diseases of dental pulp, inflamation of apical ... · diseases of dental pulp, ... trauma, gingival...

Diseases of dental pulp, Inflamation of apical

periodontium of milky dentition

5.DM - Pedo

Dental pulp

• A richly vascularized and innervated connective tissue of mesodermal origin,

contained in the central cavity of a tooth and delimited by the dentin, and having formative,

nutritive, sensory, and protective functions.

(Jablonski, Dictionary of Dentistry, 1992)

Dental pulp

- soft, pink tissue of mezodermal origin

-richly vascularized and innervated

- cells have anastomoses in basal substance, that contains

collagene and argyrophil fibrils

- on the outer surface of pulp there is a layer of cylindrical cells

(membrana eboris) - odontoblasts

- in crown part – odontoblasts form several layers

- in root part – single layer of odontoblasts

- free cells can also be found in reticulum of fibocytes:

- histiocytes, lymfocytes, monocytes, plasmatic cells

Structure of the dental pulp:

Elements similar to other connective tissues • blood vessels • lymph vessels • nerves • defence cells (lymphocytes,

macrophages, plasmatic cells) • growth substances • fibroblasts, collagen fibres • odontoblasts • histiocytes

Unique situation of dental pulp

• bordered by dentine which is hard in structure, no swelling

• during an inflamation itrapulpal pressure rises as one of the basic signs of inflamation tumor (swelling) can not take place

• artery entering the apex foramen is final, no collateral blood supply when damaged

Pathological – anatomical picture of the diseases of dental pulp

• Bacterial, chemical, thermal irritation of dental pulp

• Transmission of stimuli via odontoblasts and fibrocytes to the nervous net

• Pulp reacts to the irritation by active HYPEREMIA

• If the irritation is not removed, passive hyperemia and serous exudation

develop – followed by cell proliferation and stasis in blood circulation

• Next thrombosis develops, eventually leading to vascular rupture

• These regressive changes lead to PULP NECROSIS

• Bacterial inflamations of the pulp have persistent progressive character, leading to destruction of dental pulp, acute pulpitis

• Aseptic inflamations (thermal, chemical, traumatic) lead to fibrotic changes in pulp (rather than destruction), chronic pulpitis, necrosis

• Changes in dental pulp during inflamation:

Reversible changes of dental pulp – healing after removal of cause - restitution ad integrum

Irreversible changes – loss of tooth vitality

Etiology of dental pulp diseases

1. Septic

• per continuitatem (via dental caries),

• retrograde (parodontal absces),

• by blood from inflamation site in neighbouring area

Etiology of dental pulp diseases

2. Aseptic • Trauma – microtrauma (higher filling or

crown, harsh extraction, forcible separation), macrotrauma

• Chemical – acrylic resins, concentrated medicaments, paraformaldehyd

• Thermal – baseless filling, hot food in deep excavated caries, forcible caries preparation or tooth preparation without water-cool

• Tooth abrasion, root resorption, electrogalvanic irritation (differet metals)

Hyperesthesia

• etiology: exposed dentin (caries, trauma, gingival recessus)

• pathology: active hyperemia

• subj.: pain on stimulation, hard to localize

• obj.: infraction or fracture of enamel, caries in dentine, hypersensitivity to cold stimulus

• dg.: clinical picture, vitality test CO2

• diff.dg.: papilitis, hyperemia, partial pulpitis

• th: cause removal, impregnation

• prognosis: good

• prevention: prevention of dental caries and trauma, early treatment of caries

Classification of pulp diseases

Hyperemia

• etiology: deep caries, trauma, chemical or thermal irritation • pathology: active and passive hyperemia • subj.: hypersensitivity to external stimuli, pain on stimulation, shooting

pain, long intervals without pain, hard to localize, spontanneous pain not present

• obj.: hypersensitivity to cold test, caries in close proximity of pulp, filling without base material

• dg.: anamnesis, clinical picture (deep caries, occlusal trauma), vitality test, percussion negative

• diff.dg.: papilitis, hyperestesia, partial pulpitis • th: causative – indirect pulp capping, exclude the tooth from

occlusion/articulation • prognosis: good – reversible • prevention: primary and secondary prevention of dental caries


Pulpitis acuta serosa partialis

• etiology: deep caries, trauma, chemical or thermal irritation

• pathology: hyperemia, initiation of serous exudation, vasodilatation, leukostasis, inflamatory edema develops

• subj.: pain on external stimuli persistent for variable amount of time, pain persistent after removal of stimulus, shooting pain, intervals without pain longer then pain intervals, mild spontanneous pain, hard to localize

• obj.: deep caries in close proximity to pulp, only thin border of soft dentine, pulpitic reaction to cold- persistent after removal of cold stimulus, pain on vertical percussion negative


Pulpitis acuta serosa partialis

• dg.: anamnesis, cold (CO2), percussion

• diff.dg.: hyperemia, total pulpitis

• th: indirect pulp capping, pulpotomy

• prognosis: based on proper diagnose, early stages reversible

• prevention: secondary prevention of caries, cause removal, early treatment of dental caries


Pulpitis acuta serosa totalis

• etiology: deep caries, trauma, chemical or thermal irritation

• pathology: passive hyperemia, cell proliferation and infiltration, serous exudation, hyperemia in vessels of apical periodontium

• subj.: spontanneous shooting pain during the day and night pain as well, character of pain like neuralgia, sharp, shooting, irradiation to ear, cold stimulus provokes pain, intervals of pain getting longer

• obj.: pain on vertical percussion, cold stimulus causes pain attack, that perseveres even after removal of stimulus


Pulpitis acuta serosa totalis

• dg.: anamnesis, reaction to cold, percussion pain vertical

• diff.dg.: partial pulpitis, apical periodontitis

• th: vital extirpation, mortal extirpation, formocresol pulpotomy, endodontic treatment, extraction

• prognosis: loss of tooth vitality, loss of tooth

• prevention: secondary prevention of dental caries = early treatment of caries in milky dentition


Pulpitis acuta purulenta

• etiology: deep caries penetrating to dental pulp

• pathology: proteolytic effect of leucocytes, necrotic dental pulp, liquid change, cell infiltration, microabscesses in pulp stroma – irreversible pulpal changes. Abscesses in coronal part mean partial pulpitis, abscesses in root part of pulp mean total pulpitis

• subj.: throbing pain to hot stimulation, cold relieves pain

in total pulpitis pain is spontanneous, not ceasing, pulsating, during day and night. Pain does not react to analgetics. Patient is tired, can have elevated temperature, enlarged lymph nodes.


Pulpitis acuta purulenta

• obj.: large carious lesion penetrating to pulp, reaction to cold negative, vertical percussion positive in total pulpitis

• dg.: anamnesis, reaction to termic stimuli

• diff.dg.: serous pulpitis, apical periodontitis

• th: trepanation, extirpation, endodontic treatment, or extraction

• prognosis: depends on spread of infection, patient cooperation, root resorption



Pulpitis chronica aperta ulcerosa

• etiology: deep caries penetrating to dental pulp

• pathology: open pulp chamber with surface ulceration, non-specific changes, with mainly proliferative proces in dental pulp. Ulcerations are usually found in superficial layer of dental pulp, under which inflamatory cell infiltration can be found, resembling acute inflamation

• subj.: pain when eating due to direct mechanical trauma, sometimes bleeding from the surface of the lesion can be noticed

• obj.: deep caries with perforation of dental pulp, tooth can be tender to vertical percussion when whole pulp is involved, termic reaction is decreased or negative


Pulpitis chronica aperta ulcerosa

• dg.: caries pulpae proxima with destruction of pulpal chamber

• diff.dg.: other forms of chronic pulpitis

• th: vital extirpation (pulpectomy) and endodontic treatment or extraction,

• Mortal exstirpation is contraindicated !

• prognosis: loss of vitality



Pulpitis chronica aperta polyposa – pulpal polyp

• Freguent in milky dentition

• pathology: non-specific granulation tissue formation, in the form of polyp, under the granulation tissue perivascular inflamatory infiltration can be found.

• subj.: pain and bleeding when mechanically traumatised (eating, tooth brushing)

• obj.: large carious lesion with perforation of the pulpal wall, through which pulpal polyp penetrates to carious cavity. Tooth is tender to vertical percussion when whole pulp is involved, termic reaction is decreased or negative


Pulpitis chronica aperta polyposa – pulpal polyp

• dg.: probing

• diff.dg.: interdental papilla polyp

• th: vital extirpation (pulpectomy) and endodontic treatment or extraction

• Mortal exstirpation is contraindicated !

• prognosis: loss of vitality, loss of tooth

• prevention: : secondary prevention of dental caries = early treatment of caries in milky dentition


Pulpitis chronica clausa

• pathology: chronic fibrotic inflamation, chronic well circumscribed chronic abscess, with surrounding inflamatory cells infiltration. Granulation tissue, necrotic parts or calcified pulp may also be present.

• subj.: non-specific, without pain, often leads to a necrosis of dental pulp. • obj.: large carious cavity with a thin layer of soft dentine, but pulp is not

perforated, impaired reaction to cold • dg.: anamnesis, vitality test • diff.dg.: hyperemia • th: extirpation (pulpectomy), extraction • prognosis: loss of vitality



Necrosis of dental pulp

• etiology: trauma, untreated pulpitis • pathology: loss of vascular structures, destruction of morphologic

structures (The sum of the morphological changes indicative of cell death and caused

by the progressive degradative action of enzymes) • subj.: painless, tender to percussion(not pain), indistinctive symptoms • obj.: tooth mobility, different color (less transparent), yellow to grey in

colour • dg.: negative reaction to cold, negative percussion (only different feeling

on percussion, not pain) • diff.dg.: deep caries, gangrene • th: extirpation, root canal treatment (endodontics), or extraction • prognosis: loss of tooth vitality, success of endo therapy depends on root

anatomy



Gangrene

• etiology: necrosis + superimposed bacterial infection, nontreated pulpitis • pathology: lysis of cell elements, formation of toxic products – indol,

scatol, destruction of morphologic structures of pulp • subj.: indistinctive symptoms, pain to hot stimuli (if tooth has closed pulp

chamber, then after hot stimulus, gas expand, pressure increases leading to pain)

• (if pulp chamber is opened, then only sign is foetor ex ore – distinctive, typical)

• obj.: tooth mobility, foetor (very stong after trepanation of pulp chamber), pain to hot stimulus, negative to percussion


Gangrene

• dg.: x-ray, vitality test, trepanation (removal of pulp wall) • diff.dg.: acute pulpitis, apical periodontitis • th: trepanation, leave open, endodontics, or extraction • prognosis: loss of tooth



Acute apical periodontitis

• causes: infectious (spreading of infection from pulp), non-infectious (trauma)

• pathology: hyperemia and edema of periapical tissues, leucocytes infiltyration, sero-purulent exudation (enoseal, subperiostal, submucose phase) – as pus spreads via least resistance (locus minoris resistantiae) towards bone surface



• Stages of acute apical periodontitis

• I. Periodontal stage

• Pathologic changes localized to periodontal space

• Periapicaly – hyperemia, serous exsudation

• Subj. Feeling of tooth being in supraoclusion („higher then others“)

• Obj,: pain on vertical percussion

• Vitality - negative




• II. Enoseal stage

• Pathologic changes localized in bone

• serous inflamation and cell infiltration

• Subj. Pain increases

• Obj,: pain on vertical and horizontal percussion, edema in periapical region, tender to palpation, mild tooth mobility, vitality – negative, enlarged lymph nodes, elevated temperature

• Th: trepanation or extraction




• III. Subperiosteal stage

• Pathologic proces spreading under periosteum, purulent exsudate causing necrosis and desintegration of periosteum

• Subj. Pain increases further, pain on mastication, even when tounge touches the tooth (maximum pain in this stage)

• Obj,: pain on vertical and horizontal percussion, edema in periapical region, tender to palpation, no fluctuation, tooth mobility, vitality – negative, enlarged lymph nodes, elevated temperature

• Th: extraction




• IV. Submucosal stage

• Pathologic proces spreading under mucose membrane, absceass formation, fluctuation on palpation present Subj. Pain decreases, pain on chewing persist

• Obj,: pain on vertical and horizontal percussion, facial edema, fluctuation positive, tooth mobility, vitality – negative, enlarged lymph nodes, elevated temperature

• Th: extraction and intraoral incision


Chronic apical periodontitis granulomatosa, diffusa

• etiology: primarily chronical proces, secondary from conversion of acute process

• pathology: formation of granulation tissue in periapical region, loss of bone density

• Circumscript form – granuloma • Diffuse form • Diffuse fom with drainig abscess - fistula • subj.: asymptomatic, symptoms present when acute exacerbance of

inflamation then same as acute apicalô periodontitis • obj.: tender on percussion, mobility, transparency • dg.: x-ray, vitality test - negative • diff.dg.: pulpitis • th: extraction • prognosis: anatomy, infection


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