LEC01-Pulpal Diseases PDF

Irritants  Irritation of pulpal or periradicular tissues results in inflammation  The major irritants of these tissues can be divided into living and nonliving irritants.  The living irritants are various microorganisms and viruses.  The nonliving irritants include mechanical, thermal, and chemi...

Irritants  Irritation of pulpal or periradicular tissues results in inflammation  The major irritants of these tissues can be divided into living and nonliving irritants.  The living irritants are various microorganisms and viruses.  The nonliving irritants include mechanical, thermal, and chemical irritants. MICROBIAL IRRITANTS  Microorganisms present in the dental caries are the main sources of irritation of the dental pulp and periradicular tissues.  Carious dentin and enamel contain numerous species of bacteria such as Streptococcus mutans, lactobacilli, and Actinomyces.'  Microorganisms in caries produce toxins that penetrate to the pulp through tubules.  As a result of the presence of microorganisms and their by-products in dentin, pulp is infiltrated locally (at the base of tubules involved in caries) primarily by chronic inflammatory cells such as macrophages, lymphocytes, and plasma cells.  As the decay progresses toward the pulp, the intensity and character of the infiltrate change.  When actual exposure occurs, the pulp tissue is infiltrated locally by polymorph nuclear (PMN) leukocytes to form an area of liquefaction necrosis at the site of exposure.  After pulp exposure, bacteria colonize and persist at the site of necrosis MECHANICAL IRRITANTS  pulp or periradicular tissues can also be irritated mechanically. Ø Deep cavity preparations, Ø removal of tooth structure without proper cooling, Ø impact trauma, Ø occlusal trauma, Ø deep periodontal curettage, and Ø orthodontic movement of teeth CHEMICAL IRRITANTS  Chemical irritants of the pulp include various Ødentin cleansing, Østerilizing, and ØDesensitizing substances Øas well as some of the substances present in temporary and permanent filling materials and cavity liners. CHEMICAL IRRITANTS Ø Antibacterial irrigants used during cleaning and shaping of root canals, Ø intracanal medications, and Ø some compounds present in obturating materials  are examples of potential chemical irritants of periradicular tissues. Pulpal Pathosis  Depending on the severity and duration of the insult and the host response, the pulpal response ranges from  transient inflammation (reversible pulpitis)  to irreversible pulpitis and  then to total necrosis. Classification of Pulpal Diseases  Because there is little or no correlation between the histologic findings of pulpal pathosis and symptoms,"," the diagnosis and classification of pulpal diseases are based on clinical signs and symptoms rather than on histopathologic findings. Classification of Pulpal Diseases  Pulpal conditions can be classified as Reversible pulpitis, ii. Irreversible pulpitis, iii. Hyperplastic pulpitis, iv. Necrosis. Hard tissue responses include i. Calcifications. ii. Resorption. i. REVERSIBLE PULPITIS  Reversible pulpitis is inflammation of the pulp that is not severe.  If the cause is eliminated, inflammation will resolve and the pulp will return to normal. Symptoms  Application of stimuli such as cold or hot liquids or even air, may produce sharp transient pain.  Removal of these stimuli, results in immediate relief.  Tooth not tender to percussion  Normal radiographic findings. Treatment  Removal of irritants and sealing as well as insulating the exposed dentin or vital pulp usually result in diminished symptoms and reversal of the inflammatory process in the pulp tissue. IRREVERSIBLE PULPITIS  Irreversible pulpitis is often a sequel to and a progression from reversible pulpitis.  Irreversible pulpitis is a severe inflammation that will not resolve even if the cause is removed.  The pulp slowly or rapidly progresses to necrosis. Symptoms  Intermittent or continuous episodes of spontaneous pain (with no external stimuli).  Pain of irreversible pulpitis may be sharp, dull,  Localized, or diffuse  May last only for minutes or for hours.  Application of external stimuli such as cold or heat may result in prolonged pain.  Occasionally, application of cold in patients with painful irreversible pulpitis causes vasoconstriction, a drop in pulpal pressure, and subsequent pain relief. Tests and Treatment  If inflammation is confined and has not extended periapically, teeth respond within normal limits to Ø palpation and Ø percussion.  Extension of inflammation to the periodontal ligament causes percussion sensitivity and better localization of pain.  Root canal treatment or extraction is indicated for teeth with signs and symptoms of irreversible pulpitis. Hyperplastic Pulpitis  Hyperplastic pulpitis (pulp polyp) is a form of irreversible pulpitis, which results from growth of chronically inflamed young pulp into occlusal surfaces.  It is usually found in carious crowns of young patients  It appears as a reddish cauliflower-like outgrowth Symptoms  Hyperplastic pulpitis is usually asymptomatic.  It is occasionally associated with clinical signs of irreversible pulpitis such as spontaneous pain as well as lingering pain to cold and heat stimuli.  The teeth respond within normal limits when palpated or percussed. treatment  root canal treatment, or  extraction. Pulp Calcification  Extensive calcification (usually in the form of pulp stones or diffuse calcification) occurs as a response to trauma, caries, periodontal disease, or other irritants. irritants.  Thrombi in blood vessels and collagen sheaths around vessel walls are possible nidi for these calcifications.  Another type of calcification is the extensive formation of hard tissue on dentin walls, often in response to irritation or death and replacement of odontoblasts. This process is calcific metamorphosis Signs & symptoms Ø Obliteration of the pulp chamber and root canals' Ø A yellowish discoloration of the crown is often a Ø The pain threshold to thermal and electrical stimuli usually increases, or often the teeth are unresponsive. Ø Responses to palpation and percussion are usually within normal limits. In contrast Treatment  This condition in and of itself is not a pathosis and does not require treatment. Internal (Intracanal) Resorption  Inflammation in the pulp may initiate resorption of adjacent hard tissues.  The pulp is transformed into vascularized inflammatory tissue with dentinoclastic activity; this resorbs the dentinal walls, advancing from the center to the periphery. Signs & symptoms  Most cases of intracanal resorption are asymptomatic.  Advanced internal resorption involving the pulp chamber is often associated with pink spots in the crown.  Teeth with intracanal resorptive lesions usually respond within normal limits to pulpal and periapical tests.  Radiographs reveal a radiolucency with irregular enlargement of the root canal compartment Treatment  Immediate removal of inflamed tissue and institution of root canal treatment is recommended;  Some times these lesions tend to be progressive and eventually perforate to the lateral periodontrum.  When this occurs, pulpal necrosis ensues, creating major problems in treatment options. PULPAL NECROSIS  It is a clinical diagnostic category indicating death of the dental pulp, necessitating root canal treatment.  The pulp is non-responsive to pulp testing and is asymptomatic.  Pulp necrosis by itself does not cause apical periodontitis unless the canal is infected. Classification of Periradicular Lesions  These lesions are classified into five main groups: Ø Acute apical periodontitis, Ø Chronicapical periodontitis, Ø Condensing osteitis, Ø Acute apical abscess, and Ø Chronic apical abscess  Lesions associated with significant symptoms such as pain or swelling are referred to as acute (symptomatic), whereas those with mild or no symptoms are identified as chronic (asymptomatic). Normal Apical Tissues  Normal Apical Tissues are not sensitive to percussion or palpation testing and radiographically, the lamina dura surrounding the root is intact and the periodontal ligament space is uniform. Symptomatic Apical Periodontitis  represents inflammation, usually of the apical periodontium, producing clinical symptoms involving a painful response to biting and/or percussion or palpation.  This may or may not be accompanied by radiographic changes. Asymptomatic Apical Periodontitis  It is inflammation and destruction of the apical periodontium that is of pulpal origin.  It appears as an apical radiolucency and does not present clinical symptoms (no pain on percussion or palpation). Chronic Apical Abscess  It is an inflammatory reaction to pulpal infection and necrosis characterized by gradual onset, little or no discomfort and an intermittent discharge of pus through an associated sinus tract.  Radiographically, there are typically signs of osseous destruction such as a radiolucency. Acute Apical Abscess  It is an inflammatory reaction to pulpal infection and necrosis characterized by  rapid onset,  spontaneous pain,  extreme tenderness of the tooth to pressure,  pus formation and swelling of associated tissues. Acute Apical Abscess  There may be no radiographic signs of destruction and the patient often experiences malaise, fever and lymphadenopathy. Condensing Osteitis  is a diffuse radiopaque lesion representing a localized bony reaction to a low-grade inflammatory stimulus usually seen at the apex of the tooth.