ETIOLOGY

PULP AND PERIAPICAL DISEASES

 Caries – most common form of injury that
DISEASES OF THE PULP causes pulpitis
1. Reversible pulpitis
2. Irreversible pulpitis: symptomatic,  Operative dental procedures – may also trigger
asymptomatic, chronic hyperplastic pulpitis an inflammatory response in the dental pulp
3. Pulp necrosis
 Heat, friction, chemical associated with
ABNORMALITIES OF THE PULP filling materials are potential irritants
1. Pulp calcification
2. Internal resorption  Reduce damage by: using cooling
3. External resorption water spray during tooth preparation
and using insulating baste to protect
DISEASES OF THE PERIAPICAL TISSUES pulp from irritating chemicals
1. Periapical abscess
2. Periapical granuloma  Trauma – those that results to a root or crown
3. Radicular cyst fracture
4. Phoenix abscess
5. Condensing osteotitis  Periodontitis – that has extended to an apical
or lateral root foramen
In the dental pulp, inflammation is the response to
injury, just as it is in any other organ.
FORMATION OF PULPAL DIAGNOSIS
The level of pulpal inflammation is determined through DIAGNOSIS SIGNS&SYMPTOMS RADIOGRAPH RESPONSE
TO PULP
a combination of clinical criteria. Results of electric, TESTS
Normal pulp None +
heat, cold and percussion tests must be added to the
Reversible May have sharp +
patient history, clinical examination and clinician pulpitis pain
experience to arrive at the most appropriate diagnosis Symptomatic Sharp pain, but Response
of for the correct tooth. irreversible may have deep, (may be
pulpitis dull, gnawing extreme
pain; and/or
Generally, the more intense the pain and the longer
spontaneous lingering)
the duration of symptoms, the greater the damage to pain; referred
the pulp. Sever symptoms usually indicate irreversible pain; or a past
damage history of pain
Asymptomatic; None, may have +
irreversible past history of
THE DENTAL PULP HAS SOME UNIQUE FEATURES THAT pulpitis pain
MAKE IT UNUSUALLY FRAGILE AND SENSITIVE: Pulp necrosis No response No
response
 Encased by hard tissue (dentin/enamel)
- Does not allow for the usual swelling CLASSIFICATION
associated with the exudate of the acute  Normal pulp
inflammatory process. - A clinical diagnostic category in which the
pulp is symptom free and normally
 No collateral circulation responsive to pulp testing.
- To maintain vitality when the primary
blood supply is compromised.  Reversible pulpitis
- A clinical diagnosis based on subjective and
 Biopsies and direct application of medications objective findings indicating that the
are impossible inflammation should resolve and the pulp
- Without causing necrosis of the entire pulp return to normal if the cause is removed.

 Pain or increasing levels of sensitivity are the  Mild to moderate pain, typically
only signs intermittent, provoked, disappears
- That can be used to determine the severity upon removal of stimulus.
of pulpal inflammation
 Histologic appearance: dilation and
engorgement of BV (hyperemia),
exudation of plasma proteins.
  Treatment: remove the irritant (caries,
fracture, old restorations, etc) and
restore.
 Chronic hyperplastic pulpitis
- Occurs in the molar teeth (both primary
and permanent) of children and young
adults.
- Rather than undergoing necrosis, the pulp
tissue reacts in a hyperplastic manner,
producing a red mass of reparative
granulation tissue that extrudes through
the pulp exposure.
 Symptoms seldom occur:
- No exudate under pressure
- No nerve tissue that proliferates with the
granulation tissue
 Irreversible process
- Indicated for endodontic therapy or
extraction
 Pulp necrosis
- A clinical diagnosis category indicating
death of the dental pulp. The pulp is
usually non responsive to pulp testing and
is asymptomatic.
Teeth don’t die a natural death. You kill them :(
TREATMENT:
PERIAPICAL PATHOLOGIES
Symptomatic apical periodontitis
 Inflammation of apical periodontium
 Clinical symptoms: painful response to biting
and/or percussion or palpation
 May or may not show radiographic changes
(depending on the stage of disease)
Asymptomatic apical periodontitis
 Inflammation and destruction of the apical
periodontium that is of pulpal origin
 Appears as an apical radiolucency
 No clinical symptoms (-pain/percussion)
PERIAPICAL ABSCESS
Chronic apical abscess
 An inflammatory reaction to pulpal infection
and necrosis characterized by rapid onset,
spontaneous pain, tenderness of the tooth to
pressure, pus formation, and swelling of
associated tissues.
 Inflammatory reaction to pulpal infection and
necrosis
 Results from a long standing, low grade
infection
 CF: gradual onset, little to no
discomfort, intermittent discharge of
pus through an associated sinus tract.
 Rx appearance: periapical radiolucency
Acute apical abscess
 An inflammatory reaction to pulpal infection
and necrosis characterized by gradual onset,
little or no discomfort, and the intermittent
discharge of pus through an associated sinus
tract.
 A localized collection of pus at the root apex of
a tooth following death of the pulp
 Pulpal infection that extends to the periapical
tissues through the apical foramen
 Clinically: patient often experiences
malaise, fever and lymphadenopathy
 Rx appearance:
- No significant changes (may have widened
pdl)
- Periapical radiolucency
 Treatment: either from the tooth or via
soft tissues, followed by root canal
treatment.
 If left untreated – body will try to
establish drainage intraorally via a
sinus tract or extraorally
- Ineffective drainage: spread of infection
into facial spaces in head and neck.
 On Abx: prescribe only if there is
systemic symptoms
 DD: Periodontal abscess
PERIAPICAL GRANULOMA
 Focus of chronically inflamed granulation tissue
located at the apex of non-vital tooth
 Initiated and maintained by the degradation
products of necrotic pulp tissue
RADICULAR/PERIAPICAL/APICAL PERIODONTAL
CYST
 Most common cysts of the jaws, develops from
preexisting periapical granuloma
 Occurs as a result of epithelial proliferation which
helps to separate inflammatory stimulus (necrotic
pulp) from surrounding bone
 Usually asymptomatic and are often discovered
accidentally during routine radiographic
examination
Treatment options
 RCT only if periapical lesions resolve after removal
of the irritant (necrotic pulp)
 RCT + apicoectomy and direct curettage
 Extraction and curettage of apical zone
PHOENIX ABSCESS
 Acute exacerbation of a chronic lesion
 An acute inflammatory reaction superimposed
on an existing chronic lesion, such as cyst or
granuloma
 Can occur after a failed or an unfinished
endodontic treatment
 COHEN: phoenix abscess is CAP that became
symptomatic
CONDENSING OSTEITIS
 Osteosclerosis/condensing apical
periodontitis/focal sclerosing osteomyelitis
 Focal bony reactions due to a low grade,
chronic inflammation in response to a mild
irritation through the root canal
 Usually seen at the apex of tooth with long
standing pulpitis
 Usually asymptomatic and are discovered in
routine radiographic examination
 Only lesion with radiopacities in the periapical
area
 No treatment necessary
INTERNAL RESORPTION
 Resorption of dentin of pulpal wall
 May be seen as part of inflammatory response
to pulpal injury
 May also be seen in cases in which no apparent
trigger can be identified
 Any tooth may be involved, usually, only a
single tooth is affected
 In advanced cases, teeth may appear pink >
proximity of pulp tissue to tooth surface
 Generally asymptomatic, unless root fracture
or communication with periodontal pocket
occurs
EXTERNAL RESORPTION
 Several causes: adjacent pathologic process
such as orthodontic process reimplanted teeth,
impacted teeth, or idiopathic
 May occur in one or more teeth, any tooth can
be involved, although molars are least likely to
be affected
 No plausible or evident explanation for the
condition
 No effective treatment
 Over an extended clinical course, resorption
eventually causes loss of the affected tooth.

PERIAPICAL RADIOLUCENCY
 Asymptomatic apical periodontitis
 Periapical granuloma
 Radicular cyst (periapical/apical periodontal
cyst)
 Chronic apical abscess

PULP CALCIFICATION
 Rather common phenomenon, occurs with
increasing age for no apparent reason
 May be diffused (linear) – found in root canals
or nodular (pulp stones) – found in pulp
chamber
 No clinical significance and not associated with
any form of pulpitis
 Problematic during endodontic therapy of non-
vital teeth