Diseases Of Pulp And Periapical tissues Notes

Periapical Tissue Diseases

Barodontalgia Or Aerodontalgia

It is pain experienced in a recently restored tooth during low atmospheric pressure. Pain is experienced either during ascent or descent. Chronic pulpitis which appears asymptomatic in normal conditions may manifest as pain at high altitudes because of low pressure. It is generally seen in altitudes over 5,000 ft but is more likely to be observed in 10,000 ft and above.

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Rauch classified bar odontalgia according to the chief complaint:

• Class I: In acute pulpitis, sharp pain occurs for a moment on the ascent.
• Class II: In chronic pulpitis, dull throbbing pain occurs on an ascent.
• Class III: In necrotic pulp, dull throbbing pain occurs on descent but it is asymptomatic on ascent.
• Class IV: In periapical cyst or abscess, severe and persistent pain occurs with both ascent and descent

Possible mechanism of bar odontalgia:

• Direct ischemia results from inflammation itself.
• Indirect ischemia results from increased intrapulpal pressure due to vasodilatation and fluid diffusion to the tissue.
• Due to the expansion of intrapulpal gas which is a by-product of acids, bases, and enzymes of inflamed tissues.
• Due to leakage of gas through vessels because of decreased gas solubility.

Reversible Pulpitis Or Hyperemia Or Hyperactive Pulpalgia

This is the first stage of pulpitis giving a sharp hypersensitive response to cold, but the pain subsides on the removal of the stimulus. The patient may describe symptoms of momentary pain and is unable to locate the source of pain. This stage can last for months or years.

Reversible Pulpitis Definition:

Reversible pulpitis is a mild-to-moderate inflammatory condition of pulp caused by noxious stimuli in which the pulp is capable of returning to a normal state following the removal of stimuli.

It is an indication of peripheral Aδ-fier stimulation. Determination of reversibility is the clinical judgment which is influenced by a history of the patient and clinical evaluation.

Reversible Pulpitis  Etiology:

In normal circumstances, enamel and cementum act as an impermeable barriers to block the patency of dentinal tubules. When a stimulus interrupts this natural barrier, dentinal tubules become permeable, causing inflammation of the pulp. Etiological factors can be

• Dental caries
• Trauma: Acute or chronic occlusal trauma
• Thermal injury:
  • Tooth preparation with dull bur without coolant
  • Overheating during the polishing of a restoration
  • Keeping bur in contact with teeth too long
• Chemical stimulus—like sweet or sour foodstuff
  

Reversible Pulpitis Symptoms:

• Characterized by sharp momentary pain, commonly caused by cold stimuli.
• Pain does not occur spontaneously and does not continue after the removal of the irritant.
• Following the insertion of deep restoration, the patient may complain of mild sensitivity to temperature changes, especially cold. Such sensitivity may last for a week or longer but gradually, it subsides. This sensitivity is a symptom of reversible pulpitis.

Reversible Pulpitis Histopathology:

• It shows hyperemia to mild-to-moderate inflammatory changes
• Evidence of disruption of the odontoblastic layer
• Formation of reparative dentin
• Dilated blood vessels
• Extravasation of edema flid
• Presence of immunologically competent chronic inflammatory and occasionally acute cells.

Reversible Pulpitis Diagnosis:

1. Pain:

It is sharp but of short duration, usually caused by cold, sweet, and sour stimuli. Pain ceases after removal of the stimulus.

2. Visual examination and history:

It may reveal caries, recent restoration, traumatic occlusion, and undetected fractures.

3. Reversible Pulpitis Radiographic examination:

• Shows normal PDL and lamina dura, i.e., normal periapical tissue.
• Presence of deep dental caries or restoration.

4. Reversible Pulpitis Percussion test:

The tooth is normal to percussion and palpation without any mobility

5. Reversible Pulpitis Vitality test:

Pulp responds readily to cold stimuli.

Reversible Pulpitis  Diffrential Diagnosis:

• In reversible pulpitis, the pain disappears on the removal of stimuli, whereas in irreversible pulpitis, the pain stays longer even after the removal of stimulus.
• The patient’s description of pain, character, and duration leads to the diagnosis.

Treatment:

• The best treatment of reversible pulpitis is prevention.
• Usually, a sedative dressing is placed, followed by permanent restoration when symptoms completely subside.
• Periodic care to prevent caries, desensitization of hypersensitive teeth, and proper pulp protection by using cavity varnish or base before placement of restoration is recommended.
• If pain persists despite of proper treatment, pulpal inflammation should be considered as irreversible and it should be treated by pulp extirpation.

Irreversible Pulpitis

Irreversible Pulpitis Definition:

“It is a persistent inflammatory condition of the pulp, symptomatic or asymptomatic, caused by a noxious stimulus.” It has both symptomatic and asymptomatic stages in pulp.

Irreversible Pulpitis Etiology:

Irreversible pulpal inflammation can result from

• Dental caries (most common cause)
• Chemical, thermal, and mechanical injuries of pulp
• Untreated reversible pulpitis

Irreversible Pulpitis Symptoms

• Rapid onset of pain, caused by sudden temperature change, sweet, or acidic food. Pain remains even after the removal of the stimulus.
• Pain can be spontaneous in nature which is sharp, piercing, intermittent, or continuous in nature.
• Pain exacerbated on bending down or lying down due to a change in intrapulpal pressure from standard to supine.
• Pain is so severe that it keeps the patient awake in night.
• Presence of referred pain.
• In later stages, pain is severe, boring, and throbbing in nature which increases with hot stimulus. Pain is relieved by using cold water. Sometimes the pain is so severe that the patient may report dental clinic with jar of ice-cold water.
• Apical periodontitis develops in later stages when inflammation extends to the periodontal ligament.

Irreversible Pulpitis Histopathology:

Pulp shows acute and chronic inflammatory changes such as

• Vascular dilatation and edema
• Granular cell infiltration
• Odontoblasts are destroyed
• Formation of minute abscess formation
• In later stages, pulp undergoes liquefaction and necrosis

Irreversible Pulpitis Diagnosis:

1. Visual examination and history:

One may find deep cavities involving pulp or secondary caries under restorations.

2. Irreversible Pulpitis Radiographic findings:

• Shows depth and extent of caries
• The periapical area shows normal appearance but a slight widening may be evident in advanced stages of pulpitis.
  

3. Irreversible Pulpitis Percussion:

Sometimes a tooth is tender on percussion because of increased intrapulpal pressure due to exudative inflammatory tissue.

4. Irreversible Pulpitis Vitality tests:

• Thermal test:

Hyperalgesic pulp responds more readily to cold stimulation than for normal teeth, pain may persist even after the removal of the irritant. As pulpal inflammation progresses, heat intensifies the response because of its expansible effect on blood vessels. Cold tends to relieve pain because of its contractile effect on vessels, thereby reducing the intrapulpal pressure.

• Electric test:

Less current is required in the initial stages. As the tissue becomes more necrotic, more current is required to generate the response.

Irreversible Pulpitis Treatment:

A pulpectomy, i.e., root canal treatment.

Irreversible Pulpitis Signs and Symptoms:

• It is usually asymptomatic.
• Fleshy pulpal tissue fills the pulp chamber. It is less sensitive than normal pulp but bleeds easily due to a rich network of blood vessels.
• Sometimes this pulpal growth interferes with chewing

Chronic Hyperplastic Pulpitis

It is an inflammatory response of pulpal connective tissue due to extensive carious exposure of a young pulp. It shows the overgrowth of granulomatous tissue into carious cavity.

 

Etiology:

The hyperplastic form of chronic pulpitis is commonly seen in the teeth of children and adolescents because in these pulp tissue has high resistance and large carious lesion permits free proliferation of hyperplastic tissue.

Chronic Hyperplastic Pulpitis Histopathology:

• The tissue of pulp chamber is transferred into granulation tissue which projects out from pulp chamber.
• Granulation tissue contains PMNs, lymphocytes, and plasma cells.
• The surface of pulp polyp is usually covered by stratified squamous epithelium which may be derived from gingiva, desquamated epithelial cells of mucosa and tongue.
• Nerve fiers may be present in the epithelial layer.
  

Chronic Hyperplastic Pulpitis Diagnosis:

•  Pain: It is usually absent
•  The hyperplastic form shows a fleshy, reddish pulpal mass which fills most of the pulp chamber or cavity. It is less sensitive than normal pulp but bleeds easily when probed. When it is cut, it does not produce pain but pain can result due to pressure transmission to the apical part
• Vitality tests
  • The tooth may respond feebly or not at all to thermal tests unless one uses extreme cold.
  • More than normal current is required to elicit the response by the electric pulp tester.
•  Diffrential diagnosis:

Hyperplastic pulpitis should be diffrentiated from proliferating gingival tissue. It is done by raising and tracing the stalk of tissue back to its origin, that is, pulp chamber.

Chronic Hyperplastic Pulpitis Treatment:

• In case of hyperplastic pulpitis, removal of polypoid tissue using a periodontal curette or spoon excavator followed by root canal treatment.
• If a tooth is at the nonrestorable stage, it should be extracted.