Pulp Diseases Lecture PDF

Pulp Diseases BY Dr: Hanan Eid Gamal - The most common pulp disease is pulp inflammation (pulpitis). Pulpitis, if untreated, is followed by death of the pulp and spread of infection through the apical foramina into the periapical tissues. Criteria of pulp inflammation  Absence of col...

Pulp Diseases BY Dr: Hanan Eid Gamal - The most common pulp disease is pulp inflammation (pulpitis). Pulpitis, if untreated, is followed by death of the pulp and spread of infection through the apical foramina into the periapical tissues. Criteria of pulp inflammation  Absence of collateral circulation This accelerates degeneration of pulp tissue if subjected to irritation Constricted apical foramen This limits the blood supply to the pulp and venous return from the pulp Pulp is enclosed in a rigid chamber of dentine This will not allow pulp tissue to swell if inflammed and edema fluid will press on blood vessels. So pulp inflammation usually proceed into necrosis Pulp is not precisely presented in the sensory cortex This will leads to unlocalized type of pain on the affected side by the patient. Pain may be referred to distant sites as the ear. Etiology of Pulpitis  1. Bacterial (Living Irritants) Bacteria can gain access into the pulp through :  Dental caries: the most common cause. Tooth fracture: Fracture of crown or cusp Cracked tooth syndrome: minute invisible cracks but allow bacteria to enter the pulp Can be identified by applying pressure to occlusal surface with burnisher to open up the cracks, pulp pain then results. Blood born infection (anachoresis): It is settlement of bacteria circulating in the blood(as in tonsillitis), in a hyperaemic pulp facilitated by stasis caused by hyperaemia. -Through deep periodontal pocket via an accessory root canal. Iatrogenic comes from a Greek word that means complication caused by a physician. -Odontoiatrogenic(complication caused by a dentist) damage, in case of pulp exposure during cavity preparation.  2. Chemical causes Odontoiatrogenic damage Use of Irritant substances as alcohol or chlorofom for drying cavities. Improper mixing of cements as zinc phosphate cement. Erosion It is a chemical destruction of tooth structure by acids that causes variously shaped depressions, generally at the cemento-enamel junctions of teeth.  3. Physical causes Odontoiatrogenic damage Thermal irritants Large metallic restoration without base Heat generation during cavity preparation or tooth reduction for crown construction without cooling water spray. Electric stimulation:  due to presence of two dissimilar metallic restorations (Galvanism) without using varnish.  4. Mechanical causes Trauma leading to crushing blood supply of tooth. Abrasion: is the loss of tooth structure by mechanical forces (friction) from a foreign element as toothbrushes and toothpicks. Brushing too hard is a common cause of abrasion.  5. Aerodontalgia Is a condition in which a toothache is present in persons flying at high altitudes and are recently subjected to recent filling or carious teeth. As gas spaces may exist in infected teeth or may enter around the edge of the filling , gas expansion occur resulting in severe pain. It is recommended to insert pulp protector in the cavity after preparation to prevent pain. Classification of Pulpitis  A. According to type of inflammation Focal reversible pulpitis Acute pulpitis Chronic pulpitis Irreversible Chronic hyperplastic pulpitis  B. According to extent of pulp inflammation  Partial pulpitis The pulpitis is confined to part of the pulp  Total pulpitis The entire pulp is involved  C. According to communication between the pulp and the oral cavity  Closed pulpitis No direct communication between the pulp and the oral cavity  Open pulpitis The pulp is communicated (exposed) with the oral cavity  Focal Reversible Pulpitis ( Pulp Hyperemia) Definition  Is the active dilatation of the pulp blood vessels representing the earlier stage of pulpitis  It is reversible condition provided that the irritant is removed before the pulp is severely damaged  Focal Reversible Pulpitis ( Pulp Hyperemia) Etiology  Any cause of the previous causes Clinically  The tooth is sensitive to thermal changes particularly cold  Pain is sharp shooting and disappears rapidly on removal of the stimulus  Pain can not be localized  Tooth is more sensitive to electric pulp tester  Focal Reversible Pulpitis ( Pulp Hyperemia) Histopathology  Dilated blood vessels  Presence of inflammatory fluid exudate (edema)  No extravasation of RBCs  Intact odontoblastic layer. Treatment  Removal of the cause Prognosis  Very good, the condition is reversible if the insult is removed  Acute Pulpitis Definition  An acute inflammation of the pulp Etiology  Any of the previous causes  The condition may follow pulp hyperemia or representing acute exacerbation of chronic pulpitis  Acute Pulpitis Clinically In early irreversible pulpitis: Sharp, severe pain upon thermal stimulation especially cold although heat, sweet or sour foods also can produce pain. The pain continues after the stimulus is removed. The pain may be spontaneous and may be exacerbated when the patient lies down.  In the later stages of irreversible pulpitis: The pain increases in intensity and is experienced as a throbbing pain that can keep patients awake at night. The patient is unable to identify the offending tooth within a quadrant. At this point, heat increases the pain; however, cold may produce relief. Pain is due to : - Pressure on irritated nerve endings by inflammatory exudate - Release of pain mediators as bradykinine and serotonine from the damaged tissues - Tooth is more sensitive to electric pulp tester - Tooth is not sensitive to percussion  Acute Pulpitis Histologically  Destruction of odontoblastic layer  Dilatation of blood vessels  Inflammatory edema  Acute inflammatory cellular exudate (PNLs)  Focal areas of liquifactive tissue necrosis forming focus of pus (pulp abscess)  Pus is consists of necrotic pulp tissue, dead and alive PNLs and dead and alive bacteria  Multiple foci of pus are formed which fuse together and total liquifaction of pulp occurs ( suppurative pulpitis ) Treatment  Extraction or endodontic treatment Pulp Abscess  Total Pulpitis 1. Dilated BVs 2.Dense PNLs infiltrate 3. Loss of odontoblastic layer 1 3 1. Pus Cells in center 2. Pyogenic membrane 3. Inflammatory cells 2 Suppurative Pulpitis  Chronic Pulpitis Definition  is a chronic inflammation of the pulp  The inflammation is persistent with continuous attempts of repair Etiology  It may follow acute pulpitis or arise de novo due to low virulent bacteria  Chronic Pulpitis Clinically  Pain is dull aching, and is intermittent  Reduced reaction to thermal changes and electric pulp tester  Tooth is not sensitive to percussion Histologically  The pulp is gradually replaced by granulation tissue due to increased activity of fibroblasts  Granulation tissue is formed of :  Proliferating fibroblasts  Proliferating blood capillaries  Delicate collagen fibrils  Chronic inflammatory cells  Chronic Pulpitis As there is low-grade irritation so, considerable amounts of reactionary dentin continue to form. The dentin bridges is poorly formed, and inflammation progresses beneath it. Treatment  Endodontic treatment or extraction Fate  Acute exacerbation  Pulp necrosis  Chronic Hyperplastic Pulpitis Definition  It is a hyperplasia of chronically inflammed pulp Etiology 4 pre-requests should be fulfilled:  Good sheltered area of the newly formed tissue  Wide apical foramen for good blood supply  Wide pulp exposure to allow protrusion of the new tissue  Young aged patient for good proliferative power  Chronic Hyperplastic Pulpitis Clinically  Usually affects children and young adults  Common teeth are deciduous molars and first permanent molars  A swollen tissue is extruded from the pulp and is present in a wide carious cavity  The lesion is insensitive to manipulation as it contains few nerve endings Differential diagnosis It should be differentiated from gingival polyp which is:  Attached to gingiva  More sensitive to manipulation Chronic Hyperplastic Pulpitis  Chronic Hyperplastic Pulpitis Histologically  Granulation tissue with chronic inflammatory cells  Epithelialization of this tissue occurs by time. The source of epithelium is : 1. Desquamated epithelial cells found in saliva 2. Implantation of epithelial cells during rubbing of the cheek with the mass of granulation tissue Treatment  Extraction or endodontic treatment Chronic Hyperplastic Pulpitis Thank you