CLINICAL CLASSIFICATION & PRESENTATION OF PULP & PERIAPICAL DISEASE

what does the apical constriction allow for

the apical constriction allows in apical vessels which maintain pulp vitality

what type of tissue is the pulp

an adaptive tissue - shrinks away from caries/ trauma by laying down dentine

what gives rise to pulpal inflammation

bacteria and their by-products

what does this image show

dentinal tubule with bacteria that has entered it

what is the first irritant that will affect the pulp

the byproducts of bacteria

define sign VS symptom

sign: what you can observe as a clinician

symptom: what the patient complains about

can presenting symptoms be used to make the final diagnosis

presenting symptoms, whilst suggestive cannot be used alone to make the final diagnosis

what information is used to diagnose pulp and periapical disease

• patient complaint

• history of complaint

• clinical examination

• special investigations

  • pulp tests

  • periapical tests - palpating/ putting pressure on tooth to see patient response

  • additional tests

  • radiography

what are anatomical features unique to the dental pulp

• unyielding walls

• constricted blood source

• tooth surrounded by bone

what is the unfavourable result of unyielding walls

unyielding walls

• limited volume to accommodate pulpal swelling

• no room for expansion

what is the unfavourable result of constricted blood source

constricted blood source

• intra-pulpal pressure increases

• interferes with blood and lymph flow

• there is no other blood supply into the pulp tissue so if blood supply is interrupted, the pulp will lose vitality

what is the unfavourable result of tooth surrounded by bone 

tooth surrounded by bone

• bone infection invariably results

what are the classifications/ types of pulpal diagnoses

1. normal pulp

2. reversible pulpitis

3. symptomatic irreversible pulpitis

4. asymptomatic irreversible pulpitis

5. pulp necrosis

outline normal pulp

• pulp is symptom free

• ‘normal’ response to pulp testing e.g. cold testing results in mild or transient response of no more than 1 or 2 seconds

what is focal pulpitis and how does it arise

focal pulpitis: the initial stage of tooth pulp inflammation where only a portion of the pulp is affected

• inflammatory response in the pulp leads to focal pulpitis

what are causes of pulpitis

• caries

  • primary caries

  • secondary caries

• restorative interventions

  • restorations, crowns etc.

  • thermal damage

• trauma

• tooth surface loss

note about the causes of pulpitis

• all apart of caries will cause a transient pulpal inflammation

• however, without the involvement of bacteria, unlikely that it will be significant and lead to pulpal necrosis

how does pulpal inflammation lead to response to non-painful stimuli

pulpal inflammation will result in a lower threshold to nerve pathway firing, resulting in pain to otherwise non-painful stimuli

outline reversible pulpitis

• reversibly inflamed pulp tissue - will heal provided the initial cause of inflammation is removed

• discomfort to stimuli such as cold or sweet lasting a few seconds after the removal of the stimulus

• subjective diagnosis based on clinical findings and not related to histological status

• NO SPONTANEOUS PAIN

what may be found in conjunction with reversible pulpitis 

early caries clinically or radiographically

outline symptomatic irreversible pulpitis

• irreversibly inflamed pulp tissue with associated symptoms

• subjective diagnosis that the pulp is incapable of healing and endodontic treatment is required

• no possibility of healing - pulp will inevitably die

• tooth either needs to be extracted or RCT

what are pain characteristics of symptomatic irreversible pulpitis

• lingering pain

• spontaneous

• keeps patient awake at night

• referred pain

• pain may be difficult to localise as the inflammation has not reached the periapical tissues yet

pain will generally never cross the _______

midline

outline asymptomatic irreversible pulpitis 

• irreversibly inflamed pulp tissue without associated symptoms

• subjective diagnosis that the pulp is incapable of healing and endodontic treatment or extraction is required

• not a particularly frequent diagnosis

what is an example where a diagnosis of asymptomatic irreversible pulpitis may be made 

• vital, responsive pulp 

• extent of caries is too much for the pulp to recover

» asymptomatic irreversible pulpitis

explain what happens if pulpal inflammation is left untreated

• untreated inflammation leads to pulp necrosis

• invasion of microbes into the resulting pulp space will lead to periapical pathology

• initially, just the microbial toxins causes inflammation in the pulp but as infection progresses, the microbes themselves will penetrate the pulpal space

can pulps die/ become necrotic without any symptoms

• yes!

• many pulps die with no symptoms

• a tooth may be asymptomatic but have gone through the necrosis process already

what is the pathway to pulp death

does not necessarily have to follow this

outline pulp necrosis 

• dental pulp is necrotic and endodontic treatment is indicated

• tooth is non-responsive to pulp testing and is asymptomatic

  • a tooth might not respond to pulp testing for other reasons such as calcification - pulp can calcify as a response to a threat

can pulp necrosis cause periodontitis by itself

pulp necrosis by itself does not cause periapical periodontitis without the presence of bacteria

for what other reason can the pulp become necrotic

• the pulp can also become necrotic due to trauma

why do teeth that become necrotic due to trauma get infected quickly

• the pulp tissue has died so the tooth no longer has defensive mechanisms that are usually able to respond to any bacteria that attack it

• so as soon as that tooth has a crack or gum recession i.e. the dentinal tubules are exposed, the bacteria will have a portal of entry

how does pulp necrosis lead to infection

• pulp dies

• invasion of the pulp chamber space by microbes

• development of an ecosystem and formation of biofilm within the root canal system » infection

• toxins from the infection will eventually leak through the apical foramen » periapical pathology

why do bacteria generally stay within the pulpal space

• bacteria have something to feed on within the pulp space (the necrotic tissue)

• the bacteria are also kept away from the body’s host defences within the pulpal space 

• however bacteria can progress through the apical foramen » extraradicular infection

what happens at the periapex if it is infected 

• tissue fluid buildup 

• inflammatory exudate

• immune cells

• bony tissue around the tooth apex starts to resorb

terminology to remember

• apical periodontitis = periapical periodontitis = peri-radicular periodontitis

  • peri-radicular: around the root, not necessarily at the apex of the tooth

• chronic = asymptomatic

• acute = symptomatic

the great majority of periapical periodontitis lesions are ____________

the great majority of periapical periodontitis lesions are asymptomatic

what do the red and blue circles indicate

• red circles = periapical pathology

• blue circle = cyst

what are the classifications/ types of periapical diagnoses

1. normal apical tissues

2. symptomatic (acute) periapical periodontitis

3. asymptomatic (chronic) periapical periodontitis

4. acute periapical abscess

5. chronic periapical abscess

6. condensing osteitis

outline normal apical tissues 

normal apical tissues

• tissues are not sensitive to clinical testing

• radiographs show normal periapical tissues

outline symptomatic (acute) periapical periodontitis

symptomatic (acute) periapical periodontitis

• inflammation has spread to the periapical tissues resulting in tenderness to pressure

• patient is able to localise the source of the pain to a specific tooth - infection has now reached PDL which has mechanoreceptors that tell patient the source of pain

• radiographic changes may or may not be visible

outline asymptomatic (chronic) periapical periodontitis

asymptomatic (chronic) periapical periodontitis

• inflammation has spread to the periapical tissues

• the inflammation is low grade and presents with no symptoms

• radiographic changes appear as a periapical radiolucency

outline acute periapical abscess

acute periapical abscess

• inflammation of the periapical tissues with pus formation and swelling

• rapid onset

• spontaneous pain

• extreme tenderness of tooth to pressure 

• patient may experience malaise, fever and lymphadenopathy

• radiographic changes may or may not be visible

outline chronic periapical abscess

chronic periapical abscess

• inflammation of periapical tissues with intermittent discharge of pus through an associated sinus tract 

• usually associated with little or no discomfort because the pus is able to escape (no pressure buildup)

• radiographic changes usually appear as a periapical radiolucency

• usually presents as a little red lump just above the tooth

outline condensing osteitis

condensing osteitis

• diffuse radiopaque lesion representing a localised bony reaction to a low grade inflammatory stimulus usually seen at the apex of the tooth 

  • increased mineralisation around apices of teeth

• stimulus will often have been present for a long time 

is the tooth vital or non-vital in condensing osteitis

• tooth may still be vital but chronically inflamed

• tooth can also be non vital and unresponsive to special testing

radiographic examples of periapical pathologies

note!

important to come up with both a pulpal and a periapical diagnosis!