_3_ Pulp _ Priapical Pathosis

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					                   Pulp and priapical pathosis
At first the Dr said that the last two lectures in this semester have a lot of
important information about diagnosis and we’ll have many questions
about them in the final exam .
(Your reference in the book is chapter 4 { if u have the book  } )

Let’s start :

WHAT are the causes of pulp death ?
 1- Caries ( bacterial infection ) which is the most common insult
       for the pulp .
   2- Chemical irritants .
   3- Mechanical irritants .
   4- Thermal irritants .

   So when u have heavily restored dentition u can expect to have pulp
   pathosis in any of these teeth. And u can see the lesion by taking
   priapical radiographs because these radiographs show u the
   roots and the tissues around the roots .

The pulp is very well vasculated and has its own immune defense &
inflammatory cells , so it can resist for long time before death .

    As u know from your previous knowledge that :
    1- Dentinal tubules are opened so they are pathways for
       bacteria or irritants to reach the pulp and cause death .
    2- In outer dentine, the density of the tubules is less & the
       diameter is smaller compared to the inner dentine .
    3- In inner dentine, the density of the tubules is more & the
       diameter is larger compared to the outer dentine.
       Outer dentine :                      Inner dentine :
       Density 20,000/mm²                   Density 45,000/mm²
       Diameter 1 μm                        Diameter 2.5 μm

Soooooooo
When u do a deep cavity (you’ll be closer to the pulp) there’s an
increase in the density and diameter of dentinal tubules and this
will lead to a higher chance for irritation to pulp.
In contrast if your cavity is shallow, the density and diameter of
dentinal tubules are less so the permeability is less and this is
considered as a protective mechanism which is built in the tooth
structure .

So within 0.5-1.0 mm from the pulp, the remaining dentine is highly
permeable that’s why under your restoration u should put a liner to protect
pulp .

{Examples of liners : Ca hydroxide , vitrabond (light-cured glass
inomor) }

Pulp irritants :

  1- Microbial (bacteria) :
   The most common irritant to the pulp tissue
   Response to bacterial infection, there will be chronic inflammation
    and with more invasion it may cause pulp death.
   There were experiments and investigations have established that
    pulpal or periapical pathosis does not develop without presence of
    bacteria.
   One of these classical experiments were established by Kakehashi
    who created pulp exposure in normal and germ-free rats .
Germ-free rats don’t have bacteria in their saliva .
Normal rats have bacteria in saliva .

    After period of time from pulp exposure he examined the teeth and
     found that there’s no pulpal or periapical inflammation in germ-free
     rats but in normal rats he found that the bacteria caused
     inflammation in the pulp & periapical tissues .




   2- Mechanical :
       You’ll get mechanical irritation to the pulp :
         a) IF u do cavity with excessive pressure
         b) Excessive orthodontic forces (because ideally the tooth has to
            move only 1mm in a month during orthodontic treatment, so if
            the dentist wants to do the treatment rapidly and apply too
            much forces this will cause extra pressure on the tooth, cut the
            blood vessels leading to pulp death .
         c) Over-instrumentation beyond the apex .


   3- Chemical irritants :
    From acid itching, the patient can get irritation to pulp
    Also the microleakage around the restorations (because of the gap
     between the tooth and the restorative material ) causes irritation to
     pulp .



   You should know that we’ve classification of the pulpal diseases and
   other classification of the periapical diseases .
   And every time when we ask about diagnosis u should give pulpal
   diagnosis and periapical diagnosis.
Classification of pulpal diseases

1- Reversible Pulpitis :
 From its name (reversible), it can be reversed which means go back
  to normal .
 It can be caused by caries or fractures exposing dentinal tubules .
 The symptoms are :
      - Stimulated pain : there should be a stimulus such as hot or cold
         drink or biting .
      - Sharp pain .
      - You’ll feel the pain for short duration .
 Usually the patient cannot localize which tooth is the source of pain,
  only he can tell the dentist which side is painful (the right side or
  the left one ).
 If it’s untreated it’ll progress to irreversible pulpitis and then goes to
  pulp necrosis .



2- Irreversible Pulpitis :
 From its name it cannot be reversed to normal .
 Sever and spontaneous pain .
 The pain will be for long duration .
 The pain will be exacerbated (being more prominent) while you’re
  having drinks .
 Also here the patient cannot localise the tooth most of the time ,
  because the inflammation does not reach the periapical tissue, and as
  we know that the proprioceptors ( that are responsible to determine
  the tooth which is diseased ) are located in the periapical tissue .
 The treatment for irreversible pulpitis :
     - RCT or
     - Extraction if the patient does not want to do RCT or the tooth
        is broken too much .
        { But ideally the treatment is RCT}


3-Hyperplastic pulpitis

 Is a proliferation of pulp instead of necrosis the cell will divide and
  proliferate.

 This is seen in inflamed young pulp when the cavity expose into the
  oral environment.

 9-years old patient has his 6-molar broken and in the center of the tooth
  you can find soft tissue mass like a gum it is the pulp that proliferate
  and cause Hyperplastic pulpitis.

 The histology of hyperplastic pulpitis is loose connective tissue and the
  pulp polyp is covered with epithelium because it is exposed to the oral
  cavity.

 Usually asymptomatic because the cavity expose to the oral
  environment so there is no pressure (when the pus accumulate there is
  no concentration of pressure inside the tooth).

 Treatment depends on the restorability. If the tooth is restorable (there
  is no much breakage) you do RCT just cut the pulp polyp by high
  speed bur and the bleeding will occur then it stops. But if the tooth is
  not restorable you extract it .
4-Hard tissue changes

   Instead of death, the pulp (with less inflammation) will start lying
    down hard tissue.

   If any patient has blow on his tooth but not strong enough to cause
    pulp death it will stimulate the odontoblast to lay down more tertiary
    dentine and close the root canal.

   When you make test for pulp vitality the tooth will not response
    because the root canal space is obliterated by minerals this is called
    calcific metamorphosis.

   Sometimes Internal resorption will happen. In this case part of the
    pulp is vital and part is dead.
    The osteoclast start making resorption of the dentine and it will end
    with round resorption defect inside the canal.

  5-Pulp necrosis

   Death of the pulp.

   Most of the time is asymptomatic not as irreversible
    pulpitis the patient has history of server pain in the past then he feels
    fine it dose not mean that the healing happened because when it
    becomes irreversible there is no healing. But when abscess formed
    the symptom will occur.

   Pulp Necrosis is the result of bacterial infection or trauma
   (Strong blow on the tooth causes cutting of the blood vessels and
  pulp death will happen ).
 On the pulp test (hot or cold pulp test) usually there is no response
  because the pulp is dead.
  When the pulp is inflamed it will give exaggerated response and
  sever long pain but if the pulp is normal it will give short sharp pain.

 The treatment of necrotic pulp is either RCT or extraction if the tooth is
  unrestorable .

Classification of Periapical Lesion

 Normal periapical tissue.

   On the radiograph you will see the root and periodontal ligament
   space about 1 mm radiolucent area around the tooth but when the
   periodontal space enlarges it means that there is an inflammation.

 The periapical lesion maybe symptomatic or asymptomatic .
  In symptomatic lesion the patient can’t bite on his tooth, when
  the patient bites he will immediately open his mouth because there
  is an inflammation around the root and tooth will be elevated so
  when you bite it will be the first tooth that receive the trauma and
  you will feel severe pain.

 Radiographic changes.

      - In symptomatic lesion : It will be normal with no change
        because it is acute and there’s no time to get bone resorption .

      - If it is radiolucent lesion in the radiographs u should know
       that it is a chronic apical periodontitis and pulp must be
      necrotic .
      (Histologically it can be either as granuloma or cyst).
   Condensing ostietis.

  It happened when the inflammation is chronic and slow, in this
  case the body tries to resist bone resorption so it will start lying
  down the bone.
   It response to chronic inflammation of the pulp.




   Look at this picture there is resorption in the distal root and
    it is replaced by bone.

   Gutta percha is tracing the sinus tract in the second photo
    and it is used to confirm that this abscess related to this
    tooth.

In acute apical abscess the patient comes with swelling on the
cheek or inside the mouth (in the sulcus).

On the radiograph it still has periapical area of chronic apical
periodontitis but because the patient has abscess so it is called
acute.
In chronic suppurative periodontitis the patient has a sinus
tract which is tract for pus or exudates.

If there is no sinus tract just radiolucent on radiograph it will be
chronic apical periodontitis.




The margin of class II does not reach the gingival floor ( because
it isn’t condensed very well) so there is gap and the caries occur
again and cause pulp necrosis .
It is treatable, once you do RCT and good obturation the bone
will build again.
                                      Gutta percha is tracing
                                      the abscess.
             Chronic suppurative
             (there is swelling and
             drainge)




Remember when you have tooth with periapical lesion, the root
canal space has to be infected and necrotic so in diagnosis you
should have necrotic pulp (not reversible or irreversible) and
chronic apical periodontitis.
Healing of periapical lesion

Can be by :

  1- Regeneration (The same cell of the tissue will regenerate).

   2- Repair maybe a connective tissue but the scar will occur.
This depends on the size of the lesion ( the lesion with smaller
size , the more regeneration will occur ) ( the lesion with larger
size and more resorption especially if the two plates - labial
cortical plate and palatal cortical plate are resorbed- not all area
will be healed completely by bone , it still have fibrous tissue).




                              THE END


                                              Done by :

                                Shahed Hatamleh & Areej Al-lama’


                  GOOD LUCK IN THE FINAL EXAMS 

				
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