Chapter

three
PULPITIS
 Definition:

Inflammation of the pulp (the tooth's

innermost layer) caused by a cavity or
other trauma, and often signalled by a
painful toothache.
category

 Reversible pulpitis
 Irreversible pulpitis
 • Reversible pulpitis

The pulp is inflamed to the extent that thermal stimuli cause a

quick, sharp, hypersensitive response that subsides as soon as the
stimulus is removed.

Reversible pulpitis is not a disease but merely a symptom. If the

cause is removed, the pulp should revert to an uninflamed state
and the symptom should subside. Conversely, if the cause remains,
the symptom may persist, and the inflammation may become more
widespread, and eventually, leading to an irreversible pulpitis.
Causes: any irritant that can affect the pulp may cause
reversible pulpitis such as caries, thermal, deep
periodontal scaling and root planing.

Distinguishing reversible pulpitis from the irreversible:

1 A sharp painful response to thermal stimulation.
2 Spontaneous pain.

Treatment choice:
Sedative dressing, or called temporary restoration with
sedative package, such as zinc oxide.
• Irreversible pulpitis

An irreversible pulpitis may be acute, subacute,

or chronic, and it may be partial and total.
Clinically, acute one is symptomatic, whereas the
chronic is asymptomatic. At this stage, the
dynamic changes in the pulp are always occurring.
Symptomatic irreversible pulpitis:
•This type of pulpitis is characterized by
spontaneous intermittent or continuous paroxysms
of pain.

•The pain may be caused by sudden temperature

changes, which is prolonged.

•The pain caused by cold stimulation can be relieved

by heat, and similarly, the pain caused by heat can
be relieved by cold.
•There may even be a painful response to
both cold and heat stimulation too.

•The pain may be localized or referred

(e.g. referred from mandibular molars
toward the ear or up to the temporal area.)
A symptomatic irreversible pulpitis can be
diagnosed by a thorough dental history, visual
examination, thermal tests and radiography.
Asymptomatic irreversible pulpitis:
This type of irreversible pulpitis is asymptomatic
because the inflammatory exudate are quickly vented.

It can develop by the conversion of a symptomatic

one into a quiescent state.

It also can caused by long and low-grade pulp

irritant (carious lesions), traumatic injury.
There are three types of asymptomatic
pulpitis
1.Hyperplastic pulpitis
Clinically, it is a reddish cauliflower-like
overgrowth of pulp tissue through and around a
carious exposure. It is characteristically found
in young people since the generous vascularity
of the pulp.
2. Internal resorption
It is a resorption of the dentine from the pulp
outward, which is often caused by trauma or pulp
capping. It is usually can be diagnosed by
radiography.
3. Canal calcification
A large amounts of reparative dentine over deposit
throughout the canal system, which is caused by
periodontal therapy, abrasion, trauma etc.
 Chapter four

Periapical disease
Classification of periapical disease
• Acute apical periodontitis
• It describes acute inflammation around the
apex.
• The tooth with it may exquisitely tender to
percussion.
•Radiographically the apical periodontal
ligament may appear slightly widened or
normal.
Causes:
• Extension of pulpal disease into the
periapical tissue.

• Endodontic procedures such as canal filling

beyond the apical foramen.

• Occlusal trauma from a high restoration or

from chronic bruxism.
• Acute apical abscess
• It implies a painful, purulent exudate
around the apex.
• Rapid onset of slight to severe swelling,
pain, and pain to percussion, and possible
mobility.
• The distinguishing acute apical abscess
from the lateral periodontal abscess and
from the phoenix abscess
For periodontal abscess
Thermal and electric pulp testing indicate
the pulp vital; there is a periodontal
pocket; the tooth may be normal.

For the phoenix abscess

All symptoms of acute apical abscess plus
apical radiolucency around the apex of the
tooth.
 Diagnosis
Pain
slight frequently intense continuous throbbing
Swelling and palpation
palpable fluctuant swelling

Vitality tests Negative

Radiography
Slight widening of the apical periodontal ligament space
Periapical radiolucency of a subacute periapical abscess
Acute apical periodontitis
(painful phase)

Acute apical abscess Subacute periapical abscess

(painful phase) (painful phase)

Chronic periapical abscess

(nonpainful phase)
• Chronic apical periodontitis
• Chronic apical periodontitis implies long-standing
asymptomatic inflammation around the apex. Although
chronic apical periodontitis tends to be asymptomatic, there
may be occasional slight tenderness to palpation and
percussion.
• Only biopsy and microscopy examination can reveal
whether these apical lesions are dental granulomas,
abscesses, or cysts.
• Diagnosis is confirmed by the presence of a radiolucency
that may be either diffuse or well-circumscribed, the absence
of pulp vitality, and a sinus tract.
Diagnosis
Pain no pain or mild pain

Swelling and palpation

Slight swelling in the area around the sinus tract stoma,
surface of the face, floor of the nose and other portions of the
head and neck.
Percussion and mobility Negative

Color tooth color becomes black or grey

Vitality tests Negative

Radiography
Chronic periapical abscess :
diffuse area of bone rarefaction around the root
Chronic periapical granuloma and cyst:
diffuse area of bone rarefaction around the root,
and an opaque hyperostotic border
• Phoenix abscess
•A phoenix abscess is a chronic apical periodontitis
that suddenly becomes symptomatic.
•The symptoms are identical to those of an acute
apical abscess, the man difference being that the
phoenix abscess is preceded by a chronic condition.
• Periapical osteosclerosis
Periapical osteosclerosis is excessive bone
mineralization around the apex caused by low-
grade, relatively asymptomatic, chronic pulpal
inflammation which is most commonly found in
young people .
Causes:
• Although many factors can cause the pulpitis which further
develop into apical periodontitis, the bacteria are the most
common one.
•The factors include:
1.Bacteria
2.Trauma
3.Thermal
4.Static electricity
5.Laser
6.Filling materials
7.Etch or adhesive agents
8.Drugs for toilet the cavity
9.Immunological aspect
Treatment

1. Diagnostic phase

the tooth to be treated is determined , the

treatment plan is developed.
Once the tooth has been confirmed as irreversible
pulpitis or any of apical diseases, the endodontic
treatment must be done. Before you decide to do
the endodontic treatment you need to consider
follows:
Physical evaluation:
it mainly concerned about systemic conditions (diseases) such
as cardiovascular diseases, bleeding disorders, diabetes,
cancer, AIDS, pregnancy, allergies, steroid therapy, infectious
diseases etc.

Psychological evaluation:
A patient who shows no incentive (motivation) to maintain
good oral hygiene or one who constantly misses appointments
may not be a good candidate for endodontic therapy.
Evaluation of tooth
Morphology
• Unusual length
• Unusual shapes
• Unusual numbers (canal or roots)
• Resorptions
• Calcifications
Previous treatment
• Canal blockage
• Ledge
• perforations
Location of tooth
• Accessibility
• Proximity to other structures
• Restorability
• Periodontal status
Treatment planning
general process and sequence:
•Management of acute pulp or periodontal pain.
•Oral surgery for extraction of unsalvageable teeth.
•Caries control of deep lesions that may threaten the pulp.
•Periodontal procedures to manage soft tissue.
•Endodontic procedures for asymptomatic teeth with
necrotic pulps and surgical treatment or re-treatment of
failing root canals.
•Restorative and prosthetic procedures.
One-appointment root canal therapy
2. Preparatory phase

the contents of the root canal are removed

and the canal prepared for the filling
materials.
Reamer and file
3. Filling phase

filling the canal to gain a seal with an inert

materials as close as possible to the root apical
role.
Procedure:

1. open the pulp cavity

relieve the pressure of pulp cavity

pain ceases or relieved

2. remove infected pulp

3. apply a sedative antiseptic dressing

4. fill root canal and restore the tooth