1.
Diseases of
the pulp by
Dr.Ashuja.RB

2.
• Introduction
• Definition
• Classification
• Etiologic features
• Reversible and irreversible
• Acute pulpitis
• Chronic pulpitis
• Pulp polyp
• Gangrene of pulp

3.
Introduction:
• Like other connective tissue pulp reacts with bacterial
infection or the other irritant by inflammatory response.
• Pulpitis is the most common lesion to produce.
• A focal breach in this barrier can adversely affect the
health of the dental pulp.
• Inflammatory vascular changes increase the pulpal
volume, but swelling is restricted due to the surrounding
dentinal walls, often triggering pain.

4.
Definition:
Pulp:
Soft tissue within pulp cavity, consisting of connective t
issue containing blood vessels, nerves, and lymphatics,
and at the periphery, layer of odontoblasts capable of in
ternal deposition and repair of the dentin.
Periapical:
• Encompassing or surrounding the tip of the root of a
tooth.
Pulpitis :
• Inflammation of the pulp of a tooth.

5.
Clinically normal pulp
• Clinically, a normal pulp exhibits no signs or symptoms
that suggest pulpitis.
• Teeth respond to cold with mild pain that resolves in 1 to
2 seconds, whereas heat is not associated with pulpal
discomfort.
• No pain on percussion.
• Radiographic examination of the periradicular bone will
be within normal limits.

6.
History
• During World War II in flying personnel,condition
clinically simulating pulpitis by the incidence of
toothache was reported - aerodontalgia.
• Described in aircrew flying at high altitudes, astronauts,
submarine crews, and in deep sea divers.
• It is relatively uncommon and is associated particularly
with recently filled teeth.

7.
• The pain in decompression does not usually occur in normal
pulps.
• Some cases of pain localized to the dental area and resembling
aerodontalgia have been reported to represent aerosinusitis
and not to be related to the teeth.

8.
Classification:
1. Depending on severity:
• Acute and chronic
2. Depending upon the extent of involvement of pulp
• Partial or focal pulpitis
• Total pulpitis or generalized pulpitis
3. Based on the communication between pulp and oral environment
• Open pulpitis (Pulpitis Aperta)
• Closed pulpitis (Pulpitis Clausa)

9.
Etiologic features:
• Four main types of noxious stimuli are common
causes of pulpal inflammation (pulpitis):
1.Mechanical damage:
Traumatic accidents, iatrogenic damage from dental procedures,
attrition, abrasion, and barometric changes.
2. Thermal injury: Cavity preparation, polishing, and exothermic
chemical reactions of dental materials.

10.
3. Chemical irritation:
Erosion or from the inappropriate use of acidic dental materials.
4. Bacterial effects:
Bacteria can damage the pulp through toxins or directly after
extension from caries or transportation via the vasculature.

11.
• Anachoretic pulpitis: 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.
• Anachoresis is a phenomenon by which blood borne bacteria,
dyes, pigments, metallic substances, foreign proteins, and other
materials are attracted to the site of inflammation.

12.
• Cause: Increased capillary permeability in
the particular area.
• Anachoretic pulpitis probably occurs in a
clinically irrelevant number compared
with the number of cases occurring as a
result of dental caries.

13.
Cracked tooth syndrome
• In cracked tooth syndrome, a tooth, usually a restored premolar
may split under masticatory stress.
• These cracks are often minute and invisible clinically, and they
allow the bacteria to enter into the pulp.

14.
• Bacterial invasion may also occur as a result of a
bacteremia and septicemia.
• Pulpitis may rarely follow chronic periodontal disease
wherein the microorganisms enter through the accessory
canals of the exposed root surface especially through
lateral canals infurcation areas of molars.

15.
Reversible pulpitis
• One of the earliest forms of pulpitis - focal
reversible pulpitis.
• Pulp hyperemia.
• vascular dilatation can occur artefactually from
the ‘pumping’ action during tooth extraction as
well as pathologically as a result of dentinal and
pulpal irritation.
• Therefore, this early mild transient pulpitis,
localized chiefly to the pulpal ends of irritated
dentinal tubules, is now known as focal reversible
pulpitis.

16.
Clinical Features:
• A tooth is sensitive to cold.
• The application of ice or cold fluids  pain.
• Pain disappears upon removal of the thermal stimuli or
restoration of the normal temperature.
• Tooth responds to stimulation by the electric pulp tester at a
lower level of current.
• Deep carious lesion, large metallic restorations,or ,
restorations with defective margins.

17.
Histologic Features:
• Dilatation of the pulp vessels
• Edema fluid may collect
• Allowing actual extravasation of red blood cells or some
diapedesis of white blood cells.
• Thrombosis.

18.
Treatment and Prognosis.
• Reversible condition
• The irritant is removed before the pulp is severely
damaged.
• Excavation of caries and restoration or a replacement of
defective filling
• If the primary cause is not corrected, extensive pulpitis
 subsequent ‘death’ of the pulp.

19.
Irreversible pulpitis
• Patients with early irreversible pulpitis generally have
o sharp, severe pain on thermal stimulation,
o pain continues for a longer period of time after the
stimulus is removed.
• Cold is especially uncomfortable,
• Even heat or sweet and acidic foods also can elicit pain.

20.
• Early stages
o The pain often easily localized.
o With increasing discomfort,unable to identify the offending
tooth within a quadrant.
o Although pulpal pain never crosses the midline,it can be
referred from arch to arch,
o In difficult cases, pulp testing of both arches.

21.
• Late stages
o The pain increases in intensity
oAs a throbbing pressure that can keep patients awake at
night.
o At this point, heat increases the pain; however, cold may
produce relief.
oElectric pulp testing - at higher levels of current or
demonstrates no response.
o Mobility and sensitivity to percussion are usually absent.
oIf pulpal drainage occurs ,symptoms may resolve if the

22.
Histological features:
• The dental pulp exhibits an area of
fibrosis and chronic inflammation
peripheral to the zone of abscess
formation.
Irreversible Pulpitis. Dental pulp
exhibiting acute inflammatory infiltrate
consisting predominantly of
polymorphonuclearleukocytes.

23.
Treatment:
• Complete removal of pulp or pulpectomy
• Placement of intracanal medicament
• Extraction or root canal therapy

24.
Features of reversible and irreversible pulpitis
Reversible pulpitis Irreversible pulpitis
Pain in short, sharp stabs Constant throbbing pain with sharp
exacerbations
Stimulated by cold as hot and cold or osmotic (sweet)
stimuli.
In late stages cold may relieve the
pain
Pain resolves after
stimulus removed in
seconds or a few minutes<
20 minutes duration
Pain persists several minutes or
hours after an exacerbating
stimulus> 20 minutes duration
Easily localized Difficult to localize
Unaffected by position Affected by position

25.
Acute pulpitis
• Extensive acute inflammation of the dental
pulp.
• Frequent immediate sequela of focal reversible
pulpitis.
• It may also occur as an acute exacerbation of a
chronic inflammatory process.

26.
Causes:
• Large carious lesion or restoration,
• ‘Recurrent caries’.
Clinical features:
• Early stages
o Involves only a portion of the pulp(beneath the carious
lesion)
o Severe pain is elicited by thermal changes, particularly to
ice or cold drinks.
o Pulpal pain is poorly localized.
o Pain persists even after the thermal stimulus has
disappeared or been removed.

27.
Late stage:
• The pain may become even more severe.
• Pain - lancinating or throbbing type.
• The pain generally lasts for 10–15 minutes but may be
more or less continuous.
• Teeth of the upper or lower jaw of the affected side.
• Its intensity may be increased when the patient lies
down.
• The application of heat may cause an acute exacerbation
of pain.

28.
• The electric pulp vitality tester - lower level of current
than adjacent normal teeth, indicating increased
sensitivity of the pulp.
• When necrosis of the pulp tissue occurs, this sensitivity is
lost.
• Severe pain - entrance to the diseased pulp is not wide
open.
• Severe acute pulpitis is extremely uncomfortable and at
least mildly ill.

29.
Histopathologic features:
• Early acute pulpitis is characterized by the
o Continued vascular dilatation seen in focal reversible
pulpitis,
oAccumulation of edema fluid in the connective tissue
surrounding the tiny blood vessels.
o Increased PML becomes apparent along the walls of
these vascular channels,
o leukocytes rapidly migrate through the endothelium
lined structures.

30.
• WBC are found in the inflamed region, beneath an
area of carious penetration, the odontoblasts usually
destroyed in this area.
• The entire odontoblastic layer degenerates.
• Entire pulp tissue undergoes rather rapid
disintegration ,when there is closed pulp.
• Numerous small abscesses may form.

31.
• Eventually the entire pulp undergoes liquefaction
and necrosis.
• Acute suppurative pulpitis.
• The pulp, especially in the later stages of pulpitis
following carious invasion, contains large
numbers of bacteria.

32.
Treatment and prognosis:
• Pulpotomy (removal of the coronal pulp)
• Root canal treatment.

33.
Chronic pulpitis
• May arise on occasion through quiescence of a previous
acute pulpitis.
• But more frequently it occurs as the chronic type of
disease from the onset.
• The signs and symptoms are considerably milder than
those in the acute form of the disease.

34.
Clinical Features:
• Pain
o Not a prominent feature.
o Even sometimes the patient complains of a mild, dull ache.
o More often intermittent than continuous.
• The reaction to thermal change is dramatically reduced in
comparison to that in acute pulpitis.
• The general features are not typical.
• In the absence of significant symptoms, serious involvement
of the pulp may be present.

35.
• Even in wide-open carious lesions with open pulp, there
is relatively little pain.
• Bleeding may occur, pain is often absent.
• Pulps may become totally necrotic without pain.

36.
Histologic Features:
• Chronic pulpitis is characterized by infiltration of the
pulp tissue by varying numbers of mononuclear cells,
chiefly lymphocytes and plasma cells and more vigorous
connective tissue reaction.
• Capillaries are usually prominent;
• Fibroblastic activity is evident;
• Collagen fibers arranged in bundles.

37.
• Sometimes the pulp attempt to ward off the infection
through deposition of collagen fibers around the inflamed
area.
• The tissue reaction may resemble the formation of
granulation tissue on the surface of the pulp tissue in a wide-
open exposure.

38.
• With bacterial stains,microorganisms may be found in the
pulp tissue, especially in the area of a carious exposure.
• In some cases, the pulpal reaction fluctuates between an
acute and a chronic phase.

39.
Treatment and Prognosis:
• Does not differ intensely from that of acute pulpitis.
• Root canal therapy or extraction of the tooth.

40.
Pulp polyp
• Chronic hyperplastic pulpitis
• A unique form of pulpitis
• The inflamed pulp, instead of perishing by continued
suppuration, reacts by excessive and exuberant
proliferation.
• It occurs either as a chronic lesion from the onset or
as a chronic stage of a previously acute pulpitis.

41.
Clinical features :
• Children and young adults.
• It involves teeth with large, open carious lesions.
• Appears as a pinkish-red globule of tissue protruding from
the pulp chamber.

42.
• Deciduous molars and the first permanent molars.
• Have an excellent blood supply.
• Unusual proliferative property of the pulp tissue.
• Tooth is asymptomatic except for a possible feeling of
pressure when it is placed into masticatory function.

43.
Histopathological features:
• The surface may or may not be covered with
stratified squamous epithelium, which migrates
from the adjacent gingiva or arises from sloughed
epithelium within the oral fluids.
• The deeper pulp tissue within the canals
typically shows fibrosis and a chronic
inflammatory infiltrate.
• Pulpal calcifications are common in both the
radicular and coronal portions.

44.
• Often the apical portion of the pulp tissue is normal with
minimal inflammation or fibrosis.
• The well-vascularized granulation tissue mass often
becomes epithelialized, presumably by auto
transplantation of epithelial cells from nearby mucosal
surfaces.

45.
Treatment:
• Extraction of the tooth or by root canal therapy.

46.
Gangrenous necrosis of pulp
• Untreated pulpitis, either acute or chronic  complete
necrosis of the pulp tissue.
• Generally associated with bacterial infection, the term pulp
gangrene has sometimes been applied to this condition.
• Gangrene being defined as necrosis of tissue with
superimposed bacterial infection.

47.
• Cause: sudden traumatic event, untreated irreversible
pulpitis.
• Infected pulpal necrosis: Dental decay  Pain
• Non infected pulp necrosis: No symptoms for many months.

48.
• First sign in non infected : Discoloration of tooth due to
result of the decomposing tissue debris and breakdown
products of RBCs entering the open ends of the dentinal
tubules and becoming distributed throughout the dentin.
• After tooth is non vital - Tooth loses its ability to
rehydrate the dentin, making it more brittle and subject
to cracks and fracture.

49.
• Associated with a foul odor
• Diagnostic tool to determine pulpal necrosis – Percussion test
• Gently tapping on several teeth in the area with a blunt instrument
because pressure from tapping will produce intense pain.by this its
easily identified if tooth has undergone pulpal necrosis.

50.
• Necrosis of pulp has been reported in sickle cell anemia where
there is blockage of pulp microcirculation by sickle
erythrocytes .
• Dry gangrene sometimes occurs when the pulp dies for some
unexplained reason.
• The nonvital pulp maintains its general histologic
characteristics, being non purulent.
• This condition may be due to some traumatic injury or infarct.

51.
• Pulp gangrene should not be considered a specific form of
pulp disease but simply the most complete end result of
pulpitis in which there is total necrosis of tissue.
• following blockage of the pulp microcirculation by sickled
erythrocytes.
• Associated with a foul odor when such infected pulps are
opened for endodontic treatment.
• Necrosis of pulp has been reported in sickle cell anemia
where there is blockage of pulp microcirculation by sickle
erythrocytes

52.
Key features of pulpitis
• Caused by infection or irritation of the pulp, usually by caries.
• Severe stabbing pain in a tooth, triggered by hot or cold food or
starting spontaneously, indicates acute irreversible pulpitis.
• Pulp pain is poorly localized
• Chronic pulpitis is often symptomless.
• Untreated pulpitis usually leads to death of the pulp and
spread of infection to the periapical tissues.

53.
Treatment options for pulpitis:
• If fractured or cracked, stabilise fracture and seal pulp
temporarily.
• Removal of caries, obtundent or steroid dressing
• Removal of caries and pulp capping
• Pulpotomy in deciduous teeth
• Endodontic treatment
• Extraction
• Analgesics are largely ineffective.

54.
Pulpitis pathway
Normal pulp
Injury
Acute pulpitis Chronic pulpitis
Pulp necrosis
Periapical inflammation

55.
Diagnostic techniques
• History and nature of the pain
• Reaction to thermal changes
• Reaction to mild electric stimulation
• Reaction to percussion of tooth
• Radiograph examination
• Visual examination
• Palpation of surrounding area

56.
Guess the diagnosis?
1.
• Sharp intense pain
• Pain is spontaneous
• Sensitive to cold
• Pain remains for 5 to 10 minutes.
• Low level current responding by patient on electric pulp
testing.
• Pain disappears on removal of thermal irritant

57.
•Reversible pulpitis

58.
2.
• Dull pain
• Frequent pain
• Sensitive to hot
• Pain keeps patient awake at night on lying down to sleep
• Difficult to localize the tooth.
• Responds to higher level current on electric pulp testing
• On removal of stimuli,pain lingers for longer time.

59.
•Irreversible pulpitis

60.
3.
• Patient may complain of growth of tissue on tooth
• Painless
• Discomfort while chewing
• Children and young adults
• Deciduous molars + 1st permanent molar
• Clinically, open carious lesion and red globe like tissue
protruding from tooth.

61.
•Pulp polyp

62.
4.
• Pain during chewing
• Cracks on tooth surface
• Large restoration or RCT treated teeth
• No changes in radiograph.

63.
•Crack tooth syndrome