Pulpal and Periapical diseases.pptxhahah

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2. PULPAL AND PERIAPICAL DISEASES Presented by House Surgeon Chan Nyein & John Han Saw Date- 11.7.2024 7/10/24 2

3. Contents Introduction Review on normal pulp Causes of pulpal diseases Classification of pulpal diseases Causes of periapical diseases Interrelationships of Periapical Infection Classification of periapical diseases Differentiation of pain between pulpal and periapical origin Conclusion References 7/10/24 3

4. Introduction Inflammation of pulp is one of the most common diseases encountered in our day to day practice Pulpal diseases is only one of the several possible causes of diseases of the Periradicular tissues Because of the inter-relationship between the pulp and the Periradicular tissues, pulpal inflammation causes inflammatory changes in the periodontal ligament even before the pulp becomes totally necrotic To give proper and effective treatment one has to diagnose correctly Arriving at a correct diagnosis requires knowledge of the diseases and their symptoms, skill to apply proper test procedures, the art to correlate the facts and experiences to reach proper conclusions 7/10/24 4

5. Normal pulp Dental pulp is an unmineralized oral tissue composed of soft connective tissue, vascular, lymphatic and nervous elements that occupies the central pulp cavity of each tooth Pulp has a soft, gelatinous consistency Pulp test Delayed initial response to heat, intensify as temperature rises Immediate response to cold, but intensity decrease with time No lingering pain, no spontaneous pain It may also be sensitive to sweet and to acidic foods The electric pulp tester may produce feelings varying from a tingling sensation to pain 7/10/24 5

6. Periapical test Palpation and percussion do not cause pain Radiographic features There is a normal periodontal ligament space bounded by an intact lamina dura Figure 1. Normal pulp 7/10/24 6

7. Causes of pulpal diseases I. Bacterial Toxins associated with caries Direct invasion of pulp from caries or trauma Blood borne microorganisms(Anachoresis) II. Physical A. Mechanical 1. Trauma a. Accidental(contact sports) b. Iatrogenic dental procedures (cavity or crown preparation) 7/10/24 7

8. 2. Pathologic wear ( Attrition,abrasion , etc.) 3. Crack through body tooth (cracked tooth syndrome) 4. Barometric changes ( Barodontalgia ) B. Thermal 1. Heat from cavity preparation, at either low or high speed 2. Exothermic heat from the setting of cement 3. Conduction of heat and cold through deep fillings without a protective base 4. Frictional heat caused by polishing a restoration 7/10/24 8

9. C. Electrical Galvanic current from dissimilar metallic fillings III. Chemical A. Phosphoric acid, acrylic monomer, etc B. Erosion (Acids) 7/10/24 9

10. Classification of pulpal diseases Reversible pulpitis Irreversible pulpitis Chronic Hyperplastic pulpitis(Pulp polyp) Pulp necrosis Pulp calcification(Pulp stone) Internal (Intracanal) resorption Crack tooth syndrome 7/10/24 10

11. 1. Reversible pulpitis It is inflammation of the pulp that is not severe If the cause is eliminated, inflammation will reverse and the pulp will return to normal Clinical features Asymptomatic or Pain is induced by thermal stimuli tend to be of short duration Pulp test Application of stimuli such as cold or hot liquids or air may produce sharp transient pain Removal of these stimuli results in immediate relief 7/10/24 11

12. Periapical test The tooth responds within normal limits Radiographic features No periapical changes Treatment Removal of irritants and sealing and insulating the exposed vital dentine 7/10/24 12

13. Figure 2&3. Reversible pulpitis 7/10/24 13

14. 2. Irreversible pulpitis It is a severe inflammation of the pulp that will not resolve even if the cause is removed The pulp slowly or rapidly progress to necrosis A. Symptomatic, acute condition Clinical features Intermittent or continuous episodes of spontaneous pain with no external stimuli Pulp test A pplication of cold or heat may produce prolonged ligering pain, spontaneous pain Later-Heat intensify, cold-relief 7/10/24 14

15. Periapical test May or may not have pain on percussion or palpation Radiographic features No periapical radiolucency changes or Widening of PDL space if concomittent with acute apical periodontitis Treatment Root canal treatment or extraction 7/10/24 15

16. B. Asymptomatic, chronic condition Clinical features Asymptomatic Large carious exposure Pulp test Mild, vague pain Occasionally associated with heat/cold stimulus Periapical test The tooth responds within normal limits 7/10/24 16

17. Radiographic features No changes or more likely to have periapical changes widening of PDL Treatment Root canal treatment or extraction 7/10/24 17

18. Figure 4&5. Irreversible pulpitis 7/10/24 18

19. 3. Chronic Hyperplastic pulpitis(Pulp polyp) It is a form of irreversible pulpitis, which results from growth of chronically inflamed young pulp into occlusal surfaces It is usually found in carious crowns of young patients Clinical features Usually asymptomatic or appears as a reddish cauliflower-like outgrowth of connective tissue into large carious cavity Pulp test Vague pain Occasionally associated with heat/cold stimulus The threshold to electrical stimulation is similar to that found in normal pulps 7/10/24 19

20. Periapical test The tooth responds within normal limits when palpated or percussed Treatment Pulpotomy, root canal treatment or extraction Figure 6. Chronic hyperplastic pulpitis ( Pulp Polyp ) 7/10/24 20

21. 4. Pulp necrosis It is death of the pulp tissue Liquefaction necrosis - the sequelae of irreversible pulpitis Ischemic necrosis – the result of traumatic injury from disruption of the blood supply Clinical features Usually asymptomatic May be associated with episodes of spontaneous pain and discomfort or pain (from the periapex) on pressure 7/10/24 21

22. Pulp test No response to cold, heat, or electrical stimuli Periapical test Normal limit Occasionally sensitive to percussion and palpation when apically involved Radiographic features No changes or slight widening of PDL space Treatment Root canal treatment or extraction 7/10/24 22

23. Figure 7&8. Pulp necrosis 7/10/24 23

24. 5. Pulp calcification(Pulp stone) Extensive calcification occurs as a response to trauma, caries, periodontal disease, or other irritants Thrombi in blood vessels and collagen sheaths around vessel walls are possible nidi (nest) for these calcifications Another type of calcification is the extensive formation of hard tissue on dentin walls, often in response to irritation or death and replacement of odontoblast This process is calcific metamorphosis Clinical features Asymptomatic A yellowish discoloration of the crown is often a manifestation of calcific metamorphosis 7/10/24 24

25. Pulp test The pain threshold to thermal and electrical stimuli usually increases, or Often the teeth are unresponsive Periapical test Responses to palpation and percussion are usually within normal limits Radiographic features Calcification of pulp tissue is associated with various degrees of pulp space obliteration A reduction in coronal pulp space followed by a gradual narrowing of the root canal is the first sign of calcific metamorphosis 7/10/24 25

26. Treatment Calcific metamorphosis in and of itself is not pathosis and does not require treatment unless apical pathosis Figure 9&10&11. Pulp calcification ( Pulp stone ) 7/10/24 26

27. 6. Internal (Intracanal) resorption Inflammation in the pulp may initiate resorption of adjacent hard tissues The pulp is transformed into vascularized inflammatory tissue with dentinoclastic activity This resorbs the dentinal walls, advancing from the center to the periphery Clinical features Most cases are asymptomatic Advanced case is associated with pink spots in the crown Pulp test Responds within normal limits Increases respond due to decrease in thickness of root dentine 7/10/24 27

28. Periapical test Responds within normal limits Radiographic features Reveal a radiolucency with irregular enlargement of the root canal compartment Treatment Immediate removal of inflamed tissue and root canal treatment These lesions tend to be progressive and eventually perforate to the lateral periodontium When this occurs, pulpal necrosis will follow 7/10/24 28

29. Figure 12&13. Internal ( Intracanal ) resorption 7/10/24 29

30. 7. Crack tooth syndrome May be defined as a fracture plane of unknown depth, which originate from the crown, passes through the tooth structure and extends subgingivally , and may progress to connect with the pulp space and/or periodontal ligament Clinical features Pain after chewing or releasing from chewing Often unable to locate hair line Incomplete fracture common Commonly found in upper first and second premolars, upper first molar and lower first and second molars Crack line-Mesiodistally than Buccolingually 7/10/24 30

31. Pulp test Commonly responds to cold test, cold drink, food Additional test - bite test on cusp with rubber cup or tooth slooth Periapical test Within normal limit if crack confined to coronal structure and no apical involvement Radiographic features Not seen fracture if runs Mesiodistally If fracture beyond crown and onto root- perio defect- deep pocket adjacent to fracture can see 7/10/24 31

32. Treatment Depend on extent of crack and pulpal involvement Restoration and / or Endo treatment Figure 14. Crack tooth $ 7/10/24 32

33. Interrelationships of Periapical Infection 7/10/24 33 Pulpitis Acute Chronic Apical Periodotitis Acute Chronic

34. 7/10/24 34 Periapical Abscess Periapical Granuloma Acute Chronic Apical Peridontal Cyst (Radicular cyst, Periapical cyst, Root end cyst) Osteomyelitis Acute Chronic Focal Diffuse

35. 7/10/24 35 Periostitis Abscess Cellulitis

36. CAUSES OF PERIAPICAL DISEASES Irritants diffusing from an inflamed or necrotic pulp Bacteria, bacterial toxins Disinfecting medications- overmedication Debris pushed into the periradicular tissues Physical irritation of the periapical tissues e.g.overinstrumentation,overobturation Impact trauma 7/10/24 36

37. CLASSIFICATION OF PERIAPICAL DISEASES Acute Apical Periodontitis Chronic Apical Periodontitis Acute Apical Abscess Chronic Apical Abscess Condensing osteitis

38. 1. Acute apical peridontitis Definition Acute apical periodontitis is a painful inflammation of the periodontium as a result of trauma, irritation, or infection through the root canal Causes ( i ) In vital tooth -abnormal occlusal contacts -inserted restoration extending beyond the occlusal plane -wedging of a foreign object between the tooth

39. (ii) In non-vital tooth - sequelae of pulpal diseases -Iatrogenic causes Symptoms -Pain and tenderness of the tooth -Patient may have pain on closure and mastication -Pain on percussion

40. Radiographic changes -Non vital tooth : Widening of apical periodontal ligament and loss of lamina dura. -Vital tooth : No radiographic changes .

41. Treatment Remove the source of infection, drains the exudates Root canal therapy or extraction 7/10/24 41

42. 2.Chronic apical periodontitis(Apical granuloma) Definition Chronic apical periodontitis is the symptomless sequelae of symptomatic apical periodontitis and is characterized radiographically by periradicular radiolucent changes and histologically by the lesion dominated with macrophages, lymphocytes, and plasma cells Symptoms -May not produce any subjective reaction

43. Radiographic features - area of rarefaction is well-defined with lack of continuity of the lamina dura - tooth does not respond to thermal or electric pulp tests

44. Treatment Root canal therapy or extraction 7/10/24 44 Apical granuloma

45. 3. Acute Apical Abscess It is the first extension of pulpal inflammation into the periradicular tissue Symptoms Moderate to severe spontaneous discomfort E xcruciating pain on percussion N egative of positive response to vitility test 7/10/24 45

46. Radiographic Features Widening of PDL space or within normal limit Treatment Drainage must be made,open the pulp chamber RCT or extration 7/10/24 46

47. 4. Chronic apical abscess Definition A chronic apical abscess is a long-standing, low grade infection of the periradicular alveolar bone generally symptomless and characterized by the presence of abscess draining through the sinus tract Causes Natural sequelae of death of pulp with extension of the infective process periapically

48. Radiographic features Discontinuity of the lamina dura at the periapex or ill-defined periapical radiolucency. Treatment Elimination of the infection in the root canal.

49. 5.Condensing osteitis Definition Condensing osteitis is a diffuse radiopaque lesion believed to represent a localized bony reaction to a low-grade inflammatory stimulus, usually seen at the apex of a tooth in which there has been a long-standing pulpal pathosis Causes Condensing osteitis is a mild irritation from pulpal disease that stimulates osteoblastic activity in the alveolar bone

50. Symptoms Asymptomatic It is discovered during routine radiographic examination Diagnosis Osteitis appears in radiographs as a localized area of radiopacity surrounding the affected root It is an area of dense bone with reduced trabecular pattern

51. Cellulitis/Phlegmon Cellulitis is a diffuse inflammation of soft tissues which is not circumscribed or confined to one area, but which, in contrary to the abscess, tends to spread through tissue spaces and along fascial spaces Causes It occurs as a result of infection by microorganisms that produce significant amount of streptokinase, hyaluronidase and fibrinolysins which acts to breakdown or dissolve hyaluronic acid, the universal intracellular cement substance, and fibrin 7/10/24 51

52. Dental infection Sequela of periapical abscess or osteomyelitis Pericoronitis Tooth extraction or injection with a infected needle Clinical features Systemic features increased body temperature , general fatigue, chills, sweatings , headache, loss of appetite Swelling is because of inflammatory edema If superficial tissue space involved- skin is inflamed An orange peel appearance and is even purplish 7/10/24 52

53. If spread of infection in deeper planes- overlying skin is normal • Regional lymphadenitis present In maxilla. - Perforates the outer cortical layer of bone above the buccinator attachment → swelling in the upper half of the face Extension towards eye→ cavernous sinus thrombosis In mandible. - Perforates the outer cortical plate below the buccinator attachment → swelling in the lower half of the face. Spread to cervical tissue cause respiratory discomfort 7/10/24 53

54. Complication Cavernous sinus thrombosis Ludwig’s Angina Facial abscess Treatment • Antibiotics • Antianaerobics • Removal of the cause of the infection • To avoid massaging the affected area to avoid spread 7/10/24 54

55. Differentiation of pain between pulpal and periapical origin 7/10/24 55 Parameters Pulpal pain Periapical pain Charaters of pain Transient or spontaneous Mild or severe Dull ot throbbing or excruciating Diffuse (Difficult to locate) Spontaneous Mild or severe Dull ot throbbing or excruciating Localized Refer pain - or + - Stimulating factors Cold or hot stimulus S weet Food debris None Relieving factors Cold water Removal of stimulus (or) None None

56. Pain on occlusion - or + + Discolouration - - or + Swelling - - or + Sinus - - or + Pain on percussion - or + + Tenderness - - or + Mobility - - or + Thermal test + - Electrical pulp test + - X-ray - Widening of PDL space Apical radiolucency 7/10/24 56

57. Conclusion The diseases of the pulp are most commonly produced as a sequelae to dental caries which are of bacterial origin Proper intervention at right time and right endodontic treatment may provide good prognosis for the tooth Early detection and treatment of pulpal diseases persist it from progressing into periradicular diseases It is essential that we understand the progressive nature of the periapical disease process as well as how and why the various stages occur so they can be diagnosed and managed appropriately 7/10/24 57

58. References Endodontics ( Lecture Notes ) Adapted by Prof;U Aund Htang Endodontics ( Lecture Notes ) Adapted by Prof;Daw Myint Myint San Textbook of Operative Dentistry ( 3 rd Edition ) Oral Medicine ( Lecture Notes ) Fourth B.D.S 7/10/24 58

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