Pulpal Structure and Diseases - 2nd PDF

Tishik International University Dental Faculty Endodontic Department DIAGNOSTIC PROCEDURES IN ENDODONTICS 4th Grade ENDODONTICS-Dent 452 By Assi.st Prof. Dr. Nawfal Zakarea MSc., PhD. Conservative dentistry  P...

Tishik International University Dental Faculty Endodontic Department DIAGNOSTIC PROCEDURES IN ENDODONTICS 4th Grade ENDODONTICS-Dent 452 By Assi.st Prof. Dr. Nawfal Zakarea MSc., PhD. Conservative dentistry  Pulp structure Dental Pulp Dental pulp is an unmineralized oral tissue composed of soft connective tissue, 1. Vascular 2. Lymphatic 3. Nervous elements the occupies the central pulp cavity of each tooth. Pulp has a soft, gelatinous consistency.  Pulpal Architecture Pulp anatomy is complex with many root canals having 1- Apical deltas 2- Lateral canals 3- Accessory canals 4- Fins 5- Anastomoses Apical deltas Lateral canals Anastomoses Different sources of infections The crown is completely sound Multi foramen multi branches apically Periapicl pathosis Periapicl pathosis  Difference between accessory and lateral canal Accessory canal: Defined as a fine branch of the pulp canal that diverged at an oblique angle from the main canal to exit into the periodontal ligament space lateral canal: Defined as a branch diverging at almost right angles from the main canal For simplicity, only the term ‘accessory’ should be used for such canals, and terms such as ‘lateral’ are not necessary to avoid any potential confusion. lateral canal Accessory canal The interface between the dentine and pulp forming an interconnected tissue, often known as the pulp–dentine complex, which is normally protected from irritation by an intact layer of enamel in crown.  Causes Of Pulp Diseases Pulp reacts to various irritants Depending on the severity, duration of the irritants & the pulpal response ranges from: transient inflammation total necrosis  I-Physical Causes 1. Mechanical Injuries : Usually due to trauma or pathological wear of tooth. Trauma :- 1- Common in children , due to : violent blow to the tooth during a fight, Sports, automobile accident, household accident. 2- Habits such as opening hard object with the teeth , compulsive bruxism , nail biting & thread biting. 3- Certain dental procedures occasionally injure the pulp, some are avoidable others are not. Like crown preparation, over cutting with dull burs, reduced cooling system of turbine The overall incidence of pulp necrosis was 9% Removing dentin for a crown preparation, curing materials needed for provisionalization, and microleakage under a temporary crown can all contribute to possible preexisting pulpitis 4- May or may not be accompanied with fracture with crown or root.  Pathologic Wear From either abrasion or attrition if secondary dentin is not deposited rapidly enough also due to repeated occlusal trauma. Attrition: This is natural tooth-to-tooth friction that happens when you clench or grind your teeth such as with bruxism, which often occurs involuntarily during sleep Abrasion: This is physical wear and tear of the tooth surface that happens with faulty brushing or hard tooth Brush, fingernails, and chewing tobacco. Abfraction: Is the pathological loss of tooth substance caused by biomechanical loading forces that result in flexure and failure of enamel and dentin at a location away from the loading and may also be accompanied by pathological wear, such as abrasion and erosion the damage is wedge-shaped or V-shaped and is unrelated to cavities, bacteria, or infection. Different shapes of abfractions Erosion: This occurs chemically when acidic content hits the tooth surface such as with certain medications like aspirin or vitamin C tablets, highly acidic foods, frequent vomiting (models). Cracked tooth Syndrome: Incomplete fracture through the body of the tooth may be due to excessive masticatory forces symptoms range from mild pain to severe pain. Pulp of this teeth may become necrotic in sever cases When patient bite on a cotton or rubber wheel feel pain during releasing of biting pressure. Radiological manifestation J shaped lesion in late stage. It can be visualized by using a dye or by trans illumination with a fiber optic light. 2. Thermal injuries : Due to cavity preparation :- 1. Deeper the cavity preparation 2. High–speed engines 3. Poor coolant system 4. Extensive cavity 5. Excessive cutting of dentin 6. Dull burs 7. High pressure with cutting Affecting Factors 1. Speed of rotation 2. Amount pressure 4 halls turbine 3. Time of cutting without intermittent touching of dentin during cutting 4. Cooling system 5. Bur sharpness Polishing injury :- Polishing with dry powders lead to temperature rise. Heat conduction by restoration :- Very deep metallic restorations close to the pulp without any intermediate cement base. Sudden change in temperature from foodstuffs such as ice cream , hot coffee , ice cubes. 3. Electrical : Galvanic current from dissimilar metal fillings. Now rarely use metal restoration.  II- Chemical Causes Least common Pulpal inflammation due to: 1. Citrus ingestion 2. Acid etchants when used to exposed dentin, after new composite restoration. 3. Dehydrating chemicals for sterilizing / drying like alcohol. 4. Gastrointestinal problems that produce repeated exposure of teeth to gastric acids Up to this slide  ATTENTION Don’t use the slides of last years because there is updating every year  III- Bacterial Causes Most common cause: There are 3 pathways of bacterial invasion 1- Direct invasion through dentin such as caries , fracture of the crown or root , exposure during cavity preparation , attrition , abrasion , erosion or crack in the tooth. 2- Invasion through open blood vessels or lymphatics associated with periodontal disease , accessory canal through furcation area , gingival infection. 3- Invasion through blood (anachoretic effect ) such as during infectious diseases or transient bacteremia. Anachoretic Pulpitis: It is the type of pulpitis when the pulpal inflammation is seen due to the bacteria entering the blood stream through a Chemical or Mechanical injury to the pulp.  IV- Idiopathic Causes Aging 1. Atrophy of the pulp 2. Decrease number & size of the cells 3. Increase collagen fibre content So less likely to resist various stimulus than the young pulp Internal Resorption: Localized internal dentin destruction due to odontoclastic activity In initial stage with CBCT we can know if it is Ext. or Int. But when the communication between the pulp and PDL occur it is difficult to distinguish between ext. and int. Clinical appearance of internal resorption Pink spot on the crown  Etiology of internal resorption Exact cause is unknown Possible contributing factors are:- 1. Trauma 2. Caries 3. Ortho treatment 4. Infection/pulpitis Internal bleaching 5. Extreme heat Example ……… 6. Internal bleaching  Treatment Due to the resorptive tissue being supplied by blood vessels coming through the apex, endodontic treatment will arrest the progression of the resorption, and should, therefore, be started as soon as possible after diagnosis. In case of root perforation, Calcium hydroxide paste is placed in canal until the defect is repaired by calcific barrier. The resorption area repaired by MTA (infra bony) the canal is finally obturated. Super-EBA is a general purpose zinc oxide eugenol cement reinforced with ethoxy benzoic acid (EBA) While supra bony is repaired by other restoration like GI or composite  External resorption When external resorption destroys enough dentin to reach the pulp, pulpal inflammatory changes begin In external resorptions the resorptive area will appear less radiolucent than the root canal, The mechanism is like internal resorption Apical root resorption (orthodontic movement, periapical pathology) Generalized external resorption Localized external resorption  Treatment 1- Generalized type is treated by removal of causes. 2- Localized one treated by: A- If it is accessible (suprabony) RCT and composite restoration. accessible B- If it is non accessible (infrabony) treatment is surgical access and correction by MTA or BIODENTINE non accessible  Link of video https://www.youtube.com/watch?v=-fPfDb7nJvA https://www.youtube.com/watch?v=RY5mal5npNk https://www.youtube.com/watch?v=FmuGSMk8mkY  Diseases Of The Pulp Diseases of the pulp Pulpitis (Inflammation) 1- Reversible Pulpitis A- Acute (symptomatic) B- Chronic (Asymptomatic) 2- Irreversible Pulpitis Acute a. Abnormally responsive to cold b. Abnormally responsive to heat Chronic a. Asymptomatic with pulp exposure b. Hyperplastic pulpitis c. Internal resorption 3- Pulp degeneration: A. Calcific Atrophic degeneration Fibrous degeneration A. Pulp necrosis Reversible pulpitis / Pulp hyperemia 1. Mild to moderate inflammatory condition. 2. Pulp can return to its normal position after removal of stimuli 3. Sharp pain of short duration (less than 5 Seconds). 4. Pain subsides after stimulus is removed. 5. The affected tooth most responds to cold. 6. Tooth responds to electric pulp testing at very low levels of current than control tooth. 7. Contact with sweet and sour can also cause pain. 8. No spontaneous pain.  ACUTE IRREVERSIBLE PULPITIS 1. Immediate sequelae of reversible pulpitis or may also occur as an acute exacerbation of chronic inflammatory process. 2. Occur in a tooth with a large carious lesion or restoration. 3. Sharp, severe lancinating or throbbing localized type of pain upon thermal stimulation and continue even after stimulus is removed. 4. Cold is especially uncomfortable. 5. Heat, sweet, acidic food can elicit pain. 6. Pain increases when patient lie down. 7. The tooth responds to electric pulp testing at low levels of current. 8. Patient can point the offending tooth. 9. Spontaneous pain So, in all types of pulpitis the pulp is vital????  TREATMENT Reversible pulpitis Removal of causes (caries, old defective restoration, do restoration) Irreversible pulpitis RCT  CHRONIC IRREVERSIBLE PULPITIS 1. May rise in occasion trough calm of a previous acute pulpitis 2. Signs & symptoms are milder than acute form 3. Mild, dull, intermittent type of pain 4. The tooth responds to electric pulp testing at high levels of current  CHRONIC HYPERPLASTIC PULPITIS (PULP POLYP) 1. Unique form of pulpitis reacts by excessive cellular proliferation 2. Due to an extensive carious exposure of a young pulp. 3. Symptomless unless provoked. 4. Occur mostly in deciduous molars or first permanent molars. Seen in teeth of children and young adults. 5. It is important to distinguish it from gingival pulp (in CL II caries) 1. Epithelial cells either implanted from the desquamated oral epithelial or differentiated from Undifferentiated pulpal cells Treatment is RCT  PULP DEGENERATION Generally found in teeth of old age Result of persistent , mild irritation Symptoms : discoloration , lack of response of to stimulation 3 types :- 1. Calcific Degeneration 2. Atrophic Degeneration 3. Fibrous Degeneration  CALCIFIC DEGENERATION 1. Extensive calcification (usually in the form of pulp stones or diffuse calcification) appear as a response to trauma , caries , periodontal disease , or other irritants 2. Generally, seen in pulp chamber 3. First recognized in radiograph 4. Usually asymptomatic but may show a slight color change in crown Complete decalcification of pulp chamber & root canal  ATROPHIC DEGENERATION ❖Commonly found in old age (histological changes) ❖Sensitivity of pulp tissue also decreases ❖Asymptomatic condition. ❖Characterized by replacement of cellular elements by fibrous connective tissue which on removal from pulp gives a leathery fiber appearance.  GANGEROUS NECROSIS OF PULP Necrosis is sequel to inflammation or traumatic injury in which pulp is destroyed before an inflammatory reaction takes place. Two types of necroses seen in pulp: Partial Total Usually asymptomatic, may be associated with spontaneous pain & discomfort.