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Diseases of The Pulp
Diseases of The Pulp
DISEASES OF THE
PULP
Dr. Nithin Mathew
CONTENT
S
• Introduction • Internal Resorption
• Pathophysiology • Pulp Degeneration
• Classification • Pulp Necrosis
• Etiological Agents
• Mechanical • Conclusion
• Thermal • References
• Electrical
• Bacterial
• Pulp consists of
• Tiny blood vessels
• Lymph
• Myelinated and unmyelinated nerve fibres, etc..
• Inflammatory response of the pulp is altered by some unique features of the pulp:
• Relating clinical status of the tooth to histopathology is very difficult as there are no signs
or tests that correlate the two.
Pulp
Decreased Cellular
Degranulation
Blood Flow
Damage
9
RELEASE OF INFLAMMATORY MEDIATORS (HISTAMINE, PROSTAGLANDINS,
BRADYKININS)
Dilatation of Arterioles
10
IRRITATION TO CLINICAL
CROWN
11
Classification of
Pulpal
Diseases
GROSSMAN’S
CLASSIFICATION
1. Pulpitis (Inflammatory Diseases) 2. Pulp Degeneration
i. Reversible i. Calcific
a. Acute (symptomatic) ii. Atrophic
b. Chronic (asymptomatic) iii. Fibrous
b. Chronic
a. Asymptomatic with pulp exposure
b. Hyperplastic pulpitis
Dis e a s e s
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o f t he P
c. Internal resorption
Diseases of the Pulp – Dr. Nithin Mathew
ulp
SELTZER & BENDER’S
CLASSIFICATION
• Found little correlation between clinical symptoms and histologic appearance.
• They correlated the results of clinical tests of the pulp with the histologic diagnosis:
Treatable: Untreatable:
• Intact uninflammed pulp • Chronic partial pulpitis with necrosis
• Transitional stage • Chronic total pulpitis
• Atrophic pulp • Total pulp necrosis
• Acute pulpitis
• Chronic partial pulpitis without necrosis
1. The symptomless, vital pulp which has been injured or involved by deep caries, for
which pulp capping may be done
2. Pulps with a history of pain which are amenable to pharmacotherapy
3. Pulps indicated for extirpation and immediate root filling
4. Necrosed pulps involving infection of radicular dentin accessible to antiseptic root
canal therapy
1. Normal pulp
2. Reversible pulpitis
3. Irreversible pulpitis
4. Pulp necrosis
I. II. Thermal
Mechanical
1. Trauma 1. Heat from cavity preparation
i. Accidental 2. Exothermic heat from setting of cement
ii. Iatrogenic 3. Conduction of heat & cold through deep
1. Pathologic Wear filling without a protective base
2. Crack tooth syndrome 4. Frictional heat caused due to polishing
of restoration
3. Barodontalgia
Bacterial
Idiopathic
• Aging
• Internal resorption
• External resorption
• Hereditary hypophosphataemia
• Sickle cell anaemia
• Herpes zoster infection
• HIV and AIDS
• Accidental
• Violent blow during a fight, sports, automobile accident or household accident.
• Habits like bruxism, nail and thread biting.
• Iatrogenic
• During cavity preparation or excavation of caries.
• Rapid orthodontic tooth movement.
Diseases of•the Pulp
Pins used
– Dr. Nithin Mathewto retain amalgam restorations. Dis e a s e s
27
o f t he P
ulp
PATHOLOGIC
WEAR
• Pulp may also become exposed or nearly exposed by pathologic wear of the teeth
• Attrition
• Abrasion
• Bruxism
• Abfraction
• Occlusal trauma may also injure the pulp because of repeated irritation to
the neurovascular bundle in the periradicular area.
• Irreversible Pulpitis
• Symptomless at ground level
• Pain at high altitude due to reduced pressure
During ascent, trapped gases may expand and enter the dentinal tubules which stimulate
the nociceptors in the pulp.
Movement of the contents of the pulp chamber through the apex of the tooth causes pain
• High speed tungsten carbide/diamond bur – reduce operating time but accelerates pulpal
death if used without a coolant.
• Galvanic current produced from dissimilar metallic restoration may generate heat
and cause pulpal damage.
• Long term prognosis of a restorative material – determined by its ability to inhibit micro-
leakage and pulpal bacterial contamination
Diseases of the Pulp – Dr. Nithin Mathew Dis e a s e s
35
o f t he P
ulp
BACTERIAL
AGENTS
• Most common cause of pulpal injury.
• Presence or absence of bacterial irritation is the determining factor in pulp survival once
the pulp has been mechanically exposed.
Diseases of the Pulp – Dr. Nithin Mathew Dis e a s e s
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o f t he P
ulp
ANACHORE
SIS
• One probable cause for this phenomenon is increased capillary permeability in this
area
Irreversible Pulpitis
Calcific Degeneration/
Pulpal Calcific Metamorphosis
Necrosis
PULPITIS
Mild to moderate inflammatory condition of the pulp caused by noxious
stimuli in which the pulp is capable of returning to the uninflamed state following removal of
the stimuli.
Etiology
• Irritant that causes hyperaemic or mild inflammation in one pulp may produce secondary
dentin in another, if the irritant is mild enough or if the pulp is vigorous enough to protect
itself.
• Does not occur spontaneously and does not continue when the cause has been removed.
• Most often brought on by cold than hot food or beverages and by cold air.
• Pain:
• Pain is sharp, lasts for a few seconds and generally disappears when the stimulus is
removed.
• Cold, sweet or sour usually causes the pain.
• Sometimes, the pain may become chronic and may continue for weeks or even
months.
• Percussion:
• Reacts normally to percussion, palpation and mobility
• Radiograph:
• Periapical tissue is normal on radiographic examination.
• Vitality test:
• Hyperalgesic pulp responds more readily to cold stimulation than normal teeth.
• Electric pulp testing requires minimal current to initiate positive response, due to
increased excitability of Aδ- fibres.
Histological changes:
• Reparative dentin
• Disruption of odontoblasts
• Dilated blood vessels
• Extravasation of edema fluid
• Chronic inflammatory cells
• Thermal tests are useful in locating the affected tooth as reversible pulpitis
responds readily to cold.
• Once the symptoms has subsided, tooth must be tested for vitality to make sure that pulp
necrosis hasn’t occurred.
PULPITIS
Persistent inflammatory condition of the pulp, symptomatic or
asymptomatic in nature with the pulp becoming incapable of healing.
Types:
• Symptomatic
• Asymptomatic
Etiology
• Most common - bacterial involvement of the pulp
• Chemical, thermal or mechanical injuries
• Reversible pulpitis, if not treated may deteriorate into irreversible pulpitis.
• Pain persists for several minutes to lingering after the removal of the stimulus.
• Referred pain to the adjacent teeth, to the temple or sinuses when an upper posterior tooth
is involved or to the ear when a lower posterior tooth is affected.
• Pain:
• Pain may be mild to severe or even excruciating throbbing.
• Is generally diffuse and readily not localized by the patient.
• Pain lingers after the primary irritant has been removed.
• Pain may be referred to other areas.
• Percussion:
• Tenderness implies an increased intrapulpal pressure, as a result of hyperactive
exudative (acute) inflammatory tissue.
• Widening of the periodontal ligament space without percussion tenderness implies
a non-painful state.
• Radiograph:
• May not show anything of significance.
• May disclose an interproximal cavity or caries
under a filling threatening the integrity of the pulp.
• Vitality test:
• Thermal test:
• May respond in the same as reversible pulpitis, but pain may persist after the
stimulus is removed.
• Cold will tend to relieve the pain in advanced stages of pulpits, because, it has a contractile
effect on the remaining central or apical functional vascular bed, reducing the intrapulpal
pressure.
• This test may not be diagnostic in advanced cases of acute pulpalgia, because of mixed
responses, particulary multirootd teeth.
• Continuous vasodilatation
• Accumulation of edema fluid in the connective
tissue surrounding the tiny tissue
• White blood cell collection may be found beneath the area of
carious penetration
• Odontoblasts are destroyed
• Localized destruction of the pulp by
polymorphonuclear leucocyte cells and formation of micro-
abscess.
• Asymptomatic Stage:
• Exposed pulp exhibits little/no pain except when food in packed.
• Hence more current is required to elicit a response to EPT than in control tooth.
• Later Stages:
• Symptoms may simulate those of acute alveolar abscess.
• Abscess is differentiated from irreversible pulpitis, such that abscess will have:
• Swelling
• Tenderness on percussion
• Mobility
• Lack of response to vitality tests
• Systemic symptoms: fever or nausea
NT
IS
• Favourable if the pulp is removed and the tooth undergoes proper endodontic therapy and
restoration.
PULPITIS
Productive pulpal inflammation due to an extensive carious
exposure of a
young pulp.
Etiology
• Slow, progressive carious exposure.
• For the development of pulp polyp, a large, open cavity, a young
resistant pulp and a chronic low grade stimulus are necessary.
• Mechanical irritation from chewing and bacterial infection often
provide
Diseases the
of the Pulp – Dr. Nithinstimulus.
Mathew Dis e a s e s
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o f t he P
ulp
Chr o nic Hy pe r plas t ic P ulpi t is
SYMPTOM
S
• Symptomless, except during mastication, when pressure from the food bolus may cause
discomfort.
• Polyp tissue is clinically characteristic as a fleshy, reddish, pulpal mass which fills most of
the pulp chamber or cavity or extends beyond the confines of the tooth.
• At times, the mass is large enough to interfere with the comfortable closure of the tooth.
• Cutting of this tissue does not cause pain but pressure thereby transmitted to the apical end
of the pulp does cause pain.
• Differentiated from gingival overgrowth by tracing the stalk of the polypoid tissue.
• Radiograph:
• Show a large open cavity with direct access to the pulp chamber.
• Vitality test:
• Thermal test:
• Tooth may respond feebly or not at all to the thermal tests unless extreme cold
such as ethyl chloride spray is used.
• Hyperplastic pulpal mass is removed with a periodontal curette or spoon excavator and
the bleeding can be controlled with pressure.
• Pulp tissue of the chamber is then completely removed and a dressing of formocresol is
sealed in contact with the radicular pulp tissues.
• If time permits, the entire procedure of pulpectomy can be completed in a single visit.
• Prognosis of the pulp is unfavourable but the prognosis of the tooth is favourable after
endodontic treatment and adequate restoration.
RESORPTION
Etiology
• The cause of internal resorption is not known, but such patients often have a history of
trauma.
• Reddish area represents the granulation tissue showing through the resorbed area of the
crown.
• Presence of granulation tissue accounts for the profuse bleeding when the pulp is removed.
• Metaplasia of the pulp that is transformation to another type of tissue such as bone or
cementum, sometimes occurs.
Diseases of the Pulp – Dr. Nithin Mathew Dis e a s e s
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o f t he P
ulp
I n t e r na l R e s o r p t i o n
DIAGNOS
IS
• May affect either the crown or the root of the tooth or it may be extensive enough to involve
both.
• May be slow, progressive extending over 1-2 years or it may develop rapidly and perforate
the tooth within a matter of months.
• Radiograph:
• Radiographs show changes in the appearance of the walls in the root
canal or pulp chamber with a round or ovoid radiolucent area.
• Resorptive defect is more extensive in the pulpal wall than on the root surface.
NT
• In such a case, calcium hydroxide paste is sealed in the root canal and is
periodically renewed until the defect is repaired.
IS
DEGENERATION
• Generally present in the teeth of older people.
• May also be seen in teeth of younger people as a the result of persistent mild irritation.
Types:
• Calcific degeneration
• Atrophic degeneration
• Fibrous degeneration
Diseases of the Pulp – Dr. Nithin Mathew Dis e a s e s
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o f t he P
ulp
P ul De g ene r a t io
CALCIFIC p n
DEGENERATION
• Part of the pulp tissue is replaced by calcific material (pulp stones or denticles).
• Calcification may occur either within the pulp chamber or root canal, but it is generally
present in the pulp chamber.
• Calcified material has a laminated structure, and lies unattached within the body of the pulp
/ even attached to the wall of the pulp chamber.
• Classified according to :
• Position:
• Free: pulp stones lie freely in the pulp tissue
• Attached: pulp stones are attached to the dentinal walls
• Embedded: pulp stones are encircled by dentin
• Structure:
• True: pulp stones are similar to dentin having dentinal tubules and odontoblasts.
• False: calcified masses arranged in lamellar fashion around a nidus and do not
contain dentinal tubules
DEGENERATION
PULP
• Necrosis is death of the pulp.
• May be partial or total, depending on whether part of or the entire pulp is involved.
• Necrosis can be caused
• As the sequel to inflammation
• Following a traumatic injury in which the pulp is destroyed before an inflammatory
reaction can take place.
Etiology:
• Can be caused by any noxious insult injurious to the pulp
such as bacteria, trauma and chemical irritation.
• Liquefaction Necrosis:
• Necrosis which results when proteolytic enzymes convert
the tissue into a softened mass, a liquid, or amorphous
debris.
• Discolouration of the tooth is the first indication that the pulp is dead.
• Presence of a necrotic pulp may be discovered only by chance, because such a tooth is
asymptomatic.
• Teeth with partial necrosis can respond to thermal changes, owing to the presence of
vital nerve fibres passing through the adjacent inflamed tissue.
• Radiographs:
• Thickened PDL space
• Teeth with partial necrosis can respond to thermal changes, owing to the presence of
vital nerve fibres passing through the adjacent inflamed tissue.
Diseases of the Pulp – Dr. Nithin Mathew Dis e a s e s
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o f t he P
ulp
Nec r o s is o f P ulp
HISTOPATHOL
OGY
• Necrotic pulp tissue, cellular debris and microorganisms may be seen in the pulp cavity.
Radiograph • Deep caries • Deep caries • Chronic apical • Chronic apical Sometimes Apical
• Defective • Defective periodontitis periodontitis Periodontitis or
restoration restoration • Local condensing • Local condensing Condensing osteitis
osteitis osteitis
• Pulp is among the most densely innervated and vascularised tissues in the human body.
• The microcirculatory system serves several essential roles in maintaining the vitality of the
pulp.
• Both these systems are critically important in maintaining the homeostasis of the dental
pulp.
• The value of the pulp as an integral part of the tooth, both anatomic and functional should
be recognised and every effort must be made to conserve it.