Pathology of the pulpal and periradicular tissues 2012 2013

1. Endodontics DB 305C Module 1 Year 3. Wan Noorina WA

2. ¡  Explain the scope of endodontic treatment ¡  Explain why root canal treament needs to be carried out ¡  Describe the stages of root canal treatment ¡  Describe the standards of treatment ¡  List the factors that determine the success of treatment

3. ¡  Characterize aetiological factors causing pulpal inflammation ¡  Explain the mechanism of spread of inflammation in the pulp and periradicular tissues and its consequences ¡  Explain why the pulp has difficulty in recovering from severe injury ¡  Classify the pulpal and periradicular lesions ¡  Describe the step involve in healing(resolution) of periradicular lesions following successful root canal treatment ¡  Identify in general, non-‐endodontic lesions that may simulate endodontic periradicular lesions

4. ¡  Injuries to and diseases of dental pulp and periradicular region ¡  The study of form, function and health ¡  The prevention of:-‐ ¡  The treatment management

5. ¡  The clinical management that consists of procedures that are design to maintain the health of all or part of dental pulp ¡  When pulp is diseased or injured, treatment aimed at preserving the normal periradicular tissues ¡  When infection pursues, treatment is aimed at restoring the periradicular tissues to health ¡  This is done with root canal treatment, + surgical endodontics

6. Healthy pulp Infected Inﬂamed Maintain health Root canal treatment Pulpectomy Root canal re-‐treatment Root canal Apical surgery treatment Pulp capping Pulpotomy (Restoring The Periradicular (Preserving The Normal Tissues To Health) Periradicular Tissues)

7. WHY?

8. ¡  Living organisms §  Micro-‐organisms ▪  Bacteria ▪  Viruses ▪  ? Others ¡  Non-‐living irritants §  Mechanical §  Thermal §  Chemical

9. ¡  Kakehashi et al. The ¡  Moller et al. Inﬂuence eﬀects of surgical on periapical tissues of exposures of dental indigenous oral pulps in germ-‐free and bacteria and necrotic conventional pulp tissue in monkeys. laboratory rats. Oral Scant J Dent Res Surg Oral Med Oral 89:475, 1981 Pathol 20:340; 1965

10. ¡  Microorganisms §  Toxins §  By products ¡  Pulp is inﬁltrated at the base of the carious tubules by §  Chronic inﬂammatory cells §  Macrophages, lymphocytes §  Plasma cells

11. ¡  Pulp tissue will §  Remain inflamed for a long time or §  Undergo necrosis slowly or rapidly ¡  Depending on ¡  Once pulp is exposed, pulp §  Bacteria virulence is infiltrated by PMN to §  Ability to release form liquefaction area at inflammatory fluids the site of exposure §  Host §  The amount of circulation ¡  Bacteria colonize and §  Lymph drainage persist at the site

12. ¡  By this time pulp harbors bacteria and by-‐products. ¡  Pulp can only defend temporarily to impede the spread of infection and tissue destruction ¡  More irritantàmore damage and will spread throughout pulp ¡  Subsequently bac, toxins & by-‐products will diﬀuse periapicallyàapical inﬂammatory lesions ¡  Where is the bacteria?

13. §  Cavity prep (physical) §  Cavity prep without water (physical with thermal) §  Physical pressure on the prepared tooth (physical) §  Deep periodontal curettage (physical) §  Occlusal trauma (physical) §  Orthodontic movement (physical) §  Dentine expose §  Dental materials ▪  Restorative materials ▪  Cements

14. Chemical irritants? Leakage? IEJ 42, 422-‐444, 2009

15. ¡  Mixed pulpal response to Dycal after 3 months. CP (restorative material along with Dycal) C: Distinct but incomplete hard tissue bridge (BR), revealing gaps on either side of BR with inﬁltrate of chronic inﬂammatory cells

16. ¡  Who can survive after an injury? ¡  Type of injury ¡  The condition of the pulp ¡  Tissue involve §  Pulp tissue

17. ¡  Initial response §  Hard tissue formation §  Examples? §  How? ¡  Moderate to severe response §  Inflammatory process §  Non specific inflammatory mediators and specific immune reactions

18. ¡  Direct irritation §  Hyper-‐occlusion §  Occlusal trauma §  Endodontic procedural accidents §  Overinstrumentation §  Overextention of GP ▪  Physical ▪  Chemical ¡  Bacteria?

19. 31 Jan 2005 16 Apr 2005 25 June 2005

20. ¡  Healing ¡  Osteoclastic resorption §  Regeneration stops resorbing bone. §  Repair ¡  How can you tell? ¡  The aim of RCT is to ¡  In healing process, remove the irritant within osteoblast cells will start the canal depositing new bone and ¡  Healing by repair will take deposit new matrix. place once the irritant is removed and ‘inﬂammation’ process for healing will take its course ¡  Immune system will take its course

21. REGENERATION OR REPAIR?

22. ¡  Normal pulp, Healthy pulp ¡  Reversible pulpitis §  Symptoms §  Treatment ¡  Irreversible pulpitis §  Symptoms? Asymptomatic? §  Signs-‐ PA? §  Treatment §  Hyperplastic pulpitis ▪  Chronically inﬂamed young pulp

23. ¡  Pulp calciﬁcation ¡  Internal resorption §  Lectures in Year 4 ¡  Pulpal necrosis §  Symptoms §  Test & treatment §  Not responsive §  PA radiographs= normal

24. ¡  Normal Periapical tissues ¡  Apical abscess ¡  Apical periodontitis §  Acute apical abscess §  Acute §  Rapid onset, painful ▪  Moderate to severe pain §  No swelling if conﬁned to ▪  Tender to palpation bone, otherwise swelling is ▪  Excruciatingly painful to positive as collection of pus percussion seeps through path of least ▪  May or may not respond to EPT resistance: soft tissue ▪  PA-‐ Slight widening of lamina §  Tender to palpation and dura percussion §  Chronic apical periodontitis §  PA-‐ no lesion, + ve widening, ▪  May not be in severe pain and obvious ▪  Tender to palpation ▪  Tender to percussion ▪  Not responsive to EPT §  Chronic abscess ▪  PA-‐ apical radiolucency ▪  Presented with sinus tract ▪  + PA radiolucency

25. ACUTE APICAL PERIODONTITIS 46

26. ¡  CHRONIC APICAL PERIODONTITIS

27. ¡  Acute apical abscess

28. ¡  Chronic Apical Abscess

29. ¡  Very similar to ¡  Normal structures odontogenic lesions ¡  Non odontogenic ¡  Must be vigilant diseases ¡  Use tests to guide §  Early stage of §  Clinical findings monostotic fibro §  Sensibility testing dysplasia §  Ossifying fibroma §  PA radiographs ¡  Usually response to §  Dentigerous cysts EPTs §  Central giant cell granuloma

30. Ameloblastoma

31. Periapical cemento-‐osseous dysplasia

32. ¡  Harty’s, Endodontics in Questions? Clinical Practice, BS Chong 2010 ¡  Endodontics Principles and Practice T and Walton

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