DISEASES OF THE PULP

MADE BY ISHA PARIKH

WHAT IS PULP?

• Pulp is a formative organ of tooth.

• It produces:
a. Primary dentin: During development of tooth.
b. Secondary dentin: After tooth eruption.
c. Reparative dentine: In response to stimulation if odontoblasts remain intact.
• It consists of :
a. Tiny blood vessels.
b. Lymph
c. Myelinated and Unmyolinated nerve fibres.
 CAUSES OF PULP DISEASES

PHYSICAL
II. Thermal
I. Mechanical
A. Heat from tooth preparation.
A. Trauma
i. Accidental B. Exothermic heat from setting of cement.
ii. Latrogenic C. Conduction of heat and cold through deep
B. Pathologic Wear filling without an protective base.
C. Ground originating fracture D. Frictional heat caused due to polishing of
D. Barodontalgia restoration.
CHEMICAL
1. Phosphoric acid, acrylic monomer, etc.
2. Erosion (acids)

BACTERIAL
3. Toxins associated with caries.
4. Direct invasion of pulp from caries/ trauma
5. Microbial colonization in the pulp by blood borne micro-organisms.
(Anachoresis)
DISEASES OF THE PULP
CLASSIFICATION OF PULPAL DISEASES

1. INFLAMMATORY DISEASES
A. Reversible Pulpitis
i. Acute Reversible Pulpitis
ii. Chronic Reversible Pulpitis
B. Irreversible pulpitis
i. Symptomatic irreversible pulpitis
ii. Asymptomatic irreversible pulpitis
C. Chronic hyperplastic pulpitis (Pulpal hyperplasia)
D. Internal resorption
2. PULP DEGENERATION
i. Calcific degeneration (radiographic diagnosis)
ii. Fibrous degeneration
3. PULP NECROSIS
INFLAMMATORY DISEASES OF THE PULP

1. REVERSIBLE PULPITIS:
It is mild to moderate inflammatory condition of the pulp caused by the noxious stimuli I
which the pulp is capable of returning to the uninflamed state following removal of the
stimuli.
 Types:
• Acute – Pain present for a short time.
• Chronic – Pain present for a long time.
 Etiology:
• Trauma, disturbed occlusal relationship
• Thermal shock
• Excessive dehydration of a cavity
• Chemical stimulus from sweet or sour food stuffs
• From irritation of a filling or bacteria as from caries.

 Symptoms:
• Characterized by a short, sharp pain lasting for a moment
• Pain is always specific to a stimulus
• Pain is istantly relieved on removal of the stimulus
• More often by cold than by hot food or beverages and by cold air
• Does not occur spontaneously.
 Diagnosis:
• Pain is sharp, lasts for few seconds and disappears on removal of stimulus.
• Cold, sweet or sour usually causes the pain.
• Pain may become chronic, may continue for weeks, or even months.
• Application of cold – best method for diagnosing.
• Tooth reacts normally to percussion, palpation and mobility.
• Radiographically – periapical tissue is normal.
 Treatment:
• Best treatment is prevention – development of caries, early restoration, using cavity
varnish or cement base before insertion of filling.
• Removal of noxious stimuli.
2. IRREVERSIBLE PULPITIS:
Irreversible pulpitis is a persistent inflammatory condition of the pulp, symptomatic or
asymptomatic in nature with the pulp becoming incapable of healing.
 Types:
• Asymptomatic
• Symptomatic
 Etiology:
• Bacterial involvement through caries
• Chemical, thermal or mechanical injuries
• Reversible pulpitis may deteriorate into irreversible pulpitis
 Symptoms:
• Early stages, pain is caused by sudden temperature changes particularly cold, sweet or
acid food stuffs and pressure from packing food into a cavity.
• Pain persists for several minutes to hours lingering after removal of thermal stimulus.
• Pain is sharp, piercing, shooting and severe.
• Postural pain due to increase in intra-pulpal pressure when patient changes from
standing to supine position.
• Referred pain to adjacent teeth to temple or sinuses when upper posterior tooth is
involved or to the ear when lower posterior tooth is involved.
• Later stages, pain is severe, boring, gnawing or throbbing.
• Nocturnal pain which is intolerable despite their efforts at analgesia.
• Pain increases with heat and often relieved by cold.
• Apical periodontitis is absent except in later stages, when inflammation or infection
extends the pdl.
 Diagnosis:
• On Inspection,
deep cavity extending to the pulp or decay under a restoration or the pulp may
already be exposed.
• Probing into the area is not painful until deeper areas of the pulp are reached.
• Radiographically, may disclose an interproximal caries under a filling threatening the integrity
of the pulp.
• Thermal test: in early stages, pain persists after thermal stimulus is removed.
In late stages when pulp is exposed, it may respond normally to thermal stimulus but
generally it reacts feebly to heat and cold.
• Asymptomatic stage:
 Exposed pulp exhibits little or no pain except when food is packed into the cavity.
• Early Symptomatic stage:
 Less current is required to elicit a response in EPT.
 Pulp is abnormally responsive to cold.
 Spontaneous pain.
• Late Symptomatic stage:
 Tooth abnormally responsive to heat.
 Symptoms may stimulate those of acute alveolar abscess.
 Treatment:
• Complete removal of the pulp or pulpectomy.
• In posterior teeth pulpotomy or removal of the coronal pulp.
• Surgical removal if tooth is not restorable.
3. CHRONIC HYPERPLASTIC PULPITIS:
Also known as pulpal hyperplasia or pulp polyp.
It is a productive pulpal inflammation due to an extensive carious exposure of a young pulp.
 Symptoms and Diagnosis:
• Symptomless, except during mastication when pressure of the food may cause
discomfort.
• Seen in teeth of children and young adults.
• Polyp tissue seen as a characteristic fleshy reddish pulpal mass that fills
most of the pulp chamber or cavity or even extends beyond the confines of
the tooth.
• To differentiate a pulp polyp from proliferating gingival tissue, one should
raise and trace the stalk of the tissue back to its origin, the pulp chamber.
• Radiographically, large, open cavity with direct access to the pulp
chamber.
• Responds feebly or not to thermal tests unless extreme cold such as ethyl
chloride spray is used.
Treatment:
• Elimination of the polypoid tissue followed by extirpation of the pulp,
provided the tooth can be restored.
• The hyperplastic pulpal mass is removed with a periodontal curette or
spoon excavator.
4. INTERNAL RESORPTION:
It is idiopathic slow or fast progressive resorptive process occurring in the dentin of the pulp chamber
or in the root canals of the teeth.
 Symptoms and Diagnosis:
• Asymptomatic
• Manifested as reddish area called pink spot
• This represents granulation tissue showing through the resorbed area of crown
• Maxillary anterior teeth – most common
• Radiographically, change in the appearance of the wall in the root canal or
pulp chamber, with a round or ovoid radiolucent area.
 Treatment:
• Endodontic treatment is indicated, but obturation of the defect requires
plasticized gutta percha method.
• It is painless until the root is perforated – mineral trioxide aggregate MTA
is used.
PULP DEGENERATION

• Seen in teeth of older people.

• Cavity or filling may be present in affected tooth.
• Early stages show no signs and symptoms.
• In later stages, the tooth may become discolored and the pulp will not respond to
stimulation.
 Types:
a. Calcific Degeneration
b. Fibrous Degeneration
1. CALCIFIC DEGENERATION:
• Part of pulp tissue is replaced by calcific material – pulp stones or denticles
• May occur within the pulp chamber or root canal, but is generally present within
the pulp chamber.
• CALCIFIC METAMORPHOSIS - Degeneration of the complete pulp space when
it occurs as a sequela to a traumatic injury
• Teeth are asymptomatic and discolored.
• Radiographically, obliteration of pulp space as an intracanal radio opacity similar
to surrounding dentin.
2. FIBROUS DEGENERATION:
• Replacement of cellular elements by fibrous connective tissue.
• Pulp has characteristic appearance of leathery fiber.
 NECROSIS OF THE PULP

• Death of the pulp.

• Sequel to inflammation or traumatic injury.
 TYPES:
a. Pulp Necrobiosis – Tooth has both inflamed and necrotic pulp
tissue, so patient would report with mixed symptoms, i.e.,
symptoms of pulpitis and an infected root canal system at the same
time.
b. Pulp Necrosis With No Signs Of Infection – No apical periodontitis,
there would be no symptoms and no response to pulp sensibility
tests.
c. Necrotic And Infected Pulp – When necrosis occurs due to bacterial
invasion, it will become infected. No response to pulp sensibility
tests and there will be a periapical radiolucency.
 Symptoms:
• No painful symptoms
• Discoloration - grayish or brownish - first indication that the pulp is dead.
• Lacks brilliance and luster.
• Teeth with partial necrosis respond to thermal changes due to vital nerve fibers passing
through the adjacent inflamed tissue.
 Diagnosis:
• Radiographically,
large cavity or filling and thickening of PDL space.
• Tooth with necrotic pulp does not respond to cold and electric pulp test.
• Sometimes, minimal response to the maximum current of an electric pulp tester occurs.
 Treatment:
• Pulpectomy - Complete removal of the pulp
Obturation of the root canals