Causes of pulpal and of Periradicular diseases

1. Physical 2. Chemical
(a) Mechanical (a) Phosphoric acid, acrylic monomer, etc.
(i) Trauma (contact sports, Iatrogenic dental procedures) (b) Erosion (acids)
(ii) Pathologic wear (attrition, abrasion, etc.)
(iii) Crack through body of tooth

(b) Thermal
3. Bacterial
(i) Heat from tooth preparation
(a) Toxins associated with caries
(ii) Exothermic heat from the setting of cement
(b) Direct invasion of pulp from caries or trauma
(iii) Frictional heat caused by polishing a restoration

(c) Electrical (galvanic current from dissimilar metallic fillings)

 Clinical Classification of the Diseases of the Pulp

I. Inflammatory diseases of the dental pulp II. Pulp degeneration

(a) Reversible pulpitis (1)Calcific degeneration
(1) Acute reversible pulpitis (2)Fibrous degeneration
(2) Chronic reversible pulpitis

(b) Irreversible pulpitis

III. Pulp necrosis
(1) Symptomatic irreversible pulpitis (acute irreversible pulpitis)
(1) Pulp necrosis with no signs of infection
(2) Asymptomatic irreversible pulpitis (chronic irreversible
(2) Necrotic and infected pulp
pulpitis)
(3) Chronic hyperplastic pulpitis (pulpal hyperplasia)
(4) Internal resorption
 l us Sequelae of Pulpal Diseases
timu
S
 A. Reversible Pulpitis

Definition: is a mild-to-moderate inflammatory condition of the pulp caused by

noxious stimuli in which the pulp is capable of returning to the uninflamed state
following removal of the stimuli.

Types
• Acute reversible pulpitis: The pain has been present for a short time (e.g., a few
days); and it immediately ceases on removal of the aggravating stimuli.

• Chronic reversible pulpitis: The pain has been present for a long time (e.g.,
months); and it immediately ceases on removal of the aggravating stimuli.
Symptoms
• Short, sharp pain lasting for a moment.
• Pain does not occur spontaneously.
• This pain is always specific to a stimulus.
• The pain is instantly relieved on removal of the stimulus.
• Cold, sweet, or sour usually causes pain, often caused by cold than by hot food or
beverages.
Diagnosis
Diagnosis is by a study of the patient’s symptoms and by clinical tests.

Because the pulp is sensitive to temperature changes, particularly cold, application of

cold is an excellent method of locating and diagnosing the involved tooth.

A tooth with reversible pulpitis reacts normally to percussion, palpation, and mobility.

The periapical tissue is normal on radiographic examination.

 Treatment
 When reversible pulpitis is present, removal of the noxious stimuli will usually bring the pulp back
to a healthy state.

 When pain persists despite proper treatment, the pulpal inflammation should be regarded as irreversible, the
treatment for which is pulp extirpation.
 B. Irreversible Pulpitis

Definition: is a persistent inflammatory condition of the pulp, symptomatic or

asymptomatic in nature with the pulp becoming incapable of healing.

Types
(1) Symptomatic irreversible pulpitis (acute irreversible pulpitis)
(2) Asymptomatic irreversible pulpitis (chronic irreversible pulpitis)
(3) Chronic hyperplastic pulpitis (pulpal hyperplasia or pulp polyp)
(4) Internal resorption
 1. Symptomatic irreversible pulpitis

(acute irreversible pulpitis)

Symptoms
Pain usually caused by a hot or cold stimulus.
Pain occurs spontaneously without an apparent cause.
Pain lasts for several minutes to hours.
Pain often persists when the cause has been removed.
Pain as sharp, piercing, or shooting, and it is generally severe.
Pain may be intermittent or continuous, depending on the degree of pulpal involvement.
 The patient may complain of postural pain, i.e., change of position (bending over or
lying down) exacerbates the pain. This is due to the increase in intrapulpal pressure
when the patient changes position from a standing posture to a supine (lying down)
posture.

 The patient may also have pain referred to adjacent teeth or sinuses when an upper
posterior tooth is involved, or to the ear when a lower posterior tooth is affected.

 In later stages, the pain is more severe and is generally described as boring, gnawing,
or throbbing, or as if the tooth was under constant pressure.

 Patients are often kept awake at night by the pain (nocturnal pain), which continues
to be intolerable despite all their efforts at analgesia.
 Diagnosis
 Inspection generally discloses a deep cavity extending to the pulp
or decay under a filling. The pulp may already be exposed.

 Probing into the area is not painful to the patient until the deeper
areas of the pulp are reached. At this level, both pain and
hemorrhage may occur.

 In the early stages of irreversible pulpitis, the thermal test may

elicit pain that persists after removal of the thermal stimulus. In
the late stages, when the pulp is exposed, it it reacts feebly to heat
and cold.

 The electric pulp test induces a response with a marked variation

in current from the normal. Fractured restoration with secondary caries
showing clinical signs of irreversible
 Results of examination for mobility and percussion and palpation pulpitis.

tests are negative.

 A radiograph may also show exposure of the pulp, caries under a
filling, or a deep cavity or filling threatening the integrity of the
pulp.

Treatment
Endodontics treatment
Extraction

The clinical difference between reversible and irreversible pulpitis is quantitative; the pain of irreversible
pulpitis is more severe and lasts longer. In reversible pulpitis, the cause of the pain is generally traceable to a
stimulus, such as cold water or a draft of air, whereas in irreversible pulpitis, the pain may come without any
apparent stimulus
 2. Asymptomatic irreversible pulpitis

(chronic irreversible pulpitis)

 Mild, poorly localized, periodic pain (on and off) over several weeks or months.

 Initially vital pulp and tooth not tender to percussion, but if condition
progresses, symptoms of periapical periodontitis may eventually supervene.

 More severe cases will require removal of any restoration, placement of a

sedative dressing over the pulp, and then a provisional restoration.
 3. Chronic Hyperplastic Pulpitis

Hyperplasia or pulp polyp, is a productive pulpal inflammation due to an extensive carious exposure of
a young pulp. This disorder is characterized by the development of granulation tissue, covered at times
with epithelium and resulting from long-standing, low-grade irritation

Symptoms
Chronic hyperplastic pulpitis is
symptomless, except during
mastication, when pressure of the food
may cause discomfort.
Diagnosis
 This disorder is generally seen only in the teeth of children and young adults.

The appearance of the polypoid tissue is clinically characteristic; a fleshy,

reddish pulpal mass fills most of the pulp chamber or cavity or even extends
beyond the confines of the tooth.

 Polypoid tissue is less sensitive than normal pulp tissue. Cutting of this
tissue produces no pain, but pressure transmitted to the apical end of the
pulp does cause pain.

 This tissue bleeds easily because of a rich network of blood vessels.

 Radiographs generally show a large, open cavity with direct access
to the pulp chamber.
 The tooth may respond feebly or not at all to the thermal test,
unless one uses extreme cold. More current than what is normal
may be required to elicit a response by means of the electric pulp
tester.

Treatment
Endodontics treatment
Extraction
 Internal Resorption

Resorption is a condition associated with either a physiologic or a pathologic process resulting in loss of
dentin, cementum, or bone.
Internal resorption is an idiopathic slow or fast progressive resorptive process occurring in the dentin of the
pulp chamber or in the root canals of the teeth.

Symptoms
Internal resorption in the root of a tooth is asymptomatic. In
the crown of the tooth, internal resorption may be manifested
as a reddish area called pink spot. This reddish area represents
the granulation tissue showing through the resorbed area of
the crown.
Diagnosis
 Internal resorption may affect either the crown or the root of the tooth, or it may be extensive
enough to involve both.

 It may be a slow, progressive, intermittent process extending over 1 or 2 years; it may develop rapidly
and may perforate the tooth within months.
 Asymptomatic usually is diagnosed during routine radiographic examination.
 Treatment: Endodontics treatment or Extraction.
 II. Pulp degeneration

1. Calcific Degeneration
In calcific degeneration, part of the pulp tissue is replaced by calcific material, i.e., pulp stones or
denticles. Calcification may occur either within the pulp chamber or within the root canal, but it
is generally present in the pulp chamber.
2. Fibrous Degeneration
Is characterized by replacement of the cellular elements by fibrous connective
tissue. On removal from the root canal, such a pulp has the characteristic
appearance of a leathery fiber.

This disorder causes no distinguishing symptoms to aid in the clinical

diagnosis.

Extirpated pulp showing calcific degeneration in the coronal third

with fibrous degeneration in the remaining radicular pulp.
 III. Necrosis of pulp

 Necrosis is death of the pulp.

 It may be partial or total, depending on whether part of or the entire pulp is
involved.
 Necrosis, although a sequel to inflammation, can also occur following a
traumatic injury in which the pulp is destroyed before an inflammatory reaction
takes place. As a result, an ischemic infarction can develop and may cause a
dry gangrenous necrotic pulp.
Types

Pulp necrosis with no signs of infection: In cases of necrosis without infection, there will be no
periapical tissue response. Hence, there will be no apical periodontitis.
The key diagnostic feature would be that there would be no symptoms, no response to pulp
sensibility tests, and no other abnormal findings.

Necrotic and infected pulp: When a pulp necroses as a result of bacterial invasion of the
tooth, it will become infected over time.
The key diagnostic feature would be that there would be no response to pulp sensibility
tests and there will be a periapical radiolucency.
Symptoms
Necrotic pulp causes no painful symptoms, discovered only by chance because such a tooth
is asymptomatic, and the radiograph is nondiagnostic.

Frequently, discoloration of the tooth is the first indication that the pulp is dead. The dull or opaque
appearance of the crown may be merely due to a lack of normal translucency. The tooth may have a definite
grayish or brownish discoloration.

A tooth with a necrotic pulp does not respond to cold, the electric pulp test, or the test cavity.

Teeth with partial necrosis can respond to thermal changes, owing to the presence of vital nerve fibers
passing through the adjacent inflamed tissue.
Treatment: Endodontics treatment or Extraction
 Diseases of the
Periradicular Tissues
 Classification of Diseases of Periradicular Tissues
I. Symptomatic periradicular diseases
(1) Primary symptomatic apical periodontitis (acute apical periodontitis)
(2) Secondary symptomatic apical periodontitis (acute exacerbation of asymptomatic apical
periodontitis or phoenix abscess)
(3) Symptomatic acute alveolar abscess

II. Asymptomatic periradicular diseases

(1) Asymptomatic apical periodontitis (chronic apical periodontitis)
(2) Asymptomatic (chronic) alveolar abscess
(3) Condensing osteitis
 1. Primary Symptomatic (acute) Apical Periodontitis

A painful inflammation of the periodontium as a result of trauma, irritation, or infection through

the root canal, regardless of whether the pulp is vital or non-vital, producing clinical symptoms
including painful response to biting and percussion.

Symptoms
• pain and tenderness of the tooth.
• The tooth may be slightly sore, sometimes only when it is percussed in a certain direction, or the
soreness may be severe.
• The tooth may feel extruded and the patient may have pain on closure and mastication.
 Diagnosis
• Pain on percussion is the classical diagnostic feature of primary symptomatic apical periodontitis.
• The mucosa overlying the root apex may or may not be tender to palpation.

Treatment
• Treatment of primary symptomatic apical periodontitis consists of determining the cause and relieving
the symptoms.
• It is particularly important to determine whether apical periodontitis is associated with a vital or a
pulpless tooth.
• Adjustment of high points (in hyperocclusion cases) and removal of irritants (in case of nonvital
infected pulp) is the immediate line of management.
• When the acute phase has subsided, the tooth is treated by conservative means.
 2. Secondary Symptomatic Apical Periodontitis

This condition is an acute inflammatory reaction superimposed on an

existing asymptomatic apical periodontitis.
(Acute exacerbation of asymptomatic apical periodontitis and
phoenix abscess).

Symptoms
As inflammation progresses, the tooth gets elevated from its socket and becomes
sensitive to percussion.

The mucosa over the radicular area may appear red and swollen and is sensitive to
palpation.
Diagnosis
• The exacerbation of a chronic lesion is most commonly associated with
the initiation of root canal therapy in a completely asymptomatic tooth
with a well-defined periradicular lesion.
• The patient may also have a history of trauma that leads to discoloring
of the tooth over a period of time or a postoperative pain that had
subsided until then.
• Lack of response to vitality tests diagnoses a necrotic pulp. On rare
occasions, a tooth may respond to the electric pulp test because of fluid in
the root canal or in a multi-rooted tooth.

Treatment
 3. Symptomatic (Acute) Apical Abscess

symptomatic (acute) apical abscess is an inflammatory reaction to pulpal infection and

necrosis characterized by rapid onset, spontaneous pain, tenderness of the tooth to
pressure, pus formation, and eventual swelling of associated tissues.

Symptoms
The patient has severe, throbbing pain, with swelling of
the overlying soft tissue.

As the infection progresses, the swelling becomes more

pronounced and extends beyond the original site. The
tooth becomes more painful, elongated, and mobile.
 If left unattended, the infection may progress to asymptomatic (chronic) apical abscess wherein the
contained pus may break through to form a sinus tract, usually opening in the labial or buccal
mucosa. It may further progress on to osteitis, periosteitis, cellulitis, or osteomyelitis.

 General systemic reaction: The patient may appear pale, irritable, and weakened from pain and
loss of sleep, as well as from absorption of septic products. with severe cases, the temperature may
reach several degrees above. The patient may complain of headache and malaise.
Diagnosis
A diagnosis may be confirmed by means of the electric pulp test and by thermal tests. The
affected pulp is necrotic and does not respond to electric current or to application
of cold.
The tooth may be tender to percussion, or the patient may state that it hurts to chew with the
tooth.
The apical mucosa is tender to palpation, and the tooth may be mobile and extruded.

Treatment
The immediate treatment consists of establishing drainage and controlling the systemic reaction.
 1. Asymptomatic Apical Periodontitis (Chronic Apical Periodontitis)

Is the symptomless sequelae of symptomatic apical periodontitis and is

characterized radiographically by periradicular radiolucent changes.

Symptoms
Clinically asymptomatic and may not
produce any subjective reaction.
Develops only some time after the
pulp has died and sinus on the mucosa
adjacent to the non-vital may appear
Diagnosis
The presence of asymptomatic apical periodontitis is generally discovered by routine
radiographic examination.
The mucosa over the root apex may or may not be tender to palpation.
The tooth does not respond to thermal or electric pulp tests.

Treatment
Root canal therapy or extraction
 2. Asymptomatic (Chronic) Apical Abscess
is a longstanding, low-grade infection of the periradicular alveolar bone, generally symptomless and
characterized by the presence of an abscess draining through a sinus tract.
Symptoms
A tooth is generally asymptomatic, or only
mildly painful.
an abscess is detected only during routine
radiographic examination or because of the
presence of a sinus tract, which can be either
intraoral or extraoral.
The sinus tract usually prevents
exacerbation or swelling by providing
continual drainage of the periradicular
lesion.
Diagnosis
The first sign of osseous breakdown is radiographic evidence seen during routine examination or
discoloration of the crown of the tooth.

• A radiograph taken after the insertion of a gutta-percha cone into the sinus tract often shows the
involved tooth by tracing the sinus tract to its origin.
 The patient may complain of slight pain in relation to the tooth, particularly
during mastication.
 The tooth does not react to the electric pulp test or to thermal tests.

Treatment
Treatment consists of elimination of infection in the root canal. Once
this end is accomplished and the root canal is filled
 3. Condensing Osteitis

Condensing osteitis is a diffuse radiopaque lesion

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.

Symptoms
Asymptomatic. It is discovered during routine radiographic
examination.
Condensing 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.
Treatment
Removal of the irritant stimulus is recommended. Endodontic treatment
should be initiated if signs and symptoms of irreversible pulpitis are
diagnosed.
QUIZ
A patient attended to your clinic complaining of sever continuous pain in his upper 1 st molar

started two days ago, increased with sweets and hot food and not relieved by analgesics. See

his photograph/ radiograph. What is the most likely diagnosis? Management?

Symptomatic irreversible pulpitis (acute irreversible pulpitis)