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1
Pulp and Periradicular
Pathosis
Sunday
27 April 2014

Dr Amre Atmeh
BDS, MFDS, MSc(Endodontics), PhD
Normal pulp
Well protected:
- Encapsulation inside hard
dentine

- Body defence mechanisms

If challenged by irritants
(microbial, mechanical,
chemical ) war
(inflammation)
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Microbial Irritants
Bacterial cells, or their products (toxins)

Pulpal response before arrival of bacteria

Direct pulp exposure to bacteria PMN liquefaction
necrosis bacterial colonization pulpal inflammation &
necrosis

Persistent irritation continuous damage spread if necrosis
and infection periapical pathosis

Damage to the pulp and periradicular tissues is a product of
both the infection and host response (inflammation)
Microbial Irritants
Pulpal response depends:
1- Virulence of bacteria (strength)
2- Host resistance
3- Ability to reduce intrapulpal pressure (circulation,
lymphatic drainage)
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Mechanical irritants:
Deep cavity preparation
permeable dentine, closer to pulp
Trauma (force, apical foramen)
Deep periodontal curettage (apical BV)
Orthodontic movement (apical BV & nerves,
resorption)
Mechanical irritation to PA tissues:
Hyperocclusion
Endodontic procedures:
- Over-instrumentation, perforation, overextended GP
Chemical irritants
Alcohol, chloroform, hydrogen peroxide
Intra-canal medicaments
Root filling materials
Restorative materials
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Irritants
Transient inflammation
(Reversible)
Irreversible Pulpitis
Total necrosis
Classification of Pulpal Pathosis
Clinical signs & symptoms (not
histopathologic)

1- Normal pulp:
- No symptoms
- Responds normally to
sensitivity tests
- Radiographic no signs of deep
caries or pathosis
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2- Reversible Pulpitis
Mild inflammation of the pulp
Causes: Exposed dentine: Caries, tooth wear, pockets
Symptoms:
- Sharp and transient pain
- Only on stimulation (cold, heat (delayed), sweets, air)
- Asymptomatic
Treatment:
- Remove irritant (caries)
- Close exposed dentine (restoration)
- If irritation persisted moderate to severe inflammation

3- Irreversible pulpitis
Severe inflammation
Progression of reversible pulpitis
Other causes: Trauma, Orthodontic Tx
Symptoms:
- Spontaneous, or stimulated by cold or heat
- lingering, continuous or intermittent
- Sharp, dull localized or diffuse
- Asymptomatic
Cold application could relieve pain
Heat application: immediate pain (normally delayed)
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TTP: if inflammation affected the PDL
Radiographic no signs, slight widening in
PDL space
Treatment:
RCT or extraction (non restorable)

3- Irreversible pulpitis
Pulpal calcification
(Calcific metamorphesis)

- Hard tissue on dentine walls
- Continuous irritation
- Total obliteration of canals
- Clinically: yellowish teeth, less
sensitivity to stimuli
- Radiographic: no pulp or canal
spaces
- Treatment not required
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Internal resorption
- Inflammation triggers dentinoclasts
resorption
- Asymptomatic
- Normal response to sensitivity tests
- Radiographic: radiolucency with
enlargement of root canal
compartment
- Treatment: Immediate RCT ?
4- Necrotic pulp
Rapid or delayed, total or partial (drainage)
Partial necrosis some parts vital
Liquefaction necrosis (inflammation) or ischemic
necrosis (trauma)
Symptoms:
- Usually asymptomatic
- Spontaneous pain or discomfort
- Pain on pressure (PDL)
- Usually no responce to cold, heat or electrical stimuli
- Could respond to heat (gas expansion)
Treatment: RCT or extraction
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Periradicular Pathosis
PA pathosis can heal unlike
the pulp:
- Collateral blood supply
and lymph drainage

1- Normal Periapical tissues:
- Not sensitive to percussion
or palpation
- Radiographic: Normal
lamina dura & PDL structure





Irritants
Pulp necrosis
Irritants to Periapical tissues
Periapical inflammation
Abscess, bone resorption, cyst
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2- Symptomatic (Acute) Apical Periodontitis:
- Irreversible pulpitis or necrosis
- Trauma (overinstrumentation, hyperocclusion)
Signs and symptoms:
- Mod to severe spontaneous localized pain
- Pain on biting/ pressure (TTP)
- Radiographic : usually none, occasionally widening in PDL space

Histologic:
- PMNs and macrophages
- Bone and root resorption may be present (not radiographic)

Treatment:
- Occlusal reduction
- Removal of source of irritation (RCT, irrigation)
3- Asymptomatic (Chronic ) apical
periodontitis
Necrotic pulp, follow SAP
Signs and symptoms:
- Asymptomatic
- Pulp No response to stimuli (necrotic)
- No or slight TTP
- Slight sensitivity to palpation
- Radiographic:
Interruption of lamina dura - periapical
radiolucency.

Histology:
- Granuloma Mast and plasma cells,
macrophages, lymphocytes
- Radicular cyst Fluid filled, epithelial
lining, surrounded by
granulomatous CT
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4- Condensing Osteitis:
- Pulpitis or necrosis

- Increase in trabicular bone

- Radiographic:
Diffuse concentric
arrangements of
radiopacity
Necrotic pulp

Signs and symptoms:
- Acute rapid onset and spontaneous pain
- Swelling: with (diffuse) or without (localised)
- Painful to percussion and palpation
- Systemic manifestations

Radiographic: no change- apical radiolucency

Histological:
- Liquefaction necrosis: purulant exudate, PMNs, debris surrounded
by granulomatous tissue
5- Acute Apical Abscess:
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6- chronic Apical Abscess:
- long standing lesion draining
through a sinus tract

- Necrotic pulp with chronic apical
periodontitis

Signs & symptoms:
- Asymptomatic (drainage)

Histologically & radiographically:
- Similar to AAP, but with a sinus
tract
Postoperative healing
Repair after removing source of irritation:
- Inflammatory responses decrease
- Tissue forming cells increses
- Tissue maturation and organization


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Nonendodontic periradicular pathosis
Pulp sensitivity test most important

Other causes for PA radiolucencies:
- Anatomical variations (fossae, foramina,
bone marrow pattern)
- Nonendodontic pathosis: cysts, granuloma,
neoplasms
DONE . ANY QUESTIONS ??