44.-DISEASES-OF-PULP-PART-1 and recent advances

Pulp diseases

1. DISEASES OFTHE
DENTAL PULP
PART1

2. OBJECTIVES
•To gain a thorough knowledge of pulpal diseases and their causes.
•To understand the clinical implications of pulpal diseases in order to
make accurate diagnosis and treatment planning.

3. CONTENTS
INTRODUCTION
BASIC MORPHOLOGY OF DENTAL PULP
CAUSES OF PULPAL DISEASE
CLASSIFICATION OF PULPAL DISEASES
DIAGNOSIS OF PULPAL PATHOSIS

4. Introduction
Diseaseisdefinedasadefinitedeviationfromthenormalstate
characterizedbyaseriesofsymptoms.Itmaybecausedby
developmentaldisturbances,geneticfactors,metabolicfactors,living
agents,orphysical,chemical,orradiantenergy,orthecausemaybe
unknown.
Mosby’s Dental Dictionary -Mosby’s Dental Dictionary
Dental health is directly related to the health of a unique tissue-that is,
“Dental Pulp”.

5. Pulp horn
Pulp chamber
Root canal
Lateral canal
Apical foramen
Principles and Practice Of Endodontics by Walton & Torabinejad,4
th
edition 2010
Basicmorphology ofdentalpulp

6. Odontoblastic
zone
Dentin
Zones of Pulp
•Odontoblastic zone
•Cell free zone
(Weil’s zone)
•Cell rich zone
•Central zone
Gotjamanos:Cellular organization in the subodontoblasticzone of the dental pulp, Arch of Oral bio
14:9,1007-1010,1969.
Cell rich
zone
Central zone
Cell free
zone

7. Causes of pulpal disease
According to Grossman
➢1) Physical
a) Mechanical
i) Trauma –accidental, iatrogenic
ii) Pathologic wear( attrition, abrasion)
iii) Cracked tooth syndrome
iv) Barometric changes (Barodontalgia)
b) Thermal –Heat from cavity preparation, setting of
cement, deep fillings without protective base, polishing.
c) Electrical –(galvanic current from dissimilar metal
fillings)
Grossman, Endodontic Practice, 12
th
edition2010

8. ➢2) Chemical
a) phosphoric acid, acrylic monomer
b) erosion
➢3) Bacterial
a) toxins associated with caries
b) direct invasion of pulp from caries or trauma
c) anachoresis.
Grossman, Endodontic Practice, 12
th
edition2010

9. Classification of pulpal diseases
According to Grossman:
➢1) Inflammatory diseases of the dental pulp
(a)Reversible
i. Acute (symptomatic).
ii. Chronic (asymptomatic)
(b)Irreversible
i. Acute
Abnormally responsive to cold.
Abnormally responsive to heat.
ii. Chronic
Asymptomatic with pulp exposure
Hyperplastic pulpitis.
Internal resorption
➢2) Pulp Degeneration
(a)Calcific (radiographic diagnosis).
(b)Others (histopathologic diagnosis).
➢3) Pulp Necrosis
Grossman, Endodontic Practice, 12
th
edition2010

10. According to Ingle
➢1)Inflammatory changes
(a) Hyper-reactive pulpalgia
i. hypersensitivity
ii. hyperemia
(b) Acute pulpalgia
i. incipient(may be reversible)
ii. Moderate(may be referred)
iii. Advanced(may be relieved by cold)
(c) Chronic pulpalgia
(d) Hyperplastic pulpitis
(e) Pulp necrosis
➢2) Retrogressive (degenerative) changes
(a) Atrophic pulposis
(b) Calcific pulposis
Ingle, Bakland, Baumgartner; Endodontics ; 6
th
edition 2008

11. Diagnosis of pulpal pathosis
“Listen to your patient….. The patient will give you
the diagnosis”
-Sir William Osler

12. Flowchart in diagnosis
Radiographic Examination and interpretation
Intraoral
Radiographs
Digital
Radiography
Cone-Beam Volumetric
Tomography
Examination and testing
Extra-oral Intra-oral Pulp testsSpecial tests
Case history and record
Chief complaint Medical history Dental history
Cohen and Hargreaves, Pathway's of the pulp, 10
th
Edition

13. Case history and record
•Case history is defined as the data concerning an individual
and his or her family and environment, including the individual
medical history that may be useful in analyzing and diagnosing
his or her case
Grossman, Endodontic Practice, 12
th
edition2010

14. Symptoms
•Symptoms are defined as phenomenon or signs of departure
from the normal and are indicative of illness.
•Symptoms 1.Subjective
2.Objective
•Subjective Symptoms are those experienced and reported to
the clinician by the patient.
•Objective Symptoms are those ascertained by the clinician
through various tests.
Grossman, Endodontic Practice, 12
th
edition2010

15. Subjective Symptoms
1) pain
2) swelling
3) esthetics
4) lack of function
Pain
Most common chief complaint that leads to dental treatment
Grossman, Endodontic Practice, 12
th
edition2010

16. Objective Symptoms
•They are determined by examination and testing.
•Examination and testing have following parts
Grossman, Endodontic Practice, 12
th
edition2010
Examination and testing
Extraoral Intraoral Pulp test
Special
test

17. PALPATION TEST PERCUSSION TEST
PERIODONTAL EXAMINATIONMOBILITY TEST

18. Pulp tests
Assessment
of Pulp
Sensibility
Direct dentin
stimulation
Thermal tests
Electric tests
Assessment
of Pulp
Vascularity
Crown Surface
Temperature
Transmitted Light
Photoplethysmography
Laser Doppler
Flowmetry
Pulse Oximetry
Xenon-133
Radioisotopes
Dual Wavelength
Spectrophotometry
Cohen and Hargreaves, Pathway's of the pulp, 10
th
Edition

19. Inflammatory diseases of pulp
➢Thetypeofinflammationofpulpisnotalwaysdistinct
1
.
➢Bothacuteandchronicinflammationmaybepresenton
histologicalexamination
1
.
➢Garfunkelandassociates-directcorrelationbetweenclinical
diagnosisandhistologicalexamination-49%ofpulps
examined
2
.
➢Thusclinicalclassificationisofmorerelevancewithrespectto
treatment
2
.
1.Grossman, Endodontic Practice, 12
th
edition2010
2. Garfunkel,a.,etal.:OralSurg.,35:110,1973

20. Reversible pulpitis
Definition:
“Itisamildtomoderateinflammatoryconditionofthepulp
causedbynoxiousstimuliinwhichthepulpiscapableof
returningtotheuninflamedstatefollowingremovalofthe
stimuli”.
Itisoneoftheearliestformofpulpitisandatonetime
referredtoas“pulphyperemia”.
Grossman, Endodontic Practice, 12
th
edition2010

21. Etiology
Reversiblepulpitismaybecausedbyanyagent
thatiscapableofinjuringthepulp.Thecauses
couldbe:
•Trauma–accidentordisturbedocclusal
relationship
•Thermalshock–prolongedcavitypreparation
•Exposeddentin-dentinalsensitivity
1
•Chemicalstimulus–sweetorsourfoodsorfrom
irritationofafilling.
1.Rees JS, AddyM: A cross-sectional study of dentine hypersensitivity,J Clin Periodontol 29:997,
2002.
Grossman, Endodontic Practice, 12
th
edition2010

22. •Bacteria-caries.
•Circulatorydisturbancesduringpregnancy
•Localvascularcongestion-commoncoldorsinusdisease
cancausetransienthyperemiaofthemaxillaryposteriorteeth.
•Excessivedehydrationofcavity
Grossman, Endodontic Practice, 12
th
edition2010

23. Symptoms
•Characterizedbysharppainlastingforamoment.
•Moreoftenbroughtonbycoldthanhotfoodorbeverages
•Doesnotoccurspontaneously
•Ceaseswhenirritantisremoved.
•Asymptomaticreversiblepulpitismayresultfromincipient
cariesandisresolvedonremovalofthecariesandproper
restorationofthetooth.
Grossman, Endodontic Practice, 12
th
edition2010

24. Histopathology
•Mayrangefromhyperemiatomildtomoderateinflammatory
changeslimitedtotheareaofthecariousdentinaltubules.
•Reparativedentin,dilatedbloodvessels,extravasationof
edemafluidandthepresenceofchronicinflammatorycells
areseen.
•Chronicinflammatorycellspredominate.
Grossman, Endodontic Practice, 12
th
edition2010

25. Diagnosis
•Diagnosisisbasedonsymptomselicitedbypatient
•Painissharp,lastsforafewseconds,disappearswhenthe
stimulusisremoved.
•Cold,sweetorsourusuallycausesthepain.
•Coldpulptest-methodoflocatinganddiagnosingtheinvolved
tooth.
•Toothreactsnormallytopercussion,palpation,mobilityandthe
periapicaltissueisnormalonradiographicexamination
BermanLH:Dentinalsensationandhypersensitivity:areviewofmechanismsandtreatment
alternatives,JPeriodontol56(4):216,1984.

26. DifferentialDiagnosis
•Reversiblepulpitisshouldbedifferentiallydiagnosedfrom
irreversiblepulpitis.
Grossman, Endodontic Practice, 12
th
edition2010

27. Reversible Irreversible
Pain Momentary Continuous
Stimulus Requires external
stimulus
Spontaneous
History Recent restoration
Root planing
Deep caries, trauma,
extensive restoration
Referred pain Negative due to
minimally affected pulp
Common finding
Pain on lying downNegative May be present
Color No change May be changed due
to tissue lysisand
intrapulpal
hemorrhage
Electric pulp testPremature responsePremature or delayed
or mixed
Franklin Weine, Endodontic Therapy; 5
th
edition

28. Treatment
•Prevention-besttreatment
Preventivemethods
Periodic care to prevent the development of caries
Early insertion of a filling if a cavity has developed
Use of a cavity varnish or a cement base before insertion
of a filling
Care in cavity preparation and polishing
Grossman, Endodontic Practice, 12
th
edition2010

29. •Whenpulpitisexists-removalof
thenoxiousstimuli
•Oncesymptomssubsideafter
removalofnoxiousstimuli,tooth
shouldbecheckedforvitalityto
makesurepulpalnecrosishasnot
occurred.
•Ifpainpersistsposttreatment,the
pulpalinflammationshouldbe
regardedasirreversible.
Grossman, Endodontic Practice, 12
th
edition2010

30. Prognosis
•Theprognosisforthepulpisfavorable,if
theirritantisremovedearlyenough.
•Otherwise,theconditionmaydevelop
intoirreversiblepulpitis.
Grossman, Endodontic Practice, 12
th
edition2010

31. Conclusion
•Knowledgeofpulpaldiseasesandcorrectdiagnosisofthesameisextremely
importantinclinicalpracticeasitcanleadtosuccessfultreatmentoutcomes
•Therearevariousdiseasesofpulpwhichare
confusingandlooksimilar,thereforeoneshouldhave
properknowledgeandabilitytodiagnosethemandtreat
thepulpaldiseasesaccordingly

32. Take Home Message
•The understanding of pulpal diseases enables the determination of
the causes and accurate diagnosis.
•This would result in a thorough treatment plan.

33. Probable SAQs and LAQs
•Classification of pulpal diseases
•Causes of pulpal diseases
•Distinguish between irreversible and reversible pulpitis