Pulpal and jaw infections Flashcards
Discuss the two causes of pulpitis
- Inflammatory challenge
• The pulp is surrounded by dentine which limits the ability of the pulp to tolerate oedema
• Thus the pressure rises in the pulp and this may cause local collapse of the venous part of the microcirculation
• This leads to local tissue hypoxia and anoxia, which in turn may lead to localized necrosis
• Chemical mediators released from the necrotic tissue lead to further inflammation and oedema, and total necrosis of the pulp may follow - Bacterial challenge/ pus
• Collection of pus at the root of a tooth
• Caused by bacterial infection which causes neutrophil chemotaxis
• Neutrophils recruit a lot of free oxygen radicals, and release a lot of enzymes
• The FOR kill/damage bacteria, but also important tissues
• Pus is just dead neutrophils and inflammatory exudate
List the histopathological features of pulpitis (7)
- Pulp hyperaemia (dilation of blood vessels)
- Inflammatory cell infiltrate (neutrophils)
- Granulation tissue
- Exudate
- Reactionary dentine
- Tubules may be purple -> signifies bacterial invasion
- Local ischaemia may lead to local necrosis and pulp abscess formation
For reversible- irreversible pulpitis, explain the significance of these terms.
- Not Pathological Terms
- Not Absolutely Correlated with Pulpal Histo-Pathology
- Always Intensely Painful
Describe what happens in irreversible pulpitis
- Pulp starts to die once it loses its blood supply due to swelling
- The dead tissue is broken down by the body’s immune system, but if there is too much infection and dead tissue, then an abscess can form
- Inflammation and other symptoms, such as pain, are severe, and the pulp cannot be saved
For reversible- irreversible pulpitis, state their clinical features:
- Pain duration
- Sensitising stimuli
- Electric testing
Irreversible pulpitis:
Pain duration:
• Prolonged, Delayed
Sensitising stimuli:
• Only to hot, cold
• Irresponsive to sweet/sour
Electric testing:
• Irresponsive to electric pulp testing
Reversible pulpitis:
Pain duration:
• Short, immediate
Sensitising stimuli:
• Hot, cold, sweet and sour
Electric testing:
• Responsive to electric pulp testing
Explain how a clinical diagnosis is made for acute and chronic pulpitis
Acute pulpitis:
Clinical diagnosis is usually made:
• Patient complains of a severe throbbing pain, at times lancinating in type
• Pain is precipitated by hot or cold stimuli or on lying down, and which often keeps the patient awake
Chronic pulpitis:
Clinical diagnosis is usually made:
• Spontaneous attacks of dull aching pain that can last for an hour or more
For chronic hyperplastic pulpitis, explain how it occurs
Cause:
• Deciduous or recently erupted permanent teeth with wide-open carious cavities
• The wide-open pulpitis prevents build-up of tissue pressure compromising pulpal blood flow, and the good apical blood supply facilitates pulpal defence and repair = granulation tissue forms, creating a hyperplastic response
For chronic hyperplastic pulpitis, explain its histological features by stating:
- The origin of the epithelial border
- General histological features
Origin of epithelial border:
• Epithelial cells present in the saliva may make the polyp epithelialized
• However, it is truly unknown where these epithelial cells originate from
• It is hypothesised that the cells come from the region of the basal cell layer and might be released from trauma to the oral mucosa or from the gingival sulcus
General histology signs:
• Blob of granulation tissue on top of the pulp
• Chronic, inflammatory cell infiltrate
For chronic hyperplastic pulpitis, list the differences between the clinical features of an ulcerated polyp and an epithelialized polyp.
Ulcerated polyp:
• Dark red, yellow-flecked (because of the fibrinous exudate) mass protruding from the pulp chamber
• Bleeds readily on probing
Epithelialized polyp: • Firmer • Pinkish-white in colour • Does not bleed readily • No feeling on gentle probing
Define acute periapical periodontitis and state its histopathological features
Definition:
• Apicalportion of a tooth’s root becomes inflamed, following trauma or infection
Histopathological features:
• Acute inflammatory exudate in the periodontal ligament within the confined space between the root apex and the alveolar bone
Describe what happens in chronic periapical periodontitis, and state why granulation tissue is usually present
Cause:
• Persistent irritation from bacteria and their products in the pulp leads to chronic periapical periodontitis
• This is characterized by resorption of the periapical alveolar bone and its replacement by chronically Inflamed granulation tissue to form a periapical granuloma
Cause of granulation tissue:
• The periapical vascular network is very rich, greatly enhancing the ability of the tissue to heal if the cause of the inflammation is removed (hence the granulation tissue
State the histopathological features of chronic apical periodontitis
- Granulation tissue infiltrated by lymphocytes, plasma cells, and macrophages
- Dense bundles of collagen fibres that separate the chronically inflamed granulation tissue from the surrounding bone
- These collagen fibres, forming a sort of capsule around the lesion
- Deposits of cholesterol and haemosiderin are often present in a periapical granuloma. These are derived from the breakdown of red blood cells
- Cholesterol crystals in the granulation tissue appears as clefts
- Multinucleate foreign-body giant cells are grouped around the cholesterol clefts
- There may be foam cells as well
Explain how recrudescence occurs (apical lesions form in chronic periodontitis - why it goes from asymptomatic to symptomatic)
- Host response may be in equilibrium with level of irritation
- Then, there is imbalance in factors and this may cause recurrence of apical lesions in a chronic setting
List the clinical and radiographic features of acute apical periodontitis
Clinical features acute apical periodontitis:
• Pain occurs due to external pressure (on the tooth) because the pressure is transmitted through the fluid exudate to the sensory nerve endings (tender to percussion)
• As the fluid is not compressible, the tooth feels elevated in its socket
• Hot or cold stimulation of the tooth does NOT cause pain
Radiographic features of acute apical periodontitis:
• NO bone resorption
• Slight widening of the periodontal ligament
• Lamina dura around the apex may be less well defined than normal
List the clinical and radiographic features of chronic apical periodontitis:
Clinical features of chronic apical periodontitis:
• Usually asymptomatic
• Occasional tenderness of the tooth to palpation and percussion
• Percussion may produce a dull note because of the lack of resonance caused by the granulation tissue around the apex
• Elevated tooth
Radiographic features of chronic apical periodontitis:
• Bone resorption is seen
• Radiolucency around non- vital tooth
• May have sclerotic margins
