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Pulp polyp – A periapical lesion: Radiographic observational study

Article · January 2015

DOI: 10.4103/0972-1363.167085

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Original Article

Pulp polyp – A periapical lesion: Radiographic

observational study
Kandagal V Suresh, Nidhi Bajaj, Ajay G Nayak, Mounesh Kumar Chapi D1, Snehal Patil2, Ashwini Rani
Departments of Oral Medicine and Radiology, 1Oral and Maxillofacial Surgery and 2Public Health Dentistry, School of
Dental Sciences, Krishna Institute of Medical Sciences, Deemed University, Karad, Maharashtra, India

ABSTRACT

Introduction: Pulp polyp (PP) is a chronic hyperplastic condition resulting in formation of granulation tissue and proliferative
mass. The radiographic appearance of PP has innumerable presentations. Diagnosing and treatment planning of periapical
lesions, heavily relies on the radiographic changes surrounding the root structures. Objective: To evaluate different radiographic
periapical changes in clinically detected PP patients. Materials and Methods: Patients reporting to Department of Oral Medicine
and Radiology and who were clinically diagnosed with PP by an oral diagnostician were subjected to radiographic examination.
Digital intraoral periapical radiographs of 50 patients with PP were taken. Various periapical changes in the digital radiographs
were recorded by a skilled oral radiologist. The data obtained was subjected to statistical analysis using SPSS ver 17.0 and
P-value was set at <0.05 as significant. Result: Periapical changes like periodontal space widening (PDLW), loss of lamina dura,
periapical abscess, periapical granuloma, hypercementosis, condensing osteitis and root resorption were noted. Periodontal
space widening was seen in all patients (100%), loss of lamina dura was noted in 72%, periapical rarefying osteitis in 56%,
condensing osteitis in 8%, hypercementosis, periapical granuloma, and root resorption were seen in 4% of PP patients. Majority
of PP were asymptomatic (66%). Pulp polyp was commonly seen in mandibular first molar followed by mandibular second molar
and maxillary first molar. Statistically significant difference was noticed between periapical changes in PP patients (P value
<0.0001). All PP patients showed definite periapical changes suggesting it to be a periapical lesion. Conclusion: Pulp polyp is
confined to the pulpal portion of the tooth which, may or may not cause changes in periapical region. The results of the present
study showed that majority of the PP patients were associated with definite periapical changes. This observation suggests that
clinically detected PP are radiographically associated with definite periapical changes suggesting it to be a periapical lesion.
Key words: Hyperplastic pulpitis, lamina dura, periapical pathologies, peridontitis, pulp polyp

Introduction against the tissue inflammation resulting in hyperplastic

changes. It is occasionally associated with mild pain

P
ulp polyp (PP) is also known as chronic along with large carious cavitated lesions and may be
hyperplastic pulpitis or proliferative pulpitis. associated with rare history of bleeding. Histologically
Clinically it appears as proliferative red mass it shows abundant granulation tissue with numerous
seen in the occulsal portion of the molars in individuals blood vessels.[2] A tooth with a PP and periapical
with higher immunity.[1] It is the protective response
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DOI: How to cite this article: Suresh KV, Bajaj N, Nayak AG, Chapi DM,
10.4103/0972-1363.167085
Patil S, Rani A. Pulp polyp – A periapical lesion: Radiographic
observational study. J Indian Acad Oral Med Radiol 2015;27:68-71.

Address for correspondence: Dr. Kandagal V. Suresh, Department of Oral Medicine and Radiology, School of Dental Sciences,
Krishna Institute of Medical Sciences, Deemed University, Karad, District - Satara, Maharashtra, India. E-mail: dr.suri88@gmail.com
Received: 03-03-2015 Accepted: 14-09-2015 Published: 12-10-2015

68 © 2015 Journal of Indian Academy of Oral Medicine and Radiology | Published by Wolters Kluwer - Medknow
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Suresh KV et al.: Pulp polyp - A periapical lesion
involvement presents many difficulties in diagnosis
and treatment. It is believed that radiographically, the
pulpal lesion does not show any periapical changes.
A delay in treatment of PP usually leads to spread
of inflammation into the periodontal ligament space
through the apical foramen.[1,3]
Periapical lesion occurs due to the extension of micro-
organisms, and their metabolic products, toxins,
enzymes from pulpal tissue into the periapical space.
All periapical lesions represent two factors, firstly the
consequences of an untreated acute inflammatory
process and secondly an unsuccessful attempt of the
protective reaction of the organism in neutralizing the
harmful factors which subsequently perpetuate the
inflammatory process. The inflammatory process in
chronic periapical lesions is still not fully understood.
Humoral and cellular immunological system plays a
role in the occurrence, development and perpetuation of
these lesions.[3] Histologically, chronic periapical lesion
represents granulational tissue, with inflammatory cells;
leukocytes, T and B lymphocytes, macrophages, mast
cells and plasma cells.
The radiographic picture of PP is variable. It can be
represented radiographically as normal periapical
tissues or as a widened periodontal ligament space or
as a small to large radiolucency indicative of a long-
standing disease process.[1] Rarefaction of periapical
regions may be seen in radiographs in chronically
inflamed PP. This occurs because chronic PP does not
end at the apical foramen but involves the periapical
tissues resulting in destruction of the periapical bone.
However, the conventional radiographs are not sensitive
enough to detect small regions of chronic inflammation
in the periapical tissues at an early stage.[1]
Pulp polyps has always been categorized as pulpal
inflammatory lesions, hence its effect of the periapical
structures has largely been ignored which is also
reflected in the limited information available in the
literature regarding periapical radiographic changes
in PP patients. Hence in this study an attempt has been
made to evaluate the various periapical changes in PP
patients. Various researchers evaluated the prevalence
of different periapical pathologies in decayed teeth.
However, the occurrence of these changes has not been
studied in a PP patient. So, there is increasing need of
understanding the prevalence of these conditions in
patients having PP.
Materials and Methods
Present radiographic observational study was conducted
in the Department of Oral Medicine and Radiology.
Journal of Indian Academy of Oral Medicine & Radiology | Jan-Mar 2015 | Vol 27 | Issue 1
The subjects who participated voluntarily and signed
a written informed consent form were included in
the study. Ethical clearance was obtained from the
institutional ethics committee. Patients who were
clinically diagnosed with PP by an experienced oral
diagnostician were subjected to further radiographic
examination. Digital intraoral periapical radiographs
were taken with long cone paralleling technique in
intraoral X-ray machine at 70 kVp and 8 mA (AMS
6010 AC intraoral radiology unit) and radiovisiography
sensor (KODAK 5000) in 50 patients. Exposure time was
constantly maintained at 0.6 seconds. All the digital
intraoral radiographs were interpreted by a single
experienced oral radiologist. Various periapical changes
in PP patients were recorded.
Inclusion criteria constituted the subjects clinically
diagnosed with PP in any tooth irrespective of age and
gender. Exclusion criteria constituted subjects with
advanced periodontitis, teeth without antagonist and
mesial or distal drifting. Subjects with systemic diseases
were also excluded from the study. Diagnosis of PP
was made on clinical examination; clinically PP shows
chronic inflammation with a pedunculated or sessile
mass of tissue protruding from large pulp exposure.
The data obtained was subjected to statistical analysis
by using SPSS Ver 17.0. ANOVA was used to compare
various periapical lesions. P-value was set at <0.05 as
significant
Results
A total of 50 subjects (24 male and 26 female) were
included in the study. Out of which, 44% of PP subjects
were symptomatic [Table 1]. All 50 patients showed
definite periapical changes. Out of which PDL space
widening was seen in all 50 cases (100%), lamina
dura discontinuity was observed in 36 cases (72%),
periapical rarefying osteitis was noted in 28 cases
(56%), condensing osteitis was accounted in four cases
(8%), periapical granuloma, hypercementosis and root
resorption was observed in two cases each (4%) [Table 2].
On comparison of different periapical changes in PP
subjects by using ANOVA test, it was observed that
there was a statistically significant difference among
the periapical changes (P-value <0.0001). Out of 50
subjects, 20 cases showed involvement of mandibular
first molar (40%), 14 cases in mandibular second molar
(28%), 14 cases in maxillary first molar (28%) and two
cases showed involvement of mandibular third molar
(4%). Hence PP was commonly seen in mandibular molar
Table 1: Shows total number of patients
Male Female Total Symptomatic PP Asymptomatic PP
24 26 50 22 (44%) 28 (66%)
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Suresh KV et al.: Pulp polyp - A periapical lesion

followed by mandibular second molar and maxillary first Table 2: Showing periapical changes in PP patients
molar [Table 3]. In age-wise prevalence of PP among the Radiographic periapical changes Cases (50) Percentage (%) P-value
50 subjects, the age group with highest prevalence was PDL space widening 50 100 <0.0001
between 21 and 30 years of age accounting for 16 cases Discontinuity of Lamina dura 36 72
giving a percentile of 32%. The age group of 11-20 years Periapical rarefying osteitis 28 56
and 31-40 involved 14 cases each accounting for 28% Condensing osteitis 4 8
each and age group of 0-10 years accounted the least of Periapical granuloma 2 4
six cases (12%). Hence, pulp polyp is commonly seen in Hypercementosis 2 4
the age group of 21-30 years [Table 4]. Root resorption 2 4

Discussion Table 3: Distribution of PP in different teeth

Tooth Number of PP patients Percentage (%)
PP is a common and specific type of chronic irreversible Mandibular first molar 20 40
pulpitis that most often occurs in young adults. Majority Mandibular second molar 14 28
of the PP are asymptomatic which causes delay in Mandibular third molar 2 4
seeking the treatment. PP is usually an incidental finding Maxillary first molar 14 28
that occasionally mimics reactive and neoplastic diseases
of the gingiva and adjacent periodontium.[4] When pulp
involvement is long standing, periapical radiography Table 4: Age-wise distribution of PP
may reveal an incipient chronic apical periodontitis.[5,6] Age Number of PP patients Percentage (%)
Pulpoperiapical periodontitis is the term given to the 0-10 years 6 12
11-20 years 14 28
group of lesions which radiographically shows periapical
21-30 years 16 32
changes in a tooth whose pulp is vital.[1] The PP results
31-40 years 14 28
from both mechanical irritation and bacterial invasion
into the pulp. The exposure of pulpal tissue to the oral
environment and bacterial invasion results in a chronic advanced imaging modalities to visualize the periapical
inflammatory response that stimulates an exuberant region, IOPARs still remain the best.[10] Intraoral periapical
granulation tissue reaction. This hyperplastic tissue radiographs are needed for diagnosis and to determine the
reaction occurs because the young dental pulp has a extent of tooth and bone destruction. Radiographically,
rich blood supply and favorable immune response that PP appears as a large coronal radiolucency that extends
is more resistant to bacterial infection.[7] to the pulpal chamber with focal loss of tooth structure,
while the root apices may be either open or closed.[11,12]
No previous studies are available to discuss the The present study results showed widening of PDL space
periapical changes in PP patients. However, many in all cases and discontinuity of lamina dura in 72% cases.
studies have evaluated the most commonly occurring This could be because, in chronic PP, microorganisms and
periapical changes in decayed tooth. Pulp polyp is their metabolic products, from the pulpal tissue extend
common in the Indian population, and no epidemiologic
to the periapical area leading to inflammatory responses
studies specifically document the frequency of this
and bone destruction at the periapical area. Severity
entity. Although this lesion is reported to be common,
of radiographic changes in periapical lesions depends
the true prevalence of this reactive pulpal disease is
on the duration of PP, virulence of microorganism and
underestimated because it is a well-recognized sequel
bacterial activity.
of extensive dental caries in children and young adults.
No racial predilection is recognized for PP; however, it
Dayal et al. [1] evaluated the radiographic changes in
is more common in individuals of lower socioeconomic
background who have limited access to dental care teeth with pulpitis. They found that, 76.5% chronic
than in other people. No sexual predilection has been pulpitis cases showed radiographic changes and
documented for this oral lesion.[8,9] This pulpal disease 82.6% of PP had periapical radiographic changes. In
occurs almost exclusively in children and young adults, contrast, present study showed radiographic periapical
and it can occur in both the primary dentition and the changes in all the PP patients. Raphael Carlos Comelli
permanent dentition. These findings were consistent et al., conducted a radiographic evaluation of chronic
with the results of the present study.[9] inflammatory periapical lesions in decayed teeth. They
found that, 43.29% were chronic apical periodontitis,
Intraoral periapical radiographs (IOPARs) are the usual 35.98% as inflammatory cysts and 20.73% had no definite
screening tool and routinely employed method for diagnosis.[13] This was in accordance with the present
evaluation, diagnosis and planning the treatment for pulpal study results which showed that the majority of PP
and periapical diseases. Although there are numerous patient had periapical changes. Estrela et al., evaluated

70 Journal of Indian Academy of Oral Medicine & Radiology | Jan-Mar 2015 | Vol 27 | Issue 1
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Suresh KV et al.: Pulp polyp - A periapical lesion
common causes of pain in periapical infections. They
concluded that, most frequent cause of pulpal pain
were symptomatic pulpitis (28.3%) and hyper-reactive
pulpalgia (14.4%), and the most frequent periapical
pain was symptomatic apical periodontitis of infectious
origin (26.4%).[14] In the present study 44% of PP were
symptomatic and few cases were associated with
occasional bleeding.
In this study PP has shown radiographic periapical
pathologies in all the cases right from the initial PDL
space widening to periapical granuloma. The limitation
of the present study was that, external factors like
(anatomical noise and poor irradiation geometry), which
are not in the clinician’s control and which might affect
the detection of periapical lesions could not be controlled
for. Other limitation was the small sample size due to
the limited study duration. The imaging technique like
CBCT removes these external factors; in addition, it
allows the clinician to select the most relevant views of
the area of interest resulting in improved detection of
the presence and absence of periapical lesions.[15]
Conclusion
PP is one of the most common pulpal pathology in
young patients. The results of the present study provide
information on the distribution of various periapical
pathologies in PP patients. Periapical lesions are
significantly seen higher in PP patients. A complete
knowledge of the radiographic appearances of periapical
diseases under normal and pathologic conditions is
mandatory for the radiographic diagnosis of periapical
diseases. The present study was a radiographic
observational study conducted in a small sample.
Further studies with larger sample size and considering
various socioeconomic variables would be required to
make a clear distinction.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Journal of Indian Academy of Oral Medicine & Radiology | Jan-Mar 2015 | Vol 27 | Issue 1
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