DIAGNOSIS OF PULPAL PATHOLOGY

DIAGNOSIS OF PULPAL PATHOLOGYBy: Shirin IV year Part I BDS KMCT Dental College

(In Pediatric Dentistry)INTRODUCTION Dental pulp may be defined as, a special organ with a unique environment of the unyielding dentin surrounding a resistant,resilient soft tissue of mesenchymal origin reinforced with a ground substance.It has a close relationship between its peripheral cells,the odontoblasts and the dentin thereby making it a functional entity sometimes refered to as pulp-dentin complex.The dental pulp is a delicate connective tissue liberally interspersed with tiny blood vessels,lymphatics,nerves, & undifferentiated CT cells.The enclosure of the pulp tissue within the rigid calcified walls of dentin precludes the excessive swelling of tissue that occur in hyperemic phases of inflammation in other tissues.Pulpal injury frequently irreversible & painfulNormal PulpAsymptomaticExhibits mild to moderate transient response to thermal & electric pulpal stimuli, which subsides almost immediately with ceasation of the stimuli.No pain on percussion or palpation.R/G clearly delineated canal that tapers toward the apex. no evidence of canal calcification. intact lamina dura.CLASSIFICATION OF PULPAL DISEASES(Grossmans Classification)Pulpitis i)Reversible Pulpitis ii)Irreversible Pulpitis a)Hyperplastic Pulpitis b) Internal resorptionPulp degeneration-Pulp Calcification Pulp Necrosis Reversible PulpitisMild to moderate inflammatory condition of the pulp caused by noxious stimuli , in which the pulp is capable of returning to the uninflammed state following removal of the stimuli. A Clinical diagnosis based on subjective & objective findings.C/F : due to direct or indirect injury to pulp increased response to cold ,hot or sweets Thermal stimuli cause quick, sharp & transient hypersensitive response which lasts for a moment & subsides soon after removal of stimuli. respond to electric pulp tester at a lower level of current than that of adjacent normal teeth. Associated teeth usually show deep carious lesions,large metallic restorations(particularly w/o adequate insulation), or restorations with defective margins. Irreversible PulpitisPersistant inflammatory condition of the pulp,which is symptomatic or asymtomatic caused by a noxious stimulus.A Clinical diagnosis based on subjective & objective findings.Normally continuation of reversible pulpitis resulting in progressive damage to pulp.May be acute ,subacute or chronic.Clinically, acutely inflammed pulp symptomatic & chronically inflammed asymptomaticPain occurs as a result of increase in intrapulpal pressure due to inflammatory exudates.C/F : Irreversible pulpitis may be symptomatic or asymptomatic Symptomatic Irreversible Pulpitis spontaneous intermittent or continuous paroxysms of pain Sudden temperature changes induce prolonged episodes of pain.

There may be prolonged painful response to cold which can be relieved by heat & painful response to heat which is relieved by cold.Continuous spontaneous pain may occur by change in posturePain may be moderate to severe depending on severity of inflammation.May be sharp or dull ; localized or referred ; intermittent or constant.

CharacteristicsPotentially reversibleIrreversible PulpitisPainMomentary-dissipates readily after removal of stimulusContinuous,persistent,throbbing,intermittentStimulusRequire external stimulusspontaneousPulp Sensibility TestingNot reliable in primary & young permanent teethunreliablePercussion - veMay be +ve in advanced casesReferred pain - veCommon findingPostural variation - ve Common findingColor of tooth no changePresent-due to tissue lysis & intrapulpal hemorrhageRadiographic findings Normal periapexWidening of PDL space Asymptomatic Irreversible PulpitisMay develop on conversion of a symptomatic irreversible pulpitis into a quiescent state,probably because the inflammatory exudate was quickly vented --- large carious exposure / previous traumatic injury that resulted in painless pulp exposure of long duration.Chronic Hyperplastic Pulpitis (Pulp Polyp)a unique form of pulpitis wherin the inflammed pulp instead of perishing by continued suppuration,reacts by excessive & exuberant proliferation into the occlusal surface.Characterized by development of granulation tissue,covered by epithelium,that protrude out of pulpal chamberOccurs in teeth with extensive carious exposure of pulp,asstd with long standing ,low grade irritation.Usually asymptomatic but pain may present during mastication.

Internal Resorption Idiopathic slow or fast progressive resorptive process occuring in dentin of the pulp chamber or pulp canal of the tooth.Exhibit no additional symptoms other than existing pulpitis.Crown may appear as pink pink tooth ,when resorption is in coronal portion.Resorption involving the root canal appears as round to oval R/L area that extends from pulp canal.

Pulpal NecrosisAssociated with death of the pulp.Tooth becomes non-vital.May result from untreated irreversible pulpitis or may occur immediately after a traumatic injury that disrupts the blood supply to the pulp.Necrotic remnants may be liquefied or coagulated.May be asstd with periapical abscess.Crown of the tooth may be discolored.

Pulpal necrosis presented as apersistent greyish discoloration of crownbcessation of root development & periapical radiolucent lesion-after traumatic injury.DIAGNOSTIC PROCEDURESDiagnosis is the process of identifying a medical condition or disease by proper evaluation of signs & sypmtoms & from the results of various diagnostic procedures.Diagnostic procedure should follow a consistent & logical order & include review of medical & dental histories ,radiographic examination & clinical examination.Pulp is the essence of the tooth. It is the structure that makes the tooth vital.An understanding of the possible underlying pathological process ,combined with an exact assessment of pain history & appropriate clinical tests should aid the practitioner in determining the nature of the pulpal inflammation.Operative diagnosis there are instances when a final diagnosis can be reached only on direct evaluation of pulp tissue & decission about treatment can be made accordingly. eg:HistoryRecollecting -1st step towards establishing a diagnosis.May not determine treatment but may influence modification in treatment modalities as according to the persons health status.Detailed history of painExtra-Oral ExaminationFor localized swelling,changes in color or bruises,abrasions,cuts or scars & similar signs of disease,trauma or previous T/t.Enlarged lymphnodes important in denoting spread of infection.Intra-Oral ExaminationExamination of oral mucosa for any abnormalityCarious lesions ,discolorations & other obvious abnormalities asstd with the teethshould be noted.Coronal Evaluation by using a mouth mirror & explorer and possibly a fiber optic light source. Suspected tooth carefully & thoroughly examined for caries,defective restoration,discoloration,enamel loss or defects that allow direct passage of stimuli to pulp.Pulpal Evaluation Clinical condition of the pulp evaluated by thermal stimuli,percussion,palpation & vitality tests.

Pulpal Evaluation + History+ R/G findings DiagnosisThe various pulpal evaluation methods are: i) Pulp testing ii) Percussion iii) RadiographsDental Pulp TestingA useful & essential diagnostic aid in endodonticsAn investigation that provide valuable diagnosis & treatment planning information.Help in the assessment of pulp health based on its qualitative sendory response.3 types Pulp vitality testing assessment of pulps blood supply eg: Laser Doppler Flowmetry Pulse oximetry Pulp sensibility testing assessment of pulps sensory response. eg: Thermal & electric pulp testing Pulp sensitivity condition of pulp being very responsive to stimuli.Conventional Pulp Testing

Method Technique/Material Symptom/InterpretationThermal Cold HeatEthyl chloride,ice,air blastHot water,heated gutta parcha(used for location of symptomatic tooth)Hypersensitivity/subsiding pain-reversible pulpitis.Lingering pain-irreversible pulpitisNo response-pulpal necrosis2.ElectircOdontometerRespond to lower level of current-reversible pulpitisRespond to higher level of current-IrreversibleNo response-necrosis3.PercussionVertical

LateralApical periodontitis(irreversible pulpitis if due to caries)Lateral periodontal space inflammation4.RadiographIOPAFurcation involvement /thickening of the PDL space-indicates periapical infection(usually accompanied with irreversible pulpitis)Pulp sensibility tests unrelaible in children,recently traumatized & multi rooted teeth.Newer MethodsLaser Doppler Flowmetry Developed in 1970s to measure the velocity of RBCs in capillaries.A non-invasive,objective,painless alternative to traditional neutral-stimulation methods promising test for children.Vital teeth-produce regular signal fluctuationsNon-vital teeth-no synchronous signals;produced irregular fluctuations or very steep spike traces that are attributed to a movement artefact.Useful in assessment of post-traumatized incisors aswell.Pulse OximetryDirect measurement of pulp circulation-real measure of pulp vitality.Pulp oximetry-completely objective estimates blood oxygen saturation levels by measuring & comparing amplitudes of the ratios of transmitted infra-red with red light.The ratio varies with relative fractions of oxygen saturated to unsaturated Hb & is used to calculate oxygen saturation.Capable of evaluating the blood vasculature status within a tooth & therefore pulp vitality.Disadvantage dependance on a pulsatile blood flow

Duel Wavelength SpectrometryMeasures blood oxygenation change within the capillary bed of dental tissue & tus not dependent on a pulsatile blood flow.Hughes Probeye CameraUsed in detecting temperature change as small as 0.1o C ,hence ,been used to test pulp vitality experimentally.

OdontometerLaser Doppler Flowmeter

Pulse OximeterCONCLUSION Before initiating treatment one must first assemble all the information regarding signs,symptoms & history.That information is then combined with results from the clinical examination & tests to obtain the diagnosis.Determination of the etiology of the patients chief complaint & a correct diagnosis is are paramount prior to a recommendation of an endodontic therapy or any treatment.A diagnostician must have a working knowledge of examination procedures ,a knowledge of pathosis .its radiographic & clinical manifestations ,an awarness of various modalities of treatment and above all a questioning mind .A methodical & disciplined approach,along with a good measure of patience ,will help establish an accurate diagnosis. REferencesTextbook Of Pedodontics by Shobha Tandon,2nd Edition.Principles & Practice Of Pedodontics by Arathi RaoShafers Textbook Of Oral Pathology,6th EditionReview article Dental Pulp Testing by Eugene Chen & Paul V.Abbott ;International Journal Of Dentistry,Vol. 2009,Article ID 365785Clinical Update on Pulpal & Periradicular Diseases by Naval Post Graduate Dental School,December 2005Various Internet sources