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PULPITIS

Chapter

three

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Definition:

Inflammation of the pulp (the tooth's

innermost layer) caused by a cavity or

other trauma, and often signalled by a

painful toothache.

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category

Reversible pulpitisReversible pulpitis

Irreversible pulpitisIrreversible pulpitis

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Reversible pulpitisReversible pulpitis

The pulp is inflamed to the extent that thermalstimuli cause a quick, sharp, hypersensitive responsethat subsides as soon as the stimulus is removed.

Reversible pulpitis is not a disease but merely asymptom. If the cause is removed, the pulp should revertto an uninflamed state and the symptom should subside.

Conversely, if the cause remains, the symptom maypersist, and the inflammation may become morewidespread, and eventually, leading to an irreversiblepulpitis.

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Causes: any irritant that can affect the pulp may cause

reversible pulpitis such as caries, thermal, deep

periodontal scaling and root planing.

Distinguishing reversible pulpitis from the irreversible:1 A sharp painful response to thermal stimulation.

2 Spontaneous pain.

Treatmentchoice:Sedative dressing, or called temporary restoration with

sedative package, such as zinc oxide.

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Irreversible pulpitisIrreversible pulpitis

An irreversible pulpitis may be acute, subacute,

or chronic, and it may be partial and total.Clinically, acute one is symptomatic, whereas the

chronic is asymptomatic. At this stage, the

dynamic changes in the pulp are always occurring.

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Symptomatic irreversible pulpitis:Symptomatic irreversible pulpitis:

This type of pulpitis is characterized byThis type of pulpitis is characterized by

spontaneous intermittent or continuous paroxysmsspontaneous intermittent or continuous paroxysms

of pain.of pain.

The pain may be caused by sudden temperatureThe pain may be caused by sudden temperature

changes, which is prolonged.changes, which is prolonged.

The pain caused by cold stimulation can be relievedThe pain caused by cold stimulation can be relieved

by heat, and similarly, the pain caused by heat canby heat, and similarly, the pain caused by heat can

be relieved by coldbe relieved by cold..

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There may even be a painful response toThere may even be a painful response to

both cold and heat stimulation too.both cold and heat stimulation too.

The pain may be localized or referredThe pain may be localized or referred(e.g. referred from mandibular molars(e.g. referred from mandibular molars

toward the ear or up to the temporal area.)toward the ear or up to the temporal area.)

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A symptomatic irreversible pulpitis can beA symptomatic irreversible pulpitis can be

diagnosed by a thorough dental history, visualdiagnosed by a thorough dental history, visualexamination, thermal tests and radiography.examination, thermal tests and radiography.

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Asymptomatic irreversible pulpitis:Asymptomatic irreversible pulpitis:

This type of irreversible pulpitis is asymptomaticThis type of irreversible pulpitis is asymptomatic

because the inflammatory exudate are quickly vented.because the inflammatory exudate are quickly vented.

It can develop by the conversion of a symptomaticIt can develop by the conversion of a symptomatic

one into a quiescent state.one into a quiescent state.

It also can caused by long and lowIt also can caused by long and low--grade pulpgrade pulp

irritant (carious lesions), traumatic injury.irritant (carious lesions), traumatic injury.

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There are three types ofasymptomatic pulpitisThere are three types ofasymptomatic pulpitis

1.1.Hyperplastic pulpitisHyperplastic pulpitis

Clinically, it is a reddish cauliflowerClinically, it is a reddish cauliflower--likelike

overgrowth of pulp tissue through and around aovergrowth of pulp tissue through and around a

carious exposure. It is characteristically foundcarious exposure. It is characteristically found

in young people since the generous vascularityin young people since the generous vascularity

of the pulp.of the pulp.

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2. Internal resorption2. Internal resorption

It is a resorption of the dentine from the pulpIt is a resorption of the dentine from the pulp

outward, which is often caused by trauma or pulpoutward, which is often caused by trauma or pulp

capping. It is usually can be diagnosed bycapping. It is usually can be diagnosed by

radiography.radiography.

3. Canal calcification3. Canal calcification

A large amounts of reparative dentine over depositA large amounts of reparative dentine over deposit

throughout the canal system, which is caused bythroughout the canal system, which is caused by

periodontal therapy, abrasion, trauma etc.periodontal therapy, abrasion, trauma etc.

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Chapter

four

PeriapicaldiseasePeriapicaldisease

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Classification of periapical diseaseClassification of periapical disease

Acute apical periodontitisAcute apical periodontitis

It describes acute inflammation around theIt describes acute inflammation around the

apex.apex. The tooth with it may exquisitely tender toThe tooth with it may exquisitely tender to

percussion.percussion.

Radiographically the apical periodontalRadiographically the apical periodontalligament may appear slightly widened orligament may appear slightly widened or

normal.normal.

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Causes:Causes:

Extension of pulpal disease into theExtension of pulpal disease into the

periapical tissue. periapical tissue.

Endodontic procedures such as canal fillingEndodontic procedures such as canal fillingbeyond the apical foramen.beyond the apical foramen.

Occlusal trauma from a high restoration orOcclusal trauma from a high restoration or

from chronic bruxism.from chronic bruxism.

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Acute apicalabscessAcute apicalabscess

It implies a painful, purulent exudateIt implies a painful, purulent exudate

around the apex.around the apex.

Rapid onset of slight to severe swelling,Rapid onset of slight to severe swelling,pain, and pain to percussion, and possiblepain, and pain to percussion, and possible

mobility.mobility.

The distinguishing acute apical abscessThe distinguishing acute apical abscess

from the lateral periodontal abscess andfrom the lateral periodontal abscess and

from the phoenix abscessfrom the phoenix abscess

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For periodontalabscessFor periodontalabscess

Thermal and electric pulp testing indicateThermal and electric pulp testing indicate

the pulp vital; there is a periodontal pocket;the pulp vital; there is a periodontal pocket;

the tooth may be normal.the tooth may be normal.

For the phoenixabscessFor the phoenixabscess

All symptoms of acute apical abscess plusAll symptoms of acute apical abscess plusapical radiolucency around the apex of theapical radiolucency around the apex of the

tooth.tooth.

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Pain

slight frequently intense continuous throbbing

Swellingand palpation

palpable fluctuant swelling

Diagnosis

Vitality tests Negative

Radiography

Slight widening of the apical periodontal ligament space

Periapical radiolucency of a subacute periapical abscess

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Acute apical periodontitis

(painful phase)

Acute apical abscess

(painful phase)

Subacute periapical abscess

(painful phase)

Chronic periapical abscess

(nonpainful phase)

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Chronicapical periodontitisChronicapical periodontitis

Chronic apical periodontitis implies longChronic apical periodontitis implies long--standingstanding

asymptomatic inflammation around the apex. Althoughasymptomatic inflammation around the apex. Although

chronic apical periodontitis tends to be asymptomatic, therechronic apical periodontitis tends to be asymptomatic, there

may be occasional slight tenderness to palpation andmay be occasional slight tenderness to palpation and

percussion.percussion.

Only biopsy and microscopy examination can revealOnly biopsy and microscopy examination can reveal

whether these apical lesions are dental granulomas, abscesses,whether these apical lesions are dental granulomas, abscesses,

or cysts.or cysts.

Diagnosis is confirmed by the presence of a radiolucencyDiagnosis is confirmed by the presence of a radiolucencythat may be either diffuse or wellthat may be either diffuse or well--circumscribed, the absencecircumscribed, the absence

of pulp vitality, and a sinus tract.of pulp vitality, and a sinus tract.

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Diagnosis

Pain no pain or mild pain

Swellingand palpation

Slight swelling in the area around the sinus tract stoma,

surface of the face, floor of the nose and other portions of thehead and neck.

Percussion and mobility Negative

Color tooth color becomes black or grey

Vitality tests Negative

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Radiography

Chronicperiapicalabscess :

diffuse area of bone rarefaction around the root

Chronicperiapicalgranulomaandcyst:

diffuse area of bone rarefaction around the root,

and an opaque hyperostotic border

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PhoenixabscessPhoenixabscess

A phoenix abscess is a chronic apical periodontitisA phoenix abscess is a chronic apical periodontitis

that suddenly becomes symptomatic.that suddenly becomes symptomatic.

The symptoms are identical to those of an acuteThe symptoms are identical to those of an acute

apical abscess, the man difference being that theapical abscess, the man difference being that the

phoenix abscess is preceded by a chronic condition.phoenix abscess is preceded by a chronic condition.

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Periapical osteosclerosisPeriapical osteosclerosis

Periapical osteosclerosis is excessive bonePeriapical osteosclerosis is excessive bone

mineralization around the apex caused by lowmineralization around the apex caused by low--

grade, relatively asymptomatic, chronic pulpalgrade, relatively asymptomatic, chronic pulpal

inflammation which is most commonly found ininflammation which is most commonly found in

young people .young people .

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Although many factors can cause the pulpitis which furtherAlthough many factors can cause the pulpitis which further

develop into apical periodontitis, the bacteria are the mostdevelop into apical periodontitis, the bacteria are the mostcommon one.common one.

The factors include:The factors include:

1.1.BacteriaBacteria

2.2.TraumaTrauma

3.3.ThermalThermal

4.4.Static electricityStatic electricity

5.5.LaserLaser

6.6.Filling materialsFilling materials

7.7.Etch or adhesive agentsEtch or adhesive agents

8.8.Drugs for toilet the cavityDrugs for toilet the cavity

9.9.Immunological aspectImmunological aspect

Causes:Causes:

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TreatmentTreatment

1. Diagnostic phase

the tooth to be treated is determined , thetreatment plan is developed.

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Once the tooth has been confirmed as irreversibleOnce the tooth has been confirmed as irreversible

pulpitis or any of apical diseases, thepulpitis or any of apical diseases, the endodonticendodontic

treatmenttreatment must be done. Before you decide to domust be done. Before you decide to do

the endodontic treatment you need to considerthe endodontic treatment you need to consider

follows:follows:

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Physical evaluation:Physical evaluation:

it mainly concerned about systemic conditions (diseases) suchit mainly concerned about systemic conditions (diseases) such

as cardiovascular diseases, bleeding disorders, diabetes, cancer,as cardiovascular diseases, bleeding disorders, diabetes, cancer,

AIDS, pregnancy, allergies, steroid therapy, infectious diseasesAIDS, pregnancy, allergies, steroid therapy, infectious diseases

etc.etc.

Psychological evaluation:Psychological evaluation:

A patient who shows no incentive (motivation) to maintainA patient who shows no incentive (motivation) to maintain

good oral hygiene or one who constantly misses appointmentsgood oral hygiene or one who constantly misses appointments

may not be a good candidate for endodontic therapy.may not be a good candidate for endodontic therapy.

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Evaluation of toothEvaluation of tooth

MorphologyMorphology

Unusual lengthUnusual length

Unusual shapesUnusual shapes

Unusual numbers (canal or roots)Unusual numbers (canal or roots)

ResorptionsResorptions

CalcificationsCalcifications

Previous treatmentPrevious treatment Canal blockageCanal blockage

LedgeLedge

perforationsperforations

Location of toothLocation of tooth AccessibilityAccessibility

Proximity to other structuresProximity to other structures

RestorabilityRestorability

Periodontal statusPeriodontal status

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Treatment planningTreatment planning

general process and sequence:general process and sequence:Management of acute pulp or periodontal pain.Management of acute pulp or periodontal pain.

Oral surgery for extraction of unsalvageable teeth.Oral surgery for extraction of unsalvageable teeth.

Caries control of deep lesions that may threaten the pulp.Caries control of deep lesions that may threaten the pulp.

Periodontal procedures to manage soft tissue.Periodontal procedures to manage soft tissue.

Endodontic procedures for asymptomatic teeth withEndodontic procedures for asymptomatic teeth with

necrotic pulps and surgical treatment or renecrotic pulps and surgical treatment or re--treatment oftreatment of

failing root canals.failing root canals.

Restorative and prosthetic procedures.Restorative and prosthetic procedures.

OneOne--appointment root canal therapyappointment root canal therapy

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2. Preparatory phase

the contents of the root canal are removed

and the canal prepared for the filling materials.

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Reamer and fileReamer and file

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3.Filling phase

filling the canal to gain a seal with an inert

materials as close as possible to the root apical

role.

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1. open the pulp cavity

relieve the pressure of pulp cavity

pain ceases or relieved

P

roc

edure:

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4. fill root canal and restore the tooth

apply a sedative antiseptic dressing3.

remove infected pulp2.