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Pulpitis (exam oriented)

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Pulpitis (exam oriented)

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Definition of pulpitis, Factors causing injury to the pulp, aerodontalgia, classification of pulpitis, clinical features of various types of pulpitis, histopathology and its treatment are inlisted in this presentation.

Definition of pulpitis, Factors causing injury to the pulp, aerodontalgia, classification of pulpitis, clinical features of various types of pulpitis, histopathology and its treatment are inlisted in this presentation.

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Pulpitis (exam oriented)

  1. 1. Presented by :- Ayam Chhatkuli Roll No:- 103
  2. 2.  Dental pulp is a delicate connective tissue liberally interspersed with tiny blood vessels, lymphatics, nerves, and undifferentiated connective tissue cells  It reacts to bacterial infection or to other stimuli by an inflammatory response known as pulpitis
  3. 3.  Pulpitis are primarily a result of dental caries in which bacteria or their products invade the dentin and pulp tissue  Brannstrom and linda among others, have reported that changes in the pulp may occur even with very early dental caries represented by demineralization limited to the enamel alone  Bacteria circulating in the blood stream tend to settle out or accumulate at sites of pulpal inflammation, such as that which might follow some chemical or mechanical injury to the pulp and is known as “Anachoretic Pulpitis.”
  4. 4.  Anachoresis is a phenomenon by which blood borne bacteria, dyes, pigment, metallic substances, foreign proteins and other materials are attracted to the site of inflammation.  In cracked tooth syndrome, the cracks are often minute and invisible clinically and they allow the bacteria to enter into the pulp.  Pulpitis may also arise as a result of chemical irritation of the pulp caused by erosion or use of acidic restorative materials.  This may occur not only in an exposed pulp to which some irritating medicament is applied but also in intact pulps beneath deep or moderately deep cavities into which some irritating filling material is inserted.
  5. 5.  Severe thermal change in a tooth may also produce pulpitis  Heat produced by over-rapid tooth preparation or without sufficient collant may also cause pulpal irritation.  When two dissimilar metallic restorations are pressent, the saliva acts as an electrolyte and there will be formation of a galvanic current. This may be transmitted to the pulp through metallic restoration and may this initiate pulpitis
  6. 6.  Pain experienced in a recently restored tooth during low atmospheric pressure  Pain is experienced either during ascent or descent  Chronic pulpitis which appears asymptomatic in normal condition may also manifest as pain at high altitude because of low pressure  It is generally seen in altitude over 5000 feet but most likely to be observed in 10,000 feet and above.
  7. 7. Rouch classified barodontalgia according to the chief complaint: Class I:- In acute pulpitis, sharp pain occurs for a moment on ascent Class II:- In chronic pulpitis, dull throbbing pain occurs on ascent Class III:- In necrotic pulp, dull throbbing pain occurs on descent but it is asymptomatic on ascent Class IV:- In periapical cyst or abscess, severe and persistent pain occurs with both ascent and descent.
  8. 8. A. Physical factors  Acute injury  Accidental blow to the teeth  Heating due to grinding  Cavity preparation without water spray  Vigorous polishing with rotary instruments  Root planning in periodontal therapy  Large metallic restoration with inadequate insulation
  9. 9.  Chronic injury Attrition due to abrasive foods or brixism Abrasion due to abnormal tooth brushing B. Chemical factors Medicament or materials applied to dentin surface may cause damage to the pulp by diffusion through the dentinal tubules
  10. 10. C. Microbial Factors  Dental caries with bacterial invasion of dentin and pulp  Bacterial invasion into the pulp from a fractures tooth, where the dental pulp is exposed to the oral environment  “Anachoretic infection” off the pulp occurs, when bacteria present in the circulation bloodstream tend to accumulate in the pulp and cause infection.
  11. 11. Classification of pulpitis Acute Pulpitis Chronic Pulpitis
  12. 12. Inflammatory process is confined to a portion of the pulp, usually a portion of the coronal pulp such as a pulp horn, the condition has been called Partial or Focal pulpitis. If most of the pulp is diseased, the term total or generalized pulpitis has been used.
  13. 13. Based upon the presence or absence of a direct communication between the dental pulp and the oral environment  Open Pulpitis(pulpitis aperta) Pulpitis in which the pulp obviously communicate with the oral cavity  Closed Pulpitis( pulpitis clausa) Pulpitis in which the pulp doesn’t communicates with the oral cavity
  14. 14. Classification of the Pulpal disease  Inflammatory disease  Focal reversible pulpitis  Acute pulpitis  Chronic pulpitis  Chronic hyperplastic pulpitis  Other miscellaneous condition of the pulp  Aerodontalgia  Necrosis  Reticular atrophy  Calcifications  Pulpal metaplasia
  15. 15.  Focal reversible pulpitis or pulp hyperemia is a mild, transient, localized inflammatory reaction in the pulp. Etiology of Focal reversible pulpitis  Slowly progressing chronic carious lesion  Stimuli of short duration e.g cutting dentin while cavity preparation  Metallic restoration without proper thermal insulation  Chemical irritation to the pulp  Excessive pressure by orthodontic appliances
  16. 16.  The tooth with focal reversible pulpitis is sensitive to thermal changes, especially to cold.  Pain often results while drinking cold fluids or when ice or cold air is applied to the tooth.  Pain often is of very short duration and it disappears as soon as the thermal irritant is withdrawned.  Pain also results when the tooth is exposed to extremely high temperatures  Young people develop focal reversible pulpitis more often than the older individuals because of the more reparative capacity of the pulp tissue among the former group
  17. 17.  Pulpal stimuli, which cause reversible pulpitis in young people often causes irreversible pulpitis to the older individuals because of the less pulpal tissue viability.  The affected tooth responds to stimulation by electric pulp tooth tester at a lower level of current when compared with an adjacent normal tooth.  The involved tooth often has large carious lesions or restoration with improper insulation.
  18. 18.  Acute inflammatory reaction in the pulp limited to the odontoblastic or subodontoblastic regions, adjacent to the irritated dentinal tubules.  Dilatation of pulpal blood vessels with increased vascular permeability.  Edema in the pulp with infiltration by the polymorphonuclear leukocyte in the area.  Few odontoblast cells could be damaged in the localized area of injury
  19. 19.  Odontoblast cell nuclei may be displaced into the dentinal tubules due to either increased local tissue pressure or due to abnormal dentinal fluid movements during injury  Thrombosis of pulpal blood vessels may occur in some cases  Repair takes place by redifferentiation of odontoblast cells, which are damaged and sometimes with deposition of reparative dentin.
  20. 20.  Patient symptoms and clinical tests:-  Pain :- It is sharp but of brief duration, ceasing when irritant is removed. It is usually by cold, sweet, and sour stimuli.  Visual examination and history:- May reveals caries, traumatic occlusion and undetected fractures.  Radiograph:- o Show normal PDL and lamina dura in otherwords normal periapical tissue o Depth of caries or restoration may be evident
  21. 21.  Percussion test:- Shows negative response; i.e tooth is normal to percussion and palpation without any mobility  Vitality test:- Pulp responds, readily to cold stimuli. Electric pulp tester requires less current to cause pain. Treatment  Best treatment of reversible pulpitis is prevention.  No endodontic treatment is needed for this condition.
  22. 22.  Acute pulpitis ia an irreversible condition characterized by acute, intense inflammatory reaction in the pulpal tissue. Etiology of acute pulpitis  Caries progressing beyond the dentinal barriers and reaching the pulp  Pulp exposure due to faulty cavity preparation  Blow to tooth with subsequent damage cavity preparation without water spray  Cracked tooth syndrome  Tooth or tooth coming in the line of fracture when the jaw is traumatized  Anachoretic infection to the pulp
  23. 23.  The tooth is extremely sensitive to hot and cold stimuli, however the pain in acute pulpitis can start spontaneously in the absence of any stimuli  A short and severe “lancinating” type of pain is often elicted from the affected tooth.  Application of hot or cold stimuli cause an increase in the intensity of pain and such type of pain persist for a longer duration even after the stimuli are removed.  As the dental pulp is located within the solid confinement of dentinal walls, intrapulpal pressure builds-up quickly and so is the pain, since there is lack of escape route of inflammatory exudates during pulpal inflammation  In the initial stage of acute irreversible pulpitis the pain can be localized or rather the patient can identify the offending tooth, however in the more severe later stages the pain becomes regional and the patient is unable to identify the offending tooth.
  24. 24.  The intensity of pain increases during sleep because there is an increase in the local blood pressure in head and neck region in supine position  Acute pulpitis is often associated with micro abscess formation in the pulp along with liquefaction degeneration  When drainage is established, small amount of pus exudes from the opening, which has a noxious odor.  The affected tooth responds to a lower level of current, if electric pulp tester is used.  Pain subsides when the drainage is established or when the pulp undergoes complete necrosis.
  25. 25. Patient with acute pulpitis are often apprehensive and moderately ill. When intrapulpal pressure becomes very high during acute inflammation, it can cause collapse of the apical blood vessels. This phenomenon is known as “ pulp- strangulation.”
  26. 26.  Severe edema in the pulp with vasodilation.  Moderate to dense infiltration of polymorphonuclear  Focal or complete destruction of the odontoblast cells at the pulp dentin border  Many micro-abscess formation, characterized by areas of liquefaction degeneration in the pulp being surrounded by dense band of neutrophils and micro organisms  In sever cases, there may be complete liquefaction and necrosis of the pulp with total destruction of the odontoblastic cell layer. This phenomenon is known as acute suppurative pulpitis.
  27. 27.  Death of the pulp may also be accompanied by issue dehydration. This condition is known as “dry gangrene of the pulp”. Treatment  Drainage of exudate or pus from the pulp chamber  Direct pulp capping  Root canal treatment  Extraction of tooth
  28. 28. It is a condition characterized by a low grade, often persistent inflammatory reaction in the pulpal tissue with little or no constitutional symptoms. Etiology It is same to as of acute pulpitis but the irritants are of low virulence.
  29. 29.  Sign and symptoms are much milder in comparision to the aute pulpitis  Tooth with chronic pulpitis may be asymptomatic for quiet some time  In other cases there may ne an intermittent dull and throbbing pain in the tooth  The tooth is less sensitive to hot and cold stimuli  The tooth usually responds to a higher level of current when electric pulp test is used  Even if the pulp is exposed to the oral environment through a large open cavity in the tooth, still a very little pain is felt
  30. 30.  The chronic inflammatory response in the pulp is characterized by cellular infiltration by lymphocytes, plasma cells and macrophages e.t.c.  The chronic nature of the inflammation may continue for a long time with occasional periods of acute exacerbations  Blood capillaries are prominent and few microrganisms are also found in the pulpal tissue  Prolonged chronic inflammation may encourage fibroblastic activity in the pulp with formation of collagen bundles  Chronic inflammation in the pulp in some cases may result in integral resorption of the tooth
  31. 31. Treatment Root canal treatment Extraction of teeth
  32. 32. It is an unusal type of hyperplastic granulation tissue response in the pulp which is characterized by an overgrowth of the tissue outside the boundary of the pulp chambers as a protruding mass
  33. 33.  Pulp polyp clinically appears as a small,pinkish red, lobulated mass which protrudes from the pulp chamber and often fills up the carious cavity  The teeth in which pulp polyp commonly develops are often the deciduous molars and first permanent molars  The condition is obviously seen in either children or young adults  Affected tooth always has a large open carious cavity, which is present for a long duration
  34. 34. The lesion bleeds profusely upon provocation If traumatized, the pulp polyp becomes ulcerated and appears as a dark red, fleshy mass with fibrinous exudate on the surface The involved teeth is usually painless but it may be sensitive to thermal stimuli
  35. 35.  The hyperplastic pulpal tissue lesion presents the features of a granulation tissue mass, consisting of numerous proliferating fibroblasts and young blood capillaries  There may be edema and hyperemia of the pulpal tissue  Inflammatory cells infiltation chiefly by the lymphocytes, plasma cells and sometimes polymorphonuclear neutrophils in the tissue are common  Reparative secondary dentin may be formed adjacent to the dentinal wall of the affected tooth
  36. 36.  Stratified sqamous type epithelial lining is often observed on the surface of the pulp polyp, which resembles oral epithelium.  The epithelial cells on the surface of the polyp are believed to be the desqamated epithelial cells, which came either from the buccal mucosa, gingiva or from the salivary gland ducts  These cells are carried via saliva and are transplanted on to the surface of the pulp polyps  The epithelized surface of the pulp polyps may sometimes show even well formed rete peg formation
  37. 37. Treatment Root canal treatment Tooth extraction

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