Pulpal Diseases Guide: Causes, Symptoms and Treatments

PULPAL DISEASES

INDIAN DENTAL ACADEMY
Leader in Continuing Dental Education
www.indiandentalacademy.com


INTRODUCTION


ETIOLOGY
I. Bacterial
A. Coronal ingress
1. Caries
2. Fracture
a. Complete
b. Incomplete (cracks, infraction)
3. Nonfracture trauma
4. Anomalous tract
a. Dens invaginatus (aka dens in dente)
b. Dens evaginatus
c. Radicular lingual groove (aka
palatogingival
groove)

B. Radicular ingress
1. Caries
2. Retrogenic infection
a. Periodontal pocket
b. Periodontal abscess
3. Hematogenic


II. Traumatic
A. Acute
1. Coronal fracture
2. Radicular fracture
3. Vascular stasis
4. Luxation
5. Avulsion

B. Chronic
1. Bruxism
2. Traumatism
3. Attrition or abrasion
4. Erosion


III. Iatral
A. Cavity preparation
1. Heat of preparation
2. Depth of preparation
3. Dehydration
4. Pulp horn extensions
5. Pulp exposure
6. Pin insertion
7. Impression taking


B. Restoration
1. Insertion(condensation)
2. Fracture
a. Complete
b. Incomplete
3. Force of cementing
4. Heat of polishing


C. Intentional extirpation and root canal filling
D. Orthodontic movement
E. Periodontal curettage
F. Electrosurgery
G. Laser burn
H.Periradicular curettage
I. Rhinoplasty
J. Osteotomy
K. Intubation for general anesthesia


IV. Chemical
A. Restorative materials
1. Cements
2. Plastics
3. Etching agents
4. Cavity liners
5. Dentin bonding agents
6. Tubule blockage agents


B. Disinfectants
1. Silver nitrate
2. Phenol
3. Sodium fluoride
C. Desiccants
1. Alcohol
2. Ether
3. Others


V. Idiopathic
A. Aging
B. Internal resorption
C. External resorption
D. Hereditary hypophosphatemia
E. Sickle cell anemia
F. Herpes zoster infection
G. Human Immunodeficiency Virus (HIV)
and Acquired Immune Deficiency
Syndrome (AIDS)


Classification of Pulpal Diseases
• Ingle’s classification
A. Inflammatory changes
1. Hyperreactive pulpalgia 3. Chronic pulpalgia
a. Hypersensitivity 4. Hyperplastic pulpitis
b. Hyperemia 5. Pulp necrosis
2. Acute pulpalgia B. Degenerative changes
a. Incipient(may be 1. Atrophic pulposis
reversible) 2. Calcific pulposis
b. Moderate(may be
referred)
c. Advanced(relieved by
cold)


According to Seltzer and
Bender(Histological)
A. Inflammatory changes
1. Intact pulp with chronic 5. Chronic partial pulpitis
inflammatory cells. (hyperplastic
form).
2. Acute pulpitis.
6. Pulp necrosis.
3. Chronic partial pulpitis
with partial necrosis. B. Degenerative changes
4. Chronic total pulpitis with 1. Atrophic pulp.
liquefaction necrosis 2. Dystrophic
mineralisation.


REVERSIBLE PULPITIS

• It is a mild to moderate inflammation of
pulp caused by noxious stimuli in which
the pulp is capable of returning to the
uninflammed state following removal of
the stimuli.


Signs and symptoms
• Sharp pain but lasting for a moment
• Brought about by cold or hot
• Pain disappears when the stimulus is
removed
• Pain is never spontaneous
• Caries, Erosion, Abrasion may be seen
• Faulty restoration may be seen


Diagnosis
• Chief complaint and history
• Examination may show
Caries
Erosion
Abrasion
Faulty restoration
• Clinical tests: cold test is particularly
useful.


Histopathology

Capillary engorgement with inflammatory cells


Differential diagnosis
• Cracked tooth syndrome
• Hypersensitivity
• Trauma
• High filling


Treatment

• Restoration of caries(temporary /permanent)
• Restoration of erosion, abrasion cavities
• Correction of faulty restoration
• Taking preventive steps to stop recurrences.


IRREVERSIBLE PULPITIS

• Irreversible pulpitis is a persistent
inflammatory condition of the pulp,
symptomatic or asymptomatic, caused by
a noxious stimulus.


Signs and symptoms
• Pain due to hot, cold, pressure which lasts even
after removal of the stimulus
• Spontaneous pain described as sharp, piercing
or shooting
• Pain on bending over and lying down
• Referred pain
• Pain is increased by heat and relieved by cold.
• Inability to recognize the offending tooth


Diagnosis
• Chief complaint and history
• Examination reveals
Extensive caries,(may be exposed
pulp)
Traumatized tooth
Large restoration
• Tests : mainly thermal tests are useful


Histopathology

Chronic inflammatory cells with bacteria
penetrating and dilated blood vassals


Reversible Irreversible
Pain Momentary Continuous
Stimulus Required Spontaneous
History Recent restoration Deep caries, trauma
caries
Referred pain Negative Common finding
Pain on lying down Negative May be present
Color No change May be changed

Electric pulp test Premature Premature or delayed


Treatment
• Complete removal of the pulp however in
posterior teeth removal of only coronal
pulp and placement of formocresol over
the radicular pulp may be considered as
an emergency measure.
• Subsequent completion of the root canal
treatment and restoration.


CHRONIC HYPERPLASIC
PULPITIS

It is a productive pulpal inflammation due to
an extensive carious exposure of a young
pulp.


Signs and symptoms

• Usually no symptoms
• Pressure from food may cause discomfort
• Large carious lesion
• Polypoid tissue projecting into the caries.


Diagnosis
• History taking reveals the age of the patient
• A fleshy reddish pulpal mass fills the carious
lesion which may blend with the gingiva
• This tissue is less sensitive than the pulp but
more sensitive than gingiva
• Raising the tissue and tracing the stalk
differentiate from the proliferating gingival tissue.


Histopathology

Surface covered by the stratified epithelial tissue
containing the granulation tissue



• Proliferating gingival tissue


Treatment

• Removal of the polypoid tissue
• Initiating the root canal therapy and
restoration of tooth.


Internal Resorption
It is an idiopathic slow or fast progressive
resorptive process occurring in the dentin
of pulp chamber or root canal.
Also called ‘pink tooth of mammary’


Signs and symptoms

• Usually asymptomatic
• In crown pink spot may appear which is
the granulation tissue showing through the
resorbed area.


Diagnosis

• History taking may reveal trauma
• Usually diagnosed on routine radiography
which shows change in appearance of the
root canal wall or pulp chamber of the
involved tooth.


Histopathology

Internal resorption showing lacune and osteoclasts


• Should be distinguished from external
resorption especially when there is a
perforative type of lesion
• In internal resorption the resorptive lesion
is more extensive on the pulpal side.


Treatment

• Extirpation of the pulp
• Root canal treatment and subsequent
restoration of the tooth.


Pulp degeneration

It may be-
Calcific degeneration.
Atrophic degeneration.
fibrous degeneration.


Necrosis of the Pulp

• Necrosis is the death of the pulp.
• It may be complete or incomplete


Histologically Necrosis may be..

Cogulative Necrosis Liquefactive Necrosis


Signs and symptoms

• Usually asymptomatic
• Opaque appearance or grayish
discoloration of the tooth
• Is associated with sinus tract in many
cases


Diagnosis

• History
• On examination
– Discoloration
– Sinus tract
– No response to tests (heat or cold)


Treatment

• Routine endodontic treatment followed by
restoration


Pulpal Diseases Guide: Causes, Symptoms and Treatments

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