PULP PATHOLOGY Etiologies – Pathogenesis – Classifications and symptomatology
1-Introduction:
The pulp is normally protected from aggressors present in the external environment and in particular from bacteria. The destruction of the hard tissues that protect it exposes it to exogenous irritants which can be biological, physical or chemical agents.
It is bacteria and their metabolites which constitute the essential cause of inflammatory pulp reaction (PULPITIS) sometimes leading to pulp necrosis.
2-Etiologies of pulpopathies:
2-1-Infectious etiologies:
2-1-1- General:
Septic inoculation of the pulp through the bloodstream has been reported in people whose general condition is impaired (tuberculosis, influenza, typhoid fever, etc.) which is called hematogenous pulpitis.
2-1-2- Local order:
– Tooth decay:
Microbial penetration occurs through the dentinal tubules or by breaking through the cameral wall.
– Dentin exposed by:
-Trauma
-Attrition, abrasion, erosion, cracks.
– Periodontal diseases and their in-depth treatment which exposes the dentin : scaling, root planing.
3-1- Physical etiologies:
3-1-1- General:
These are the variations in altitude and the variations in atmospheric pressure.
Increased intrapulpal pressure which can cause severe pain called: aerodontalgia
3-1-2- Local order:
a- Mechanical origin:
-Sudden trauma, Polymicrotrauma.
-Orthodontic movements: too rapid can produce secondary pulp damage following vascular compression at the periapex.
-Preparation on pulped teeth.
b- Thermal origin:
-A rise in temperature ° causes damage to the pulp-dentin system: tissue burns which will lead to the burning of the Tomes fibers and therefore to the death of the odontoblasts. Heating due to the exothermic reaction during the setting of certain cements.
-The thermal conductivity of certain materials.
c- Electrical origin:
-Electric shocks can also be caused by the improper use of electrical instruments such as the pulp tester.
d- Radiotherapeutic origin:
During X-ray treatments performed not only on the jaws but even remotely in the cervical region can cause calcification disorders with pulp degeneration (atrophy).
4-Chemical etiologies:
4-1- General : This involves pulp poisoning in two ways:
*Endogenous poisoning: diabetes, arteriosclerosis, phlebitis, etc.
*Exogenous poisonings: lead, mercury, arsenic, bismuth.
4-2- Local order:
-Dental medications: phenol, alcohol, formocresol, eugenol, etc. cause tolerable or serious irritations to the pulp-dentin system depending on their chemical composition and toxicity.
-Dental products:
*Dental cements and composite resins have significant irritation potential.
*Amalgam: its aggressiveness depends on its composition and its proximity to the pulp.
5-Pathogenesis of pulpitis:
All these etiological factors trigger inflammatory phenomena within the pulp tissue, however, it should be said that these aggression mechanisms have actions on the pulp of quite variable duration and intensity. In fact, the action of the stimuli can be short-lived, brief, even instantaneous or on the contrary prolonged or repeated for days and months.
To this the pulpal responses will be varied, and the pulpal inflammation caused by short-term irritation will be quite different from that due to prolonged action.
In a fracture, acute inflammation will immediately occur, the intensity of which will vary more or less; in caries or trauma, the inflammation will develop into chronicity.
Clinical experience shows that there may be a transition from the acute to the chronic form and vice versa, and this is due to the appearance of an additional etiological factor, or the failure of the body’s defense mechanisms.
6-Classifications of pulpopathies:
The difficulty of establishing a correct diagnosis using clinical signs alone, the diversity of histopathological forms, and the poor correlation between clinical and histopathology encourage us to abandon the old classifications based on etiology and histopathology, which are considered too complex.
Nowadays, the classification of pulpopathies is based on the clinic, that is to say on the observation of symptoms during the clinical examination, and by providing precise indications on the therapy to be applied.
Classification by JC Hess 1968:
Hess classifies pulpitis into two categories:
1-Healthy pulp condition: -Healthy young pulp.
-Healthy old pulp.
2- Pathological pulp conditions:
*live pulp:
a-Acute pulpitis primary or secondary to chronic pulpitis.
b-chronic pulpitis: – Closed (simple, secondary acute pulpitis)
– Open (ulcerative, hyperplastic)
*total pulp necrosis: a-Aseptic: necrobiosis.
b-Septic: gangrene
2) BENDER & SELTZER classification:
This classification offers two categories of treatment for teeth affected by pulpopathy.
| Category A | Intended for teeth where an attempt is being made to preserve all or part of the pulp |
| Category B | Intended for teeth from which all the pulp will be removed, or those whose canals will be disinfected before being filled. |
3) Classification of BAUME modified by MARMASSE:
| Category | Changes made by MARMASSE | |
| Category I | Living pulps without symptoms, accidentally damaged or close to a deep caries likely to be protected by capping | |
| Category II | Living pulps with symptoms, in which we will try, especially in young people, to preserve the vitality of the pulp by capping or biopulpotomy | |
| Category III | Living pulps whose biopulpectomy and immediate canal obturation are indicated for symptomatic, prosthetic or iatrogenic reasons | |
| Category IV | Necrotic pulps with infection of the root dentin, with or without periapical complications requiring antiseptic treatment | Add And Obturation Of The Channels |
| Category IV bis Added by Marmasse | Necrotic pulps with infection of the root dentine, with or without periapical complications on immature teeth, antiseptic treatment and temporary obturation of the canals with resorbable paste. |
7-Symptomatology of pulpitis:
Pulpopathies present physical and functional signs, the latter are more important in acute forms and are represented by pain. On the other hand, there are no general signs.
Physical signs:
Due to the anatomical location of the pulp in the depth of the tooth, these physical signs are often non-existent, the crown retains its usual light yellow color; except in the case of chronic ulcerative pulpitis and pulp necrosis where the color becomes grayish.
Functional signs:
Pulp syndrome is characterized by provoked and spontaneous pain.
Provoked pain: It is caused by contact, temperature changes, acids and sugars; and unlike dentin syndrome where the pain stops as soon as the stimulus stops, in pulp syndrome the pain continues for some time after the causal action stops.
Spontaneous pain: Due to congestive attacks occurring during pulp inflammation. This spontaneous pain is intermittent, in the form of attacks separated by periods of total remission. During attacks, this pain can be throbbing, acute, paroxysmal (toothache), sometimes pulsatile. This is pain that responds favorably to analgesics. Its duration is variable, from a few seconds to hours. These attacks are often nocturnal, and can occur at fixed times (cyclalgia). The pain is sometimes radiating:
For the I > : towards the nose
For C > : towards the eye
For PM and M >: towards the temple
For the I <: towards the chin
For PM and M <: towards the ear
For DDS <: towards the neck and shoulder
*Reflex phenomena: Are of sympathetic origin, and are rarely observed, they can give rise to facial neuralgia, nasal pruritus, redness of the skin, and alopecia of dental origin.
8- Means of diagnosing pulpopathies:
Questioning the patient: It is of capital importance, it will be necessary to note:
The evolution of the disease.
The description of subjective signs (pains) of which the nature, intensity, duration and location must be specified.
Take into account remote reflex phenomena.
The clinical examination: This will consist of inspecting the arches, which allows us to note the existence of fractures, abrasions, cavities, tartar, etc.
The practitioner will then use other methods of investigation either to confirm the diagnosis or to investigate it if the signs previously noted are insufficient.
Pulp vitality research: this research will be done using different tests which will cause pulp pain:
Temperature variation test
Electrical test (Pulp tester)
9-Clinical studies of pulpopathies:
9-1-Reversible pulpitis : By definition, reversible pulpitis is a clinical situation associated with subjective and objective data suggesting the presence of mild inflammation of the pulp tissue. If the cause is eliminated, the inflammation regresses and the state of the pulp returns to normal. Mild or short-term stimuli can cause reversible pulpitis, namely: incipient caries, cervical erosion or occlusal attrition; to this must be added a number of interventions such as the Creation of enamel fractures exposing the dentinal tubules.
9-1-1-Pulpal hyperemia : It is a congestion of the pulp, it is a pathological entity characterized by its reversibility. It is the potentially reversible beginning which constitutes the starting point of the inflammatory cycle
9-1-2 Histopathology:
− It is an increase in blood volume leading to an increase in intrapulpal pressure in the affected area.
9-1-3 Symptoms:
− Spontaneous pain is absent,
− The pain caused (by sugars, acids, thermal variations) is acute, localized and lasts 1 to 2 minutes after the stimulus stops.
9-1-4 Diagnosis:
− Based on clinical signs and questioning
− During the clinical examination, caries, old restorations, trauma and occlusal disorders should be looked for.
X-ray:
− The radio can tell us about the proximity of the cavity to the pulp chamber.
9-1-5 Evolution:
The injury is reversible if caught in time (healing)
In the absence of treatment, this results in acute or chronic total pulp inflammation and then necrosis.
9-2-Irreversible pulpitis:
Irreversible pulpitis can be classified as symptomatic or asymptomatic. This corresponds to a clinical picture whose subjective and objective data suggest
The presence of severe inflammation of the pulp tissue. Irreversible pulpitis is often a sequela or progression of reversible pulpitis.
Irreversible pulpitis is a severe inflammatory process that does not heal, even if the cause is eliminated. The pulp is unable to heal and evolves more or less quickly towards necrosis.
9-2-1-Acute total serous pulpitis:
− The pain is caused by increased intrapulpal pressure (severe).
9-2-2 Histopathology:
Typical vascular phase of the inflammatory reaction,
✓ Increase in the number of leukocytes in the vessels,
✓ Rupture of capillaries with intrapulpal hemorrhage,
✓ Destruction of odontoblasts,
9-2-3 Pathophysiology:
− The most immediate consequence: the cessation of dentinogenesis.
− The pulp environment is modified; it becomes acidic: pH between 5.5 and 7.2; this is the well-known acidosis of inflammation.
− The vascularization is very disturbed.
− Compression of nerve fibers causes pain and reflex vasomotor disorders.
9-2-4- Symptomatology:
❖ Physical signs:
• The crown usually keeps its natural color.
❖ Functional signs:
Spontaneous and provoked pain constitute the majority of functional signs.
► Spontaneous pain
➢ Character:
• Acute pain: intermittent and presents in the form of painful attacks, separated by periods of complete remission.
• During the crisis it is continuous, throbbing, pulsating with exacerbations
➢ Intensity:
• Of variable intensity: subacute, acute, hyperacute or paroxysmal.
• Pulpitis pain, unlike periodontal pain, responds favorably to analgesics.
➢ Duration:
• The duration of attacks and periods of remission is extremely variable (can last a few seconds, a few minutes, or even hours).
• Attacks are more or less frequent, often nocturnal, and can sometimes occur at fixed times (cyclalgia)
• They can extend over several days, a week
➢ Location:
• The patient may be able to localize the pain and identify the exact tooth involved.
• However, it often happens that the pain radiates to adjacent teeth, antagonists or neighboring regions.
• The irradiations are homolateral, we classically describe a set of topographic correspondences between the synalgia and the tooth judged to be causal:
* Temporals (upper molars)
* Pretragic (lower molars)
* Suborbital (canines and upper incisor)
* Chin straps (canines and lower incisor)
► The pain caused:
Pain is triggered mainly by:
– Heat, cold, contact, sugars, acids and the supine position
– These pains continue for some time after the causal action to the point of triggering a new painful attack
9-2-5 Diagnosis:
− Based on questioning and clinical signs
− The description of subjective signs is represented essentially by spontaneous pain.
− Pain caused by thermal variations may persist despite cessation of excitation.
− The patient may react slightly to percussion (an advanced inflammatory state of the pulp and in the presence of a desmodontal complication) but usually does not react.
− The X-ray may reveal:
The depth and extent of caries and restorations.
9-2-2-Acute purulent pulpitis:
Also called acute yellow pulpitis with the presence of intrapulpal abscesses.
Physical signs: When the pulp cavity is opened, the pulp appears as a yellow dot containing pus
Functional signs: The pain caused is increased by heat and decreased by cold. Percussion is positive. Opening the pulp chamber relieves the patient who suffers from violent, pulsatile, lasting and radiating spontaneous pain.
9-2-3-Chronic pulpitis:
Definition: Chronic pulpitis is an inflammatory response of connective tissue following irritation. Proliferative forces play a predominant role.
It is not painful, because the intrapulpal pressure is reduced and balanced.
Chronic closed pulpitis:
No clinical pulp signs exist. When there is a loss of coronal substance, a painful dentin syndrome may be observed.
If it is an occlusal disorder, only a facet of wear and a little mobility are noticed; and yet, in all these cases, there is chronic pulpitis.
Histopathology:
•Chronic pulpitis is characterized by the presence and persistence of mononuclear cells: lymphocytes, plasma cells, numerous capillaries and strong fibroblastic activity.
• Chronic inflammatory damage will lead to premature and generalized aging of the tissue during which we observe:
• atrophy of odontoblasts
• a decrease in the number of blood vessels
• the replacement of cellular elements by bundles of collagen fibers.
B-Symptomatology:
There are no functional signs: clinical silence, except for the dentin syndrome: dentin denudation
Chronic open pulpitis:
Ulcerative pulpitis:
It is a lesion characterized by an ulceration bordered by:
Either by a layer of granulation tissue under which we find more or less intense inflammatory signs.
Either by pulp calcifications which indicate a more or less anarchic reaction of the odontoblasts.
Physical signs: The crown appears gray where the pulp is exposed.
Functional signs: The pain is more provoked than spontaneous, percussions are not very sensitive.
PULP PATHOLOGY Etiologies – Pathogenesis – Classifications and symptomatology
Chronic hypertrophic pulpitis or pulp polyp:
It is a chronic inflammation of the exposed pulp that presents as an exuberant proliferation of pulp tissue
Physical signs: The widely opened hypertrophied pulp insinuates itself into the orifice created by the caries, thus destroying the pulp ceiling.
Functional signs: The pain caused is almost non-existent, except for slight pain when chewing due to contact with the polyp. This contact can cause significant hemorrhages. Spontaneous pain is non-existent.
10-Degenerative manifestations of the pulp:
This is often the result of pulp senescence or sometimes secondary to carious damage.
-Atrophy: Corresponds to a reduction in the number and size of all pulp cells.
– Pulp degeneration:
A-Definition: It is the pathological transformation of an organized biological structure into a structure that has lost its characteristics and its usual “WHO” function. There is a cellular reproduction but disordered; fibrous, calcic degeneration.
10-1-Calcium degeneration:
It is the exaggeration of a physiological phenomenon: dentinogenesis which can be due to: light, continuous or repeated irritations. This phenomenon occurs slowly with age.
True pulpoliths: contain Tomes fibers and at the periphery we note the presence of newly formed odontoblasts.
False pulpoliths: constitute an amorphous mass without tubules surrounded by undifferentiated cells.
Calcic degeneration is the only clinically detectable degeneration.
10-2-Fibrous degeneration: There is exaggerated and disordered neoproduction of fibrous tissue, it is often associated with calcic degeneration. The increase in collagen fibers can truly suffocate the pulp.
10-3-Fatty degeneration:
-It is not only a pathological deposition of fats due to exogenous and endogenous causes but also frequently to metabolic disorders conditioned by aging.
10-4-Hyaline degeneration:
This involves thickening of connective tissues by deposition of albuminoid material forming compact, transparent and amorphous masses.
10-5-Amyloid degeneration:
It is much rarer. The phenomena are analogous to hyalinization.
11-Internal root resorption: internal granuloma:
A-Definition:
Characterized by granulation tissue contained at the periphery of the odontoclasts.
-The resorption process takes place centrifugally at the expense of the coronal or radicular dentin.
-This phenomenon can affect any area of the root canal or pulp chamber and results in cavitation inside the tooth.
-Affect any tooth but more often the anterior ones.
PULP PATHOLOGY Etiologies – Pathogenesis – Classifications and symptomatology
12-CONCLUSION:
Current conceptions insist on the impossibility of proving the anatomy/clinical binomial, and all authors agree that it would be wiser to listen to the patient recount the symptoms he feels. Symptoms are influenced by many factors such as: the patient’s sensitivity , the difficulty in expressing oneself and also the way in which questions are asked by the practitioner. It will always be necessary to establish a relationship between physical and functional signs to allow a positive and differential clinical diagnosis to be made.
PULP PATHOLOGY Etiologies – Pathogenesis – Classifications and symptomatology
Wisdom teeth can cause infections if not removed.
Dental crowns restore the function and appearance of damaged teeth.
Swollen gums are often a sign of periodontal disease.
Orthodontic treatments can be performed at any age.
Composite fillings are discreet and durable.
Composite fillings are discreet and durable.
Interdental brushes effectively clean tight spaces.
Visiting the dentist every six months prevents dental problems.