Inflammatory conditions of the pulp

INFLAMMATORY CONDITIONS OF THE PULP

Dr. Marwan A. Wahab Al TamimiB.D.S

Conservative Dentistry Department Faculty of Dentistry University of Aden

Yemen

IMPORTANT FEATURES OF HUMAN PULP

Introduction The pulp is surrounded by a hard

tissue (dentine), which limits the area for expansion and restricts the pulp's ability to tolerate edema.

The pulp has almost a total lack of collateral circulation, which severely limits its ability to cope with bacteria, necrotic

tissue and inflammation.

Normal Pulp:Gives moderate response to pulp test,

which subside when the stimulus is removed.

The tooth is free of spontaneous pain.

X-ray shows intact lamina dura.

There is no signs of any abnormalities ( calcifications and resorption. )

CLASSIFICATION OF PULPAL PATHOLOGIES

Grossman’s Clinical Classification

I. Pulpitis.A. Reversible Pulpitis.B. Irreversible Pulpitis: i. Acute : a. Abnormally responsive to cold.b. Abnormally responsive to heat.

ii. Chronic :a. Asymptomatic with pulp exposure.b. Hyperplastic pulpitis. c. Internal resorption.

II. Pulp degeneration. A. Calcific ( Radiographic diagnosis ) B. Other ( Histopathological diagnosis )

III. Necrosis.

PULPITIS

Pulpitis Is inflammation of the dental pulp due to

dental caries, trauma or dental procedures.Its principle symptom is pain.Diagnosis is based on clinical finding and

can be confirmed by X-ray.Treatment involves removing the offending

factors.It sequelae includes apical preiodontitis,

periapical abscess and osteomyelitis of the jaw and other life threading conditions

Pulpitis It sequelae includes apical preiodontitis,

periapical abscess and osteomyelitis of the jaw and other life threading conditions

Spread from maxilla may cause :Purulent sinusitis, orbital cellulitis and C.S.T.

Spread from mandibular may cause :Ludwig’s angina, mediastinitis and

paraphayngeal abscess

REVERSIBLE PULPITIS

DefinitionIt is the general category which may

represent a range of responses varying from dentin hypersensitivity to an early phase of inflammation.

There is a sharp hypersensitive response to cold but the pain subside when the stimulus is removed.

Determination of reversibility is clinical judgment influenced by history and clinical evaluation.

Etiology Dental Caries.

Trauma.

Thermal injury.

Chemical irritation.

Symptoms Reversible pulpitis is characterized

by sharp pain.

The pain stay for few minutes,

Always provoked, never spontaneous.

disappear by itself or after the patient takes some analgesic.

Diagnosis Pain : sharp of brief duration ceasing when

irritant is removed.

Examination and history: caries, traumatic occlusion.

X-Ray: normal PDL and lamina dura. Depth of caires lesion may be evident.

Percussion : negative , not tender to percussion.

Vitality : responds readily to cold and electric test requires less current to cause pain.

Treatment No R.C.T is needed.

Remove the cause, set a pellet of cotton with eugenol for 5 minutes and Zinc oxide and Eugenol as Temporary filling.

After 2 or 3 days in which the tooth has been asymptomatic final restoration may be place.

Dentinal HyperesthesiaAppear when the dentine is exposed ex: tooth abrasion and periodontal

disease.The pain is characterized by a short

duration (1-2 seconds), which appears always

by stimulus: cold liquids, sweet, air, tooth brushing and disappear immediately after the stimulus is removed.

Treatment:Application of agents to promote

dentinal sclerosis: Fluoride and varnish.

PULP HYPEREMIASlight pain, always after different

stimulus: cold or hot water, sweets or food impaction in the cavity, which disappear when the stimulus is retired and may stay for few seconds.

Frequently associated with dental caries, bad restorations.

Treatment:Remove the cause, set the base and

final restoration.

IRREVERSIBLE PULPITIS

Definition It is a persistent inflammatory

condition of the pulp, symptomatic or asymptomatic, caused by noxious stimulus.

It has both acute and chronic stages.

Etiology Untreated or incorrectly treated :

Dental Caries.

Trauma.

Thermal injury.

Chemical irritation.

Symptoms rapid onset of pain which remains after removal of stimulus.

Pain can be spontaneous in nature intermittent or continuous in nature.

In later stages pain is sever, boring, throbbing in nature , increases with hot stimulus.

Pain is relived by cold water.

Diagnosis

Examination and history: deep carious lesion involving the pulp or secondary caries.

X-Ray: Depth and extent of caries lesion may be evident, normal PDL but slight widening may be seen in advanced stages.

Percussion : positive, tooth is tender to percussion.

Vitality : heat intensifies the response and clod tend to relieve the pain and electric test requires less current to cause pain. In initial stages but when the tissue becomes more necrotic more current is required

Treatment

Root canal treatment

CHRONIC PULPITIS

Chronic PulpitisIt is inflammatory response of pulpal

tissue to an irritant with absence of pain because of :

a. Low inflammatory activity.b. Decreased intrapulpal pressure below

the threshold limits of pain receptors.

Its of 3 formsa. Ulcerative form.b. Hyperplastic form.c. Closed form.

Etiology Same as acute irreversible pulpitis,

in which the irritant factor in chronic pulpitis is slow and progressive.

The nature of pulpal response depends on :

a. Strength & duration of the irritant.b. Previous health of pulp.c. Extent of tissue affected.

SymptomsAbsence of pain.

Symptoms arise when there is interference with drainage of exudate.

Hyperplastic form is seen in children and adolescents because high resistance of pulp.

Diagnosis Pain , is usually absent.

In Hyperplastic form a reddish pulpal mass filling most of the pulp chamber is seen.

X-Ray shows :- Ch. Apical periodontitis in long standing cases.- Condensing osteitis, low grade long standing

irritation stimulates periapical bone deposition.

Vitality Tests shows :- Usually not responding to thermal test unless

extreme cold is used.- More current is required.

Treatment

Root canal treatment.Or

Extraction if the tooth is non – restorable.

PULP NECROSIS

Pulp NecrosisIs a condition following untreated pulpitis.

Noxious materials will leak from pulp space forming lesion of endodontic origin.

Necrosis may be partial or total, depending on extent of pulp tissue involvement.

Pulp necrosis is of 2 types :a. Coagulation necrosis.b. Liquefaction necrosis.

Etiology

Is caused by noxious insult and injuries by :

- Bacteria.- Trauma.- Chemical irritation.

Symptoms

Discoloration of tooth – 1st indication of pulp death.

History from patient.

Tooth might be asymptomatic.

Diagnosis Pain is absent in total necrosis.

History of patient reveals past trauma or past history of sever pain which may last for some time followed by complete and sudden cessation of pain.

X-Ray shows :- - Large cavity or filling or normal

appearance unless there is concomitant apical periodontitis or condensing ostitis.

DiagnosisVitality test :-Single rooted = not responding.Multi rooted = mixed response.

• Sometimes in liquefaction necrosis may show positive response to electric test when the current is conducted through moisture present in a root canal

• Visual examination shows color change.

Treatment

Root canal treatment.Or

Extraction if the tooth is non – restorable.

PULP DEGENERATION

PULP DEGENERATION Is generally present in old people.

May result from persistent mild irritation in younger people.

Is induced by :- attrition.- Abrasion.- Erosion.- Operative procedures.- Dental Caries.- Pulp capping.- Other.

FORMS

Atrophic degeneration and fibrosis.Decrease in size which occur slowly as

the tooth grows old.

Calcifications.Has 3 types :- Dystrophic Calcifications.- Diffuse Calcifications.- Denticles / pulp stones.

Classification of Denticles / pulp stones .According to location :-- Free.- Embedded.- Attached.

According to structure :-- True.- False.

BIBLIOGRAPHY

Endodontics. Ingle. 2002. 5th edition.

Textbook of Endodontics. Nisha Garg, Amit Garg. 2007.1st edition.