Pulp disorders and periridicular lesions - Pulp Flashcards
What is pulpitis?
inflammation of the dental pulp
Most common cause of pulpitis?
caries
What can cause severe pain in pulpitis?
bacterial products may cause pulp to develop hyperaemia and the patient may experience pain
Is early pulpitis reversible or irreversible?
reversible
What can happen when bacteria enter the pulp?
a pulp abscess can form or complete pulpal necrosis may occur
Clinical features of pulpitis?
hard to localise pain
Radiating to the jaw, face, ear or neck
Continuous or intermittent
Can be acute or chronic (reversible or irreversible)
Clinical features of acute pulpitis?
severe throbbing pain
Hot and cold stimuli
Keeps pt awake
Severe pain lasts for 10-15 mins
Maybe continuous
Chronic pulpitis clinical features?
spontaneous attacks
Dull aching pain
Lasts for an hour or more
Clinical features of reversible pulpitis vs irreversible?
age (secondary dentine and blood supply to tooth)
Size of various lesion
Symptoms
Radiography
Vitality tests
Most common aetiology of pulpitis?
microbial insult
Attrition vs abrasion?
abrasion - foreign body (e.g tb)
Attrition - tooth to tooth contact
How can bacteria reach the pulp? (microbial insult)
dental caries
Attrition
Abrasion traumatic restorations
Traumatic cracks and fractures
Invaginated odontomes
Periodontal disease involving apical pockets
Accessory root canals
Why does age affects how oulpitis proceeds?
younger have more patent tubules and richer blood supply
Bacteria pioneer pulp from further away
older people have secondary dentine and less blood supply, bacteria have to travel further to reach the pulp
How does chemical injury cause pulpitis?
restorative procedures
Irritant substances directly applied to exposed pulp
They Diffuse through dentine and form Reactionary dentine, leading to Sclerosis and exults in Dead tracts of fish
Chemical vs bacterial injury?
chemical injury one time
Bacterial continuous
How does thermal injury cause pulpitis?
restorative procedures
- Frictional heat during cavity prep
Need Coolant
Forms Reactionary dentine, causing Sclerosis, leading to Dead tracts
Barotrauma?
changes in atmospheric pressure
E.g. divers, pilots etc
If tooth is cracked, rapid expansion causes severe pain
How does barotrauma cause pulpitis?
aerodontalgia
High altitudes
Divers
Nitrogen bubbles - causing irreversible pulpitis
Fat emboli from altered lipoproteins - causing irreversible pulpitis
Does barotrauma cause pulpitis?
not directly but can cause irritation
It’s an exacerbating factor of there is a various lesion of breach of integrity of the pulp
Effect of pulp anatomy and pulpitis?
a chamber totally surrounded by dentine (confined tissue surrounded by a chamber - dentine) - no space to expand
- no space for swelling, cause collapse of the vasculature and necrosis of teh cells and cause even more inflammatory infiltrate coming in
Limited ability to tolerate oedema
Venous collapse due to rise in pressure
Local tissue hypoxia and anoxia - no oxygen as the blood vessels have collapsed
- leading to Localised necrosis
What is the initial mild inflammatory response of the pulp caused by caries?
infiltration of the sub odontoblastic zones with lymphocytes and macrophages
Response to antigenic products from bacteria and various dentine
What happens to blood vessels when bacteria reach the pulp? (Pulpitis caused by caries)
Congested and dilated blood vessels
More exudate coming form blood vessels
Due to confined area it will lead to the collapse and necrosis
What eventually happens in pulpitis caused by caries?
formation of exudate:
Compromised circulation
Cell death
Suppuration - pus
Neutrophils
Lose structure leading to Pulp abscess
Causing pain until the pulp is completely necrotic - unless spreads to surrounding tissues
Features of a pulp abscess caused by caries?
may become static - if the host immune response is strong enough
May reduce in size - if treat tooth and allow to heal
Suppuration surrounded by proliferating granulation tissue (pyogenic membrane) - how the pup keep the abscess contained
Puss may become walled by fibrous tissue
what is the end result if caries are untreated?
pulp necrosis
Will be sterile unless bacteria reach the pulp
In a pulp polyp what type of response occurs?
hyperplastic response, granulation tissue formation
What can happen to the surface of the polyp?
May become epitheliailsed - pink in colour
Occurs through spontaneous grafting of cells in the saliva
what does an ulcerated polyp appear like?
appears dark red yellow flecked fleshy mass
- no sensation
Why may cavity prep and restorative material cause pulpitis?
speed of instrument rotation
Heat generated
Presssure (really rough preparing cavity)
Lack of Coolants
Increased cavity depth - more likely to cause inflammation
Frictional heat
Hard tissue ablation using lasers
And chemical pulpitis from the materials used
How does an epithelialised polyp appear?
firm, pink, does not bleed easily
No sensation
What happens if you over dry dentine - previous inflammation?
Odontoblasts nuclei aspirated into the dentine tubules - shown in picture
What can you do to the pulp before using an irritating material?
pulp capping
Maintain vitality following traumatic exposure and pulpotomy
Can the pulp heal without removal of caries?
yes, focal pulpitis could heal when tubules are blocked with sclerotic dentine and formation of tertiary
True pulp stones resemble what?
True Denticles resemble dentine (tubular)
What do false pulp stones resemble?
False denticles resemble bone (trapped cells)
When do pulp stones become interstitial?
when they become surrounded by secondary or tertiary dentine
What can cause pulp stones?
complication of root canal therapy
Increase with age and after restorative procedures
What type of pulp stone is shown here and what causes it?
dystrophic calcifications
Looks like Snow storm on radiograph
Due to trauma to the apical blood supply leads to pulp obliteration through formation of irregular dentine
Pulp necrosis associated with what disease?
sickle cell anaemia pts
Can the pt experience no pain with an advancing carious lesion towards the pulp?
yes,
immune cells in response to advancing caries and low-grade inflammation can spread through the root apex to the apical periodontal tissues without symptoms
What are odontomes?
Odontomas are hamartomas of aborted tooth formation which account for 22% of the odontogenic tumors. They are the most common benign
In a carious lesion, what occurs in the pulp first: bacteria or inflammation?
inflammation precedes bacteria
due to toxins.
When bacteria reach the pulp through caries, at what distance do you see histological changes in permanent teeth?
1mm from pulp
twice the distance in primary teeth - primary has patent tubules so bacteria cause irritation from further away
What modifications/differences can change the inflammatory process?
The nature of the insult
The severity f the insult
Host defence
Anatomy
Once there is cell death due to collapse of the blood vessels, what occurs/ what is the result?
Chemical mediators release by the necrotic tissue
Further inflammation
Total necrosis
Some teeth will have protection by the tertiary dentine
How does the pulp try to contain the abscess and allow it to not spread?
For in fibrous tissue sounding the pulp tissue called a pyogenic membrane
What is shown here?
Pyogenic membrane
- can see collapse of structures
Containing the abscess
If not treated it will spread
What happens if pulpitis card by caries is left untreated?
May continue to expand
Bacteria entering the pulp will be destroyed by the neutrophils
If there is a cavity, pus drainage
Pulp polyp?
Chronic hyperplastic pulpitis, granulation tissue formation
Tissue protrudes beyond the boundaries of the pulp chamber
Paeds pt have highly vascularised teeth and and a wide apical foramina
When tooth has a large cavity the pulp bulges out - from wide open pulp cavities with good apical blood supply
Colour of an epithelialised?
More pink rather than reddish - protected by epithelium
Don’t bleed as much
What happens if you dry dentine that has preexisitng inflammation?
Wheat sheaving appearance ofodontoblasts
What is wheat sheaving?
Fluid collecting into vacuoles and compressing groups of cells together
Why can cavity prep and restorative materials affect the pulp differently?
The effect of materials is variable
Effect affected by thickness of dentine remaining
Nature of dentine (younger the dentine is patent, older dentine obliterated)
Pulp capping using materials that provide no irritation
Younger or older dentine more effected by dental materials?
More badly affected as dentine is patent
What causes pulp necrosis?
Main cause: pulpitis
Trauma to the apical blood supply - apical blood supply is cut and causes ulnar necrosis
—> this causes coagulation necrosis due to ischaemia
Liquefactive necrosis following pulpitis and break down of inflammatory cells
- if becomes infected could lead to abscess formation
- foul smell during endontic tx
- sickle cell anemia
