Abnormalities of The Pulp

ABNORMALITI
ES OF THE
PULP
Prepared by:
Dr. Rea Corpuz
Pulp Calcification
 may be located
 pulp chamber
OR
 root canals
Pulp Calcification
 Cause
 no clear-cut etiology
 no relation between
inflammation + irritation
• since pulp calcification

can be found in unerupted
teeth
Sundell Schematic
Presentation
Local
Metabolic Hyalinization Vascular
Trauma
Dysfunction of injured cell Damage
Thrombosis
Growth
Mineralization Fibrosis Vessel Wall
Damage
Pulp Stones
Classification
 Three types :
 (1) Denticles
 (2) Pulp stones
 (3) Diffuse linear calcifications

(1) Denticles
 believed to form as a result

of epitheliomesenchymal
interaction within
developing pulp
 form during period of root

development
 occur in root canal + pulp

chamber adjacent to furcation
areas of multirooted teeth
(2) Pulp Stones
 believed to develop around

central nidus of pulp tissue
examples:
 collagen fibril
 ground substance
 formed within coronal portions

of pulp
(2) Pulp Stones
 may arise as part of age-

related or local pathologic
changes
 most develops after tooth

formation is completed
 usually free or attached
 some instances, may be embedded

(3) Diffuse Linear
Calcifications
 doesn’t demonstrate lamellar
organization of pulp stones
 exhibit areas of:

 fine
 fibrillar
 irregular calcification
 may be present in pulp

chamber or canals
 frequency increases with age

(3) Diffuse Linear
Calcifications
 Clinical Significance:
 very little clinical significance
 except insofar as they may

obstruct endodontic treatment
(3) Diffuse Linear
Calcifications
 discovered on radiograph
only as radioopacity
 may cause pain from

mild pulpal neuralgia to
severe excruciating pain
resembling tic douloureux
• as denticle may impinge

on nerve of pulp
(3) Diffuse Linear
Calcifications
 difficulty may be encountered

in extirpating pulp
during root canal therapy
(3) Diffuse Linear
Calcifications
 Treatment & Prognosis
 No treatment is required
Resorption of the Teeth
 deciduous teeth are progressively

loosened
 result of progressive
resorption of roots
 physiological process arising

from pressure of underlying
successors
 resorption of permanent is
always pathological
Resorption of the Teeth
 Pathology
 pressure is probably main

factor
 resorption is mainly carried

out by osteoclast
 humoral mediators, such

as prostgalndins
• may contribute to resorption

Idiopathic Resorption
 (1) Internal Resorption
 (2) External Resorption

 Internal Resorption
 pink spot
 curious + uncommon
condition
 dentin is resorbed from

within the pulp
 tends to be localized
 well-defined rounded area

of rediolucency in crown
 can affect any part of teeth
 NO signs until pulp is

opened + allows access to
infection
 may be detected by chance

in routine radiograph


 may be localized or
generalized
 unkown cause
 mild degree of inflammation

is often suspected

Heithersay Classification
 usually a limited area of

root is attacked from
external surface near
amelocemental junction
• resorption goes on until

pulp is reached
 often preferentially
destroys root before
penetrating the pulp
 accessible defects may be

amenable to restoration
with mineral trioxide or
other materials
 long term success in infrequent;

unpredictable
 Pathology
• vascular granulation
tissue replaces part
or periodontal ligament
or pulp
• osteoclasts border the

affected dentin or enamel
 Treatment
• usually untreatable
• if a pink spot in an incisor

tooth is noticed at an early
stage
 endodontic treatment should

be carried out before
 Treatment
• resorption of teeth may

result from pressure
exerted by impacted teeth
 indication for removal

of unerupted teeth
DISEASES OF
PERIAPICALTISSU
ES
Prepared by:
Dr. Rea Corpuz
Diseases of Periapical Tissues
 (1) Periapical Abscess
 (2) Periapical Granuloma
 (3) Radicular Cyst
 (4) Phoenix Abscess
 (5) Condensing Osteitis

(1) Periapical Abscess
 also known as Dento-alveolar

Abscess; Alveolar Abscess
 acute or chronic supporative

process of dental periapical
region
 usually arises as a result of

infection
 abcess ay develop directly

as an acute apical periodontitis
following an acute pulpitis
 but more commonly it

originates in an area of
chronic infection
 Clinical Feature
 presents features of
acute inflammation of
apical peridontium
 tooth is extremely painful
 slightly extruded from its

socket
 Clinical Feature
 chronic periapical
abscess generally presents
no clinical features
 mild, circumscribed area

of suppuration that shows
little tendency to spread from
local area
 Radiographic Feature
 except for SLIGHT thickening

of periodontal membrane
 no roentgenographic
evidence of its presence
 chronic abscess, developing

in a periapical granuloma
• radioluscent area at apex

 Histopathologic Features
 area of suppuration is
composed chiefly of central
area of disintegrating
polymorphonuclear
leukocytes
 dilation of blood vessels

in periodontal ligament
 Histopathologic Features
 tissue surrounding area

of suppuration contains
serous exudate
 drainage must be
established
• open pulp chamber
• extract the tooth

 under some circumstances

tooth may be retained
• root canal therapy

 left untreated, spread

of infection
• osteomyelitis
• cellulitis
• bacterimia
• formation of fistulous
tract opening on skin
or oral mucosa
(2) Periapical Granuloma
 also known as Apical

Periodontitis
 one of the most common

sequeala of pulpitis
 localized mass of chronic

granulation tissue
 response to infection
 Clinical Features
 1st evidence; spread beyond

confines of tooth pulp
 may be noticeable sensitivity

of involved tooth to
percussion
 mild pain when biting or

chewing on solid food
 some cases tooth feels

elongated in its socket
 sensitivity is due to
• hyperemia
• edema
• inflammation of apical
periodontal ligament
 Radiographic Features
 earliest evidence,
thickening of ligament at root
apex
 proliferation of granulation
tissue
 concomitant resorption of bone

continue
 appear as a radiolucent
area of variable size
seemingly attached to
root apex
 some cases, well

circumscribed lesion
• definitely demarcated
from surrounding bone
 Histologic Features
 arises as chronic process

from onset
 does not pass through an

acute phase
 begins as:
• hyperemia
• edema of periodontal
ligament with infiltration
of chronic inflammatory cells
 chiefly lymphocytes
 plasma cells
 inflammation + locally
increased vascularity
of tissue
• induce resorption
of supporting bone
adjacent to this area
 as bone is resorbed
• proliferation of fibroblast
+ endothelial cells
• formation of more tiny

vascular channels
• numerous delicate connective

tissue fibrils
 extraction of involved
teeth
 under certain conditions,

root canal therapy with or
without subsequent
apicoectomy

 left untreated, may

undergo transformation
into an apical periodontal
cyst
• proliferation of epithelial
rests in the area
(3) Radicular Cyst
 also known as Apical
Periodontal Cyst;
Periapical Cyst;
Root End Cyst
 common
 not inevitable sequela of

periapical granuloma originating
as a result of:
 bacterial infection
 necrosis of dental pulp
 following carious involvement of tooth
(3) Radicular Cyst
 Pathogenesis
 initial reaction leading

to cyst formation
• proliferation of epithelial
rest in the periapical
area involved by granuloma
• epithelial proliferation
follows an irregular pattern of
growth
(3) Radicular Cyst
 asymptomatic
 present no clinical evidence

of their presence
 seldom painful or even

sensitive to percussion
(3) Radicular Cyst
 represents chronic
inflammatory process
• develops only over

a long period of time
(3) Radicular Cyst
 identical with periapaical

granuloma
 since the lesion is a chronic

progressive one developing
in a pre-existing granuloma
• cyst may be of greater

size than granuloma
• due to longer duration
(3) Radicular Cyst
 occasionally, exhibits
thin, radioopaque line
around the periphery
of radiolucent area
• indicates reaction of
bone to slowly expanding
mass
(3) Radicular Cyst
(3) Radicular Cyst
 epithelium lining apical

periodontal cyst is usually
stratified squamous in
type
(3) Radicular Cyst
 similar to periapical
granuloma
• involved tooth may be

removed
• periapical tissue carefully

curetted
(3) Radicular Cyst
 under some condition;
• root canal therapy
• with apicoectomy
of cystic lesion
(3) Radicular Cyst
(4) Phoenix Abscess
 localized collection of pus
 surrounded by an area of
inflammed tissue
 hyperemia
 infiltration of leucocytes
(4) Phoenix Abscess
(4) Phoenix Abscess
(4) Phoenix Abscess
 can occur immediately

following root canal treatment
 another cause is due to untreated

necrotic pulp (chronic apical
periodontitis)
 result of inadequate debridement

during endodontic procedure
(4) Phoenix Abscess
 Bacteriology
 Staphylococci are frequently

associated with pus formation
• produce enzyme called

coagulase
• causes fibrin formation
• helps in walling off of lesion

(4) Phoenix Abscess
 Bacteriology
• coagulase promotes
virulence by inhibiting
phagocytosis
(4) Phoenix Abscess
 when palpated clinically
• superficial abscess is
fluctuant
 offending tooth is carious

+ mobile
 symptoms of acute inflammation

• swelling
• fever
(4) Phoenix Abscess
 Treatment
 repeating endodontic
treatment with improved
debridement
 tooth extraction
 antibiotics may be indicated

to control a spreading or
systemic infection
(5) Condensing Osteitis
 also known as Chronic

Focal Sclerosing Osteomyelitis
 unusual reaction of bone
 occuring in instances of
extremely high tissue resistance
 or in cases of low grade infection

 occurs in almost young

person before the age of
20 years old
 commonly affected is
mandibular 1st molar
with large carious lesion
 associated with non vital

teeth or teeth undergoing
process of degeneration
 tooth is usually asymptomatic
 some cases, pain or tenderness
• percussion
• palpation
 well circumscribed
radiopaque mass of
sclerotic bone surrounding
 extending below apex of

one or more roots
 dense mass of bony trabeculae

with little interstitial
marrow tissue
 dense mass of bony trabeculae

with little interstitial
marrow tissue
 chronic inflammatory cells;

plasma cells, lymphocytes
are seen scanty in bone
marrow
 endodontic treatment
 extraction
 surgical removal of sclerotic

should not be attempted
unless symptomatic
References:
 Books
 Cawson, R.A: Cawson’s Essentials of Oral
Oral Pathology and Oral Medicine,
8th Edition
• (page 70-72)
 Ghom, Ali & Mhaske, Shubhangi: Textbook of
Oral Pathology
• (pages 429-433)
 Neville, et. al: Oral and Maxillofacial Pathology
3rd Edition
• (pages 127-138)
Shafer, et al: A textbook of Oral Pathology,

3rd Edition

Abnormalities of The Pulp

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Abnormalities of The Pulp

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ABNORMALITI

• since pulp calcification

 (2) Pulp stones

 (3) Diffuse linear calcifications

 believed to form as a result

 form during period of root

 occur in root canal + pulp

 believed to develop around

 formed within coronal portions

 may arise as part of age-

 most develops after tooth

 usually free or attached

 some instances, may be embedded

 exhibit areas of:

 may be present in pulp

 frequency increases with age

 very little clinical significance

 except insofar as they may

 may cause pain from

• as denticle may impinge

 difficulty may be encountered

 deciduous teeth are progressively

 physiological process arising

 pressure is probably main

 resorption is mainly carried

 humoral mediators, such

• may contribute to resorption

 (1) Internal Resorption

 (2) External Resorption

 dentin is resorbed from

 (1) Internal Resorption

 well-defined rounded area

 can affect any part of teeth

 NO signs until pulp is

 (1) Internal Resorption

 may be detected by chance

 (1) Internal Resorption

 (1) Internal Resorption

 (2) External Resorption

 mild degree of inflammation

 (2) External Resorption

 (2) External Resorption

 (2) External Resorption

 usually a limited area of

• resorption goes on until

 (2) External Resorption

 accessible defects may be

 long term success in infrequent;

• osteoclasts border the

• if a pink spot in an incisor

 endodontic treatment should

• resorption of teeth may

 indication for removal

 (1) Periapical Abscess

 (2) Periapical Granuloma

 (3) Radicular Cyst

 (4) Phoenix Abscess

 (5) Condensing Osteitis

 also known as Dento-alveolar

 acute or chronic supporative

 usually arises as a result of

 abcess ay develop directly

 but more commonly it