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Pulp and periapical pathologies

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Pulp and periapical pathologies

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As heart is to the body, the pulp is to the tooth, providing a constant source of nutrition to maintain the vitality of a tooth. Every precaution should be taken to preserve vitality of the pulp. A simple dental infection if neglected , can proceed to life threatening complications. So early detection , early treatment and early prevention is very important.

As heart is to the body, the pulp is to the tooth, providing a constant source of nutrition to maintain the vitality of a tooth. Every precaution should be taken to preserve vitality of the pulp. A simple dental infection if neglected , can proceed to life threatening complications. So early detection , early treatment and early prevention is very important.

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Pulp and periapical pathologies

  1. 1. PulP and periapical pathologies Presented by - Dr. Ruchika Garg
  2. 2. Contents • Introduction • Causes of pulp disease • Diseases of pulp • Interrelationships of periapical infections • Diseases of periradicular tissues • Conclusion
  3. 3. Introduction • Pulp is a soft tissue of mesenchymal origin residing within the pulp chamber and root canal of teeth. • It is the formative organ of the tooth. • It builds Primary dentin Secondary dentin Reparative dentin
  4. 4. Functions of Pulp • Produces dentin Formative : • Pulp nourishes the dentin Nutritive : • Through sensory nerves in the tooth Protective : • Produces reparative dentin and mineralizes any affected dentinal tubules Defensive or reparative :
  5. 5. Whyis the pulp unique ? 6 • Lack of collateral blood supply. • The anatomic limitation of unyielding walls of dentin. • Inflammatory reactions result in an increase in tissue pressure. • Perceives all types of stimuli as pain. Pulp is placed in a low - compliance environment. Thus, pulp tissue has limited ability to expand so vasodilatation and increased vascular permeability evoked during an inflammatory reaction results in an increase in pulpal hydrostatic pressure.
  6. 6. Causes of pulp diseases • Trauma • Pathologic wear • Crack through body of tooth • Barometric changes Mechanical • Heat from cavity preparation • Exothermic heat from setting of cement • Frictional heat Thermal • Galvanic current Electrical Physical Bacterial Chemical • Phosphoric acid • Erosion • Toxins associated with caries • Direct invasion • Anachoresis
  7. 7. Investigations for vitality of pulp • Heat test • Cold test • Electric pulp test Pulp Tests • Laser Doppler Flowmetry • Pulse Oximetry • Test cavity • Selective Anesthesia Special Tests Eugene Chen and Paul V. Abbott. Dental Pulp Testing: A Review. International Journal of Dentistry. Volume 2009, Article ID 365785, 12 pages.doi:10.1155/2009/365785
  8. 8. Salivary Biomarkers in the dentin-pulpcomplex in disease Dental Caries Pulpal and Periapical Pathoses Matrix Metalloproteinases (MMP) Production of MMP-20 occurs in primary dentinogenesis by the dentin- pulp complex which was integrated in dentin. Use of MMP-9 and MMP-2 as biological markers can be substantiated Bone Sialoprotein (BSP) Expression of osteocalcin was higher in reversible pulpitis compared to irreversible pulpitis Alkaline Phosphatase (ALP) Marker for odontoblast-like differentiation. IL-1β is present in the periapical lesion and is locally released in periapical lesions which mediate bone resorption MMP-8 - Biochemical indicator to assess the inflammatory status of the periapical tissue. Emilia E , Neelakantan P. Biomarkers in the Dentin-Pulp Complex: Role in Health and Disease. The Journal of Clinical Pediatric Dentistry. Volume 39, Number 2/2015.
  9. 9. Pulpitis Acute Apical periodontitis Acute Periapical abscess Periapical granuloma Periodontal cyst Osteomyelitis Acute Periostitis Cellulitis Ludwigs angina Focal Diffuse Chronic Chronic ChronicAcute Chronic
  10. 10. WHO Classificationof pulpal diseases
  11. 11. Reversible pulpitis • Early mild transient pulpitis, localized chiefly to pulpal ends of irritated dentinal tubules. • Cause - Caries , Restoration , Defective margins • C/F- Sensitive to thermal changes Disappears on removal of stimulus
  12. 12. • Electric pulp tester (EPT) – Low current • R/F – Deep carious lesion , Restored tooth • T/t – Remove cause
  13. 13. Irreversible pulpitis • It is a persistent inflammatory condition of pulp, symptomatic or asymptomatic, caused by a noxious stimuli. • Cause - Bacterial, thermal, mechanical or chemical • C/F – Early stages- paroxysm of pain Severe , sharp , piercing , shooting pain Continues on stimulus removal, Exacerbates on change in posture Later stages – Pain - severe, boring, gnawning, throbbing ↑ses by heat ;↓ses by cold
  14. 14. • R/F – Usually normal apex • D/d – Reversible pulpitis Acute alveolar abscess • T/t – RCT, extraction
  15. 15. Acute pulpitis • It can occur as de novo or an acute exacerbation of chronic inflammatory process. • Cause - Trauma , thermal shock , chemical stimulus • C/F – Early stages - Pain to thermal changes Spontaneous Later stages – Severe pain , lancinating and throbbing Continuous , increase on lying down Large open cavity - Dull throbbing pain
  16. 16. • EPT – Low current • R/F– Deep caries , restoration • T/t- RCT
  17. 17. Chronic pulpitis • It may arise on occasion through quiescence of previous acute pulpitis, but more frequently occurs as chronic type from onset. • Cause – Mild chronic irritation • C/F – Mild, dull, intermittent ache Reduced reaction to thermal change
  18. 18. • EPT – High current • T/t – RCT
  19. 19. Chronic hyperplastic pulpitis (pulp polyp) • It is a productive pulpal inflammation due to an extensive carious exposure of a young pulp. • Cause – Large open cavity , young resistant pulp, chronic low grade stimulus • C/F – Children , young adults Deciduous and 1st permanent molars Pinkish red globule
  20. 20. • R/F – Large carious lesion • D/d – Gingival polyp • T/t – RCT, extraction
  21. 21. Internal resorption • It is an idiopathic slow or fast progressive resorptive process occurring in dentin of pulp chamber or root canals of teeth. • Cause – Trauma / Unknown • C/F – Maxillary anterior teeth Slow, progressive, intermittent or continuous In root- Radiographs In crown- pink spot
  22. 22. • R/F – Ballooning of root canal • D/d – External resorption • T/t – RCT If root perforated - Ca(OH)2 paste
  23. 23. Necrosis of pulp • Necrosis is the death of pulp • Types – Coagulation and liquefaction • Cause – Bacterial, trauma, chemical irritation • C/F – Discoloration, asymptomatic Not respond to cold and electric tester
  24. 24. • R/F – Large cavity , Restoration Widened PDL • T/t – RCT
  25. 25. Interrelationships
  26. 26. Diseases of periradicular tissues • Acute periradicular disease Acute alveolar abscess Acute apical periodontitis Vital Nonvital • Chronic periradicular diseases with areas of rarefaction Chronic alveolar abscess Granuloma Cyst • Condensing osteitis • External root resorption • Diseases of periradicular tissues of nonendodontic origin
  27. 27. WHO Classification
  28. 28. Apical periodontitis • It is the inflammation of periodontal ligament around the apical portion of the root. • Types • Cause – Spread from pulp, occlusal trauma Inadvertent endodontic procedures
  29. 29. Acute apicalperiodontitis • It is a painful inflammation of the periodontium as a result of trauma, irritation, or infection through the root canal, regardless of whether pulp is vital or non-vital. • Cause – Vital - Occlusal trauma , wedging , blow Non-vital - Sequel of pulp disease , over instrumentation • C/F – History of pulpitis , no response to thermal change Tooth slightly sore , extruded
  30. 30. • R/F – Thickened PDL at apex with small radiolucency or normal • D/d – Acute alveolar abscess • T/t – Remove cause , RCT
  31. 31. Chronic apicalperiodontitis (periapical granuloma) • It is essentially a localized mass of chronic granulation tissue formed in response to the infection. • Cause – Death of pulp by mild infection • C/F – Nonvital, slightly tender Pain on biting Can be asymptomatic Simon JHS , Hemple RL , Rotstein , Salter PK. Role of virulence in periapical lesions. . J. Endod 1999; 16 :534.
  32. 32. FISH Zones • Zone of Infection – (Necrotic) or infected root canal • Zone of Contamination - (Exudative inflammatory zone) • Zone of Irritation – (Granulomatous zone) • Zone of Stimulation - (Zone of encapsulation)
  33. 33. • R/F – Thickened PDL Radiolucent area at apex Well defined or diffuse • D/d – Cementoma • T/t – RCT with or without apicoectomy Extraction
  34. 34. Acute exacerbation of chroniclesion (phoenix abscess) • This condition is an acute inflammatory reaction superimposed on an existing chronic lesion, such as a cyst or granuloma. • Cause – Bacterial, mechanical irritation • C/F – Non-vital Onset - Tender to touch Later - Tooth elevated Radicular mucosa - Tender, red , swollen
  35. 35. • R/F – Large periapical radiolucency Well defined or diffuse • D/d – Acute apical abscess • T/t – Drainage to be established RCT, extraction
  36. 36. Apical periodontal cyst (radicular cyst) • A cyst is a closed cavity or sac internally lined with epithelium, the center of which is filled with fluid or semisolid material. • Cause - Death of pulp Stimulation of epithelial cell rests of malassez • C/F – Majority asymptomatic Maxillary anteriors Non-vital
  37. 37. • R/F – Dark radiolucent area at apex Sharp clearly defined margins Thin white line at periphery • D/d – Granuloma Fissural cysts Traumatic bone cyst Globulomaxillary cyst Nasopalatine cyst • T/t – RCT ; Surgical enucleation
  38. 38. Acute periapical abscess • It is a localized collection of pus in the alveolar bone at the root apex of a tooth following death of pulp, with extension of infection through apical foramen into periradicular tissues. • Cause – Bacterial • C/f – Early - Tenderness relieved by slight pressure Later - Severe throbbing pain, swelling Fever with chills, headache, malaise, foul breath
  39. 39. • R/F – Thickening PDL Radiolucency at apex - irregular • D/d – Periodontal abscess • T/t – Control systemic reaction Drainage RCT, extraction
  40. 40. Chronic alveolar abscess • It is a long standing, low-grade infection of the periradicular alveolar bone. • Cause – Sequeale of pulp death • C/F – Generally asymptomatic Discoloration of tooth Presence of sinus tract
  41. 41. • R/F – Thickened PDL Diffuse radiolucency at apex Fistula by gutta percha • D/d – Granuloma Periapical cyst • T/t – RCT
  42. 42. Parulis / Gum boil (Acute / Chronic) Stoma (Chronic)
  43. 43. Condensing Osteitis / Focal sclerosing osteomyelitis • It is a mild inflammatory response of periapical bone to a low grade long standing pulpal irritation. • Cause – Pulpitis / Pulpal necrosis • C/F – Usually asymptomatic Mild pain James L. Gutmann et al. Identify and Define All Diagnostic Terms for Periapical/ Periradicular Health and Disease States. JOE — Volume 35, Number 12, December 2009.
  44. 44. • R/F – Well circumscribed , radiopaque mass of sclerotic bone extending below the apex • D/D – Cementoblastoma Periapical cemental dysplasia Osteosclerosis • T/t – Endodontic therapy Radiologic features (Eversole and colleagues ) - 1984 A focal pattern characterized as a homogeneous radiopaque mass lacking a perilesional radiolucent halo A target pattern consisting a central radiopacity with a circumferential radiolucent band A radiolucent pattern described as a non expansile periapical radiolucency A multiconfluent pattern where several target lesions at the apices of a single multirooted tooth become closely apposed A resorption pattern characterized by external root resorption
  45. 45. Externalroot resorption • It is a lytic process occurring in cementum or cementum and dentin of roots of teeth. • Cause – Periradicular infection Idiopathic • C/F – Root completely resorbed - Mobility Replacement resorption - Ankylosis
  46. 46. • R/F – Scooped - out pattern of root • D/d – Internal resorption • T/t – Varies with etiologic agent
  47. 47. Radiographic Differential Diagnosis of Common Periapical Lesions Abscess Granuloma Cyst Size Any size Not more than More than 1.6 cms 1.6 cms (Lalonde 1970) Shape No shape Round or oval Round or oval Outline Irregular Regular Regular Border Ill-defined Well-defined Well-defined Other Root Tooth elevated Features resorption Root displacement Expansion of jawThinning of cortex
  48. 48. Diseases of periradicular tissuesof non-endodontic origin • Periodontal diseases • Cementoblastoma • Fissural cysts • Central giant cell granuloma • Odontogenic cysts
  49. 49. Conclusion • As heart is to the body, the pulp is to the tooth, providing a constant source of nutrition to maintain the vitality of a tooth. Every precaution should be taken to preserve vitality of the pulp. • A simple dental infection if neglected , can proceed to life threatening complications. • So early detection , early treatment and early prevention is very important.
  50. 50. References • Textbook of oral pathology – Shafer (6th edition) • Diagnostic imaging of the jaws – Langland and Langlais • Endodontic practice – Grossman (12th edition) • Endodontics 6 – Ingle • Rahul Maria , Vijay Mantri , Shraddha Koolwal. Internal resorption : A review & case report. Endodontology. • Abbott PV, Yu C. A clinical classification of the status of the pulp and the root canal system. Aust Dent J 2007;52 (Endod Suppl):S17-31. • Rosenberg PA, Schindler WG, Krell KV, Hicks ML, Davis SB. Identify the endodontic treatment modalities. J Endod 2009;35:1675. • Emilia E , Neelakantan P. Biomarkers in the Dentin-Pulp Complex: Role in Health and Disease. The Journal of Clinical Pediatric Dentistry. Volume 39, Number 2/2015. • Atul Jain, Rachana Bahuguna. Role of matrix metalloproteinases in dental caries, pulp and periapical inflammation : An overview. http://dx.doi.org/10.1016/j.jobcr.2015.06.015.

Notas do Editor

  • Even mature pulp bears resemblance to embryonic tissue.
  • Anachoresis is a phenomenon in which blood borne bacteria , dyes, pigments , metallic substances, foreign proteins, and other materials are attracted to the site of inflammation.
  • Cause- deep carious lesion, large metallic restorations, defective margins
    c/f- sensitive to thermal changes, disappears on removal of stimulus
    Electric tester- lower current
    r/f- generally deep caries or filled tooth
    t/t-reversible if fast, excavate caries
    P- favourable if fast t/t
  • Cause- bacterial, other thermal, reversible progress
    c/f- early stages- paroxysm of pain
    pain continues on removal of stimulus, spontaneous, sharp, piercing or shooting n generally severe
    bending down increase pain, referred to adjacent teeth
    later stages- pain severe boring, gnawing or throbbing
    pt awake at night, intolerable pain
    r/f- normal apical pdl space,lamina dura, slight widening of apical pdl space
    d/d- reversible pulpitis, acute alveolar abscess
    t/t- rct, extraction
    P- favourable after rct

  • Cause- trauma, thermal shock, chemical stimulus, excessive dehydration
    c/f- early stages, severe pain to thermal changes
    pain not spontaneously n does not continue on removing stimulus
    later stages, pain is severe lancinating and throbbing type
    intensity increase on lying down and is mostly continuous
    in large open cavity- pain is dull throbbing
    pt is atleast mildly ill
    Electric- low current
    r/f- deep carious lesion or filling
    d/d- irreversible pulpitis, chronic reversible pulpitis
    t/t- prevention, pulpotomy, rct
    P- favourable with fast t/t
  • Cause- mild chronic irritation
    c/f- all signs n symptoms r milder
    Pain not prominent. Mild dull ache, intermittent
    reaction to thermal change- reduced
    Electric- threshold of stimulus increased
    t/t- rct or extraction
    P- favourable
  • Cause- slow progressive carious lesion, mechanical, bacterial irritation
    large open cavity, young resistant pulp, chronic low grade stimulus
    c/f- children, young adults, deciduous n 1st molars
    pinkish red globule protruding, few nerves, rich blood supply
    d/d- gingival polyp
    t/t- elimination of polyp n rct
    P- favourable
  • Cause- unknown, trauma
    c/f- in root- asymptomatic
    in crown- pink spot
    maxillary anterior teeth
    may be slow, progressive, intermittent or rapid
    r/f- change in appearance of wall in root canal or chamber, with round or oval radiolucent area
    d/d- external resorption
    t/t- rct
    if root perforated- ca(oh)2 paste
    P- best before perforation
  • Types- coagulation n liquefaction
    Cause- trauma, chemical irritation
    c/f- discoloration, tooth asymptomatic, not respond to cold, electric tester
    r/f- large cavity or filling approaching pulp, thickening of pdl
    t/t- rct
    P- favourable
  • Type- acute or chronic – virulence of microbes, type n severity of irritants, host resistance
    Cause- spread of pulpal, occlusal trauma, inadvertent endo procedures
  • Cause- vital tooth- occlusal trauma, wedging foreign object, blow to tooth
    nonvital- sequel of pulpal disease, root canal overinstrumentation
    c/f- pt have h/o previous pulpitis, thermal change not induce pain
    tooth may be slightly sore, extruded
    r/f- may exhibit small periapical radiolucency or pdl thickening at apex or can be normal
    d/d- acute alveolar abscess
    t/t- remove cause, rct
    P- favourable
  • Cause- vital tooth- occlusal trauma, wedging foreign object, blow to tooth
    nonvital- sequel of pulpal disease, root canal overinstrumentation
    c/f- pt have h/o previous pulpitis, thermal change not induce pain
    tooth may be slightly sore, extruded
    r/f- may exhibit small periapical radiolucency or pdl thickening at apex or can be normal
    d/d- acute alveolar abscess
    t/t- remove cause, rct
    P- favourable
  • Cause-death of pulp followed by mild infection
    c/f- nonvital tooth, slightly tender to percussion
    pt has mild pain on biting, can be asymptomatic
    Tooth not respond to electric and thermal test
    r/f- pdl thickening, radiolucent area of variable size attached to root apex
    well defined or diffuse
    d/d- cementoma, -vital tooth
    t/t- rct with or without subsequent apicoectomy, extraction
    P- excellent

  • Cause-death of pulp followed by mild infection
    c/f- nonvital tooth, slightly tender to percussion
    pt has mild pain on biting, can be asymptomatic
    Tooth not respond to electric and thermal test
    r/f- pdl thickening, radiolucent area of variable size attached to root apex
    well defined or diffuse
    d/d- cementoma, -vital tooth
    t/t- rct with or without subsequent apicoectomy, extraction
    P- excellent

  • Cause- bacteria from necrosed pulp, mechanical irritation
    c/f- onset- tender to touch
    as progresses- tooth elevated
    mucosa over radicular area may be sensitive to palpation and may be red swollen
    nonvital may respond to tester due to multi root
    r/f- large periapical radiolucency, well defined or diffuse
    d/d- acute alveolar abscess, acute irreversible pulpitis
    t/t- same as acute alveolar abscess
    P- good
  • Cause- bacteria from necrosed pulp, mechanical irritation
    c/f- onset- tender to touch
    as progresses- tooth elevated
    mucosa over radicular area may be sensitive to palpation and may be red swollen
    nonvital may respond to tester due to multi root
    r/f- large periapical radiolucency, well defined or diffuse
    d/d- acute alveolar abscess, acute irreversible pulpitis
    t/t- same as acute alveolar abscess
    P- good
  • Cause- irritation cause death of pulp- stimulation of epithelial cell rests of malassez
    c/f- majority asymptomatic, maxillary anteriors
    Nonvital, deep carious lesion
    r/f- bone destruction, dark radiolucent area
    margins sharp clearly defined, uncomplicated cases thin white line surrounds
    d/d- granuloma, incisive foramen, globulomaxillary traumatic bone cyst
    t/t- rct
    P- depends on extent of cyst
  • Cause- irritation cause death of pulp- stimulation of epithelial cell rests of malassez
    c/f- majority asymptomatic, maxillary anteriors
    Nonvital, deep carious lesion
    r/f- bone destruction, dark radiolucent area
    margins sharp clearly defined, uncomplicated cases thin white line surrounds
    d/d- granuloma, incisive foramen, globulomaxillary traumatic bone cyst
    t/t- rct
    P- depends on extent of cyst
  • Cause- bacterial invasion
    c/f- 1st symptom mere tenderness relieved by slight pressure
    later severe, throbbing pain with attendant swelling of overlying soft tissue
    fever often preceded or accompanied by chills, headache, malaise, foul breath
    if untreated- osteitis, cellulitis, periostitis, osteomyelitis
    r/f- early stages- difficult to locate tooth
    later- locate by caries, leaky restoration, thickened pdl, bone breakdown at apex
    d/d- periodontal abscess
    t/t- drainage n controlling systemic reaction
    when symptoms subside- rct, extraction
    P- favourable
  • Cause- bacterial invasion
    c/f- 1st symptom mere tenderness relieved by slight pressure
    later severe, throbbing pain with attendant swelling of overlying soft tissue
    fever often preceded or accompanied by chills, headache, malaise, foul breath
    if untreated- osteitis, cellulitis, periostitis, osteomyelitis
    r/f- early stages- difficult to locate tooth
    later- locate by caries, leaky restoration, thickened pdl, bone breakdown at apex
    d/d- periodontal abscess
    t/t- drainage n controlling systemic reaction
    when symptoms subside- rct, extraction
    P- favourable
  • Cause- pulpal death sequel
    c/f- generally asymptomatic, presence of sinus tract
    discoloration of tooth
    r/f- diffuse area of radiolucency at apex of tooth. Lesser density than granuloma or cyst
    fistula by gutta percha thickened pdl
    d/d- periapical granuloma, pariapical cyst, cementoma
    t/t- rct
    P- depends on extent
  • Cause- pulpal death sequel
    c/f- generally asymptomatic, presence of sinus tract
    discoloration of tooth
    r/f- diffuse area of radiolucency at apex of tooth. Lesser density than granuloma or cyst
    fistula by gutta percha thickened pdl
    d/d- periapical granuloma, pariapical cyst, cementoma
    t/t- rct
    P- depends on extent
  • Cause- periradicular infection, idiopathic
    c/f- when root completely resorbed- mobile tooth
    replacement resorption- ankylosis
    r/f-
    d/d- internal resorption
    t/t- varies with etiologic factor
    P- depends on cause
  • Cause- periradicular infection, idiopathic
    c/f- when root completely resorbed- mobile tooth
    replacement resorption- ankylosis
    r/f-
    d/d- internal resorption
    t/t- varies with etiologic factor
    P- depends on cause

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