Diseases of pulp

• Dental pulp is a connective tissue which

contains of small blood vessels,
lymphatics, myelinated and unmyelinated
nerve and undifferentiated connective
tissue.

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• Pulp is the formative organ of the tooth.
• Pulp builds primary dentin during the
development of tooth eruption, secondary
dentin after tooth eruption and tertiary or
reparative dentine in response to
stimulation as long as odontoblast remain
intact.

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• Functions-
Nutritive: surrounding tissues supplied with
moisture and nutrients
Sensory: Pain perception
Protective: the formation of
reparative /secondary dentin.

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 Causes of pulp disease
1. Physical
A. Mechanical
a) Trauma
b) Pathologic
B. Thermal
C. Electrical
2. Chemical
A. Erosion
3. Bacterial

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 Diseases of pulp
• Inflammation
A. Reversible pulpitis
B. Irreversible pulpitis
• Pulp degeneration
A. Calcification
B. Others
• Necrosis

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 Reversible pulpitis
• Inflammatory condition of pulp caused by
noxious stimuli in which pulp is capable of
returning to the uninflamed state after the
removal of stimuli.
• Symptoms-
Sharp pain, lasting for moment.
Most commonly by cold stimuli, does not continue
when the cause is removed.
• Symptomatic ( acute ) / Asymptomatic
( Chronic)
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• Diagnosis
Application of cold.
• Treatment
Prevention,
Filling of cavity.

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 Irreversible Pulpitis
• Persistent inflammatory condition of the
pulp
• Pain persists after the stimulus is been
removed.
• Cause-
Bacterial involvement through caries,
Reversible pulpitis may deteriorate into
irreversible pulpitis.

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• Symptoms-
Short duration of pain following temperature
changes
Sharp, shooting type of pain
Bending/ Lying down or change in position
may exacerbate the pain.
Pain is increased by heat and relieved by
cold
In later stages apical periodontitis develop.
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• Diagnosis
On inspection deep cavity / decay under
filling
Radiographically proximal cavity.

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 PULP POLYP ( Chronic
hyperplastic pulpitis )
• Excessive,exurbent
proliferation of chronically
Inflammed pulp tissue.
• Mushroom-shaped
polyp-stalk.
• Pulp appears as
pinkish-red globule of
tissue, feeling the
entire cavity 12
• Diagnosis-
Polypoid pulp tissue in the confines of tooth
Radiographas show large cavity.
• Treatment-
Removal of pulp tissue followed by extirpation

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 Internal Resorption
• It is slow or fast resorptive process
occurring in the dentin or pulp of tooth.
• Cause is not known, but such patient has
h/o trauma

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 Symptoms-
Asymptomatic, common in maxillary ant.
The crown may be manifested as pinkish area,
The pink spot appears late when the disease
affects the integrity of tooth.

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• Radiographs show defects- change in the wall
of
• pulpal space or root canal
• Round radiolucent shadow.

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• Treatment
Extirpation of pulp.

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 Pulp degeneration
• A part of pulp tissue replace by calcific
material.
• Asymptomatic.
• Radiographic detection.

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 Diseases of Pariapical tissue
• Apical peiodontitis
• Periapical abscess
• Periapical granuloma
• Periodontal cyst
• Osteomyelitis
• Focal Diffuse Periosteitis
• Cellulitis

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 Apical Periodontitis
• Apical Periodontitis Inflammation of
around apical portion of root.
• Cause: spread of infection following pulp
necrosis,occlusal trauma, inadvertent
endodontic procedures etc.
• Types: 1.Acute Apical Periodontitis
2.Chronic Apical Periodontitis

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 Acute Apical Periodontitis
• CLINICAL FEATURES:
– Thermal changes does not induce pain.
– Slight extrusion of tooth from socket.
– Cause tenderness on mastication due to
inflammatory edema.
– Due to external pressure, forcing of edema
fluid against already sensitized nerve endings
results in severe pain.
RADIOGRAPHIC FEATURES: Appear normal
except for widening of PDL space.
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 Chronic Apical Periodontitis
(Periapical Granuloma)
• Most common sequelae of pulpitis or
apical periodontitis.
• Periapical granuloma is localized mass of
chronic granulation tissue formed in
response to infection.
• CLINICAL FEATURES: Tooth involved is
non vital /slightly tender on percussion.
Percussion may produce dull sound
instead metallic due to granulation tissue
at apex.
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 • Mostly pain on chewing on solid food.
• Tooth may be slightly elongated in socket.
• Sensitivity is due to hyperemia, edema &
inflammation of P .
• In many cases, asymptomatic.
• Fully developed granuloma seldom
presents more severe clinical symptoms.
• No perforation of bone & oral mucosa
forming fistulous tract unless undergoes
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 • RADIOGRAPHIC FEATURES: Thickening
of PDL at root apex.
• As bone resorption & proliferation of
granulation tissue appears to be
radiolucent area.
• radiopaque line or zone of sclerotic bone
sometimes seen outlining lesion.
• Long standing lesion may show varying
degrees of root resorption
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 Periapical Abscess (Dento-Alveolar
abscess, Alveolar Abscess)
• Developed from acute periodontitis AND
periapical granuloma.
• Acute exacerbation of chronic lesion
Phoenix Abscess Cause due to – pulp
infection, traumatic injury pulp necrosis,
irritation of periapical tissues ( endo
procedures).

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• CLINICAL FEATURES: Features of acute
inflammation. Tenderness of tooth, which
relives after pressure application.
• Chronic abscess generally presents no
features, since it is mild, well
circumscribed area of suppuration which
spread from local area.
• RADIOGRAPHIC FEATURES: Slight
thickening of PDL space. Radiolucent area
at apex of root.
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 Periapical Cyst
• Apical Periodontal Cyst, Radicular Cyst,
Periapical Cyst, Root End Cyst,
• Common odontogenic cyst encountered.
• True cyst, since consits of pathological
cavity lined byepithelium & fluid filled.
• Etiopathogenisis: Caries, trauma,
periodontal disease Pulp death Apical
bone inflammation Granuloma formation
Stimulation, then proliferation of epithelial
cell rests of Malassez Cystification 30
• CLINICAL FEATURES:
– Most cases are Assymptomatic
– Age: commonly 20-60 yrs,
– Common tooth maxillary anteriors.
– Non vital tooth/deep caries/restoration which
is painfull on percussion.
– In some cases, cyst may undergo acute
exacerbation & develop abscess that may
proceed to cellulitis/ fistula.

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• RADIOGRAPHIC FEATURES:
– Radolucency – round/ ovoid with a narrow
opaque margin which is continuous with
lamina dura.
– In long standing cyst bone resorption of
affected teeth & occasional resorption of adj.
teeth may be seen.

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 Osteomyelitis
• The word “osteomyelitis” originates from the
ancient Greek words osteon (bone) and
muelinos (marrow) and literally means infection
of medullary portion of the bone.
• Predisposing Factors: - trauma, accidents,
gunshot wounds, radiation damage, Paget’s
disease & osteoporosis.
• systemic conditions like malnutrition, acute
leukemia, uncontrolled DM Immunosuppression
sickle cell anemia & chronic alcoholism.

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 • TYPES OF OSTEOMYELITIS:
– SUPPURATIVE OSTEOMYELITIS
– FOCAL SCLEROSING OSTEOMYELITIS
– DIFFUSE SCLEROSING OSTEOMYELITIS
– PROLIFERATIVE PERIOSTITIS

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• SUPPURATIVE OSTEOMYELITIS
ONSET OF DISEASE 4 WEEKS
– Acute suppurative osteomyelitis
– Chronic suppurative osteomyelitis
• Onset of disease Deep bacterial invasion
into medullary & cortical bone
• SUPPURATIVE OSTEOMYELITIS Source
of infection is usually an adjacent focus of
infection associated with teeth or with local
trauma. 35
• It is a polymicrobial infection,
predominating anaerobes such as
Bacteriods, Porphyromonas or Provetella.
• Staphylococci may be a cause when an
open fracture is involved.
• Mandible is more prone than maxilla as
vascular supply is readily compromised..

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 ACUTE SUPPURATIVE
OSTEOMYELITIS
• Organisms entry into the jaw, mostly
mandible, compromising the vascular
supply Medullary infection spreads
through marrow spaces
• Thrombosis in vessels leading to
extensive necrosis of bone Lacunae empty
of osteocytes but filled with pus ,
proliferate in the dead tissue

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• Suppurative inflammation extend through
the cortical bone to involve the periosteum
• Stripping of periosteum comprises blood
supply to cortical plate, predispose to
further bone necrosis
• Sequestrum is formed bathed in pus,
separated from surrounding vital bone

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• CLINICAL FEATURES
– EARLY :
• Severe throbbing, deep- seated pain.
• Swelling due to inflammatory edema.
• Gingiva appears red, swollen & tender.
– LATE : Distension of periosteum with pus.
• Subperiosteal bone formation cause swelling to
become firm.

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• RADIOGRAPHIC FEATURES
– May be normal in early stages of disease .
– Do not appear until after at least 10 days.
– Radiograph may demonstrate ill-defined
radiolucency.
– After sufficient bone resorption irregular,
moteaten areas of radiolucency may appear.

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 CHRONIC SUPPURATIVE
OSTEOMYELITIS
• Inadequate treatment of acute
osteomyelitis
• Periodontal diseases
• Pulpal infections
• Extraction wounds
• Infected fractures
• Infection in the medulllary spaces spread
and form granulation tissue

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• Granulation tissue forms dense scar to
wall off the infected area
• Encircled dead space acts as a reserviour
for bacteria & antibiotics have great
difficulty reaching the site
• CLINICAL FEATURES Swelling Pain
Sinus formation Purulent discharge
Sequestrum formation Tooth loss
Pathologic fracture
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 • RADIOLOGY FEATURES:
– Patchy, ragged & ill defined radiolucency.
Often contains radiopaque sequestra.
– Sequestra lying close to the peripheral
sclerosis & lower border.
– New bone formation is evident below lower
border.

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 • FOCAL SCLEROSING OSTEOMYELITIS
Also known as “Condensing osteitis”.
Localized areas of bone sclerosis. Bony
reaction to low-grade peri-apical infection
or unusually strong host defensive
response. Association with an area of
inflammation is critical.

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• CLINICAL FEATURES
– Children & young adults are affected.
– In mandible, premolar & molar regions are
affected.
– Bone sclerosis is associated with non-vital
tooth.
– No expansion of the jaw.

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• RADIOLOGY FEATURES
– Localized but uniform increased radiodensity
related to tooth.
– Widened periodontal ligament space or peri-
apical area.
– Sometimes an adjacent radiolucent
inflammatory lesion may be present.
– Increased areas of radiodensity surrounding
apices of nonvital mandibular first molar

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 DIFFUSE SCLEROSING
OSTEOMYELITIS
• It is an ill-defined, highly controversial,
evolving area of dental medicine. Exact
etiology is unknown. Chronic intraosseous
bacterial infection creates a smoldering
mass of chronically inflammed granulation
tissue.

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 • CLINICAL FEATURES
– Arises exclusively in adult-hood with no sex
pre-dominance.
– Primarily occurs in mandible.
– No pain. No swelling.
• RADIOLOGY features
– Increased radiodensity may be seen
surrounding areas of lesion.
– Diffuse area of increased radiodensity of Rt.
Side of mandible
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 PROLIFERATIVE
PERIOSTITIS
• Also known as “ Periostitis ossificans” &
“Garee’s osteomyelitis”. It represents a
periosteal reaction to the presence of
inflammation. Affected periosteum forms several
rows of reactive vital bone that parallel each
other & expand surface of altered bone.
• PATHOGENESIS The spread of low-grade,
chronic apical inflammation through cortical
bone Periosteal reaction occurs.

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• CLINICAL FEATURES
– Affected patients are primarily children & young
adults.
– Incidence is mean age of 13 years.
– No sex predominance is noted.
– Most cases arise in the premolar & molar area of
mandible.
– Hyperplasia is located most commonly along lower
border of mandible.
– Most cases are uni-focal, multiple quadrants may be
affected.

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• RADIOLOGY FEATURES
– Radiopaque laminations of bone roughly
parallel each other & underlying cortical
surface.
– Radiolucent separations often are present
between new bone & original cortex.

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 CELLULITIS
• An acute, diffuse, spreading infection of
the skin, involving the deeper layers of the
skin and the subcutaneous tissue.
• unilateral swelling and redness of the face
as well as fever and malaise are usually
present.

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 • CAUSES:
– Staphylococcus
– Streptococcus
– H. Influenzae (periorbital cellulitis)

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