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pulp and periradicular pathosis Nawaf Hazaymeh Yahya alOmary Sun. 14-4-2013

‫بسـ ــم اهلل الرحمن الرحيم‬
Today we will talk about Pulpal and Periradicular Pathosis . why these pathoses is

exist ? its due to certain causes like : - Microorganisms like bacteria and viruses. -Mechanical like a punch on the face , thermal, and chemical irritants . by these physical and chemical causes there will be a fracture , pulp exposure , infection which will lead to swelling . Now , thermal causes will come from your hand piece , if you don’t use cooling agent ( water spray ) and by this the friction between the bur and the tooth will cause heat , and the person that set beside you will start to smell barbeque smell :p . this will lead to pulp irritation and damage because of the high temperature on the pulp cells or tissue . so first thing , you need to keep your water spray ( or any cooling agent ) on running in your hand piece , under no circumstances you should turn it off . The chemical irritation comes from our material . the material that we use inside the pulp cavity or chamber or canal may lead to pulpal or periapical or periradicular tissue irritation and inflammation event . The microorganisms comes from the caries in the crown , and it will cause irritation to pulpal cells or tissue through direct and indirect way : direct if it comes in contact with the tissue and by its byproducts and toxins will lead to irritation of the pulp tissue . theses microorganisms like Streptococcus mutans, lactobacilli, and Actinomyces are mainly present in dentin caries which will cause the irritation , and for sure these not the only microorganisms will cause irritation to the pulpal tissue , but these are the most common in the pulpal tissue . When these microorganism come in contact with the pulpal tissue and cause irritation , the tissue will react to defend itself and the body by certain reaction like inflammatory process . in the area where inflammation start , you will find inflammatory cells that infiltrate this area like macrophages , plasma cells and lymphocytes. If these causes continue in irritating the pulp tissue , the pulp will continue to respond by forming a liquefaction necrosis at the site of exposure , it will

start as a localized inflammation or necrotic area adjacent to the exposure area . Pulpal tissue may remain inflamed for long period of time and may undergo eventual or rapid necrosis. This depends on : • the severity of the materials that produced from bacteria and according to the previous condition of the pulpal tissue whether its already exhausted or healthy . • the ability to release inflammatory fluids to avoid a marked increase in intrapulpal pressure. As we know the pulp is encapsulated inside a rigid space its surrounded by dentin , there is only one escape channel which is apical foramin . so blood supply as well as nerve supply and lymphatic drainage go through this tiny foramin unless there is a lateral canal which is the same as periapical foramin . so the pulp capacity to react with inflammation is limited by the presence of these tissues inside a close environment so there is no collateral circulation where it can help to resolve inflammatory process and by this there’ll be limited response and the pulp cant withstand the infection for long period unless its weak infection . while in any other place in the body where there’s infection or irritation , there will be collateral circulation to the area of injury that can resolve these inflammations . • the host resistance, when your immune system is weak you cant resist any simple infection , so the aids patient cant tolerate any infection . • the amount of circulation, and most importantly, • lymph drainage

now , if the microorganisms remain producing its toxins , the will be sustained and spread inside the pulpal tissue rather than localized . periradicular infections : how the periradicular tissue get irritated by instruments ? if you use your instrument during root canal preparation and extend it beyond the apex , it will lead to irritation or infection or injury of the periradicular tissue . so this is a direct traumatic injury . chemical irritant is the same thing , when our irrigant solution comes in direct contact with the tissue , it cause severe pain and irritation to this tissue . so you need to keep this irrigant solution inside the canal and don’t let it go out . PULPAL PATHOSIS : how these pathosis manifest it self inside the pulp ?

Again depends on the severity and duration of the insult , and the host capacity to respond the infection . Now , the pulp when become inflamed “ pulpitis “ could be reversible or irreversible and the result will be necrosis , and sometimes these happen without the patient notice . So Irritation of the dental pulp results in the activation of a variety of biologic systems such as nonspecific inflammatory reactions mediated by histamine, bradykinin, and arachidonic acid metabolites. ( the dr said that he wont bring a Q about these mediators , but don’t believe him any more ;p ) Unlike the connective tissues in other parts of the body, normal and healthy dental pulps lack mast cells. However, these cells are found in pulps after the start of the inflammatory process . Studies shows that pulpal neuropeptides undergo dynamic changes after injury. In addition stimulation of the dental pulp by caries results in the formation of various interleukins and recruitment of inflammatory cells to the site of injury. Without the presence of nervous system inside the pulp , the pulpal tissue will be necrosed easily . If the injury was minor , the reaction to this will be limited and can be contained . but if the injury become moderate or severe or persist the reaction will be more severe due to the pulp is contained in a closed environment . So it start as localized inflammation and release a high concentration of inflammatory mediators and that will lead to increase the vascular permeability ( the vascular pressure will lead to increase the vascular permeability where the fluid goes out of the vascular tissue and accumulate inside the pulpal tissue where it’ll increase the pressure on these cells and result in pulpal death because there is a continuous pressure and there is no escape . ) The lymphatic drainage has a limited capacity in reducing ( drainage ) these fluids , but if it persist and its pressure continues it will block the apical part where there will be no escape channel to these fluids , and when the pulp get under pressure you will feel a severe pain as well as the pulp will get

damaged . and in the end it will collapse and we wont be able to drain these fluids . Pain is often caused by several factors. The release of mediators of inflammation causes pain directly by lowering the sensory nerve threshold. These substances also cause pain indirectly by increasing both vasodilation in arterioles and vascular permeability in venules, resulting in edema and elevation of tissue pressure. This pressure acts directly on sensory nerve receptors • Now the aim of this lecture , CLASSIFICATION OF PULPAL DISEASES : • As we said the pulpitis could be reversible where it can go back to normal if we remove the cause . or if the cause persist and the pulp cant withstand it , it will transform into irreversible pulpitis where it cant go back to its normality even we removed the cause because the pulp is already happened . Hard tissue responses include calcification and resorption. Normal pulp : normal is normal , clinically no symptoms you can eat ice cream or a hot “ phlaphel “ . • Reversible pulpitis : If the cause is eliminated, inflammation will reverse and the pulp will return to its normal state . the Causes of reversible pulpitis :  Mild or short-acting stimuli such as incipient caries, cervical erosion, or occlusal attrition; most operative procedures; deep periodontal curettage; and enamel fractures resulting in exposure of dentinal tubules ( and when it exposed it will lead to the pulp directly ) can cause reversible pulpitis. Now symptoms : Reversible pulpitis is usually asymptomatic. However, when present, symptoms usually follow a particular pattern. Application of stimuli, such as cold or hot liquids, as well as air, may produce sharp, transient pain ( you feel the pain as sharp when the cause is present and when you remove the cause the pain will disappear ). Removal of these stimuli, which do not normally produce pain or discomfort, results in immediate relief . Treatment : remove the cause as simple as that .

Irreversible pulpitis : its usually follow the reversible pulpitis , if the cause persist and neglected , it will lead irreversible pulpitis . The causes like Severe pulpal damage from extensive dentin removal during operative procedures or impairment of pulpal blood flow as a result of trauma or orthodontic movement of teeth may also cause irreversible pulpitis. This condition is a severe inflammatory process that will not resolve even if the cause is removed. It can be symptomatic or asymptomatic with no clinical signs and symptoms. Symptoms • Pain resulting from an irreversibly inflamed pulp may be sharp, dull, localized, or diffuse and can last anywhere from a few minutes up to a few hours. Now when the patient cant localize the pain whether its in the upper or the lower jaw , we need to anesthetize the jaw in order to exclude it , if the pain disappear then it’s the jaw that cause pain , if not then it’s the other jaw . • application of heat to teeth with irreversible pulpitis may produce an immediate response; also, occasionally with the application of cold, the response does not disappear and is prolonged. Application of cold in patients with painful irreversible pulpitis may cause vasoconstriction, a drop in pulpal pressure, and subsequent pain relief tests : the tooth In the primary stages wont show any response to pulpal palpation because the infection still doesn’t reach beyond the pulpal tissue , so palpation on enamel or dentin wont change the symptoms . but when the infection spread beyond the apical part to the periradicular area then the palpation test will help us . treatment : Root canal treatment or extraction is indicated for teeth with signs and symptoms of irreversible pulpitis.

Hyperplastic Pulpitis • Hyperplastic pulpitis (pulp polyp inside the crown) is a form of irreversible pulpitis that originates from overgrowth of a chronically

inflamed young pulp onto the occlusal surface. It is usually found in

carious crowns of young patients • Hyperplastic pulpitis is usually Asymptomatic treatment : RCT or Extraction - when we touch this tissue it will give us a severe bleeding . necrosis : the pulp is dead , rate of spread of necrosis increased in closed or sealed teeth , asymptomatic , treatment is RCT . now the reaction of the hard tissue toward infection or inflammation by calcification or internal resorption . calcification like when the pulp champer is obliterated by calcific material or deposition . resorption like when the internal canal resorped , and by this you will see the tooth pink in color . PERIAPICAL PATHOSIS When the pulpal inflammation spread beyond the apical part toward the periapical area , you will see it in a different situations . The classification depends on clinical situation ( signs and symptoms ) and histological appearance . NOW : the dr read the following slides as it is by a letter :

‫تـ ـ ـ ــم بحمد اهلل‬ ‫قبل أن ‪:‬‬ ‫قبل أن تتكلم اسمع‬ ‫قبل أن تتفـاعل فكر‬ ‫قبل أن تنتقد انظر‬ ‫قبل أن تصلي سامح‬ ‫قبل أن تستسلم حاول‬
‫‪Sorry for any mistake‬‬ ‫‪Done By :‬‬ ‫‪Yahya Al-Omary‬‬