9

Nawaf Hazaymeh

Yahya alOmary

pulp and periradicular pathosis

Sun. 14-4-2013

بســــم 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 :

تــــــــم 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