producing ankylosis if the root does o Only single tooth is involved referred to as Turner’s tooth and the not completely resorbed condition is called Turner’s hypoplasia pg. 2 DISEASE OF THE PULP Histologic 1. Dilatation of the pulp vessels Features 2. Edema fluid may be collected because of the damage to the capillary walls allowing actual extravasation of red blood cells CLASSIFICATION OF PULP DISEASE Dilated – Become wider, larger or more open Extravasation – Passage or escape Pulp disease of inflammatory nature has been classified as acute and Edema – Abnormal accumulation of fluid in interstitial chronic spaces 3. Slowing of flood flow and hemoconcentration due to A. Depending upon the extent of pulp involvement transudation of fluids from the vessels 1. Partial or focal or subtotal pulpitis if the inflammatory 4. Diapedesis of WBC process if confined to the portion of the pulp usually the Transudation – Passage coronal portion such as the pulp horn Diapedesis – Passage of blood cells through the intact walls 2. Generalized pulpitis if most of the pulp is diseased of the capillaries B. Depending upon the presence or absence of direct communication between the dental pulp and the oral environment through a large carious lesion 1. Open pulpitis (pulpitis aperta) in which the pulp openly communicates with the oral cavity 2. Closed pulpitis (pulpitis clausa) in which the pulp has no communication with the oral environment ETIOLOGIC FACTORS OF PULP DISEASE Treatment 1. Irritant is removes before the pulp is severely damaged and 2. Carious lesion should be restored Prognosis 3. Replace defective filling as soon as it is discovered ACUTE PULPITIS Extensive inflammation of the dental pulp Bacterial invasion may also occur in absence of caries, ex. Fracture, that Sequela if focal reversible pulpitis expose the dental pulp to the oral fluids and microorganisms or as a May occur I acute exacerbation of chronic inflammatory process result of bacteremia Exacerbation – Increase the seriousness of the disease Bacteremia – Prescence of bacteria in the blood Clinical 1. Usually occurs in a tooth with large carious lesion or Features restoration 2. There has been recurrent caries 3. Even in early stages then the inflammatory reaction involves only a portion of the pulp, usually that area just beneath the carious lesion, relatively severe pain is elicited by thermal changes by ice or cold drinks 4. Pain persists even after the thermal stimulus has disappeared or removed The study of Mitchell and Tarplee provided evidence that there is an increase in sensitivity to both heat and cold 5. Severe lancinating pain if large proportion of the pulp FOCAL REVERSIBLE PULPITIS becomes involved with intrapulpal abscess Intra – Within Often referred to as pulp hyperemia (increase or excessive amount of 6. Severe pain may be continuous, and its intensity may be blood in a tissue) increased when the patient lies down 7. Application of heat may cause an acute exacerbation of pain The vascular condition can occur from pumping action during tooth 8. Tooth reacts to the electric pulp vitality tester at a lower level extraction, therefore, this mild transient pulpitis, localized chiefly to the of current than normal teeth, indicating increased sensitivity pulpal ends or irritated dentinal tubules of the pulp Transient – Lasting only for short time; temporary Lying down or bending causes exacerbation of pain due to changes in intrapulpal pressure and keep the patient Clinical 1. Sensitive to thermal changes particularly to cold awake at night 9. When necrosis of the pulp tissue occurs, the sensitivity is lost Features Application of ice or cold fluids to the tooth results Abscess formation is more likely to occur when the in pain, but disappears upon the removal of the entrance to the pulp is tiny and there is lack of drainage thermal irritant or restoration of normal temperature 2. Tooth responds to stimulation by the electric pulp tester at the lower level of current indicating lower pain threshold or greater sensitivity than that of the adjacent normal teeth 3. Teeth with deep carious lesions, large metallic restorations (particularly without adequate insulations or defective margins) pg. 3 Histologic 1. Continued vascular dilatation seen in focal reversible CHRONIC PULPITIS Features pulpitis accompanied by accumulation of edema fluid in connective tissue surrounding the tiny blood vessel Occurs as chronic lesion from the onset Edema – Abnormal accumulation of fluid in May arise from previous inactive acute pulpitis interstitial spaces Signs and symptoms are milder than acute pulpitis 2. Pavementing of polymorphonuclear leukocytes Classified as open and closed form become apparent along the walls of vascular channels Open pulpitis (pulpitis Aperta) in which the pulp openly communicates 3. In the early course of the disease, there may be a with the oral cavity localized destruction of pulp tissue and formation of Closed pulpitis (pulpitis clausa) in which the pulp has no communication small abscess called pulp abscess containing pus with the oral environment arising from breakdown of leukocytes and bacteria 4. Loss of liquid pus frequently appears as a small void Histologic 1. Infiltration of pulp tissue by different numbers of surrounded by a dense band of leukocytes Features mononuclear cells 5. In only a few days, the acute inflammatory process 2. Capillaries are usually prominent spreads to involve most of the pulp so that 3. Collagen fivers are often gathered in bundles neutrophilic leukocytes fill the pulp, there is Infiltration – The process in which a fluid passes considerable pressure formed and the entire pulp into the tissues undergoes rapid degeneration Collagen – Fibrous insoluble protein Degeneration – Decline or deteriorate 6. Numerous abscesses may form and the pulp undergoes liquefaction and necrosis called acute suppurative pulpitis Suppurative – Discharge of pus 4. Deposition of collagen about the inflamed area may resemble the formation of granulation tissue on the pulp with wide-open exposure is called ulcerative Treatment 1. No successful treatment pulpitis and 2. Once the degree of pulpitis occurs, the damage is Ulcerative – A circumscribed, crater-like lesion Prognosis irreparable resulting from necrosis that accompanies some 3. Patient with high tissue resistance to infection with inflammatory, infections or malignant process open cavity may become inactive and enter chronic stage 4. Root canal therapy When the pulp is initially opened to evacuate any pus, and the operation is performed without anesthesia, the patient is afforded to relief from pain In early cases of acute pulpitis involving a limited area of tissue and in cases of mechanical exposure without obvious infection 5. Pulpotomy and placing a bland material such as calcium hydroxide over the entrance of the root canals in very early stage of acute pulpitis 5. In cases of open wide carious lesions and with Pulpotomy – Removal of the coronal pulp exposure of pulp to oral environment, there is relatively little pain 6. Exposed pulp may be manipulated by a small instrument but bleeding may occurs, pain is absent 7. May become necrotic without pain Suppurative – Discharge of pus Treatment 1. No successful treatment and 2. Once the degree of pulpitis occurs, the damage is Prognosis irreparable (similar 3. Patient with high tissue resistance to infection with treatment to open cavity may become inactive and enter chronic acute pulpitis) stage 4. Root canal therapy 5. Pulpotomy pg. 4 CHRONIC HYPERPLASTIC PULPITIS (PULP POLYP) GANGRENOUS NECROSIS OF PULP Uncommon pulp disease Occurs as chronic lesion from the onset or chronic stage of previously acute pulpitis Hyperplasia – Proliferation of abnormal growth of tissue Clinical Features 1. Excessive, exuberant proliferation of chronically inflamed pulp 2. Occurs exclusively in children and young adults 3. Commonly involved are deciduous and permanent molars 4. Excellent blood supply because large root opening Untreated acute or chronic pulpitis will result to complete necrosis of Exuberant – Existing in large amount pulp tissue 5. Involves teeth with large carious lesions Gangrene – Necrosis or death of tissue usually as result of 6. Pulp appears pinkish-red globule protruding from pulp ischemia (loss of blood supply) chamber and often filling the entire cavity Necrosis – Death of a tissue in response to disease or injury 7. Because the hyperplastic tissue contains few nerves it Pulp gangrene is necrosis of the tissue due to ischemia with is insensitive to manipulation superimposed bacterial infection 8. Lesion may or may not bleed rapidly depending upon Most complete end results of pulpitis in which there is total necrosis of the degree of vascularity of the tissue tissue On occasion, the gingival tissue adjacent to a Ischemia – An inadequate blood supply to an organ or part of the broken-down, carious tooth may proliferate into body, especially the heart muscles the carious lesion and superficially resemble an Dry gangrene occurs when the pulp dries for some unexplained reason, example pf hyperplastic pulpitis may be due to traumatic injury or infarct Infarct – Death of a tissue caused by partial occlusion of a vessel or vessels supplying the area Tissue reaction in inflammatory hyperplasia does not differ from inflammatory hyperplasia in the oral cavity and elsewhere in the body Treatment May and prognosis and Prognosis 1. Extraction 2. Pulp extirpation Extirpate – Root out and destroy completely pg. 5
