6- Pulp and Periradicular Pathosis

8/12/2019 6- Pulp and Periradicular Pathosis

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Pulp and Periradicular

Pathosis

Sunday

27 April 2014

Dr Amre AtmehBDS, MFDS, MSc(Endodontics), PhD

Normal pulp

Well protected:

- Encapsulation inside harddentine

- Body defence mechanisms

If challenged by irritants(microbial, mechanical,chemical )war(inflammation)


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Microbial Irritants

Bacterial cells, or their products (toxins)

Pulpal response before arrival of bacteria

Direct pulp exposure to bacteriaPMNliquefactionnecrosisbacterial colonizationpulpal inflammation &necrosis

Persistent irritationcontinuous damagespread if necrosisand infectionperiapical pathosis

Damage to the pulp and periradicular tissues is a product ofboth the infection and host response (inflammation)

Microbial Irritants

Pulpal response depends:

1- Virulence of bacteria (strength)

2- Host resistance

3- Ability to reduce intrapulpal pressure (circulation,

lymphatic drainage)


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Mechanical irritants:

Deep cavity preparationpermeable dentine, closer to pulp

Trauma (force, apical foramen)

Deep periodontal curettage (apical BV)

Orthodontic movement (apical BV & nerves,resorption)

Mechanical irritation to PA tissues: Hyperocclusion

Endodontic procedures:- Over-instrumentation, perforation, overextended GP

Chemical irritants

Alcohol, chloroform, hydrogen peroxide

Intra-canal medicaments

Root filling materials

Restorative materials


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Irritants

Transient inflammation

(Reversible)

Irreversible Pulpitis

Total necrosis

Classification of Pulpal Pathosis

Clinical signs & symptoms (not

histopathologic)

1- Normal pulp:

- No symptoms

- Responds normally to

sensitivity tests

- Radiographic no signs of deep

caries or pathosis


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2- Reversible Pulpitis

Mild inflammation of the pulp

Causes: Exposed dentine: Caries, tooth wear, pockets

Symptoms:

- Sharp and transient pain

- Only on stimulation (cold, heat (delayed), sweets, air)

- Asymptomatic

Treatment:

- Remove irritant (caries)

- Close exposed dentine (restoration)

- If irritation persistedmoderate to severe inflammation

3- Irreversible pulpitis

Severe inflammation

Progression of reversible pulpitis

Other causes: Trauma, Orthodontic Tx

Symptoms:- Spontaneous, or stimulated by cold or heat

- lingering, continuous or intermittent- Sharp, dull localized or diffuse

- Asymptomatic

Cold application could relieve pain

Heat application: immediate pain (normally delayed)


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TTP: if inflammation affected the PDL

Radiographicno signs, slight widening in

PDL space

Treatment:

RCT or extraction (non restorable)

3- Irreversible pulpitis

Pulpal calcification(Calcific metamorphesis)

- Hard tissue on dentine walls

- Continuous irritation

- Total obliteration of canals

- Clinically: yellowish teeth, lesssensitivity to stimuli

- Radiographic: no pulp or canal

spaces

- Treatment not required


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Internal resorption

- Inflammation triggers dentinoclasts

resorption

- Asymptomatic

- Normal response to sensitivity tests

- Radiographic: radiolucency with

enlargement of root canal

compartment

- Treatment: Immediate RCT ?

4- Necrotic pulp

Rapid or delayed, total or partial (drainage)

Partial necrosissome parts vital

Liquefaction necrosis (inflammation) or ischemicnecrosis (trauma)

Symptoms:

- Usually asymptomatic

- Spontaneous pain or discomfort

- Pain on pressure (PDL)

- Usually no responce to cold, heat or electrical stimuli

- Could respond to heat (gas expansion)

Treatment: RCT or extraction


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Periradicular Pathosis

PA pathosis can heal unlike

the pulp:

- Collateral blood supply

and lymph drainage

1- Normal Periapical tissues:

- Not sensitive to percussion

or palpation- Radiographic: Normal

lamina dura & PDL structure

Irritants

Pulp necrosis

Irritants to Periapical tissues

Periapical inflammation

Abscess, bone resorption, cyst


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2- Symptomatic (Acute) Apical Periodontitis:

- Irreversible pulpitis or necrosis- Trauma (overinstrumentation, hyperocclusion)

Signs and symptoms:

- Mod to severe spontaneous localized pain

- Pain on biting/ pressure (TTP)

- Radiographic : usually none, occasionally widening in PDL space

Histologic:

- PMNs and macrophages

- Bone and root resorption may be present (not radiographic)

Treatment:

- Occlusal reduction

- Removal of source of irritation (RCT, irrigation)

3- Asymptomatic (Chronic ) apicalperiodontitis

Necrotic pulp, follow SAP

Signs and symptoms:

- Asymptomatic

- PulpNo response to stimuli (necrotic)

- No or slight TTP

- Slight sensitivity to palpation

- Radiographic:

Interruption of lamina dura - periapicalradiolucency.

Histology:

- GranulomaMast and plasma cells,macrophages, lymphocytes

- Radicular cystFluid filled, epitheliallining, surrounded by

granulomatous CT


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4- Condensing Osteitis:

- Pulpitis or necrosis

- Increase in trabicular bone

- Radiographic:

Diffuse concentric

arrangements of

radiopacity

Necrotic pulp

Signs and symptoms:

- Acuterapid onset and spontaneous pain

- Swelling: with (diffuse) or without (localised)

- Painful to percussion and palpation

- Systemic manifestations

Radiographic: no change- apical radiolucency

Histological:

- Liquefaction necrosis: purulant exudate, PMNs, debris surroundedby granulomatous tissue

5- Acute Apical Abscess:


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6- chronic Apical Abscess:

- long standing lesion drainingthrough a sinus tract

- Necrotic pulp with chronic apicalperiodontitis

Signs & symptoms:

- Asymptomatic (drainage)

Histologically & radiographically:- Similar to AAP, but with a sinustract

Postoperative healing

Repair after removing source of irritation:

- Inflammatory responses decrease

- Tissue forming cells increses

- Tissue maturation and organization


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Nonendodontic periradicular pathosis

Pulp sensitivity testmost important

Other causes for PA radiolucencies:

- Anatomical variations (fossae, foramina,

bone marrow pattern)

- Nonendodontic pathosis: cysts, granuloma,

neoplasms

DONE . ANY QUESTIONS ??

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6- Pulp and Periradicular Pathosis