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Pulp & periapical disease

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Pulp & periapical disease

  1. 1. Pulp & Periapical Diseases Dr. Ashraf Refai BDS MSc DD HMD Associate Professor of Endodontics

  2. 2. Normal Response of Tissue to Irritants Goals of Inflammation 1. Dilute the irritant 2. To destroy the irritant 3. To set the stage for healing and repair
  3. 3. Sequence of the Inflammatory Process Pulpal Irritation Infammatory Mediators Increased Vascular Premeability Increased Vascular Premeability Tissue Damage Exudate Formation
  4. 4. Uniqueness of Pulpal Inflmmation 1. Non-Compliant environment (Dentinal Walls) 2. Lack of collateral circulation 3. Reparative dentin formation
  5. 5. Pulpal Disease
  6. 6. Classification of Pulpal Disease ❖ Reversible Pulpitis ❖ Irreversible Pulpitis ❖ Acute Pulpitis ❖ Chronic Pulpitis ❖ Chronic Ulcerative Pulpitis ❖ Chronic Hyperplastic Pulptis ❖ Pulp Necrosis ❖ Other Causes
  7. 7. Etiology Reversible Pulpitis (Hyperemia) Due to mild stimulus • Incipient caries • Cavity preparation • Cervical erosion • Leaking restorations
  8. 8. 1. Sharp transient pain which subsides after removal of the stimulus 2. Pulp Test: Normal 3. Radiograph: Normal 4. Palpation & Percussion: Normal Signs & Symptoms Reversible Pulpitis (Hyperemia)
  9. 9. 1. Vasodilatation 2. Mild infiltration of inflammatory cells Histopathological PIcture Reversible Pulpitis (Hyperemia)
  10. 10. Classification of Pulpal Disease ❖ Reversible Pulpitis ❖ Irreversible Pulpitis ❖ Acute Pulpitis ❖ Chronic Pulpitis ❖ Chronic Ulcerative Pulpitis ❖ Chronic Hyperplastic Pulptis ❖ Pulp Necrosis ❖ Other Causes
  11. 11. Etiology Acute Pulpitis
 (Irreversible Pulpitis) Due to increased intrapulpal pressure • Symptoms vary according to degree of inflammation • Can be Initial, Moderate or Severe
  12. 12. Pain Initially mild shooting pain that increases when patient lies down Signs & Symptoms Acute Pulpitis
 (Irreversible Pulpitis)
  13. 13. Pain Initially it is initiated with cold stimulus and lasts for awhile after removal of stimulus in later stages it is spontaneous Signs & Symptoms Acute Pulpitis
 (Irreversible Pulpitis)
  14. 14. Pain • Initially it is intermittent but in later stages becomes continuous • Diffuse not localized hard to identify offending tooth Signs & Symptoms Acute Pulpitis
 (Irreversible Pulpitis)
  15. 15. Pain • Initially cold stimulus causes pain in the later stages heat as well. (Hot tooth) • Pain can be referred to adjacent of opposing teeth Signs & Symptoms Acute Pulpitis
 (Irreversible Pulpitis)
  16. 16. Signs & Symptoms Acute Pulpitis
 (Irreversible Pulpitis) 1. Pulp Test: Exaggerated response 2. Radiograph: Normal or slight widening in PD membrane space 3. Palpation & Percussion: Normal
  17. 17. Histopathological Picture Acute Pulpitis
 (Irreversible Pulpitis) 1. Increased infiltration of inflammatory cells (Neutrophils) 2. Formation of Micro-abscesses lymphocytic infiltration around abscess as well macrophages & plasma cells
  18. 18. Classification of Pulpal Disease ❖ Reversible Pulpitis ❖ Irreversible Pulpitis ❖ Acute Pulpitis ❖ Chronic Pulpitis ❖ Chronic Ulcerative Pulpitis ❖ Chronic Hyperplastic Pulptis ❖ Pulp Necrosis ❖ Other Causes
  19. 19. Etiology Chronic Ulcerative Pulpitis
 (Irreversible Pulpitis) • Can occur after a period of acute pulpitis • Or can occur from the onset • Usually due to low grade stimulus • Large carious exposure pulp appears ulcerated
  20. 20. Signs & Symptoms Chronic Ulcerative Pulpitis
 (Irreversible Pulpitis) • Pain: Mild or absent no intrapulpal pressure • Large carious lesion with exposed area of the pulp • Pulp testing: Responsive • Radiograph: Normal or slight widening of PD membrane space • Palpation & Percussion: Normal
  21. 21. Histological Picture Chronic Ulcerative Pulpitis
 (Irreversible Pulpitis) • Zone of necrosis • Zone of leukocytic infiltration • Zone of proliferation fibroblasts
  22. 22. Classification of Pulpal Disease ❖ Reversible Pulpitis ❖ Irreversible Pulpitis ❖ Acute Pulpitis ❖ Chronic Pulpitis ❖ Chronic Ulcerative Pulpitis ❖ Chronic Hyperplastic Pulptis ❖ Pulp Necrosis ❖ Other Causes
  23. 23. Etiology Chronic Hyperplastic Pulpitis
 (Irreversible Pulpitis) • Usually occurs in young patients • Mild inflammatory low grade response • Overgrowth of granulomatous tissue from a large pulp exposure
  24. 24. Signs & Symptoms Chronic Hyperplastic Pulpitis
 (Irreversible Pulpitis) • Presents as a pulp polyp extruding out of a carious exposure • Polyp is not painful but easily bleeds • Pain: Mild pain • Pulp Test: Responsive • Radiograph: Normal or slight widening of PD membrane space • Palpation & Percussion: Normal
  25. 25. Histopathological Pictures Chronic Hyperplastic Pulpitis
 (Irreversible Pulpitis) Pulp polyp is made up of: • Proliferation of fibroblasts • New capillaries • Inflammatory cells • Few nerve cells
  26. 26. Classification of Pulpal Disease ❖ Reversible Pulpitis ❖ Irreversible Pulpitis ❖ Acute Pulpitis ❖ Chronic Pulpitis ❖ Chronic Ulcerative Pulpitis ❖ Chronic Hyperplastic Pulptis ❖ Pulp Necrosis ❖ Other Causes
  27. 27. Etiology Pulp Necrosis • The inflammation progresses due to acute or chronic pulpitis results in pulp disintegration and necrosis.
  28. 28. Signs & Symptoms Pulp Necrosis • Pain: Mostly very mild or absent. • Pulp Test: Negative • Radiograph: Normal of Widening of PD membrane space • Palpation & Percussion: Negative
  29. 29. Histopathological Picture Pulp Necrosis • Liquefaction necrosis
  30. 30. Classification of Pulpal Disease ❖ Reversible Pulpitis ❖ Irreversible Pulpitis ❖ Acute Pulpitis ❖ Chronic Pulpitis ❖ Chronic Ulcerative Pulpitis ❖ Chronic Hyperplastic Pulptis ❖ Pulp Necrosis ❖ Other Causes
  31. 31. Etiology Other Causes • Pulp atrophy • Calcification • Internal resorption
  32. 32. Periapical Disease
  33. 33. Classification of Periapical Disease ❖ Acute Periapical Disease ❖ Acute Apical Periodontitis ❖ Acute Apical Abscess ❖ Recrudescence Absecess (Pheonix Abscess) ❖ Chronic Periapical Disease ❖ Chronic Aical Periodontitis ❖ Chonic Apical Abscess ❖ Condensing Osteitis
  34. 34. Etiology Acute Apical Periodontitis • Localized inflammation of the apical area • Due to either • Toxic component of pulp necrosis • Mechanical irritation • Chemical causes (irrigant & filling materials)
  35. 35. 1. Tooth is tender and slightly elevated 2. Patient can localize pain 3. Pain can be mild to severe 4. Pulp test: Postive or Negative 5. Radiograph: Slight Widening 6. Palpation & Perscussion: Positive Signs & Symptoms Acute Apical Periodontitis
  36. 36. 1. Connective tissue shows migration of inflammatory cells into the interstitial tissues 2. Beginning of bone resorption Histopatholog Acute Apical Periodontitis
  37. 37. Classification of Periapical Disease ❖ Acute Periapical Disease ❖ Acute Apical Periodontitis ❖ Acute Apical Abscess ❖ Recrudescence Absecess (Pheonix Abscess) ❖ Chronic Periapical Disease ❖ Chronic Aical Periodontitis ❖ Chonic Apical Abscess ❖ Condensing Osteitis
  38. 38. Etiology Acute Apical Abscess • Localized collection of pus in an a cavity formed by disintegration of tissues • Advanced exudative inflammatory response • Neglected apical periodontitis (Same Eitology)
  39. 39. 1. Severe throbbing & tooth is elevated 2. Localized or diffuse swelling 3. May present with fever & lymph node affection 4. Pulp test: Negative 5. Radiograph: Slight Widening or large lesion 6. Palpation & Perscussion: Positive Signs & Symptoms Acute Apical Abscess
  40. 40. Classification of Periapical Disease ❖ Acute Periapical Disease ❖ Acute Apical Periodontitis ❖ Acute Apical Abscess ❖ Recrudescence Abscess (Pheonix Abscess) ❖ Chronic Periapical Disease ❖ Chronic Aical Periodontitis ❖ Chonic Apical Abscess ❖ Condensing Osteitis
  41. 41. Etiology Recrudescence Abscess (Pheonix Abscess) • It is an acute exacerbation of chronic periapical lession. It occurs when there is an imbalance between the host response & irritant. • Symptoms are similar to an acute apical abscess • Usually large lesion related to the tooth
  42. 42. Classification of Periapical Disease ❖ Acute Periapical Disease ❖ Acute Apical Periodontitis ❖ Acute Apical Abscess ❖ Recrudescence Abscess (Pheonix Abscess) ❖ Chronic Periapical Disease ❖ Chronic Aical Periodontitis ❖ Chonic Apical Abscess ❖ Condensing Osteitis
  43. 43. Etiology Chronic Apical Periodontitis • It can develop from acute apical periodontitis • Or it can develop independently without previous symptoms
  44. 44. 1. Usually no significant pain 2. Pulp test: Negative 3. Radiograph: Lesion related to the tooth 4. Palpation & Perscussion: Mild or none Signs & Symptoms Chronic Apical Periodontitis
  45. 45. 1. Growth of granulation tissue around root apex 2. 4 Zones: 1. Zone 1: Necrosis zone (Neutrophills) 2. Zone 2: Contamination zone (Multi Nucleated Giant Cells 3. Zone 3: Irritation zone (Neutrophills, lymphocytes & macrophages 4. Zone 4: Stimulation zone (Fibroblasts & Osteoblasts) Histopatholog Chronic Apical Periodontitis (Periapical Granuloma)
  46. 46. 1. Considered a granuloma with a fluid filled center & an epithelium lined cavity 2. Epithelial cells originate from the cells of Malassez 3. The fluid in the center maybe clear or viscous yellow (fatty degeneration). Contains cholesterol crystals. Histopatholog Chronic Apical Periodontitis (Periapical Cyst)
  47. 47. Classification of Periapical Disease ❖ Acute Periapical Disease ❖ Acute Apical Periodontitis ❖ Acute Apical Abscess ❖ Recrudescence Abscess (Pheonix Abscess) ❖ Chronic Periapical Disease ❖ Chronic Aical Periodontitis ❖ Chonic Apical Abscess ❖ Condensing Osteitis
  48. 48. Etiology Chronic Apical Abscess • Condition after an acute apical abscess has drained
  49. 49. 1. Usually very mild pain 2. Usually a draining sinus tract 3. Pulp test: Negative 4. Radiograph: Lesion related to the tooth (Not well defined) 5. Palpation & Perscussion: Mild or none Signs & Symptoms Chronic Apical Abscess
  50. 50. 1. Could be either periapical granuloma or periapical cyst. 2. Usually looks like a periapical granuloma with pus in the center Histopatholog Chronic Apical Abscess
  51. 51. Classification of Periapical Disease ❖ Acute Periapical Disease ❖ Acute Apical Periodontitis ❖ Acute Apical Abscess ❖ Recrudescence Abscess (Pheonix Abscess) ❖ Chronic Periapical Disease ❖ Chronic Aical Periodontitis ❖ Chonic Apical Abscess ❖ Condensing Osteitis
  52. 52. Etiology Condensing Osteitis • Low grade long standing irritation • Resulting in unusual body response by increased density of periodical bony tissue due to hyperactive osteoblastic activity • Young patients with large carious session
  53. 53. 1. Usually no pain 2. Pulp test: Negative 3. Radiograph: Radioopacity related to the root apex 4. Palpation & Perscussion: Negative Signs & Symptoms Condensing Osteitis
  54. 54. “Thank You”

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