Oral pathology sheet # 6 - maha alrfo3

Pulpitis
definition:
inflammation of dental pulp.
Aetiology:
1.bacteria:mostly enter the tooth by dental caries or through fracture in tooth caused by
trauma .
2.Chemical irritant:chemical used in restoration like, acid etching or bleaching agent.
3.Thermal damage:caused by doing preparation or removing caries without using water;so
the temperature increase in dentin firstly then in pulp .
Note :chemical and thermal causes are sterile factors (mean no bacterial participation).
Generally inflammation in soft tissue lead to swelling &this will decrease the pressure
( compare with no swelling )applied on nerves &
blood vessels so it can remain vital after infection ,but pulp is a special case ,
although the pulp is a soft tissue ,but inflammation happen within rigid walls from all sides &
no swelling happen so pressure increase on :
1. blood vessels lead to ischemia then necrosis
2. nerves lead to stimulation on nerves that cause sever pain .
Patient of pulpitis cant recognize well from any tooth the pain come out ,patient can
determine the side of pain only ,the reason is that the pulp does not contain proprioceptive
receptors .
Classification :
there are many classification ,some have no direct relation with status of the pulp & severity
of inflammation ,but there is a classification that related to vitality of pulp which is :
1. reversible pulpitis
2. irreversible pulpitis
it is important to distinguish the 2 types in order to determine the suitable treatment
-reversible pulpitis need to remove the caries &make a restoration only.
-Wheres irreversible pulpitis need root canal treatment or extraction .
Keep in your mind that pulpitis can also occur without any pain at all ,so the severity of
pain can not classify pulpitis because of that some cases which pain not occur with .
The most important question for dentist to be able to answer it ,is if the patient need root
canal treatment or only restoration for painful tooth ????
REVERSIBLE PULPITIS
-capable of full recovery
-inflammation does not cause sever destruction .
-early mild inflammatory response ,how???
The area of pulp under the caries :
dilation of blood vessels ,increase permeability ,increase filtration of fluids out side vessels ,
edema ,scattered of inflammatory cells ,
abnormal arrangement of odontoblast cells near the legion of infection.
how to distinguish this type of inflammation ,what are the question that I have to ask the
patient about ???
1. whether pain is spontaneous or broaden by thermal or other stimuli (cold,hot
,sweet ),the most important is cold ,you know that the movement of fluid in dentinal
tubules initiate the pain .
2. Body position does not affect the pain ,ask patient if pain wake him /his during night ?
The answer :must be no to be reversible pulpitis
3. duration of each episode must be short ,supside within seconds .
4. Mild to moderate pain ,mean patient does not take medicine for pain relieving .
5. Electric pulp testing respond at lower level of current than control teeth .
6. Mobility and sensitivity to percussion are absent ,because no inflammation around
tooth .
Treatment :
conservative (remove caries & make restoration ,no root canal treatment )
IRREVERSIBLE PULPITIS
-pulp has been damaged beyond the point of recovery .
-Wide spectrum of acute inflammatory response (AIR) & chronic inflammatory
response(CIR).
Diagnosis :
-within temperature change or spontaneous ,pain with stimulus or without stimulus ,but
in late stage cold stimulus decrease the pain .
- duration of pain >20 minutes or continue to hours.
-sharp severe throbbing pain .
- increase patient reclines ,wake patient at night , because pressure increase in night
according to position of the body.
-electrical pulp testing (EPT) ;respond at higher level of current (when large number of
nerves were destroyed ) or no response (full necrosis )
-mobility & sensitivity to percussion are absent ,no pain during mastication ,because
inflammation is still inside tooth .
Treatment:
root canal treatment (RCT).
Diagnostic technique : how to distinguish between reversible & irreversible pulpitis ??
1. history (most important component )& nature of pain .
2. visual examination :
a- swelling & edema mean inflammation reached periodontium mean that tooth had
been irreversible pulpitis since period of time .
b- no swelling ,no edema mean the inflammation still within pulp ,so you can not
know if it reversible or irreversible .
3. palpation of surrounding area :
a- positive test (mean patient feel tenderness during palpation) mean that tooth had
been irreversible pulpitis since period of time ,so by palpation we can know if the
inflammation is still inside tooth or it went out .
b- negative test (patient feel no pain during palpation ) ,it may be reversible or
irreversible .
4. percussion ,hit the tooth with handle of the mirror:
a- positive test (feeling of pain ),so it had been irreversible pulpitis ,& the
inflammation reach the periodontium.
b- negative test (feeling no pain ), so it may be reversible or irreversible .
5. Radiograph :
a- signs of inflammation outside tooth mean that inflammation reach
periodontium .
b- depth of caries help us to judge if the pulpitis is reversible or irreversible .
6. reaction to thermal changes, by putting cold irritant on the tooth ,then:
a- if pain was relieved within seconds ,then it is reversible pulpitis .
b- if pain was relived within hours ,then it is irreversible pulpitis .
7.electric stimulation by low -voltage direct current ,this tool a low the dentist to
increase the current gradually & notice the response,at which voltage .
Histopathology :
we do not care ,because no role of it in diagnosis ,
no sense if I open the pulp to take specimen for examination ,because by this I had
already make irreversible pulpitis stage .
CHRONIC HYPERPLASTIC PULPITIS (PULP POLYPS OR PROLIFERATIVE
PULPITIS)
destructive crown with open pulp chamber ,tooth components are exposed tooral
enviroment,
pulp swelling appears as polyp out of pulp chamber .
**Requirement of pulp polyp formation :
1.newly erupted first permanent or primary molars (large pulp chamber )
2. young patient (has good immunity &blood supply)
3. teeth with open or incomplete apexification (good blood supply )of the root apices
are the most susceptible ,note that complete root mean small apices ,& poor blood
supply ,& this mean no healing appear.
4. open cavity (pulp open to oral environment ,no pressure mean healing appear
-usually asymptomatic (no pain ),only mild to moderate tenderness ,&may be sometimes
localized bleeding happen during mastication.
-composed of :
granulation tissue (immature fibrous tissue )(this is healing process) ,covered with
epithelium ( stratified squamous epithelium).
-reaches maximum size within a couple of months and then remain static
in some cases root canal treatment then put crowns (some cases that have not high
destructive stage).
(the more conservative pulptomy treatment
has been successful in selected cases when only the coronal pulp is affected.
pulp calcification(calcification with dental pulp)
2 types:
1.pulp stones:
calcified round masses that form within the pulp in crown or pulp chamber or
canals.
-asymptomatic
-etiology: unknown
some thought that the causes may be trauma to pulp
-in radiograph round opaque structure within the the pulp chamber
in coronal pulp and might be in canals.
-pulp stones increase in number and size with age mostly in old persons.
-associated with syndrome e.g:Ehlers Danlos syndrome.
2.Dystrophic (linear) calcification:
granules of calcified material scattered or large masses
mostly in root canals
-age related degenerative change
both types affect root canal treatment because root canals will be closed.
periapical periodontitis
-it is inflammation in the periodontal ligament beneath the apex.
-confined space ,above it there is root of tooth and beneath it there is bone.
-there is swelling
-sensitive tooth for percussion
-painful during mastication
rich collateral circulation in periodontal ligaments ,so the healing ability is
better than healing of pulpitis .
-presence of proprioceptive nerve fibers help in diagnosis of painful tooth
specifically ,mean that patient can know from where the pain come ,no chance
for wrong .
Aetiology :
-pulpitis .
- trauma ,through damaging of periodontal ligaments,or may be biting on small
piece of stone during eating
- root canal treatment :for example the file go out of canal accidentally or some
irritants(chemicals & acids ) using in root canal treatment ) pass out to periodontium
nature : acute & chronic .
Factors affecting nature :
1. open & closed tooth ; open tooth to oral environment mean chronic
inflammation,where closed canals has acute inflammation.
2. bacteria numbers ,types & destructive ability .
3. immune response ,if there is a good immunity there is a decrease in damage ,so no
acute inflammation happen .
ACUTE PERIAPICAL PERIDONTITIS
nature:inflammation under apex .
Tooth elevated & even light touch is painful.
Well localized ,no spread .
Pain not affected by temperature change ,but mainly on high pressure .
Diagnosis:no bone resorption ,
no change or slight widening of periodontal ligament .
Less clear (less density )lamina dura ,”the white line around the pulp
is absent.
Seqelae:if the irritants persist the inflammation becomes chronic apical
periodontitis .
CHRONIC PERIAPICAL PERIDONTITIS (PERIAPICAL GRANULOMA )
*Diagnosis :oval round translucency with well-defined line of static less than 1 cm in
diameter attached to apex }this structure called granulation tissue which is soft tissue .
*Signs :loss of bone (resorption of bone that surrounding the apex ) & radiolucent area
around apex contain :macrophages ,blood vessels contain lymphocytes ,
fibroblast (which deposit collagen in site of infection ).
In conclusion there is a balance between body immunity & bacterial effect
Microbiology: mixed infection
Obligate anaerobes (e.g. Prevotella sp.)
Facultative anaerobes (e.g. St. Milleri & Sanguis)
note that there are a lot types of bacteria there.
Histologically :
*infiltration of lymphocytes plasma cells ,macrophages .
* production of granulation tissue ,bone resorption
* breakdown of RBCs ,that give :
a-HSN : brownish in color ,HSN: haenosidren.
b- CC : foreign material in site of infection , CC:cholesterol clefts .
*macrophages engulf the cholesterol clefts then called foamy cell .
* cholesterol clefts need stronger cells than macrophages like ;multinucleate giant cells,so you
can notice multinucleate giant cells surrounding the cholesterol clefts particles in
histological section .
* epithelial cells rest of malassez which found in periapical region will divide & make
radicular (apical) cyst (cystic legion)
-remember: epithelial cell rest of malassez in periodontal ligament which are remnant of
hertwing sheath (island ,strands).
Clinically :Painless ± tenderness to palpation & percussion (dull note) ,
no signs ,mostly .
No response to thermal or electrical stimuli ,because the pulp was dead .
Note that the professional expert can diagnosis the presence of granulation tissue by hearing
the sound that formed from hitting the tooth (by dentist),so if the sound is high ,you notice the
presence of bone ,normal condition ,but if the sound is low ,this indicate presence of
granulation tissues beneath ,abnormal condition ,.
Sequelae :
1.increase in size if it was small originally .
2.AAA(acute alveolar abscess): pain, redness, swelling, mobility & tenderness ,(the bacteria
suddenly make invasion .
3. CAA(chronic alveolar abscess): w-d (well-defined )area of suppuration ,abscess surrounded
by fibrous tissue .
4. RC(radicular cyst)
5. Osteosclerosis:(it is the deposition of bone ,to resist the spread of bacteria) ,asymptomatic
6. Hypercementosis:caused by chronic mild irritant for cementum .
now study this diagram;
AP
this diagram show some possible scenarios for “AP”
AP: apical(periapical ) periodontitis
AAP: acute apical ( periapical ) periodontitis.
CAP: chronic apical (periapical) periodontitis .
AAA:acute alveolar abscess .
PG :periapical granuloma .
CAA :chronic alveolar abscess .
APP AAA CAA
cellulitis
CAP PG RC
RC :radicular cyst .
ACUTE ALVEOLAR ABSCESS
signs :
-sever pain ,patient can not sleep .
-systemic signs :fever, malaise .
- tooth extrusion .
- sever pain during percussion (the patient not allow you to do percussion).
-swelling & redness in area around the tooth (gingiva, vestibule ).
-no response to temperature ,electrical stimuli because the pulp had already been dead ).
–
caused by virulent microorganism that make a lot of damages .
Associated with closed pulpitis (high pressure on periodontium ).
in radiograph :
-slight widening of periodontal ligament (PL) .
- less clear lamina dura ,because of less density in comparison with bone.
-Radiolucent structure beneath tooth .
Sequelae:
-CAA(chronic alveolar abscess )
- enlargement of abscess , increase suppuration ,lead to increase pus formation ,then the
pus will escape out through :
1. root canal if there is open pulpitis .
2. or gingival sulcus .
3. or cancellous bone ,& by this way the pus can reach soft tissues (e.g. vestibule ,facial
spaces ) &cause cellulitis .
**In general (AAA ) is not specific type of inflammation .
Note: if pus reach facial spaces, then caused ,ludwig's angina.
pus may reach vital areas in brain & increase fatality .
The end
done by :maha AL- Rfou'