BDS 11129 Causes of Pulp and Periapical Injuries PDF

Causes of pulp periapical injuries BDS 11129 Date : xx / xx / xxxx and Aims: The educational aims of this lecture are: To explain types of endodontic infections To detail the etiology and progress of pulp and periapical injuries To explain the pulp and surrounding tissues response to pulp and p...

Causes of pulp periapical injuries BDS 11129 Date : xx / xx / xxxx and Aims: The educational aims of this lecture are: To explain types of endodontic infections To detail the etiology and progress of pulp and periapical injuries To explain the pulp and surrounding tissues response to pulp and periapical injuries Objectives: On completion of this lecture, the student should have: An understanding of different injuries of the pulp An understanding of how pulp and periapical injuries develop An understanding of what causes pulp and periapical injuries Normal Periapical Tissues: • This condition represents a clinical and radiographic diagnostic category in which the tooth has normal periapical tissues and will not be abnormally sensitive to percussion or palpation testing. • The teeth in this category have normal lamina dura and periodontal ligament structures. Pulpoperiapical Pathosis Definition: It is an inflammatory response of the periapical connective tissue due to a pulpal irritant The pathway of the pulp and periapical pathosis set out from caries Pulpoperiapical Diseases Etiology: 1-Pulpal inflammation 2-Pulp extirpation 3-Over-instrumentation 4- Improper manipulation 5- Incomplete removal of the pulp tissue 1- Pulpal inflammation: Extending from the root canal to the periapical tissues across the apical foramen. 2- Pulp extirpation: creates a wound due to tearing of tissues ,leading to inflammation of the periapical tissue. 3- Overinstrumentation: as a result of inaccurate measurement of the R.C length. 4- Improper manipulation: - Pushing some chemicals into the surrounding periapical tissue. - Pushing toxic material or remnants of dentine or pulp into the periapical area 5- Incomplete removal of the pulp tissue: Infected remnants extended to the periapical area. Classification of Pulpoperiapical pathosis: Symptomatic Asymptomatic 1-Acute apical periodontitis(incipient stage) 1-Chronic apical periodontitis(incipient stage) 2-Acute apical periodontitis(advanced stage): 2-Chronic apical periodontitis (advanced stage): a-Acute periapical abscess b-Recrudescent (phoenix) c-Subacute periapical abscess a-Chronic periapical abscess. b-Periapical granuloma . c-Periapical cyst 3-Condensing osteitis:(pulpoperiapical osteosclerosis) Symptomatic pulpoperiapical disease: 1-Definition: An inflammatory response of the periapical C.T, due to pulpal irritation in which exudative forces are hyperactive & play a dominant role. 2- Pathogenesis: ( sequel of events) Irritant passes from pulp to periapical tissues Vasodilatation & extravasation of fluids Increase intraperiapical pressure Sensation of tooth elongation & pain Biting on the tooth relieves pain Irritant persists Tooth becomes more tender Acute Periapical abscess Cells of periapical tissue suffers from hypoxia & anoxia Release of proteolytic enzymes & pus formation Agglutination of fluids & pus & pain on biting Stimulation of osteoclastic activity 1-Acute apical periodontitis (incipient stage): Diagnosis & Examination: 1-History & visual examination: Trauma, old carious cavity or crown preparation. 2-Sign & symptoms Moderate to severe pain Pain is localized due to the presence of proprioceptors in the periodontal ligament 3-Percussion: pain increases on percussion 4-Vitality test:  If Pulp is necrotic  -ve result  If in the early stage , the pulp may still have residual viable nerve fibers +ve result 5-Palpation & mobility: Palpation, no swelling Mobility, immobile 6-Radiography: normal or slight widening of the PMS which increases with time. 1-Acute apical periodontitis (incipient stage): Treatment: Root canal treatment. N.B.: In case of acute pulpitis with apical periodontitis signs & symptoms of both conditions will be shown Considered most difficult condition to be treated: • Depth of anesthesia is a common problem. • Complete pulpectomy have to be removed to assure complete pain relief. 2-Acute apical periodontitis (advanced stage): Some features are the same as in the incipient stage except for the throbbing pain which increases:  With biting on the tooth  At night a-Acute periapical abscess b-Recrudescent (phoenix) c-Subacute periapical abscess A- Acute periapical abscess: 1- Definition: Advanced exudative & severe symptomatic inflammatory response of periapical C.T . • It is caused by contaminants from the R.C that causes an increase in: Inflammatory exudate, leucocytic infiltration, suppuration 2-Visual examination & history: • Redness & hotness of the mucosa opposite to the periapical region of the affected tooth. • Swelling of the oral mucosa & skin is noticed later. A- Acute periapical abscess: 3- Signs & symptoms: A) Severe throbbing pain increases on biting or at night. B) Feeling of fullness or elongation of the tooth. C)The patient suffers from fever, malaise and loss of appetite. The most intense pain occurs, as the pus penetrates the outer plate of bone & begin to raise the periosteum. Once the periosteum & the mucosa rupture , due to: Pressure of the suppurative material or Operator’s scalp. The pain subsides & will not return unless the drainage is blocked. A- Acute periapical abscess: 4-Percussion : Severe pain 5-Vitality test : -ve ( pulp is necrotic) 6-Radiography: Normal or slight widening of PMS 7-Palpation and mobility:  No swelling in the early stage , but firm pressure against the mucosa over the root end will result in a painful response.  Resorption of overlying cortical bone and localization of the suppurative mass beneath the mucosa leading to palpable fluctuant swelling.  Mobility; slight mobility. 8-Treatment: Drainage should be achieved either through access cavity or through incision & drainage. 2- Recrudescent Abscess :(Phoenix abscess) 1- Definition : It is an acute exacerbation of a chronic lesion. (phoenix: breaking out a new) 2- Etiology: It develops as granulomatous zone which becomes contaminated or infected by elements from the root canal as during endodontic procedures 3- Diagnosis: Similar to acute periapical abscess (Except a Large ill defined radiolucent area.) 3- Subacute periapical Abscess : Definition : It is a painful phase of a chronic periapical abscess cycle. Etiology: It develops due to blockage of the drainage of the sinus. e.g: temporary filling. Signs and symptoms: - Mild to moderate pain. - Red ballooning out ( gum boil) opposite to the area of drainage. Asymptomatic Pulpoperiapical Pathosis: 1-Definition: • • • Any reaction of the periapical tissue to inflammation where proliferative forces are hyperactive and play a dominant role. If irritant is of low intensity , the chronic periapical response may develop from the onset. It usually results from pulp necrosis or may develop from an acute apical periodontits whose acute features have dissipated. 1- Chronic apical periodontitis (incipient stage) 1- History and visual examination:  Long standing caries.  Trauma.  The color of the tooth is dark due to pulp necrosis. 2- Signs and symptoms: Painless ( pulp is necrotic) 3- Percussion: -ve or slight discomfort. 4-Palpation and mobility: normal. 5- Vitality test: -ve or false positive response in case of liquefactive necrosis. 6- Radiographically : widening of the PMS. Treatment: Root canal treatment. 2- Chronic apical periodontitis (Late stage): A- Chronic Periapical Abscess: 1- Long standing low grade inflammatory reaction of the periapical C.T to pulpal irritants 2- Characterized by the formation of pus draining through a sinus tract. 3- It develops from: Chronic apical periodontitis or acute periapical abscess that found a pathway for drainage through the mucosa. 4- All diagnostic features are the same as chronic apical periodontitis incipient stage, except: a) Palpation & mobility: some degree of mobility due to bone loss. b) Radiographically: ill defined hazy radiolucent area around the apex ( making it different from cyst and granuloma) • Treatment: Root canal treatment Chronic Periapical Abscess B-Periapical Granuloma: • Characterized by growth of granulomatous tissues and presence of chronic inflammatory cells. • Clinically: No sinus tract is present All diagnostic features are the same as chronic apical abcess except: Radiographically: well defined radiolucent area surrounded by radioopaque+ loss of lamina dura. Clinically : no sinus tract is present  PERIAPICAL GRANULOMA C-Periapical Cyst: • Definition: Central fluid-filled epithelium-lined cavity surrounded by granulation tissue and a fibrous capsule Pathogenesis: Periapical granuloma Irritation & proliferation of epithelial rests of Malassez Large mass of cells Inner cells are deprived of nourishment & undergo liquefactive necrosis Formation of a cavity in the centre of granuloma Periapical Cyst Diagnosis: 1- History and visual examination:  history of periapical granuloma , due to pulp affection by caries 2- Signs and symptoms: Painless or slight discomfort 3- Percussion: -ve or slight discomfort. 4-Palpation: egg shell crackling. and mobility: increased mobility due to bone resorption. 5- Vitality test: -ve or false positive response in case of liquifactive necrosis. 6- Radiographically : well defined periapical radiolucency surrounded by radioopaque marrgins Treatment: Root canal treatment+ surgical removal of the cyst + apicectomy 3-Condensing osteitis(pulpoperiapical osteosclerosis): 1- It is a productive response of the periapical bone to a low grade long standing pulpal irritaion 2- Characterized by increase in the density of bone not due to high concentration of minerals but due to osteoblastic hyperactivity 3- So bone increases at apex in the expense of bone marrow space 4- Radiographically it appears radio-opaque. 5- Treatment: root canal treatment and the condition subsides. Aims: The educational aims of this lecture are: To explain types of endodontic infections To detail the etiology and progress of pulp and periapical injuries To explain the pulp and surrounding tissues response to pulp and periapical injuries Objectives: On completion of this lecture, the student should have: An understanding of different injuries of the pulp An understanding of how pulp and periapical injuries develop An understanding of what causes pulp and periapical injuries Reading material: Students are advised to read details at: 1. Cohen`s pathways of the pulp, 11th edition, 2016, Kenneth M. Hargreaves and Louis H. Berman. (chapters 14 and 15) 2. Endodontic science (two volumes), 2nd edition, 2009, Carlos Estrela. (chapters 8 and 9) 3. Problems in endodontics, Etiology, diagnosis and treatment, 2009, Michael Hulsmann and Edgar Thank you