DEN 4201 | M: 1st Quiz (Pulp and Periapical Dis.)

• Bacterial

• Traumatic

• Chemical

• Thermal

• Electrical

• Systemic

6 ETIOLOGIES OF PULPAL AND PERIAPICAL LESIONS

main etiology; cause dental caries that may progress into pulp tissue, leading to pulpitis

explain pulpal and periapical lesions due to bacteria

injury to tooth causing pulp necrosis

• Trauma to a tooth can damage the pulp, leading to pain and nerve death, which may spread to the root area, causing infection, abscess, or cyst formation, requiring a root canal or extraction.

explain pulpal and periapical lesions due to trauma

Acidity to pulp; erosion

explain pulpal and periapical lesions due to chemicals

galvanism; amalgam restorations

explain pulpal and periapical lesions due to electricals

Systemic diseases that cause resorption and calcification in tooth, may lead to pulpal disease and infection (e.g. hyperthyroidism and hypercalcemia)

explain pulpal and periapical lesions due to systemic conditions

toothache or tooth sensitivity

the usual chief complaint of patient

• reversible pulpitis

• irreversible pulpitis

• pulp necrosis

• previously treated

• previously initiated

5 CLASSIFICATION OF PULPAL DISEASE

Reversible pulpitis

PULPAL DISEASE

- Mildest form; does not need RCT

- Pulp can go back to normal when appropriate treatment is done

○ Restorations with base

○ Correct sealing of crown to avoid leakage

If reversible pulpitis is recognized early, what measures can be done?

Clinically, the acutely inflamed pulp is symptomatic, while the chronically inflamed pulp is asymptomatic.

compare symptomatic and asymptomatic irreversible pulpitis

Pulp Necrosis

PULPAL DISEASE

- pulp is not only damaged but already dead from trauma or injury

- death of the pulp

Previously Treated

PULPAL DISEASE

- For re-treatment cases

Previously Initiated

PULPAL DISEASE

- RCT is not completed

• thermal tests (cold/heat)

• electric pulp test

in a normal/healthy pulp tissue, which diagnostic tests should positive as the result?

• percussion test

• palpation test

• mobility test

in a normal/healthy pulp tissue, which diagnostic tests should negative as the result?

pulp hyperemia

other term for reversible pulpitis

Reversible pulpitis (or Pulp Hyperemia) is the early, mild inflammation of the pulp that can heal if treated promptly with proper restorations and sealing but may worsen into irreversible pulpitis if ignored. The result is positive in thermal test and electric pulp test.

what is reversible pulpitis?

Irreversible pulpitis is a severe pulp inflammation, often caused by caries or trauma, where the pulp remains vital but cannot heal, causing pain in acute cases and silent damage in chronic cases, eventually leading to pulp death if untreated. If you treat it with restoration, pressure will buildup and pain will be more severe. The result is positive in thermal test and electric pulp test.

what is irreversible pulpitis?

Symptomatic irreversible pulpitis

- Characterized by intermittent paroxysms of pain; continuous lingering pain

- No triggers; there is pain even without stimulus

- Mild to severe pain

- There is immediate reaction to pulp test; after removing stimulus, there is still pain lingering

● Pulp Polyp

● Internal Resorption

● Calcification

3 ASYMPTOMATIC IRREVERSIBLE PULPITIS

CHRONIC HYPERPLASTIC PULPITIS (PULP POLYP)

- reddish cauliflower-like growth; big cavity with exposure of the pulp exhibiting inflammation (redness)

- usually happens in young permanent teeth or deciduous dentition with big cavity

- low-grade chronic irritation of the pulp and generous/high vascularity; big pulp chamber or root canals in deciduous teeth, incomplete closure of root development in young permanent teeth
- may cause mild, transient pain during mastication especially when food contacts with the pulp

- Pulp is epitheliated usually to withstand mastication, otherwise pulp will always bleed

A pulp polyp (chronic hyperplastic pulpitis) is a reddish cauliflower-like overgrowth of inflamed pulp tissue from a large cavity or an exposed pulp chamber, usually seen in young teeth with open apices. Typically painless due to lack of nerve involvement.

what is pulp polyp?

depending on the extent of caries and the amount of sound tooth tissue structure, know when to do RCT or extraction instead

treatment for pulp polyp

INTERNAL RESORPTION

Painless expansion of the pulp resulting from destruction of dentin (odontoclastic activity)

- Identified during routine radiograph

- Might lead to root perforation

- Prompt RCT prevents tooth destruction

- Leads to pink tooth of mummery then calcification (repair → pulp stones) later on

PINK TOOTH OF MUMMERY

• Resorption of dentin occurs in the crown portion, leaving a thin shell of enamel only; may be treated with RCT and crown

• if there is internal resorption in the crown portion, there is thinning of dentin; only a shell of enamel is remaining; color of the pulp shows through

CANAL CALCIFICATION

Happens when the pulp produces excess dentin to narrow or completely block the canal as a response to irritation, trauma or old age

- A sign that the pulp is protecting itself by “walling off”

- Presence of pulp stones → irregular calcifications

- Caused by old age, trauma, injury, caries and old restorations

Reversible pulpitis causes momentary sharp pain that disappears quickly after removing the stimulus, with no referred pain and no change when lying down. It requires an external stimulus like heat, cold, or sugar. In contrast, irreversible pulpitis leads to continuous throbbing pain lasting minutes to hours, with referred pain common. Pain increases when lying down due to pressure buildup and can occur spontaneously, especially at night.

compare reversible pulpitis and irreversible pulpitis based on their time of pain, location of pain, when lying down and stimulus

Reversible pulpitis shows early response in EPT, negative percussion, no color change, and no radiographic findings. In contrast, irreversible pulpitis may have a mixed or delayed EPT response, negative percussion in early stages but positive when the periapex is involved, possible tooth darkening, and radiographic signs like slight PDL space widening or trabecular changes in late stages. If left untreated, necrotic byproducts can spread to periapical tissues.

compare reversible pulpitis and irreversible pulpitis based on EPT, PERCUSSION, COLOR AND RADIOGRAPH

widening of the PDL

what happens during late of stage of symptomatic irreversible pulpitis

Pulp Necrosis/Necrotic Pulp

death of the pulp tissue

- may be due to trauma/accidents or from irreversible pulpitis if left untreated

- asymptomatic, negative in thermal test and electric pulp test

Gangrene

necrosis of tissue due to ischemia with superimposed bacterial infection

Putrefaction

anaerobic process of splitting enzymes by bacteria and fungi with formation of foul smelling

incompletely oxidized products

Previously Treated

- a clinical diagnostic category indicating that the tooth has been endodontically treated and the canals are obturated with various filling materials other than intracanal medicaments.

- the tooth typically does not respond to thermal or electric pulp testing since it is previously treated and there is no pulp tissue anymore

- tooth already has RCT; after a long-time, it became symptomatic again, so there is need for re-treatment of RCT

Previously Initiated

- is a clinical diagnostic category indicating that the tooth has been previously treated by partial endodontic therapy such as pulpotomy or pulpectomy.

- depending on the level of therapy, the tooth may or may not respond to pulp testing modalities.

- transfer cases or incomplete cases of RCT going to other dentists

in a radiograph, the previously treated cases have gutta percha in the tooth whereas the previously initiated cases have intracanal medicament, restoration and open cavity access preparation in the tooth

previously treated vs previously initiated in a radiograph

Periapical disease occurs when bacterial toxins from a necrotic pulp spread through the apical foramen, affecting surrounding tissues, starting asymptomatic but later causing pain and tenderness when biting.

• usually caused by the overflow of endotoxin bacterial byproducts of necrosis to the apical foramen, causing spread to the periapical tissues

• asymptomatic in early stage (necrosis)

• tenderness when biting

what is a periapical disease?

• symptomatic apical periodontitis

• asymptomatic apical periodontitis

• chronic apical abscess

• acute apical abscess

• condensing bone osteitis

5 CLASSIFICATION OF PERIAPICAL DISEASES

inflammation in apical area due to BACTERIA or TRAUMA

etiology of symptomatic apical periodontitis

Inflammation spreading to periapical tissues

○ Reversible Pulpitis

○ Irreversible Pulpitis

○ Necrosis → pulp is non-vital

symptomatic apical periodontitis pulpal in origin

symptomatic apical periodontitis

• due to trauma from over-contoured restorations and premature contacts which should only be corrected, no need for RCT

• due to overextension beyond apical foramen of instruments or materials during RCT, iatrogenic → secondary apical periodontitis

symptomatic apical periodontitis periodontal or endodontic in origin

The widening of the PDL space at the apex and tenderness to percussion are signs of asymptomatic apical periodontitis in its early stages. But, it is usually painless, with negative palpation and no mobility, unless the infection worsens and spreads. The infection causes chronic inflammation in the periapical tissues, leading to bone changes visible on X-rays.

what is ASYMPTOMATICAPICALPERIODONTITIS?

CHRONIC APICAL ABSCESS

- presence of sinus tract is seen clinically (gum boil)

- result of untreated necrosis or acute apical periodontitis

- non-vital pulp; (-) pulp test, (+) percussion, palpation, little to no mobility

interruption of lamina dura - where there is loss of bone or bone resorption

what can be seen in the radiograph of chronic apical abscess?

RCT - not antibiotics

treatment of chronic apical abscess

A gum boil is a sinus tract opening formed when pus from chronic apical abscess drains through bones/gums releasing infection.

what is a gum boil?

Sinus tract tracing involves inserting gutta-percha into the gum boil (sinus tract opening) and taking an X-ray to locate the source of a chronic apical abscess.

what is sinus tract tracing?

ACUTE APICAL ABSCESS

a rapidly spreading infection due to necrotic pulp resulting in localized collection of pus in the periapex

- (+) percussion, palpation and mobility tests

- tooth is painful when biting

- swelling, intraoral and facial near tooth involved; there is swelling in one side or part of the face where the involved tooth is located

- tooth may be excluded from the socket

- may have fever and weakness

5 SYMPTOMS OF ACUTE PERIAPICAL ABSCESS

antibiotics to prevent spread of pus (unlike chronic periapical abscess which RCT is the only effective tx)

treatment for acute apical abscess

Condensing osteitis is defensive mechanism wherein the bone calcifies/mineralizes to form walls around an infection and prevent it from spreading to the periapical area.

WHAT IS CONDENSING OSTEITIS?

● Do RCT immediately before it fully calcifies to the root, so that it will be easier because calcification hasn’t reached the root yet; OR

● Wait and see until symptoms arise because tooth is still healthy; only do RCT when condition progresses

treatment for condensing osteitis

increased trabecular bone density

radiographic features of condensing osteitis

PHOENIX ABSCESS

• acute apical abscess second time on the same tooth

• symptoms: swelling or significant pain

• radiograph: apical radiolucency

• (-) pulp test, (+) periapical test

ACUTE DENTOALVEOLAR ABSCESS

• when abscess reaches the other tooth

• symptoms: swelling and significant pain

• radiograph: PDL within normal limits or widened

• (-) pulp test, (+) periapical test

REVERSIBLE PULPITIS

almost all pulpal and periradicular lesions need RCT, but which does not need it?

if the tooth is already necrotic and severely mobile

when is extraction, instead of RCT, is indicated?