Pulp diseases

Pulp: is a delicate connective tissue occupying the

center of a tooth. It is formed of collagen fibers,
cells, nerves, blood vessels, and lymphatics.
Pulpitis: is an inflammation of the dental pulp. If
untreated it will be followed by death of the pulp
and spread of infection through the apical foramina
into the periapical tissues.
As the bacterial infection extends into dentin after
attacking dentin, the dental pulp will be invaded. This
because dentinal tubules extend from the dentino-
enamel junction to the pulp, pathways exist for bacterial
invasion. Moreover, once bacteria enter the pulp they
can be transported into the surrounding bone.
II-Anatomic features of the dental pulp that tend to alter the nature and
the course of the response to inflammation:

1-The enclosure of the pulp tissue within the rigid calcified walls of the
dentin which prevent excessive swelling of tissue that occurs in the
hyperemic phases of inflammation in other tissues.

2-There is no collateral circulation to maintain vitality when the primary

blood supply is compromised (obstructed).

3-Nerves, arteries and veins enter through small apical foramen. In

inflammation, dilatation of arteries occur that exerts pressure on veins
causing its constriction. When the outflow of venous blood is prevented
and the veins are not capable of draining this increased blood supply,
degeneration and necrosis of the pulp occur.

4-The pulp can respond to temperature from 20°C to 45°C. Temperature

below 20°C and above 45°C may produce inflammation of the pulp.

5-The pulp lacks the power of regeneration.

III-Etiologic factors of pulp diseases:

*Four main types of noxious stimuli are common causes of pulp inflammation:

1. Bacterial effects 2. Mechanical damage

3. Thermal injury
4. Chemical irritation
1- Bacterial effects :
a- Dental caries:
b- Direct communication between the pulp and oral environment in case of:
o Fracture of the crown or root.
o Odontoiatrogenic damage, in case of pulp exposure during cavity preparation.
Odontoiatrogenic means complication caused by a dentist it comes from a Greek Word
"Iatrogenic" that means complication caused by a physician.
c- Advanced periodontal disease:
Causes of Pulpitis

1. Physical irritation
 Most generally brought on by extensive decay.

2. Trauma
 Blow to a tooth or the jaw

3. Anachoresis
- retrograde infections
 IV-Classification of pulp diseases:

According to the severity of inflammation:

1- Acute pulpitis.
2- Chronic pulpitis.

According to the extent of pulp involvement :

1- Partial pulpitis (focal pulpitis).
2- Complete pulpitis (generalized pulpitis).

According to communication between the dental pulp and the oral

environment:
1- Open pulpitis.
2- Closed pulpitis.

4- According to the fate into

A- Reversible pulpitis
B- Irreversible pulpitis
5-According to presence or absence of infection into
A- Infected pulp
B- Sterile pulp
 1-Focal Reversible Pulpitis
Definition & characteristics

Focal reversible pulpitis also known by (pulp hyperemia) is

one of the earliest forms of pulpitis. It localized mainly to
the pulpal ends of irritated dentinal tubules.

Causes:

The causative factors are irritants (caries, restoration,

operative procedures. Just after placement of a dental
restoration, due to its sensitivity to hot and cold.
Signs and symptoms

• It typically follows a deep carious destruction of a tooth

or placement of a large metallic filling without an insulating
base.
• A tooth with focal pulpitis is sensitive to thermal changes
particularly to cold, mild to moderate pain with thermal
stimuli especially cold which subsides after the stimulus is
removed.

.
Histological features:

• Dilation and engorgement of blood vessels (hyperemia).

• Chronic inflammatory cellular infiltrate (Plasma cells,
lymphocitis and macrophages).
• Intact odontoblastic layer.
• Reparative dentin.
Treatment and Prognosis:

Focal pulpitis is a reversible condition which

subsided after removal of the irritant. Thus, a
carious lesion should be excavated and restored
or a defective filling replaced as soon as it is
discovered.
 Acute pulpitis

Definition & characteristics

Definition:
Acute pulpitis is an acute inflammatory reaction of the
pulp that may results from:
• Progression of focal reversible pulpitis.
• Acute exacerbation of chronic pulpitis.

Causes: See Etiology of Pulp Inflammation, in addition: It

follows the pulp hyperemia or an acute exacerbation of
chronic pulpitis.
Clinical Features:

• Sharp, severe pain upon thermal stimulation especially cold

although heat, sweet or sour foods also can produce pain.
• The pain continues after the stimulus is removed.
• The pain may be spontaneous and may be exacerbated when the
patient lies down.
• Later on the pain increases in intensity and is experienced as a
throbbing pain that can keep patients awake at night.
• The patient is unable to identify the offending tooth within a
quadrant.
• At this point, heat increases the pain; however, cold may produce
relief.
• If there is an opening from the pulp to the oral environment
(fractured crown), symptoms may be decreased or disappeared
because of the escape of the exudate that causes pressure on and
chemical irritation of the pulpal nerve tissues.
Histological features:

• Initial hyperemia limited to the area immediately

beneath the irritant.
• Infiltration of the pulp by acute inflammatory cells
(neutrophils) which are directed toward the site of
bacterial invasion.
• Focal necrosis due to congestion of the venues.
• Destruction of odontoblastic layer.
• Abscess formation:
.
Acute pulpitis. Infection has
penetrated the reactionary
dentine causing inflammation
to spread down the pulp and
pus to form in the corner.
Acute pulpitis - terminal stage.
The entire pulp has been
destroyed and replaced by
inflammatory cells and dilated
vessels.
Treatment and prognosis:

Acute pulpitis treated by root canals treatment.

 Chronic pulpitis

Definition & characteristics

Chronic pulpitis is a chronic inflammatory reaction of the
pulp that may results from:
• Long term, low-grade injury (as in case of slowly
progressing caries, or when the organisms are of low
virulence).
• Quiescence of an acute process.

Causes: See etiology of Pulp Inflammation., in addition to ,

It follows quiescence of acute.
Signs and symptoms:

• Sensitivity to heat & cold is less than that in acute

pulpitis due to degeneration of nerve fibers.
• Dull intermittent pain, brought on by hot or cold stimuli
or coming on spontaneously. There are often prolonged
remissions.
• Pain is poorly localized and may be felt in any of the
teeth of the upper or lower jaw of the affected side (but
never cross the midline).
Histological Features

• The pulp tissue shows:

a. Chronic inflammatory cells (plasma cells, Lymphocysts)
b. Prominent blood capillaries.
c. Collagen fibers (fibroblastic activity which is an attempt
by the pulp to wall off the infection).
• A small area of pulp necrosis and pus formation may be
localized by a well-defined wall of granulation tissue, and a
minute abscess may thus form

Treatment:
Endodontic therapy or extraction.
 Chronic hyperplastic
pulpitis pulp Polyp

This type of reaction is believed to be related to the

open root foramen, through which a relatively rich
blood supply flows. Although the pulp tissue is viable,
the process is not reversible and necessitates
treatment..

Causes: Extensive caries

Clinical Features:

• Pulp polyp appears as a red or pinkish soft nodule

protruding into the cavity.
• It is painless (as there is no exudate under pressure)
but may be tender and bleed on probing.
Signs and symptoms
A soft-tissue mass grows out of the affected pulp. In a young
persons.
There is usually little or no pain. Most common involved
teeth are the deciduous or first permanent molars because
they have large pulp chamber and large apical foramen &
good blood supply.
Root development isn't completed, however, until some
years after eruption. Therefore, the apical foramen is not
constricted in a youngster's permanent teeth. The pulps of
these incompletely-formed teeth are large and are supplied
with blood by a number of vessels entering it through a wide
apical foramen (clinicians call this a "wide- open apical
foramen" or "blunderbus canal"). The point of this digression
is that young incompletely-formed permanent teeth can
withstand inflammation better than older fully-formed ones.
Pulps of young teeth can recover where pulps of older teeth
Pulp polyp. An inflamed nodule of
granulation tissue can be seen growing
from the pulp chamber of this broken
down first permanent
molar.
Histological features:

• The pulp becomes replaced by a well-vascularized

granulation tissue mass.
• The deeper pulp tissue demonstrates a chronic
inflammatory cells infiltrate.
• Gradually the surface becomes epithelized (covered by
a layer of well-formed stratified squamous epithelium) as a
result of implantation of desquamated epithelial cells
(from the oral mucosa) on it is surface.
Treatment: Chronic hyperplastic pulpitis is treated
by extraction of the tooth or by pulp extirpation..