open pulpitis

Open Pulpitis

By : Mohammed El-Said Abu By : Mohammed El-Said Abu El-NagaEl-Naga

Oral and Maxillofacial Oral and Maxillofacial SurgerySurgery

By:Dr/M.Abuelnaga 1

CLASSIFICATION OF PULPITIS

Pulpitis

Depending upon the extend of involvement

Depending on direct communication

between pulp and oral cavity.

Partial pulpitis(Focal)

Subtotal pulpitis(Generalized)

Open pulpitis (pulpitis aperta)

Closed pulpitis(pulpitis clausa)

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Chronic open pulpitis.

The extension of a carious The extension of a carious lesion or trauma may result in lesion or trauma may result in a connection between the a connection between the oral cavity and the pulp tissueoral cavity and the pulp tissue ..

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Chronic open pulpitis.

Ulcerative open chronic pulpitis

Granulomatous open chronic

pulpitis

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Ulcerative open chronic pulpitis

Ulcerative open chronic pulpitis is associated with Ulcerative open chronic pulpitis is associated with an ulcerative pulp surface in the area of exposure an ulcerative pulp surface in the area of exposure of the pulp cavity, ie healing prospects are poorer of the pulp cavity, ie healing prospects are poorer

in this areain this area . .

The pulp tissue lying beneath this surface either The pulp tissue lying beneath this surface either presents as a diffuse chronic inflammation or presents as a diffuse chronic inflammation or

merely shows signs of hyperaemiamerely shows signs of hyperaemia..

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ClinicallyClinically

Chronic ulcerative pulpitis sharp probes Chronic ulcerative pulpitis sharp probes have to wear marrow cavities deep have to wear marrow cavities deep exploration hole, a moderate degree of exploration hole, a moderate degree of exploration can be painful; diagnosis or exploration can be painful; diagnosis or electric hot and cold reaction diagnosis can electric hot and cold reaction diagnosis can be slow or sensitive; percussion may have be slow or sensitive; percussion may have mild discomfortmild discomfort . .

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X-rays examination may have the X-rays examination may have the periodontal ligament space widened periodontal ligament space widened periapical plate blurred or hard to periapical plate blurred or hard to changechange . .

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Granulomatous open Granulomatous open chronic pulpitischronic pulpitis ((pulp pulp

polyppolyp)) If the blood supply is sufficient, open chronic pulpitis can change to granulomatous open chronic pulpitis (pulp polyp) .

Granulation tissue sprouts from the ulcerative surface tissue and slowly grows to an enlarging mass of tissue from the pulp cavity through the opening of the pulp roof into the oral cavity.

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Pulp polypBy:Dr/M.Abuelnaga 9

Pulp polyp

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HistoryHistory

Pulp polyps are usually asymptomaticPulp polyps are usually asymptomatic. .

Direct pressure during mastication may cause mild-to-Direct pressure during mastication may cause mild-to-moderate tendernessmoderate tenderness. .

Localized bleeding may occur when the soft tissue is Localized bleeding may occur when the soft tissue is manipulated or traumatizedmanipulated or traumatized. .

All lesions are associated with a history of a long-All lesions are associated with a history of a long-standing carious lesion, a fractured tooth due to standing carious lesion, a fractured tooth due to trauma, or a combination or these 2 insultstrauma, or a combination or these 2 insults. .


Pulp polyps reach a maximum size Pulp polyps reach a maximum size within a couple of months and then within a couple of months and then remain staticremain static. .

Mobility of the tooth and sensitivity to Mobility of the tooth and sensitivity to percussion are usually absentpercussion are usually absent. .

Drainage of a purulent exudate is not a Drainage of a purulent exudate is not a characteristic findingcharacteristic finding. .


PhysicalPhysical

A spongy, soft tissue nodule extrudes from the cavitated or A spongy, soft tissue nodule extrudes from the cavitated or fractured surface of a toothfractured surface of a tooth. .

The surface varies from pink and smooth to red and white and The surface varies from pink and smooth to red and white and granulargranular. .

Polyps typically enlarge to fill the entire cavitated area or pulpal Polyps typically enlarge to fill the entire cavitated area or pulpal chamber of the toothchamber of the tooth. .

Soft tissue may merge with the adjacent attached gingivaSoft tissue may merge with the adjacent attached gingiva. .

Polyps usually develop in carious primary molars and first Polyps usually develop in carious primary molars and first permanent molars because, anatomically in young persons, permanent molars because, anatomically in young persons, these teeth have large pulp chambersthese teeth have large pulp chambers..


Less frequently, maxillary central incisors in both Less frequently, maxillary central incisors in both dentitions are affecteddentitions are affected. .

A pulp polyp is a single lesion, but multiple teeth may A pulp polyp is a single lesion, but multiple teeth may be affectedbe affected. .

Teeth with open or incomplete apexification of the root Teeth with open or incomplete apexification of the root apices are the most susceptibleapices are the most susceptible. .

Extrusion of the opposing molar or tipping of the Extrusion of the opposing molar or tipping of the adjacent teeth with space loss may be observed when adjacent teeth with space loss may be observed when significant destruction of the crown occurssignificant destruction of the crown occurs. .


CausesCausesCauses of a pulp polyp include the followingCauses of a pulp polyp include the following: :

Carious tooth with significant loss of tooth structureCarious tooth with significant loss of tooth structure. .

Loss of a dental restoration that results in pulpal Loss of a dental restoration that results in pulpal exposureexposure. .

Fractured tooth due to trauma with a pulpal exposureFractured tooth due to trauma with a pulpal exposure. .

Pulpal tissue with access to a good blood supplyPulpal tissue with access to a good blood supply. .

Possible hormonal (estrogen and progesterone) Possible hormonal (estrogen and progesterone) influenceinfluence. .


Differential DiagnosesDifferential Diagnoses

Pyogenic Granuloma )Lobular Capillary Hemangioma (


Imaging StudiesImaging StudiesIntraoral radiographs, in particular periapical and bite-wing film Intraoral radiographs, in particular periapical and bite-wing film views, are needed to confirm this diagnosis and to determine the views, are needed to confirm this diagnosis and to determine the extent of tooth destruction and if the inflammatory lesion extent of tooth destruction and if the inflammatory lesion involves the surrounding alveolar boneinvolves the surrounding alveolar bone. .

Radiographic findings demonstrate a large coronal radiolucency Radiographic findings demonstrate a large coronal radiolucency that extends to the pulpal chamber with focal loss of tooth that extends to the pulpal chamber with focal loss of tooth structure, while the root apices may be either open or closedstructure, while the root apices may be either open or closed. .

Although no bony changes are usually observed, the surrounding Although no bony changes are usually observed, the surrounding alveolar bone may reveal either an incipient periapical alveolar bone may reveal either an incipient periapical radiolucency that is consistent with chronic apical periodontitis radiolucency that is consistent with chronic apical periodontitis or a localized radiopacity that is referred to as focal sclerosing or a localized radiopacity that is referred to as focal sclerosing osteomyelitis (condensing osteitis)osteomyelitis (condensing osteitis) . .


In addition, vertical alveolar bone height may be In addition, vertical alveolar bone height may be decreased surrounding the involved tooth, decreased surrounding the involved tooth,

which is indicative of periodontitiswhich is indicative of periodontitis. .

Radiographic imaging is required to determine Radiographic imaging is required to determine the most appropriate treatment for the involved the most appropriate treatment for the involved

toothtooth. .


Pulp polyp radiographically By:Dr/M.Abuelnaga 19

Other TestsOther Tests

Diagnosis and determination of the most Diagnosis and determination of the most appropriate treatment options are based on appropriate treatment options are based on adjunctive tests, including response to adjunctive tests, including response to percussion, thermal stimuli, and electric pulp percussion, thermal stimuli, and electric pulp

testingtesting . .

In most cases, the results of these adjunctive tests In most cases, the results of these adjunctive tests are similar to those obtained for healthy teeth, are similar to those obtained for healthy teeth, which is in contrast to most teeth that exhibit which is in contrast to most teeth that exhibit

irreversible pulpitisirreversible pulpitis.. By:Dr/M.Abuelnaga 20

Electrical pulp tester


The normal responses should not confuse The normal responses should not confuse the practitioner that the pulpal tissue is the practitioner that the pulpal tissue is healthy and therefore requires only healthy and therefore requires only conservative treatmentconservative treatment . .

In addition, these tests help to differentiate In addition, these tests help to differentiate a true pulp polyp from hyperplastic a true pulp polyp from hyperplastic gingivitis that is overlying a cavitation gingivitis that is overlying a cavitation from a nonvital toothfrom a nonvital tooth. .


Correlation between Pulp Correlation between Pulp Vitality & Chronic Open Vitality & Chronic Open

PulpitisPulpitis

Examination of human non-epitheliated and Examination of human non-epitheliated and epitheliated pulp polyps, using paraffin epitheliated pulp polyps, using paraffin sections stained with Holmes' silver stain, sections stained with Holmes' silver stain, showed nerve fibers present in the showed nerve fibers present in the connective tissue of the pedicle region, in connective tissue of the pedicle region, in the granulation tissue of the polyp, and in the granulation tissue of the polyp, and in the epitheliumthe epithelium..


A similar innervation was present in some of A similar innervation was present in some of the epitheliated polyps to that described in the epitheliated polyps to that described in the oral mucosathe oral mucosa . .

Pulp nerves never innervate epithelium under Pulp nerves never innervate epithelium under normal circumstances, so that the normal circumstances, so that the innervation of epithelium covering a pulp innervation of epithelium covering a pulp polyp is a unique example of innervation of polyp is a unique example of innervation of a newly formed mature tissue after fetal life a newly formed mature tissue after fetal life (Southam et al, 1973)(Southam et al, 1973)..


An electron microscope study of ultra-thin sections of hypertrophic pulps removed from human teeth showed that the epithelial cells which covered the oral surface of the polyps were closely related to one another by

“intercellular bridges” and desmosomes .

Structures resembling half desmosomes attached the epithelial cells to the underlying basement membrane and were a prominent feature of the scalloped boundary zone between epithelial

and connective tissue elements.


Although somatic myelinated nerve fibres were not seen, small Although somatic myelinated nerve fibres were not seen, small bundles of unmyelinated nerve fibres were observed in the bundles of unmyelinated nerve fibres were observed in the connective tissue of the polyps (Dixon et al, 1965)connective tissue of the polyps (Dixon et al, 1965) . .

Chronic inflammation is often associated with irreversible Chronic inflammation is often associated with irreversible destruction of parenchymal tissue, and fibrous connective destruction of parenchymal tissue, and fibrous connective tissue fills the resultant defecttissue fills the resultant defect . .

Proliferation of fibroblasts, collagen production, and Proliferation of fibroblasts, collagen production, and neovascularization are enhanced by the secretion of cytokines neovascularization are enhanced by the secretion of cytokines by T cells and macrophages. It may be concluded that by T cells and macrophages. It may be concluded that epithelium of pulp polyps show morphologic characteristics epithelium of pulp polyps show morphologic characteristics similar to the epithelium of oral mucosasimilar to the epithelium of oral mucosa. .

The connective tissue shows characteristics of chronic The connective tissue shows characteristics of chronic inflammation of varied intensity (Trowbridge, 1990)inflammation of varied intensity (Trowbridge, 1990)..


Presumably the young pulp does not become necrotic Presumably the young pulp does not become necrotic following exposure, because its natural defenses and following exposure, because its natural defenses and rich supply of blood allow it to resist bacterial infectionrich supply of blood allow it to resist bacterial infection . .

Transudates and exudates which are inflammatory Transudates and exudates which are inflammatory response products in open chronic pulpitis, drain into response products in open chronic pulpitis, drain into the oral cavity and do not accumulatethe oral cavity and do not accumulate . .

Thus intra-pulpal pressure, which may consequently cause Thus intra-pulpal pressure, which may consequently cause tissue damage and destruction of the microcirculation, tissue damage and destruction of the microcirculation,

does not develop (Faryabi & Adhami, 2008)does not develop (Faryabi & Adhami, 2008)..


Histologic FindingsMicroscopic findings reveal a mass of granulation tissue Microscopic findings reveal a mass of granulation tissue protruding from the crown of a fractured or carious tooth protruding from the crown of a fractured or carious tooth that resembles a pyogenic granulomathat resembles a pyogenic granuloma . .

The fibrovascular stroma contains numerous small, delicate The fibrovascular stroma contains numerous small, delicate vascular channels and a prominent inflammatory infiltrate vascular channels and a prominent inflammatory infiltrate composed of primarily lymphocytes, plasma cells, and composed of primarily lymphocytes, plasma cells, and neutrophilsneutrophils . .

Although the surface may be ulcerated, it is covered by Although the surface may be ulcerated, it is covered by stratified squamous epithelium that resembles oral stratified squamous epithelium that resembles oral mucosa in approximately 50% of these inflammatory mucosa in approximately 50% of these inflammatory

hyperplastic lesionshyperplastic lesions..


The source of this epithelium appears to be from The source of this epithelium appears to be from the engraftment of desquamated oral epithelial the engraftment of desquamated oral epithelial cells or the migration of the epithelium from cells or the migration of the epithelium from the adjacent gingival tissuesthe adjacent gingival tissues..

In more mature lesions that are covered with In more mature lesions that are covered with squamous epithelium, the granulation tissue is squamous epithelium, the granulation tissue is replaced by fibrous connective tissue with replaced by fibrous connective tissue with minimal inflammation and foci of dystrophic minimal inflammation and foci of dystrophic

calcificationcalcification. .


Bacteria (primarily gram positive) are found on the Bacteria (primarily gram positive) are found on the surface of the polyp and within the carious lesion. In surface of the polyp and within the carious lesion. In many cases, the histopathologic changes are limited many cases, the histopathologic changes are limited to the coronal pulp tissue with the apical tissue to the coronal pulp tissue with the apical tissue exhibiting only mild vasodilation and minimal exhibiting only mild vasodilation and minimal chronic inflammationchronic inflammation. .

Ultrastructural examination of nerve fibers associated Ultrastructural examination of nerve fibers associated with the pulp polyp exhibits variable findings within with the pulp polyp exhibits variable findings within the same tooth, ranging from normal to moderate or the same tooth, ranging from normal to moderate or severe degeneration of both myelinated nerve fibers severe degeneration of both myelinated nerve fibers

and unmyelinated nerve fibersand unmyelinated nerve fibers. . . .


pulp polyp histologically


TreatmentTreatment Medical CareMedical Care

Treatment of a pulp polyp in a permanent tooth includes Treatment of a pulp polyp in a permanent tooth includes either root canal therapy or extraction of the tootheither root canal therapy or extraction of the tooth. .

The more conservative pulpotomy treatment has been The more conservative pulpotomy treatment has been successful in selected cases when only the coronal successful in selected cases when only the coronal pulp is affectedIn immature teeth with incomplete pulp is affectedIn immature teeth with incomplete root development, placement of an apical barrier and root development, placement of an apical barrier and strengthening of the thin root with composite resin strengthening of the thin root with composite resin may be indicated prior to root canal treatmentmay be indicated prior to root canal treatment. .


Pulp revascularization of an immature Pulp revascularization of an immature permanent tooth is another new treatment permanent tooth is another new treatment approach that results in the formation of approach that results in the formation of vital pulpal tissuevital pulpal tissue. .

The tooth requires a full-coverage crown The tooth requires a full-coverage crown following endodontic therapyfollowing endodontic therapy. .


Surgical CareSurgical Care

The affected tooth is extracted when primary teeth are The affected tooth is extracted when primary teeth are involved or when minimal tooth structure in involved or when minimal tooth structure in permanent teeth is available for restoration or the permanent teeth is available for restoration or the alveolar bone support is unfavorablealveolar bone support is unfavorable. .

A surgical crown lengthening procedure may be needed A surgical crown lengthening procedure may be needed to prepare a tooth for a full-coverage crownto prepare a tooth for a full-coverage crown. .

Healing is uneventful in most casesHealing is uneventful in most cases. .


MedicationMedicationSystemic medications are not recommended for Systemic medications are not recommended for

the management of this lesionthe management of this lesion . .

Antibiotics are not prescribed for the treatment Antibiotics are not prescribed for the treatment of the pulp polyp, despite a bacterial of the pulp polyp, despite a bacterial

componentcomponent . .

However, an antibiotic paste mixture is used However, an antibiotic paste mixture is used within the canals of the infected tooth when within the canals of the infected tooth when the revascularization process is performed for the revascularization process is performed for

the treatment of the nonvital tooththe treatment of the nonvital tooth. . By:Dr/M.Abuelnaga 36

Further Outpatient CareFurther Outpatient Care

Periodic dental examinations are recommended to Periodic dental examinations are recommended to monitor the success of the root canal therapy or to monitor the success of the root canal therapy or to intercept problems associated with the premature loss intercept problems associated with the premature loss of a toothof a tooth. .

Orthodontic treatment may be needed to restore the Orthodontic treatment may be needed to restore the occlusionocclusion . .

If a tooth is extracted, either a dental implant or fixed If a tooth is extracted, either a dental implant or fixed dental prosthesis (bridge) is a treatment option to dental prosthesis (bridge) is a treatment option to restore function and aestheticsrestore function and aesthetics. .


ComplicationsSpace discrepancy from crown destruction or Space discrepancy from crown destruction or premature loss of a tooth may result in a crowded premature loss of a tooth may result in a crowded malocclusion, supereruption of an opposing malocclusion, supereruption of an opposing

tooth, or the impaction of a succedaneous toothtooth, or the impaction of a succedaneous tooth. .

Without definitive treatment, some of these long-Without definitive treatment, some of these long-standing, nonvital teeth may progress to standing, nonvital teeth may progress to symptomatic disease, including periapical symptomatic disease, including periapical inflammatory disease and (rarely) cellulitis and inflammatory disease and (rarely) cellulitis and

osteomyelitis of the jawsosteomyelitis of the jaws. .


Prognosis

The prognosis is excellentThe prognosis is excellent . .

No risk for recurrence exists once No risk for recurrence exists once definitive treatment has been rendereddefinitive treatment has been rendered. .


Patient EducationPatient Education

Reinforce the importance of routine Reinforce the importance of routine oral health care to prevent the oral health care to prevent the development of deep carious lesions development of deep carious lesions that may cause inflammatory pulpal that may cause inflammatory pulpal disease and more serious sequelaedisease and more serious sequelae. .


Histological evaluation of teeth with hyperplastic pulpitis caused by trauma or caries: case reports

AIMAIM The purpose of this histological study was to The purpose of this histological study was to examine teeth with hyperplastic pulpitis caused by examine teeth with hyperplastic pulpitis caused by trauma or cariestrauma or caries . .

SUMMARY SUMMARY The pulp tissue of one young permanent The pulp tissue of one young permanent incisor with a complicated crown-root fracture and a incisor with a complicated crown-root fracture and a hyperplastic pulpitis, which had been contaminated with hyperplastic pulpitis, which had been contaminated with oral microflora for 40 days, and pulp polyps from four oral microflora for 40 days, and pulp polyps from four permanent first molars whose crowns were destroyed by permanent first molars whose crowns were destroyed by extensive caries were prepared for standard histological extensive caries were prepared for standard histological examinationexamination..


HistologicallyHistologically , ,Normal pulp tissue organization was Normal pulp tissue organization was observed in the tooth with a observed in the tooth with a complicated crown-root fracture in the complicated crown-root fracture in the cervical radicular region. Irregular cervical radicular region. Irregular calcification was seen in the coronal and calcification was seen in the coronal and radicular portion of the pulp in the four radicular portion of the pulp in the four carious teeth with pulp polypscarious teeth with pulp polyps . .

Radicular pulp tissue in the middle and Radicular pulp tissue in the middle and apical third of root canals beneath apical third of root canals beneath irregular calcification showed intensive irregular calcification showed intensive fibrosis but was free from inflammatory fibrosis but was free from inflammatory cellscells . .


KEY LEARNING POINTS

Hyperplastic pulpitis is a type of Hyperplastic pulpitis is a type of irreversible chronic open pulpitisirreversible chronic open pulpitis . .

Young permanent teeth with hyperplastic Young permanent teeth with hyperplastic pulpitis caused by trauma or caries have a pulpitis caused by trauma or caries have a great inherent defensive capacity to healgreat inherent defensive capacity to heal..


Pulp polyp associated with Pulp polyp associated with a natal tooth: case reporta natal tooth: case report

Natal teeth are an infrequent occurrence at birthNatal teeth are an infrequent occurrence at birth . .

Often these teeth are extracted because they are very mobile and Often these teeth are extracted because they are very mobile and pose a risk of aspirationpose a risk of aspiration . .

This is a rare case in which a natal tooth was extracted by the This is a rare case in which a natal tooth was extracted by the pediatrician with his fingerspediatrician with his fingers . .

A root fragment remained and out of this developed a large pulp A root fragment remained and out of this developed a large pulp polyppolyp . .

This relationship has not been previously reportedThis relationship has not been previously reported. .


ReferencesReferences Catherine M, Jan 23, 2012Pulp Polyp Clinical Presentation.

Medscape Reference

Assem M, Jan 2012 Correlation between Pulp Vitality & Chronic Open Pulpitis.

PathXchange / Global Online Pathology Community

Calişkan M.K, Oztop F, Calişkan G, 2003 Jan,Histological evaluation of teeth with hyperplastic pulpitis caused by trauma or caries: case reports.

Endod J.; 36 (1):64-70

Vergotine R, Hodgson B, Lambert L, 2010Pulp polyp associated with a natal tooth: case report.

J Clin Pediatr Dent.; 34 (2):161-3By:Dr/M.Abuelnaga 45

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open pulpitis

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