Pulp diseasesLP DISEASES Most common cause of dental pain

Significance of pulp anatomy There are special anatomical features makes the response of the pulpal inflammation have a special way: Significance of pulp anatomy

1. The pulp lies in rigid chamber, to decrease the accommodation ion of the inflammatory fluid exudates, Rapid degeneration and necrosis. 2. Have constricted narrow apical formen, limits the blood supply. 3. No collateral circulation, low resistance of the pulp. 4. Decrease below 20C and above 45C pulp hyperaemia

Aetiology of pulp diseases Living irritants (M.O) Non living irritants Physical :Mechanical, thermal, electrical, aeronautical and irradiation Chemical: Acids , alkalies and poisons Enter pulp through: An open cavity Via the p.lig. Adjacent teeth Haematogenous

Through an open cavity Fracture and pulp exposure Caries which exposes the pulp Pulp exposure during operative work

Via the p.lig. Bacteria present in deep pockets are close to the periapical area and enter the pulp from the apical foramen

Spread from adjacent teeth Due to the intercommunication of blood and lymph systems Also, pressure of the periapical infection of one tooth pushes bacteria to the adjacent tooth

Haematogenous infection In Tonsilitis Meningitis influenza and diphteria bacteria circulating in the blood stream localizes in irritated pulp and periapical areas and this is called ANACHORESIS PHENOMENON

Non-living irritants

Physical A-Mechanical: Pulp exposure Grinding of tooth 1-Accidental Fall or blow to the face 2-Odontoiatrogenic: dentist induced pulpitis examples: Pulp exposure Grinding of tooth Rapid separation of teeth High speed instruments Traumatic occlusion

B-Thermal irritation (Odontoiatrogenic) Heat by bur or stone Large metallic fillings without lining Prolonged cooling of teeth with ethyl alcohol Rapid polishing Prolonged thermal pulp testers Using lazer for tooth ablation

C-Electric irritation Gold and amalgam come in contact with each other electric current pulp necrosis or pulp will attract bacteria which irritate the pulp Saliva

D-Aeronautical irritation In flying personnels

In submarines (low pr. chambers)

Which teeth will be affected? Carious or recently filled teeth contain nitrogen bubbles or fat emboli which expand under low pressure and press on nerves)

What to do? Avoid heat during cavity prep. Avoid chemical irritation Insert Zn Oxide and oil of clove after preparation to prevent pain It is better to do a temporary filling to give chance for pulp to heal then fill it permenantly

Odontoiatrogenic Idiopathic Chemical irritation Odontoiatrogenic Idiopathic Alcohol or chloroform *Bacteria in caries to dry the cavity * Gingival recession which exposes Improper mixing of cementum to Zn Ph cement or silicate irritants in food cement

The main cause of pulp diseases is Caries

Diseases of the pulp Acute Closed Chronic Open Focal reversible pulpitis B-Communication with the oral cavity A-Type of inflammation Open Closed Chronic

Focal reversible pulpitis (or Pulp Hyperaemia) Focal : localized under the carious lesion Reversible if irritant is removed before pulp is severely damaged Early form of pulpitis

Clinical picture Deep caries or large metallic restorations without isolation or restorations with defective margins Transient pain on cold only

Histologically 1-Intact odontoblastic layer 2-Vasodilatation (V.D) 3-Inflamatory fluid exudate (I.F.E) leaks out from b.v leading to hemoconcentration and increase in blood viscosity

4-Then thrombosis will occur . It is due to: 1-Inc. in bld. viscosity and slow down of blood 2-Inflamatory fluid exudate (I.F.E) outside presses on the b.v

Acute pulpitis Follows hyperaemia if virulence of bacteria increases and resistance of the body is decreased May be an acute exacerbation of a chronic condition It begins in the part of the pulp below the carious process PARTIAL ACUTE PULPITIS

Aetiology Pulp is capped following traumatic exposure Remnants of caries Haematogenous i.e Trauma caries anachoresis odontoiatrrogenic

Clinically Hotness No Swelling Spontaneous , severe, continuous and throbbing pain Pain increases if the patient is lying down and with change in temperature Electric pulp tester reacts at a lower level

Pain is due to: Oedema is compressed in a rigid chamber Histamine and Serotonin act upon the nerve endings

Mic. Appearance V.D and I.F.E goes out of blood vessel Swelling of odontoblastic nuclei due to osmotic imbalance Disintegration of nuclei (so in acute pulpitis the odontoblastic layer is interrupted)

Pavementation of PNL Diapedesis Migration These changes are first localized and the remainder of the pulp is normal then it becomes generalized

Hypremia Acute Pulpitis Pain transient spontaneous Continuous &throbbing On cold on cold & hot V.D + I.F.E V.D + I.F.E + PNL Intact od. Layer interupted Reversible Irreversible

Pulp Abscess Abscess occurs first at the pulp horn (area of minimum drainage) If drainage is inadequate and the enterance to the pulp is minute (small carious exposure)

Mechanism of abscess PNL X M.O PNL die and are called pus cells and release proteolytic enzymes cause liquifaction to the necrotic pulp tissue, then pus is formed

Liquified necrotic tissue Very important Pus is formed from Dead and living PNL Liquified necrotic tissue Dead and living M.O

Abscess is formed of pus surrounded by inflammatory cells

Collagen fibers surround the abscess Sometimes Collagen fibers surround the abscess Abscess gets calcified and isolate the necrotic tissue The remainder of the pulp shows V.D and CH. Inf. cells

Later on multiple abscesses are formed followed by complete liquification of the pulp tissue TOTAL SUPPURATIVE PULPITIS

CHRONIC PULPITIS

Classification Closed Open Ulcerative Hyperplastic

Chronic pulpitis Aetiology is as acute pulpitis BUT The irritant is of low virulence The body resistance is high

Characteristics of chronic pulpitis: Destructive changes Repair (granulation tissue or fibrosis )

Closed pulpitis

Mechanism and Microscopic picture of chronic closed pulpitis In chronic caries, toxins are not strong enough to destroy the odontoblasts, but irritate them Odontoblasts lay down tertiary or reparative dentine D.tubules are sealed by sclerotic dentine This reduces the access of irritants to the pulp

Mild Caries

Microscopic appearence B.V are dilated Lymphocytes &plasma cells invade the pulp Fibrosis &collagen fiber bundles are prominent in order to wall off the inflammatory process

Clinical pict. Intermittent dull aching pain Less sensitive to hot and cold than acute pulpitis due to degeneration of nerves Tooth responds at a higher level to electric pulp testers than normal TTT: As acute pulpitis endo. ttt or extraction

Chronic closed pulpitis

Chronic Open Pulpitis (Ulcerative) chronic inflammation The area of carious exposure is replaced with G.T infiltrated with inflammatory cells Symptoms range from none to minimum bec. Edema escapes from the area of exposure Pain worsens by thermal changes

Chronic Open hyperplastic pulpitis ( PULP POLYP) Criteria: 1-Deciduous molars & first perm. molars (children & young adults) 2-Wide apical foramen (excellent bld. supply) 3-Large carious exposure (excellent drainage)

So Pulp is replaced by Granulation Tissue which becomes hyperplastic due to the Good blood supply so it extends from the pulp and forms a polyp and gets covered by epithelium

Gradually the surface gets epithelialised as a result of implantation of epithelial cells on its surface Source of epith: Desquamated epith. cells in saliva Rubbing between the polyp & oral mucosa Epithelium Protects the nodule of pulp from infection

Clinical pict. Globular mass of tissue protruding from the pulp chamber & filling the entire cavity Pink in colour When young , it bleeds easily With age, it becomes pedunculated and lobulated

On palpation with a probe, it is slightly sensitive because the hyperplastic tissue contains few nerves.

Alveolar abscesses are not associated with this condition because here the vitality of the tooth is maintained.

Microscopic features G.T covered by Keratinized stratified squamous epith. Components of G.T: Newly formed capillaries Newly formed collagen fibrils Proliferating fibroblasts

Pulp polyp is a misnomer? Because polyp means a mucous membrane projection and pupl is not a mucous membrane

Thank you