PULPITIS

Chapter three

O.R.GANESHM.Sc.D ENDO

Definition:

Inflammation of the pulp (the tooth's

innermost layer) caused by a cavity or

other trauma, and often signalled by a

painful toothache.

category

Reversible pulpitisReversible pulpitis

Irreversible pulpitisIrreversible pulpitis

• Reversible pulpitisReversible pulpitis

The pulp is inflamed to the extent that thermal stimuli cause a quick, sharp, hypersensitive response that subsides as soon as the stimulus is removed.

Reversible pulpitis is not a disease but merely a symptom. If the cause is removed, the pulp should revert to an uninflamed state and the symptom should subside. Conversely, if the cause remains, the symptom may persist, and the inflammation may become more widespread, and eventually, leading to an irreversible pulpitis.

Causes: any irritant that can affect the pulp may cause reversible pulpitis such as caries, thermal, deep

periodontal scaling and root planing.

Distinguishing reversible pulpitis from the irreversible:

1 A sharp painful response to thermal stimulation.

2 Spontaneous pain.

Treatment choice:

Sedative dressing, or called temporary restoration with

sedative package, such as zinc oxide.

• Irreversible pulpitisIrreversible pulpitis

An irreversible pulpitis may be acute, subacute, or chronic, and it may be partial and total. Clinically, acute one is symptomatic, whereas the chronic is asymptomatic. At this stage, the dynamic changes in the pulp are always occurring.

Symptomatic irreversible pulpitis:Symptomatic irreversible pulpitis:

•This type of pulpitis is characterized by This type of pulpitis is characterized by

spontaneous intermittent or continuous paroxysms spontaneous intermittent or continuous paroxysms

of pain.of pain.

•The pain may be caused by sudden temperature The pain may be caused by sudden temperature

changes, which is prolonged.changes, which is prolonged.

•The pain caused by cold stimulation can be relieved The pain caused by cold stimulation can be relieved

by heat, and similarly, the pain caused by heat can by heat, and similarly, the pain caused by heat can

be relieved by coldbe relieved by cold. .

•There may even be a painful response to There may even be a painful response to both cold and heat stimulation too. both cold and heat stimulation too.

•The pain may be localized or referred The pain may be localized or referred (e.g. referred from mandibular molars (e.g. referred from mandibular molars toward the ear or up to the temporal area.)toward the ear or up to the temporal area.)

A symptomatic irreversible pulpitis can be A symptomatic irreversible pulpitis can be

diagnosed by a thorough dental history, visual diagnosed by a thorough dental history, visual

examination, thermal tests and radiography. examination, thermal tests and radiography.

Asymptomatic irreversible pulpitis:Asymptomatic irreversible pulpitis:

This type of irreversible pulpitis is This type of irreversible pulpitis is

asymptomatic because the inflammatory exudate are asymptomatic because the inflammatory exudate are

quickly vented. quickly vented.

It can develop by the conversion of a It can develop by the conversion of a

symptomatic one into a quiescent state. symptomatic one into a quiescent state.

It also can caused by long and low-grade pulp It also can caused by long and low-grade pulp

irritant (carious lesions), traumatic injury. irritant (carious lesions), traumatic injury.

There are three types of asymptomatic pulpitisThere are three types of asymptomatic pulpitis

1.1.Hyperplastic pulpitisHyperplastic pulpitis

Clinically, it is a reddish cauliflower-like Clinically, it is a reddish cauliflower-like overgrowth of pulp tissue through and around a overgrowth of pulp tissue through and around a carious exposure. It is characteristically found carious exposure. It is characteristically found in young people since the generous vascularity in young people since the generous vascularity of the pulp. of the pulp.

2. Internal resorption2. Internal resorption

It is a resorption of the dentine from the pulpIt is a resorption of the dentine from the pulp

outward, which is often caused by trauma or pulpoutward, which is often caused by trauma or pulp

capping. It is usually can be diagnosed bycapping. It is usually can be diagnosed by

radiography. radiography.

3. Canal calcification3. Canal calcification

A large amounts of reparative dentine over depositA large amounts of reparative dentine over deposit

throughout the canal system, which is caused bythroughout the canal system, which is caused by

periodontal therapy, abrasion, trauma etc. periodontal therapy, abrasion, trauma etc.

Chapter four

Periapical diseasePeriapical disease

Classification of periapical diseaseClassification of periapical disease• Acute apical periodontitisAcute apical periodontitis

• It describes acute inflammation around the It describes acute inflammation around the apex. apex.

• The tooth with it may exquisitely tender to The tooth with it may exquisitely tender to percussion.percussion.

•Radiographically the apical periodontal Radiographically the apical periodontal ligament may appear slightly widened or ligament may appear slightly widened or normal.normal.

Causes: Causes:

• Extension of pulpal disease into the Extension of pulpal disease into the

periapical tissue.periapical tissue.

• Endodontic procedures such as canal filling Endodontic procedures such as canal filling

beyond the apical foramen.beyond the apical foramen.

• Occlusal trauma from a high restoration or Occlusal trauma from a high restoration or

from chronic bruxism.from chronic bruxism.

• Acute apical abscessAcute apical abscess

• It implies a painful, purulent exudate It implies a painful, purulent exudate around the apex.around the apex.

• Rapid onset of slight to severe swelling, Rapid onset of slight to severe swelling, pain, and pain to percussion, and possible pain, and pain to percussion, and possible mobility.mobility.

• The distinguishing acute apical abscess The distinguishing acute apical abscess from the lateral periodontal abscess and from the lateral periodontal abscess and from the phoenix abscessfrom the phoenix abscess

For periodontal abscessFor periodontal abscess

Thermal and electric pulp testing indicate Thermal and electric pulp testing indicate the pulp vital; there is a periodontal the pulp vital; there is a periodontal pocket; the tooth may be normal. pocket; the tooth may be normal.

For the phoenix abscessFor the phoenix abscess

All symptoms of acute apical abscess plus All symptoms of acute apical abscess plus apical radiolucency around the apex of the apical radiolucency around the apex of the tooth.tooth.

Pain

slight frequently intense continuous throbbing

Swelling and palpation

palpable fluctuant swelling

Diagnosis

Vitality tests Negative

Radiography

Slight widening of the apical periodontal ligament space

Periapical radiolucency of a subacute periapical abscess

Acute apical periodontitis

(painful phase)

Acute apical abscess

(painful phase)

Subacute periapical abscess (painful phase)

Chronic periapical abscess (nonpainful phase)

• Chronic apical periodontitisChronic apical periodontitis• Chronic apical periodontitis implies long-standing Chronic apical periodontitis implies long-standing asymptomatic inflammation around the apex. Although asymptomatic inflammation around the apex. Although chronic apical periodontitis tends to be asymptomatic, there chronic apical periodontitis tends to be asymptomatic, there may be occasional slight tenderness to palpation and may be occasional slight tenderness to palpation and percussion.percussion.

• Only biopsy and microscopy examination can reveal Only biopsy and microscopy examination can reveal whether these apical lesions are dental granulomas, whether these apical lesions are dental granulomas, abscesses, or cysts. abscesses, or cysts.

• Diagnosis is confirmed by the presence of a radiolucency Diagnosis is confirmed by the presence of a radiolucency that may be either diffuse or well-circumscribed, the absence that may be either diffuse or well-circumscribed, the absence of pulp vitality, and a sinus tract.of pulp vitality, and a sinus tract.

DiagnosisPain no pain or mild pain

Swelling and palpation

Slight swelling in the area around the sinus tract stoma,

surface of the face, floor of the nose and other portions of the

head and neck.

Percussion and mobility Negative

Color tooth color becomes black or grey

Vitality tests Negative

Radiography

Chronic periapical abscess :

diffuse area of bone rarefaction around the root

Chronic periapical granuloma and cyst:

diffuse area of bone rarefaction around the root, and an opaque hyperostotic border

• Phoenix abscessPhoenix abscess

• A phoenix abscess is a chronic apical periodontitis A phoenix abscess is a chronic apical periodontitis that suddenly becomes symptomatic.that suddenly becomes symptomatic.

•The symptoms are identical to those of an acute The symptoms are identical to those of an acute apical abscess, the man difference being that the apical abscess, the man difference being that the phoenix abscess is preceded by a chronic condition.phoenix abscess is preceded by a chronic condition.

• Periapical osteosclerosisPeriapical osteosclerosis

Periapical osteosclerosis is excessive bone Periapical osteosclerosis is excessive bone

mineralization around the apex caused by low-mineralization around the apex caused by low-

grade, relatively asymptomatic, chronic pulpal grade, relatively asymptomatic, chronic pulpal

inflammation which is most commonly found in inflammation which is most commonly found in

young people .young people .

• Although many factors can cause the pulpitis which further Although many factors can cause the pulpitis which further develop into apical periodontitis, the bacteria are the most develop into apical periodontitis, the bacteria are the most common one. common one.

•The factors include: The factors include:

1.1.Bacteria Bacteria

2.2.TraumaTrauma

3.3.Thermal Thermal

4.4.Static electricityStatic electricity

5.5.LaserLaser

6.6.Filling materials Filling materials

7.7.Etch or adhesive agentsEtch or adhesive agents

8.8.Drugs for toilet the cavityDrugs for toilet the cavity

9.9.Immunological aspectImmunological aspect

Causes:Causes:

TreatmentTreatment 1. Diagnostic phase

the tooth to be treated is determined , the

treatment plan is developed.

Once the tooth has been confirmed as irreversible Once the tooth has been confirmed as irreversible

pulpitis or any of apical diseases, the pulpitis or any of apical diseases, the endodontic endodontic

treatmenttreatment must be done. Before you decide to do must be done. Before you decide to do

the endodontic treatment you need to consider the endodontic treatment you need to consider

follows:follows:

Physical evaluation:Physical evaluation:

it mainly concerned about systemic conditions (diseases) such it mainly concerned about systemic conditions (diseases) such as cardiovascular diseases, bleeding disorders, diabetes, as cardiovascular diseases, bleeding disorders, diabetes, cancer, AIDS, pregnancy, allergies, steroid therapy, infectious cancer, AIDS, pregnancy, allergies, steroid therapy, infectious diseases etc. diseases etc.

Psychological evaluation:Psychological evaluation: A patient who shows no incentive (motivation) to maintain A patient who shows no incentive (motivation) to maintain

good oral hygiene or one who constantly misses appointments good oral hygiene or one who constantly misses appointments

may not be a good candidate for endodontic therapy.may not be a good candidate for endodontic therapy.

Evaluation of toothEvaluation of tooth MorphologyMorphology

• Unusual lengthUnusual length• Unusual shapesUnusual shapes• Unusual numbers (canal or roots)Unusual numbers (canal or roots)• ResorptionsResorptions• Calcifications Calcifications

Previous treatmentPrevious treatment• Canal blockageCanal blockage• LedgeLedge• perforationsperforations

Location of toothLocation of tooth• AccessibilityAccessibility• Proximity to other structuresProximity to other structures• RestorabilityRestorability• Periodontal statusPeriodontal status

Treatment planningTreatment planning

general process and sequence:general process and sequence:

•Management of acute pulp or periodontal pain.Management of acute pulp or periodontal pain.

•Oral surgery for extraction of unsalvageable teeth.Oral surgery for extraction of unsalvageable teeth.

•Caries control of deep lesions that may threaten the pulp.Caries control of deep lesions that may threaten the pulp.

•Periodontal procedures to manage soft tissue.Periodontal procedures to manage soft tissue.

•Endodontic procedures for asymptomatic teeth with Endodontic procedures for asymptomatic teeth with necrotic pulps and surgical treatment or re-treatment of necrotic pulps and surgical treatment or re-treatment of failing root canals.failing root canals.

•Restorative and prosthetic procedures. Restorative and prosthetic procedures.

One-appointment root canal therapyOne-appointment root canal therapy

2. Preparatory phase

the contents of the root canal are removed

and the canal prepared for the filling

materials.

Reamer and fileReamer and file

3. Filling phase

filling the canal to gain a seal with an inert

materials as close as possible to the root apical

role.

1. open the pulp cavity

relieve the pressure of pulp cavity pain ceases or relieved

Procedure:

4. fill root canal and restore the tooth

apply a sedative antiseptic dressing 3.

remove infected pulp 2.