Abnormalities of The Pulp

ABNORMALITI
ES OF THE
PULP
Prepared by:
Dr. Rea Corpuz
Pulp Calcification
may be located
pulp chamber
OR
root canals
Pulp Calcification
Cause
no clear-cut etiology
no relation between
inflammation + irritation
since pulp calcification
can be found in unerupted
teeth
Sundell Schematic
Presentation
Local
Metabolic
Dysfunction
Growth
Pulp Stones
Trauma
Mineralization
Hyalinization
of injured cell
Fibrosis
Vascular
Damage
Thrombosis
Vessel Wall
Damage
Classification
Three types :
(1) Denticles
(2) Pulp stones
(3) Diffuse linear calcifications
(1) Denticles
believed to form as a result
of epitheliomesenchymal
interaction within
developing pulp
form during period of root

development
occur in root canal + pulp
chamber adjacent to furcation

areas of multirooted teeth
(2) Pulp Stones

believed to develop around
central nidus of pulp tissue

examples:
collagen fibril
ground substance
formed within coronal portions

of pulp
(2) Pulp Stones

may arise as part of age-
related or local pathologic

changes
most develops after tooth

formation is completed
usually free or attached
some instances, may be embedded
(3) Diffuse Linear

Calcifications
doesnt demonstrate lamellar

organization of pulp stones
exhibit areas of:
fine
fibrillar
irregular calcification
may be present in pulp
chamber or canals
frequency increases with age
(3) Diffuse Linear

Calcifications
Clinical Significance:
very little clinical significance

except insofar as they may
obstruct endodontic treatment
(3) Diffuse Linear

Calcifications
discovered on radiograph
only as radioopacity
may cause pain from
mild pulpal neuralgia to

severe excruciating pain
resembling tic douloureux
as denticle may impinge
on nerve of pulp
(3) Diffuse Linear

Calcifications
difficulty may be encountered

in extirpating pulp
during root canal therapy
(3) Diffuse Linear

Calcifications
Treatment & Prognosis

No treatment is required
Resorption of the Teeth

deciduous teeth are progressively
loosened
result of progressive
resorption of roots
physiological process arising

from pressure of underlying
successors
resorption of permanent is
always pathological
Resorption of the Teeth

Pathology
pressure is probably main
factor
resorption is mainly carried

out by osteoclast
humoral mediators, such

as prostgalndins
may contribute to resorption
Idiopathic Resorption
(1) Internal Resorption
(2) External Resorption
Internal Resorption
pink spot
curious + uncommon
condition
dentin is resorbed from

within the pulp
tends to be localized
well-defined rounded area
of rediolucency in crown
can affect any part of teeth

NO signs until pulp is
opened + allows access to

infection
may be detected by chance
in routine radiograph
may be localized or
generalized
unkown cause
mild degree of inflammation
is often suspected
Heithersay Classification
usually a limited area of
root is attacked from
external surface near
amelocemental junction
resorption goes on until

pulp is reached
often preferentially
destroys root before

penetrating the pulp
accessible defects may be

amenable to restoration
with mineral trioxide or
other materials
long term success in infrequent;

unpredictable
Pathology
vascular granulation
tissue replaces part
or periodontal ligament
or pulp
osteoclasts border the
affected dentin or enamel
Treatment
usually untreatable
if a pink spot in an incisor
tooth is noticed at an early
stage
endodontic treatment should
be carried out before
Treatment
resorption of teeth may
result from pressure
exerted by impacted teeth
indication for removal
of unerupted teeth
DISEASES OF
PERIAPICALTISSU
ES
Prepared by:
Dr. Rea Corpuz
Diseases of Periapical Tissues

(1) Periapical Abscess
(2) Periapical Granuloma
(3) Radicular Cyst
(4) Phoenix Abscess
(5) Condensing Osteitis

also known as Dento-alveolar
Abscess; Alveolar Abscess
acute or chronic supporative

process of dental periapical
region
usually arises as a result of

infection

abcess ay develop directly
as an acute apical periodontitis

following an acute pulpitis
but more commonly it
originates in an area of
chronic infection

Clinical Feature
presents features of
acute inflammation of
apical peridontium
tooth is extremely painful

slightly extruded from its
socket

Clinical Feature
chronic periapical
abscess generally presents

no clinical features
mild, circumscribed area
of suppuration that shows

little tendency to spread from
local area

Radiographic Feature
except for SLIGHT thickening
of periodontal membrane
no roentgenographic
evidence of its presence
chronic abscess, developing

in a periapical granuloma
radioluscent area at apex

Histopathologic Features
area of suppuration is
composed chiefly of central

area of disintegrating
polymorphonuclear
leukocytes
dilation of blood vessels

in periodontal ligament

Histopathologic Features
tissue surrounding area
of suppuration contains
serous exudate

drainage must be
established
open pulp chamber

extract the tooth

under some circumstances
tooth may be retained
root canal therapy

left untreated, spread
of infection
osteomyelitis
cellulitis
bacterimia
formation of fistulous
tract opening on skin
or oral mucosa

also known as Apical
Periodontitis
one of the most common

sequeala of pulpitis
localized mass of chronic

granulation tissue
response to infection

Clinical Features
1st evidence; spread beyond
confines of tooth pulp
may be noticeable sensitivity

of involved tooth to
percussion
mild pain when biting or

chewing on solid food

Clinical Features
some cases tooth feels
elongated in its socket
sensitivity is due to
hyperemia
edema
inflammation of apical
periodontal ligament

Radiographic Features
earliest evidence,
thickening of ligament at root

apex
proliferation of granulation
tissue
concomitant resorption of bone

continue

appear as a radiolucent
area of variable size
seemingly attached to
root apex
some cases, well
circumscribed lesion
definitely demarcated
from surrounding bone

Histologic Features
arises as chronic process
from onset
does not pass through an

acute phase

Histologic Features
begins as:
hyperemia
edema of periodontal
ligament with infiltration
of chronic inflammatory cells
chiefly lymphocytes
plasma cells

Histologic Features
inflammation + locally
increased vascularity
of tissue
induce resorption
of supporting bone
adjacent to this area

Histologic Features
as bone is resorbed
proliferation of fibroblast
+ endothelial cells
formation of more tiny
vascular channels
numerous delicate connective
tissue fibrils

extraction of involved
teeth
under certain conditions,
root canal therapy with or

without subsequent
apicoectomy


left untreated, may
undergo transformation
into an apical periodontal
cyst
proliferation of epithelial
rests in the area
(3) Radicular Cyst

also known as Apical
Periodontal Cyst;
Periapical Cyst;
Root End Cyst
common
not inevitable sequela of
periapical granuloma originating

as a result of:
bacterial infection
necrosis of dental pulp
following carious involvement of tooth
(3) Radicular Cyst

Pathogenesis
initial reaction leading
to cyst formation
proliferation of epithelial
rest in the periapical
area involved by granuloma
epithelial proliferation
follows an irregular pattern of
growth
(3) Radicular Cyst

Clinical Features
asymptomatic
present no clinical evidence
of their presence
seldom painful or even
sensitive to percussion
(3) Radicular Cyst

Clinical Features
represents chronic
inflammatory process
develops only over
a long period of time
(3) Radicular Cyst

identical with periapaical
granuloma
since the lesion is a chronic
progressive one developing

in a pre-existing granuloma
cyst may be of greater
size than granuloma
due to longer duration
(3) Radicular Cyst

occasionally, exhibits
thin, radioopaque line

around the periphery
of radiolucent area
indicates reaction of
bone to slowly expanding
mass
(3) Radicular Cyst

(3) Radicular Cyst

Histologic Features
epithelium lining apical
periodontal cyst is usually

stratified squamous in
type
(3) Radicular Cyst

similar to periapical
granuloma
involved tooth may be

removed
periapical tissue carefully
curetted
(3) Radicular Cyst

under some condition;
root canal therapy
with apicoectomy
of cystic lesion
(3) Radicular Cyst
(4) Phoenix Abscess

localized collection of pus
surrounded by an area of
inflammed tissue
hyperemia
infiltration of leucocytes
(4) Phoenix Abscess
(4) Phoenix Abscess
(4) Phoenix Abscess

can occur immediately
following root canal treatment
another cause is due to untreated

necrotic pulp (chronic apical
periodontitis)
result of inadequate debridement

during endodontic procedure
(4) Phoenix Abscess

Bacteriology
Staphylococci are frequently
associated with pus formation

produce enzyme called
coagulase
causes fibrin formation
helps in walling off of lesion
(4) Phoenix Abscess

Bacteriology
coagulase promotes
virulence by inhibiting
phagocytosis
(4) Phoenix Abscess

Clinical Features
when palpated clinically
superficial abscess is
fluctuant
offending tooth is carious
+ mobile
symptoms of acute inflammation

swelling
fever
(4) Phoenix Abscess

Treatment
repeating endodontic
treatment with improved

debridement
tooth extraction
antibiotics may be indicated
to control a spreading or
systemic infection

also known as Chronic
Focal Sclerosing Osteomyelitis
unusual reaction of bone
occuring in instances of
extremely high tissue resistance
or in cases of low grade infection

Clinical Features
occurs in almost young
person before the age of

20 years old
commonly affected is
mandibular 1st molar

with large carious lesion

Clinical Features
associated with non vital
teeth or teeth undergoing

process of degeneration
tooth is usually asymptomatic

some cases, pain or tenderness
percussion
palpation

well circumscribed
radiopaque mass of
sclerotic bone surrounding
extending below apex of

one or more roots

Histologic Features
dense mass of bony trabeculae
with little interstitial
marrow tissue

Histologic Features
dense mass of bony trabeculae
with little interstitial
marrow tissue
chronic inflammatory cells;

plasma cells, lymphocytes
are seen scanty in bone
marrow

endodontic treatment
extraction
surgical removal of sclerotic
should not be attempted
unless symptomatic
References:
Books
Cawson, R.A: Cawsons Essentials of Oral
Oral Pathology and Oral Medicine,
8th Edition
(page 70-72)
Ghom, Ali & Mhaske, Shubhangi: Textbook of
Oral Pathology
(pages 429-433)
Neville, et. al: Oral and Maxillofacial Pathology
3rd Edition
(pages 127-138)
Shafer, et al: A textbook of Oral Pathology,
3rd Edition

Abnormalities of The Pulp

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Abnormalities of The Pulp

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ABNORMALITI

form during period of root

occur in root canal + pulp

chamber adjacent to furcation

(2) Pulp Stones

central nidus of pulp tissue

formed within coronal portions

(2) Pulp Stones

related or local pathologic

most develops after tooth

(3) Diffuse Linear

doesnt demonstrate lamellar

frequency increases with age

(3) Diffuse Linear

very little clinical significance

obstruct endodontic treatment

(3) Diffuse Linear

may cause pain from

mild pulpal neuralgia to

(3) Diffuse Linear

difficulty may be encountered

(3) Diffuse Linear

Treatment & Prognosis

Resorption of the Teeth

physiological process arising

Resorption of the Teeth

resorption is mainly carried

humoral mediators, such

may contribute to resorption

dentin is resorbed from

can affect any part of teeth

opened + allows access to

resorption goes on until

destroys root before

accessible defects may be

long term success in infrequent;

Diseases of Periapical Tissues

(1) Periapical Abscess

acute or chronic supporative

usually arises as a result of

(1) Periapical Abscess

as an acute apical periodontitis

but more commonly it

(1) Periapical Abscess

tooth is extremely painful

(1) Periapical Abscess

abscess generally presents

mild, circumscribed area

of suppuration that shows

(1) Periapical Abscess

evidence of its presence

chronic abscess, developing

radioluscent area at apex

(1) Periapical Abscess

(1) Periapical Abscess

composed chiefly of central

dilation of blood vessels

(1) Periapical Abscess

(1) Periapical Abscess

open pulp chamber

(1) Periapical Abscess

(1) Periapical Abscess

(2) Periapical Granuloma