Les pathologies pulpaires PDF

# PULP PATHOLOGIES ## I. Introduction The dental pulp is a singular connective tissue that defends itself against any aggression through inflammation. However, the pulp's response to aggression is not always predictable (cavity, trauma, treatment). Certain pulps become necrotic after a weak stimul...

# PULP PATHOLOGIES ## I. Introduction The dental pulp is a singular connective tissue that defends itself against any aggression through inflammation. However, the pulp's response to aggression is not always predictable (cavity, trauma, treatment). Certain pulps become necrotic after a weak stimulus, others resist significant aggressions; some pulps become inflamed with the worst pain, while others undergo the same mechanisms without signs. The pulp context is particular: * The pulp is enclosed in a space with inextensible mineralized walls, which limits the possibilities of the pulp to tolerate internal edema. * The pulp lacks collateral circulation which limits the management of the different stages of inflammation * The pulp possesses cells (odontoblasts, fibroblasts) that manufacture mineralized tissue to protect itself from aggressions. Despite this, the pulp is capable of healing, but its degree of survival remains uncertain. For the clinician, the difficulty lies in the fact that there is no concordance between the histological state of the pulp and the clinical symptomatology (pain ≠ pulp involvement). ## II. Classifications of the pulpal state 1. The clinical classification of Baume (cf. Clinical Realities 1995 (6) 2 pp. 135-143 Bouillaguet) **Stage I:** pulp without clinical symptoms, near a deep cavity or accidentally injured and susceptible to being treated and protected by capping (in particular on a young pulp). **Stage II:** Pulp with clinical symptoms, reversibly affected, which will be preserved to maintain vitality. **Stage III:** Vital pulp for which a pulpectomy is indicated for reasons of irreversible inflammation, prognosis, prosthetic indications or iatrogenic reasons. **Stage IV:** necrotic pulp, with or without infection of the radicular dentin, with or without periradicular complications. Baume's classification has the merit of being simple and does not attempt to establish a correlation between the clinical and the histological. It provides for a reversible, pivotal stage, which is stage II where the decision to preserve the vital pulp is made. Any difficulty comes from there: how and on what criteria do we make the decision to institute endodontic treatment when the pulp, even if it is relatively asymptomatic, contains irreversible inflammatory phenomena? 2. The histological classification of Seltzer and Bender **Stage 1:** intact non-inflamed pulp (normal cells, normal blood vessels) **Stage 2:** atrophied pulp following senescence (reduced volume, reparative dentin, fibrosis, narrowed odontoblast palisade) **Stage 3:** pulp still intact, infiltrated with scattered chronic inflammatory cells (still reversible stage, in any case transitory.) **Stage 4:** acute pulpitis characterized by vascular phenomena \- after operative procedure: reversible stage if the cause has not been too violent \- under a carious process: most often irreversible stage **Stage 5:** partial chronic pulpitis: \- with partial liquefaction necrosis \- with ischemic necrosis (so-called coagulation) partial **Stage 6:** total chronic pulpitis: \- with partial liquefaction necrosis **Stage 7:** total pulpal necrosis. Seltzer's classification is a gradual classification of a histological picture. However, the clinician cannot access histological observations of the pulpal state. and must be satisfied with the clinical, subjective and objective signs, the examination and complementary exams (such as retro-alveolar X-ray). 1. The dynamics of development of pulpal pathologies What pulpopathies are to be diagnosed? * pulpitis: reversible/irreversible * pulpal necrosis: partial/total * degenerative or dystrophic phenomena: pulpal hyperplasia / resorption internal The image shows a flowchart explaining the dynamic development of pulpal pathologies with clinical signs. **Starting from a Non-treated cavitie:** *Pulpal Alterations*, which can have two different courses: * A transitory stage: *the pulp is still intact, showing chronic inflammatory cells*. From this stage we can go back if the damage is not irreversible. * On one side, **Signs clinics**: * Zero or light pain at the begininng * Pain with sweets or acid * Pain with cold or hot * Essential criteria: it does not last **Pulpal Limits of reversibility** * On one side is **chronic pulpitis**: in the event of acute exarcerbation: efficient vascular and lymphatic drainage and to the exposure of pus originating from bacterial byproducts. * On the other side is **Chronic Total Pulpitis**: partial or limited necrocis and chronic apical periotontitis. This stage goes to *acute exarcerbation*. ## III. The «healthy» clinical pulp A healthy, or clinically normal, pulp is a vital pulp that responds to various stimuli without any spontaneous symptoms. The pulp reacts to cold, to heat with a sensation of pain that disappears shortly after the stimulus is stopped. Inevitably, between normality and irreversible damage, there is a subtle boundary where intrapulpal fluctuations can cause the pulpal state to shift either towards pathology or towards remission. Pulpal healing takes place at the expense of its territory, depending pathological or therapeutic process, the pulp builds a mineralized barrier by secreting reactive dentin. ## IV. Reversible pulpitis It is often called pulpal hyperemia or pulpal hyperalgesia or hyperalgesia. The pulp may be attacked in different ways. 1. In the carious process Aggressions are continuous in time. At the beginning, they are far from the pulp by the entire thickness of the dentin. Communication between the outside and the pulp is through the dentinal tubules, pathways taken by the diffusion of bacterial antigens. The pulp reacts to the slightest stimulus by intracellular cellular modifications from the carious destruction of enamel to the amelo-dentinal junction (Brännström). Heat or cold, applied to the tooth, causes vascular modifications inside the pulp. On the dentin, touch or acidity causes the same effects: hypersensitivity or hyperemia. The zone of Weill is brutally invaded by a large number of capillaries. The vessels are gorged to the extreme with blood. Endothelial cells have a nucleus that tends to separate from the vascular wall by crossing it. Red blood cells aggregate to the walls due to the slowing of blood flow and the release of cellular mediators. If the stimulus is brief and not too strong, these vascular changes are ephemeral and circulation returns to normal in a short time. The blood flow short-circuits the capillaries by using the arterio-venous shunts. If the stimulus continues, as in the cavity, the inflammatory process is triggered with the margination of leukocytes, plasma exudation, and cellular infiltration in the interstitial tissue. These phenomena remain confined in view of the affected canaliculi and if these are not too numerous and if the degree of inflammation linked to the antigenic load is not too strong, a possibility of healing exists after treatment of the cavity. 1. In a traumatic stimulus Inflammatory phenomena arrive brutally and express acute inflammation. The reversibility of these phenomena depends on the incriminated pulpal territory and the risk of penetration of bacteria into the pulpal tissue. Ex: fissure, occlusal interference, thermal irritation, physical and/or chemical after crown preparation (size of posts, cavity of inlays / onlays). 1. In therapeutic treatment During the preparation of an obturation cavity from a tooth decay the clinician uses rotary instruments that cause aggressions on an inflamed pulp chronically. The risk of irreversibility depends on 2 factors: * the inflammatory degree of the pulp related to the carious process * the trauma caused by the clinical act The prognosis depends on the first 24 hours that follow. 1. Diagnostics Pain: acute, short, provoked, non-remnant Anamnesis and Inspection: past dental history and associated signs Percussion: negative, except in cases of occlusal interference Vitality tests: positive with a lowered threshold X-ray: decay, restoration, no abnormal image. 1. Treatment Preventative and sedative. The cavity must be treated, a coiffage carried out, if necessary a temporary sedative filling (eugenate, IRM) placed, a defective restoration replaced, the occlusion relieved, a fractured tooth covered. ## V. Irreversible pulpitis 1. Definition and micro-abscesses By definition, a pulp that has undergone alterations and lesions beyond its repair capabilities can no longer heal, even if the aggressive stimulus has disappeared. The tissue degenerates more or less slowly, creating necrosis and destructive mechanisms in reaction. What is the point of no return? In general, it is known that the introduction of bacteria into the pulpal tissue is the most frequent step in irreversibility of pulpopathy. The PMNs, lymphocytes, and macrophages are attracted by bacterial antigens and one or more micro-abscesses are formed. Structure of these micro-abscesses: \- central purulent nucleus (dead cells ...) * around, a zone of inflammatory infiltrate with dying or dead cells (fibroblasts) * in the periphery, a fibrous zone which is a tentative repair without organization. * Histological studies show that the nature of the pulpal response is variable. The number of micro-abscesses is variable, the transition to necrosis is very variable over time. The clinician would like to link these histological modifications to clinical symptoms. However, if the destructive process is sometimes painful, it is often asymptomatic, it can be rapid or very slow (years). 1. Irreversible pulpitis with painful symptoms a. Etiology It is the same as the stage of reversible pulpitis. The appearance of painfull simptoms results from an exarcebation of the pulpal inflammation, following new aggressions: primary tooth decay which is developing, food packed into the cavity, cavities under an older filling, new treatment on the hyperalgesic pulp. b. Clinic The acute pulpitis: Tooth with with severe symptoms of pain (toothache) due to compression of the nerve fibers by inflammatory exudation and abscess which can affect all of the pulp (acute purulent pulpitis). The subacute pulpitis: Tooth with true or discomfort true, pain more than pain. Subacute pulpitis cannot be classified as acute or as hronic. It is often exacerbation of chronic-old pulpitis. c. Diagnostics The pain: acute pulpitis: spontaneous, intermittent, remnants pain. Crises are favored by lying down, the pain are refractory to analgesics, the tooth is difficult to locate by the patient, pain is referred (synaligies) and irradiating. Subacute Pulpitis: The diagnosis gets more dificult because the painfull episodes have variable intensity, occuring over the months or years. The possibility of Observing hybrid with partial necrosis of the pulp can only be met in the pluriradiculated teeth. Examination: medical record, caries, restorations, traumas, signs The percussion and radiography: Percussion and negative radiology image * Percussion postitive:Acute apical peridontitis associated with with the periferal ligaments. 1. Irreversible pulpitis with painful symptoms a. Etiology It is the same as the stage of reversible pulpitis. The appearance of painful symptoms results from an exacerbation of the pulpal inflammation, as a result of new aggressions: primary cavity evolving at the stage of cavitation, impacted food in a cavity, recurrent cavities under an old filling, new operative procedures on a hyperalgesic pulp b. Clinic #### The acute pulpitis: Tooth with with severe symptoms of pain (toothache) due to compression of the nerve fibers by inflammatory exudation and abscess which can affect all of the pulp (acute purulent pulpitis). #### The subacute pulpitis: Tooth with true or discomfort true, pain more than pain. Subacute pulpitis cannot be classified as acute or as chronic. It is often exacerbation of chronic-old pulpitis. #### Clinic The pain: acute pulpitis: spontaneous, intermittent, remnant pain. Crises are favored by lying down, the pain is refractory to analgesics, the tooth is difficult to locate by the patient, pain is referred (synaligies) and irradiating. Subacute Pulpitis: The diagnosis gets more difficult because the painful episodes have variable intensity, occurring over the months or years. The possibility of Observing hybrid with partial necrosis of the pulp can only be met in the pluriradiculated teeth. Examination: medical record, caries, restorations, traumas, signs The percussion and radiography: Percussion and negative radiology image * Percussion positive: Acute apical periodontitis associated with with the periapical ligaments. Tests of vitality: They are positive with a lowered threshold and remnant pain. The pain gets lowerd by the cold and exarcebated with heat. In advance stages, the answers get diminuted as Necrosis occurs 1. Treatment Pulpectomy Treatment of the channels one meeting by filling canallaire 3. Irreversible pulpitis without painful symptoms a. Clinical situations : The Chronic Ulcerated Pulpitis: The Pulp being exposed by the cavity is going to be ultered(Opened Shape).The pulp can be painfull in contact with the teeth or pain in contact with blood. The Chronic hyperplasic pulpitis: It can be described as Polypep Prolifering with the cavity It is not a Gum polyps) It is not a Spontaneous Pain. The chronic degenerative palpitis: Eitologie: -Procedures: *traumtism *Orthodontic Force in Teeth This shape is closed: We Can Observe some of the Chonic Inflatrations which are going to week in the future. 1. Diagnostic *Absence of Pain. *We can visualize the shape. 2. Treatment Pulpactamy VI Degenerative pulpities 1. Etiology This is caused by the abrasive. Hyperpasic pupities(Bortmycome) They have no Symptones are in the the pulpotomy VII Les résorptions internes 1)Eitology The cause can be traumatic 2)Shapes -The internal resorption The canal will be the lost of substance and of the bones. The Inflatmatory internal We can only observe and treat if we can see the canal itself Treatment no care if the pulp is limited the removal of the pulp comes down if it' After pulpectomy and the of obturation it can be intracanare with a treatmen VII Necrosis the Palpal The Palpal is very importent A) Autolize B)The cause Of coagulation This is causes y lack of Oxigen . and we get The Necriosis. 5. treatment 2 sesions to disinfect the and irrigation.