pulp and periapical disease
TRANSCRIPT
Pulpal & periapical diseases
BY
DIAA ELDIN
TEACHING ASSISTANT, NUBENDODONTIC DEPARTMENT
Introduction
Structure & function of the dentin
pulp complex
Inflammation & histopathology of
inflammation
Pathways of the pulp & etiology of
pulpal pathosis
Structure & function of dentin pulp complex
Dental pulp complex
Dentin structure
&Permeability
Dental pulp :
(histology ,function &special environment)
Dental pulp complex
Protective barrier
If communication
Pathological pulp condition
Dentin structure & permeability
A) dentin structure
component
D.T : (number ,diameter)
B) factors affecting dentin permeability
-number of D.T
-thickness
-exposed dentin-smear layer
Dental pulp
A) histology :
1- cellular structures
a) fibroblast
b) odontoblast
Arises from ???
Where ???
Shape
function
c) Immunocompetent cells
d) Reserve cells
2) extracellular matrix
3) pulp microvasculature & lymph
4) nerves of the pulp : (sensory & sympathetic)
C fibersA delta fibers
0.4-1.2 UM2-5 UMdiameter
0.5-2 M/S12-30 M/Sspeed
NOYESmyelinated
Throbbing,achingSharp,pricklingpain
highlowthreshold
painPain,temperature,touchresponse
b) Functions of the dental pulp
1) formative
2) nutritive
3) defensive
4) nervous
4) nervous
Dentin innervation
Hydrodynamic theory
Dentinoblastictransduction
Predentin – inner dentinal zone
Subdentinoblastic,dentinoblastic
Chemical –
electrical -mechanical
Thermal stimulation
hot cold
Pulpal & periapical inflammation
Definition
Is there difference ??
Objectives of inflammatory
Histopathology of inflammation
1) preinflammatory
2) inflammatory
b) proliferative
a) exudative
early
late
1) Exudative phasea) Early exudative phase
[ Blood ]
• SERUM -COMPLEMENT-FIBRINOGEN-KININOGEN
• PNLS – MONOCYTES
[ Damaged tissues ]
• BRADYKININ - LYSYLBRADYKININ - ARACHIDONIC ACIDS
• HISTIOCYTES - RESERVE CELLS
[ Suppuration ]
(neutrophils)
b) Late exudative phase
• SENSITISED LYMPHOCYTES :
{ B - CELLS PRODUCING ANTIBODIES }
OPSONINS - AGGLUTENINS - PRECIPTINS - ANTITOXINS
{ T - HELPER - T - SUPRESSIVE - T - KILLER CELLS -
- CELLS PRODUCING LYMPHOKINS -OAF - MAF -MIF }
2- - Proliferative phase
Significances pf pulp anatomy in inflammation
compliance temperature
Collateral circulation
repaire
Etiological factors of pulp diseases
1) living irritants
Open cavity haematogenousperiodontal Adjacent
teeth
Through open cavity
Periodontal membrane
Adjacent teeth
Haematogenousinfection
2) non-living irritantsa) mechanical irritation
2) odontoiatrogenic1) accidental
b) Thermal irritationodontoiatrogenic
Electrical irritation Aeronautical irritation
Chemical irritation
odontoiatrogenic idiopathic
PULPAL PATHOSIS
PULPAL
INFLAMMATION
PULPAL NECROSIS
PULPAL IRRITATION
PERIAPICAL PATHOSIS
PROGRESSION OF PULPAL
PATHOSIS Bacteria +Byproducts in deep layers of Dentin
Pulp is affected by bacterial byproducts before actual bacterial invasion
(via exposed D.T.)
Local cellular invasion
When actual exposure occurs, pulp is locally infiltrated with PMNs
Followed by liquefaction necrosis at site of exposure
Eventually necrosis spreads all across pulp then if not treated to periapicaltissues
CLASSIFCATION OF DISEASES
OF THE PULPGrossman’s Clinical
Classification
Pulpitis
Reversible Irreversible
Acute Chronic
Pulp Degeneration
Pulp Necrosis
Inflammatory diseases of the pulp
according to
Severity & duration:
i) Acute ii) Chronic iii)Subacute
Presence or absence of symptoms:
i)Symptomatic ii)Asymptomatic
Ability to heal:
i)Reverible ii) Non reversible
1-Inflammatory diseases of the pulp(Pulpitis)
A- HYPERALGESIA- HYPERSENSITIVITY- REVERSIBLE PULPITIS-HYPERSENSITIVE DENTIN-HYPEREMIA- HYPERACTVE PULPALGIA
B – IRREVERSBLE PULPITIS
a) SYMPTOMATIC PULPITIS :PAINFUL PULPITIS: ACUTE PULPITIS
b) ASYMPTOMATIC PULPITIS: NON PAINFUL PULPITIS: CHRONIC PULPITIS-
i. CHRONIC ULCERATIVE PULPITIS
ii. CHRONIC HYPERPLASTIC PULPITIS
iii. CLOSED FORM OF CHRONIC PULPITIS
A- HYPERSENSITIVITY- REVERSIBLE PULPITIS- HYPERSENSITIVE
DENTIN-HYPEREMIA- HYPERACTVE PULPALGIA
Definition: A clinical diagnosis based on
subjective and objective findings indicating
that the inflammation should resolve and the
pulp return to normal
Etiology:
Histopathology: Range from hyperaemia to
mild to moderate inflammatory changes limited
to the are a of involved D.T., V.D.→ ↑I.P.P.
→ Oedema → W.B.C.s infiltration
→followed by odontoblast differentiation and reparative dentin formation
B – IRREVERSBLE PULPITIS
SYMPTOMATIC IRREVERSBLE PULPITIS :PAINFUL
PULPITIS: ACUTE PULPITIS
Definition: A clinical diagnosis based
on subjective and objective findings
indicating that the vital inflamed
pulp is incapable of healing. (lingering
thermal pain, spontaneous pain,
referred pain)
Etiology:
Histopathology:
B – IRREVERSBLE PULPITIS
b) ASYMPTOMATIC PULPITIS: NON PAINFUL PULPITIS:
CHRONIC PULPITIS-
Definition: A clinical diagnosis based on
subjective and objective findings
indicating that the vital inflamed pulp is
incapable of healing. (no clinical
symptoms)
i. CHRONIC ULCERATIVE PULPITIS
ii. CHRONIC HYPERPLASTIC PULPITIS
iii. CLOSED FORM OF CHRONIC PULPITIS
• Etiology:
CHRONIC PULPITIS
Examination & diagnosis:
Non painful - mild discomfort
Spontaneous pain
Heat elicits pain
Exacerbation with lowered
body immunity
Delayed reaction to EPT
X - ray may be -ve , internal
resorption or condensing osteitis
CHRONIC ULCERATIVE PULPITIS
Chronic inflammation with
abscess formation at the
exposure site, and the
abscess is surrounded by
granulomatous tissues
Examination & diagnosis:
Painful with food impaction
All signs of chronic pulpitis
CHRONIC HYPERPLASTIC PULPITIS
Seen in young permanent cariouslyexposed teeth
It is an attempt of healing and repair by walling off the irritation
Proliferative reaction of the pulpal granulation tissue with formation of a polyp
May become epithelialized from desquamated epithelial cells
PULP NECROSISDefinition: A clinical diagnostic category in dicating death of the pulp. The pulp is usually nonresponsive to pulp testing. 2 types are present.
LIQUEFACTIVE NECROSIS
(WITH GOOD BLOOD SUPPLY.)
COAGULATIVE NECROSIS
(WITH DIMINISHED BLOOD SUPPLY.)
Examination & diagnosis:
If not treated ►►►Periapical leson of endodontic origin
Usually non painful untill the periapex is envolved.
Radiographic findings are -veunless there is a concomitant periapical disease.
-Ve with EPT except (some times) in liquefactive necrosis &multi rooted teeth.
RETROGRESSIVE PULP CHANGES(Pulp Degeneration)
1 - ATROPHY AND FIBROSIS Definition: waisting away or decrease in sze of the
pulp, with age.
MAY BE CONSIDERED AS AGE CHANGES.
Histopathology:
Mature collagen incrase / unit area and the cells
deminish in no. And size.
Excessive secondary dentin deposition deminishes the
size of the pulp chamber & canal lumen.
Decrease in blood supply.
2- CALCIFICATIONS
DYSTROPHIC CALCIFICATION
IN DEAD OR DEGENERATING TISSUES.( LOCAL ALKALINITY).
DENTICLES
According to location:
FREE
EMBEDED
ATTACHED
According tostructure:
True
False
INTERNAL RESORPTION ETIOLOGY:
Unknown , often histore of trauma Or chronic pulpitis. Or
pulpotomy
Examination & diagnosis
The pulp is vital .
Delayed response to EPT
In the pulp chamber it forms the pink spot.
In the canal it may perforate causing a lateral lesion.
At the cervical level it may be mixed with external cervical
resorption.
Radiographically,in int. Resorption disrupts the canal while
in ext .Resorption the canal contour is unaltered.
Periapical disease
SYMPTOMATIC (ACUTE) APICAL
PERIODONTITIS SYMPTOMATIC (ACUTE) APICAL PERIODONTITIS
Definition: Inflammation of the apical periodontium
producing clinical symptoms including a painful
response to biting and/or percussion . It might or not
be associated with apical radiolucent area.
• Etiology:
• ) Histopathology: (as explained before)Inflammatory
reaction in apical periodontal ligament ? Dilation ob
B.V.? Exudation and accumulation of PMNs
?Distension of P.L. and extrusion of tooth ----with
continuous irritation ---?loss of alveolar bone
• Examination & diagnosis:
• : Treatment : R.C.T----
– TOOTH REDUCTION OUT OF OCCLUSION
ACUTE APICAL ABSCESS : Definition: An inflammatory reaction to pulpal
infection and necrosis characterized by rapid onset ,
spontaneous pain , tenderness to tooth pressure, pus
formation and swelling of associated tissues
• Etiology:
• Histopathology: Inflammatory reaction in apical
periodontal ligament ? Dilation ob B.V.? Exudation
and accumulation of PMNs ?Distension of P.L. and
extrusion of tooth ----with continuous irritation ---?loss
of alveolar bone---- localized area of liquefactive
necrosis containing PMNs , debris , cell remnants and purulent exudate
Examination & diagnosis: Tooth severely painful & tender
• Localized vestibular swelling or
facial cellulitis• Pain starts
severe and decrease after
swelling
• Patient may become febrile
with lympf nodes affection
• Tooth becomes loose
• -Ve EPT findings except in
liquefactive necrosis & multiple
canals
• Radiograph: HAZY APICAL RAREFACTION
RECRUDECENT ABSCESS(PHOENIX ABSCESS)
Definition: ACUTE EXACERBATION OF A PRE- EXISTING
CHRONIC PERIAPICAL PATHOSIS
RECRUDECENT ABSCESS
• Clinically often undistinguishable from AAA
• DIAGNOSIS IS BASED ON PATIENT HISTORY,
CLINICAL PICTURE AND RADIOGRAPHIC
FINDINGS REVEALING THE PREVIOUS
CHRONIC PERIAPICAL PATHOSIS
CHRONIC APICAL PERIODONTITIS Definition::Inflammation of the apical
periodontiumof pulpalorigin, that does not produce clinical symptoms and
radiographicallyappears as apical R.L. area
Inflammation of the apical
periodontiumof pulpalorigin, that does not
produce clinical symptoms and
radiographicallyappears as apical R.L. area
– asymptomatic or slight discomfort
– little or no pain on percussion
• X-ray:
– apical radiolucency or Condensing
osteitis: radiopaque
PULPOPERIAPICALOSTEOSCLEROSIS
• Productive response of
periapical bone to a low-grade
long standing pulpal irritation
• Increase in density of bone
due to osteoblastic hyperactivity
• Seen in young permenant
teeth with carious exposures & chronically inflammed pulps
CHRONIC APICAL ABSCESS(SUPPURATIVE APICAL PERIODONTITIS)
Nonpainful low grade long
standing chronic inflammatory
reaction to pulpal irritants
• It represents a balance between
body resistance and the periapical
pathosis
• Formation of pus that
drainsthrough a sinus tract
• Ill defined periapical
radiolucency
• The tooth may be slightly mobile
PERIAPICAL GRAMULOMA
• Examination & diagnosis:
• Non painful• -Ve EPT findings
• Well defined periradicular radiolucency•
Histopathology:
• periapical granulomatous tissue
• Encapsulated with a fibrous capsule
• May show epithelial strands
• May transform into a phoenix abcess if
infected or manipulated
PERIAPICAL CYST Definition::Inflammatory cyst due to extension of
infection from pulp into surrounding periapical
tissues
• Histopathology:
• Central fluid-filled epithelium-lined cavity
surrounded by granulation tissue and a fibrous capsule
• Forms on heals of a periapical granuloma
• Examination & diagnosis:
• Well defined apical radiolucency
• Non painful untill infected (phoenix abscess)
• Slowly growing destroying bone and moving teeth