SEQUELAE OF DENTAL

CARIES
• inflammation of the pulp
• Acute or Chronic (Histologically)
• With or without symptoms
• Reversible and Irreversible
(clinically)
• Inflammatory process is confined to
a portion of the pulp, usually a
portion of the coronal pulp such as
pulp horn, the condition has been
called Partial or Focal Pulpitis
• If most of the pulp is diseased, the
term total or generalized pulpitis
has been used.
 Based upon the presence or absence of a direct
communication between the dental pulp and oral
environment
• Open Pulpitis
• Pulp obviously communicate with the
oral cavity
• Closed Pulpitis
• Pulp doesn’t communicates with the
oral cavity
Classification of the Pulpal Diseases
• Inflammatory Response
• Focal reversible pulpitis
• Acute Pulpitis
• Chronic pulpitis
• Chronic hyperplastic pulpitis
• Other miscellaneous condition of the pulp
• Necrosis
• Reticular atrophy
• Calcifications
• Pulpal metaplasia
Focal Reversible Pulpitis/Hyperemia
• First sign of distress in the pulp
• A condition where there is an increase in the amount of blood in the
blood vessel of the pulp
• Dilatation of pulpal blood vessels with inc. vascular permeability
• Acute inflammatory reaction in the pulp limited to the odontoblastic
or subodontoblastic region, adjacent to the irritated dentinal tubules
• Edema in the pulp with infiltration by the polymorphonuclear
leukocyte in the area
Focal Reversible Pulpitis/Hyperemia
• Etiology
• Slowly progressing chronic carious lesion
• Stimuli of short duration (cutting dentin during cavity preparation
• Metallic restoration without proper thermal insulation
• Chemical irritation to the pulp
• Excessive pressure due to orthodontic treatment
Focal Reversible Pulpitis/Hyperemia
• Clinical Symptoms
• Ordinary changes of temperature produce sharp pain usually lasting for a
short time
• Sweet and Sour foods will produce sharp pain of short duration
• Tooth affected usually has deep cavity or has a big filling without pulp
protection (Liner or Base)
• Radiograph will reveal normal periodontal membrane and lamina dura
• Vitality test shows lower reading than normal
Acute Pulpitis
• Irreversible condition characterized by acute, intense inflammatory
reaction in the pulpal tissue
• Etiology
• Caries progressing beyond the dentinal barrier and reaching the pulp
• Pulp expose due to faulty cavity preparation
• Cracked tooth syndrome
Acute Pulpitis
• Acute serous pulpitis
• Acute suppurative pulpitis
 Acute Serous Pulpitis
• Acute inflammation of mild form, usually
involving a portion of the unexposed pulp

• Acute Partial and Total serous pulpitis

• In acute partial serous pulpitis, the bacteria may

not have reached the pulp but toxins may have.

• There is an escape of plasma from distended

wall of the blood vessel forming serous
exudates on the affected portion
Acute Partial Serous Pulpitis
• Clinical features
• Pain is more severe than hyperemia
• Tooth is sensitive to hot and cold temperatures
but cold can cause distressing pain than heat
• Pain persists even after removal of irritant
• Histological features
• Cellular infiltration particularly
polymorphonuclear leukocytes is observed in
portion of the pulp under carious lesion
• Dilation of blood vessel along affected portion
• Edema of pulp tissue
• The rest of pulp
Acute Total Serous Pulpitis
• Bigger portion of the pulp is involved
• Clinical features
• Pain is more severe persistent throbbing
• Pain becomes worse in recumbent position
• Heat can cause pain of “lancinating” character and cold seems to relieve
the pain
• Histological features
• Cellular infiltration is increases
• Greater part of the pulp becomes edematous
Acute Suppurative Pulpitis(Purulent)
• Acute inflammation of unexposed pulp with accumulation of pus and
exudates
• It can be an open form but the exposed pulp may not have sufficient
drainage for the escape of exudate and pus
• Entrance of infection into the pulp from carious lesion
• Progressive type and more advanced condition
• As a result of breakdown of the infected pulp tissue by action of
bacteria and leukocytes, small cavities containing pus develop known
as abscesses
Acute Suppurative Pulpitis(Purulent)
• Clinical Features
• Pain is intense pulsating type which later becomes intermittent throbbing
• Pain is continuous for a long period and becomes worse when heat is applied
but usually temporarily with cold water
• Pain is reflected to a tooth in the opposite jaw or the ear or to a tooth
anterior to an offending one
• Radiograph reveal periapical changes if inflammation progresses to the apex
• In severe type, lymph nodes may be swollen, fever, headache and general
malaise may develop
Acute Suppurative Pulpitis(Purulent)
• Histopathological Features
• Presence of abscess cavity in some areas
• A fibrous capsule with cellular infiltration may surround the abscess cavity
Chronic Closed Pulpitis
• Most common type of pulpitis and is distinguished from its open
counterpart by the fact that carious process has not produced any
gross big cavity in the hard tissues surrounding the pulp
• Pulp may have involved by a slow advancing caries and with low
virulence of bacteria the pulp inflammation at the start is a low grade
chronic inflammation may follow an acute pulpitis when drainage is
established
• The basic pathologic condition of chronic pulpitis is a combination of
degenerative changes in pulp along with varying amounts of chronic
inflammatory infiltrate involving lymphocytes, large mononuclears
and plasma cells
Chronic Open Pulpitis
• Less common and usually an opening of significant size due to carious
process in the crown may be observed
• 2 types
• Chronic ulcerative
• Chronic hyperplastic
Chronic Ulcerative Pulpitis
• This is a chronic inflammation of an exposed pulp and may follow an acute
form if the symptoms had been relieved by an opening into the pulp
chamber, without removal of infection for free drainage.
• Clinical features
• Pain is not common symptom if the pulp is undisturbed
• Pulp is moderately sensitive to extremes of temperature and to direct pressures of
the instruments or of food that may be packed into the cavity
• Histological features
• The exposed chronically inflamed pulp reveals an ulcer or necrotic surface
• Inflammatory cells are accumulated below the ulcer together with the fibrous
capsule
• Formation of granulation tissue may be observed
Chronic Hyperplastic Pulpitis
• Chronic inflammation of the exposed pulp which
results in the proliferation of abnormal growth of
the tissue which protrude from pulp chamber as a
red mass of granulation tissue
• Most commonly occurs on children’s teeth where
teeth have been broken down extensively by rapid
decay. The cause of pulp proliferation is the
continuous irritation of the young exposed pulp
with persistent vitality
• Types
• Epitheliated pulp polyp
• Non-epitheliated pulp polyp
Chronic Hyperplastic Pulpitis
• Clinical features
• The protruded mass is not sensitive unless injured
• Injury may bring forth hemorrhage
• Tooth may have lost a big part of the crown and a big cavity is observed
• Histopathological features
• The protruded mass consists of granulation tissue
• Fibrous connective tissue core is observed to connect the granulation tissue
to the rest of the pulp
• Inflammatory cells observed
• Distended blood vessels engorged with blood are observed
Terminal Stages of Inflammatory process of
pulp
• Necrosis – the death of the pulp
• 2 ways in which necrosis of the pulp can take place
• Caseation necrosis – pulp assumes a cheese-like consistency brought about by
coagulation of proteins and fatty substances
• Liquefaction necrosis- brought about by protein splitting enzymes liberated by
leukocytes at the site of inflammation and dead pulp cells
PERIODONTITIS
• Inflammation of the periodontal
tissues
• Apical periodontitis
• Acute and Chronic apical
Periodontitis
ACUTE APICAL PERIODONTITIS
• Acute inflammation of the soft
tissues surrounding the apical
region of the tooth especially the
periodontal membrane.
• The tissue injury and
inflammation has developed
within the periodontal ligament
but gross death of tissue has not
accompanied it.
 ACUTE APICAL PERIODONTITIS
• Acute infective apical periodontitis
• Acute inflammation due to pathognomonic microorganisms that
reached the apical foramen through the pulp canal and spreads into the
periodontal tissue
• Inflammation could be too slight to cause clinical symptoms and would
tend to cause bacteria localize in the area during transient bacterimia
ACUTE APICAL PERIODONTITIS
• Acute infective apical periodontitis
• The tooth appears extruded from the socket because of the increased
tissue tension at the root and from the increase in volume of the tissues
and since the periodontal membrane is enclosed between bone and
cementum , the pressure is directed to the root

• The looseness of the tooth is due to tearing and irritation of fibers of

periodontal ligament
ACUTE PERIAPICAL/APICAL ABSCESS
• The inflammatory process has infiltrated the periapical soft
tissues with high virulence of bacteria, low resistance of the
tissue and lack of drainage, the inflamed tissue breaks down.

• Bacterial toxins cause necrosis of tissue and necrotic cells are

liquified by enzymes released by dead and dying leukocytes. Pus
accumulates in the periodontal membrane around the root
 ACUTE PERIAPICAL/APICAL ABSCESS
• Clinical Pathology
• During this stage the tooth is often very sore
and continuous pulsating pain indicates the
presence of a purulent process in the depth of
the alveolar bone.

• Lymph nodes may be swollen and tender

• If drainage has been established by opening

the tooth pus is sometimes discharged thru
the root canal and patient is relieved of the
throbbing pain
 ACUTE DENTO-ALVEOLAR ABSCESS
• Pus formation may spread through the bone
and osteoclast resorbs the bone resulting in
the formation of purulent alveolar osteitis.
• If drainage is not established, the purulent
inflammation burrows through the bone.
• As it approach the surface of the bone, there
is edema and swelling of the soft tissue of the
face this condition is called cellulitis
• If a spread of inflammatory process is
temporarily halted by layer of periosteum, a
condition known as subperiosteal abscess is
formed.
ACUTE DENTO-ALVEOLAR ABSCESS
• Clinical features
• Pus follows the line of least resistance and escapes the bone through
various routes
• If inflammation starts from upper anterior teeth the upper lip becomes
swollen and stiff and distended
• Upper bicuspids and molars the upper portion of the cheek is swollen
and lower eyelid is edematous
• From lower anterior teeth the lower lip and chin region are swollen
• From lower posterior teeth swelling extends over the lower part of the
cheek and angle of the mandible and sometimes into the submandibular
region (Ludwig’s angina)
ACUTE DENTO-ALVEOLAR ABSCESS
• Clinical features
• After the pus perforates the plate of bone, it spreads along the bone
surface, separating the periosteum and mucous membrane from the
bone. The mucoperiosteum is elevated by pressure of the pus and
fluctuates when palpated. If pus accumulates under the gingiva the
abscess is called parulis/gumboil
OSTEOMYELITIS
• Acute or chronic infection of bone marrow by pus producing
microorganisms. In course of an acute osteomyelitis the periosteum
and endosteum of bone lose their blood supply and die.
• The inflammatory process comes to standstill, granulation tissue and
osteoclast separate the dead from living bone. Detached piece of dead
bone is called sequestrum.
Chronic periapical inflammation
• Chronic conditions of the periapical tissues is usually a reaction
to a long standing irritation with more or less successful attempts
to repair.
• Factors that can bring about chronic condition
• Low virulence of bacteria
• High body resistance
• Presence of drainage
Chronic periapical inflammation
• Types of Chronic Periapical Inflammation
• Dental granuloma
• Radicular cyst
• Chronic periapical abscess
Dental Granuloma
• A mass of granulation tissue at the periapical area
as a response to a mild irritation.
• Granulation tissue is a young vascular tissue with
plenty of young fibroblasts. It is a sign of healing
but in the periapical area, it is a reaction of the
tissue to injury or mild irritation
• Simplest form of chronic periapical inflammation
Radicular Cyst
• This may develop from epitheliated granuloma
• There will be dissolution of central part of the
granuloma and transudation of fluid through the
epithelium into the lumen
• Pressure exerted by the cystic fluid causes a
compression of the cystic wall and later an enlargement
of the cystic cavity in bone.
• In radiographs radicular cyst appears as clearly
demarcated radiolucency connected to the infected
tooth
• Histopathology
• Thich fibrous capsule encloses the cyst, the cystic cavity
contains fluids surrounded by epithelium. Foam cells may be
observed in abundance. Cholesterol slits are seen.
Chronic Periapical Abscess
• Originates from acute periapical abscess or
from granuloma.
• During the course of acute periapical
abscess, pus may establish an opening into
labial or lingual mucosa forming a fistula.
• It may develop from granuloma when at
the center, the tissue undergoes necrosis.
The dead and dying cells are liquified by
proteolytic enzymes of the leukocytes, by
ferments produced by necrotic tissue cells
and bacteria resulting into pus formation.
 Chronic Periapical Abscess
• Clinical features of chronic infection
• Pain is not prominent symptom. Patient may just
complain of transient uneasiness
• In chronic discharging infection, the gingiva over the
affected area appears normal however, healed sinus and
fistula is detected by slight nodule on the gingiva.
• In acute exacerbation, pain and swelling may be present
and a small spherical mass of gum (gumboil) with fistula
is observed
• In chronic abscess, tooth is sensitive to percussion and
the gingiva on the apical region is swollen and red
• The infection appears radiolucent in radiograph
Condensing osteitis
• Chronic periapical inflammation which does not cause bone
destruction but due to a long standing irritation, it causes
stimulation of the osteoblasts to form bone (hyperplasia) known
as bone sclerosis. There is increased bone trabeculae and
decreased bone marrow spaces.