Abnormalities of the pulp

ABNORMALITIES OF THE PULP

Prepared by:Dr. Rea Corpuz

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

Pulp Calcification

Sundell Schematic Presentation

Local Metabolic

DysfunctionTrauma

Hyalinization of injured cell

Vascular Damage

Thrombosis Vessel Wall

DamageFibrosisMineralization

Growth

Pulp Stones

Three types :

(1) Denticles

(2) Pulp stones

(3) Diffuse linear calcifications

Classification

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

(1) Denticles

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

(2) Pulp Stones

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



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



difficulty may be encountered in extirpating pulp during root canal therapy


Treatment & Prognosis

No treatment is required


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

Resorption of the Teeth

(1) Internal Resorption

(2) External Resorption

Idiopathic 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 pulp chamber becomes widely exposed



Treatment

• resorption of teeth may result from pressure exerted by impacted teeth

indication for removal of unerupted teeth


DISEASES OF PERIAPICALTISSUE

S

Prepared by:Dr. Rea Corpuz

(1) Periapical Abscess

(2) Periapical Granuloma

(3) Radicular Cyst

(4) Phoenix Abscess

(5) Condensing Osteitis

Diseases of Periapical Tissues

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


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


Clinical Features

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


Histologic Features

begins as:

• hyperemia• edema of periodontal ligament with infiltration of chronic inflammatory cells

chiefly lymphocytes plasma cells


Histologic Features

inflammation + locally increased vascularity of tissue

• induce resorption of supporting bone adjacent to this area


Histologic Features

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


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

Clinical Features

asymptomatic

present no clinical evidence of their presence

seldom painful or even sensitive to percussion

(3) Radicular Cyst

Clinical Features

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

Histologic Features

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

(3) Radicular Cyst

localized collection of pus

surrounded by an area of inflammed tissue

hyperemia infiltration of leucocytes

(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

Clinical Features

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

(4) Phoenix Abscess

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


Clinical Features

occurs in almost young person before the age of 20 years old

commonly affected is mandibular 1st molar with large carious lesion


Clinical Features

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


Histologic Features

dense mass of bony trabeculae with little interstitial marrow tissue


Histologic Features

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:References:

BooksBooks

Cawson, R.A: Cawson’s Essentials of OralCawson, R.A: Cawson’s Essentials of Oral Oral Pathology and Oral Medicine,Oral Pathology and Oral Medicine, 88thth Edition Edition

• (page 70-72)(page 70-72) Ghom, Ali & Mhaske, Shubhangi: Textbook ofGhom, Ali & Mhaske, Shubhangi: Textbook of Oral PathologyOral Pathology

• (pages 429-433) (pages 429-433) Neville, et. al: Oral and Maxillofacial PathologyNeville, et. al: Oral and Maxillofacial Pathology 33rdrd Edition Edition

• (pages 127-138) (pages 127-138)

Shafer, et al: A textbook of Oral Pathology,Shafer, et al: A textbook of Oral Pathology, 33rdrd Edition Edition• (pages 441-456)(pages 441-456)

Abnormalities of the pulp

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