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Disorders of the Dental Pulp

Today the topic is about Disorders of the dental pulp We talked about the developmental changes of teeth, non carious tooth, loss or changes affecting the teeth we said there is erosion, abrasion, attrition; all of these can result in loss of the tooth structure but without caries. We skipped caries in your text book because caries is extensively explained to you in Dental Caries and in conservative lectures etc.. , so we won't talk about caries, but the caries and other trauma to the teeth can induce pulp response. How the connection between dentine and pulp occur, through what? The channels between the external environment and the pulp are dentinal tubules. Even if there is caries in the enamel or dentine; the product of caries will reach the pulp through the dentinal tubule; and before the pulp exposure or the bacteria enter the pulp, [before the caries reach the pulp], the pulp will start showing responses.

What are the types of trauma to the pulp? How can the pulp be traumatized? 1. The first thing or the most significant cause of pulpitis or pulp response is Caries 2. other cause of pulp irritation, cavity preparation without cooling; without water spray we are generating heat and this heat will affect the pulp 3. another cause is chemical restorative material when they are placed directly on the pulp they may induce pulp response regardless of the type of the pulp response 4. and there is another trauma to the pulp called Barotrauma [differences in the pressure] example; when divers goes a deep inside the water and there is a big difference in the pressure the nitrogen bubbles will formed inside the pulp; and this is painful
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this will induce toothache; but later on they found that if the tooth is not carious barotrauma will not induce pain, so barotrauma is just exacerbating factor for pain in a previously carious tooth. Barotrauma: is difference in pressure and its will lead to nitrogen bubbles formation

A student asked something about barotrauma and the doctor answered: In barotrauma the difference in pressure will induce nitrogen bubbles formation, the nitrogen bubbles within the pulp will cause pressure on the nerve inside the pulp and because the pulp is contained within dentine (hard tissue) there is no area to expand so it will induce not pulpitis, but pain and when the cause is gone the tooth will come back to normal. Where got the bubbles come from? They are formed due to difference in atmospheric pressure like in the diver for example or going in high altitude. From oral pathology text book
Barotrauma (aerodontalgia)

Dental pain has been described by air crew flying at high altitudes in unpressurized aircraft, and in divers subjected to too rapid decompression following deep-sea diving. This pain has been attributed to the formation of nitrogen bubbles in the pulp tissues or vessels, similar to the decompression syndrome elsewhere in the body. However, gas bubbles are seldom found in decompressed organs and the possibility of fat emboli from altered lipoproteins and platelet thrombi around the fat is suggested by some investigators. Aerodontalgia is really a marker of inadequate pulp protection from the atmosphere and this usually means caries. It is not a direct cause of pulpitis, rather an exacerbating factor.

Pulpitis
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Is inflammation of the pulpal tissue regardless of the infective agent. The types of inflammation: 1. Maybe Acute or Chronic and this classification depends on; nature of pain if it's severe pain or mild; and duration of the pain. 2. Now according pulpitis it's also classified as Reversible and Irreversible The Reversible Vs. Irreversible Classification is more important than Acute Vs. Chronic, Why? Because the first ; Reversible Vs. Irreversible; you have to decide based on it your treatment plan ;if the tooth is having reversible pulpitis then you can do for example filling for the tooth but if the tooth is having irreversible pulpitis maybe you have to do Root Canal Treatment [RCT] So your treatment choice depends mainly on the diagnoses of reversible Vs. irreversible not on acute Vs. chronic Sometimes pulpitis occurs without symptoms; that's mean absence of symptoms doesnt mean that the pulp normal, maybe the pulp is necrotic but there is no symptoms. So we have to decide if the process is reversible or irreversible so that we can decide: to restore the tooth , or to remove the pulp , or even to remove the entire tooth.

Causes of pulpitis
1. It is maybe Bacterial . From where the bacteria will enter or reach the pulp? The bacteria may occur : due to caries ,

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 due to cracks in the tooth; if the tooth is fractured with cracks in the crown the oral environment is filled with bacteria then the bacteria may enter the pulp through cracks. Periodontal pockets; when the bacteria enter the pulp through the periodontal pockets there are lateral accessory canals the bacteria may enter through them and reach the pulp directly through the canals, or if there is a periodontal pockets reaching the apex the bacteria may enter through the main apex not the lateral accessory canals. so the periodontal pockets is another route for bacteria to reach the pulp and we call it endo perio lesion When the bacteria enters the pulp through periodontal pockets without caries without cracks we will call it Endo perio lesion if the tooth malformed; for example having dense invaginatus then caries may reach the pulp through the depth of the pit " you remember that, right !!" ** Dense invaginatus when there is a pit inside the tooth and then caries may occur inside the pit and then the stimuli will reach the pulp.

2. Traumatic causes
Like: crown fractures ;will expose dentine and then the bacteria will enter through the fracture or the root will be exposed to the oral environment root fractures also the bacteria will find a way to reach the pulp Partial avulsion the tooth is going out its socket due to trauma maybe so the bacteria will enter from the oral environment to the apex Bruxism and Abrasion All of these will induce loss of tooth structure exposing dentine and dentinal tubules. Then the irritant will reach the pulp through the expose dentinal tubule.

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Why there is sensitivity in abrasion? Because there is a fluid movement in the dentinal tubules affecting the pulp.

3. Iatrogenic causes:
Maybe the dentist will cause to the patient include: heat generation like cavity preparation without coolant, deep preparation; sometimes the preparation comes very close to the pulp even with a coolant the pulp maybe irritated Pulp exposure during cavity preparation, the book write about experiments done on the rats without bacteria exposure , there was no pulpal inflammation ,so the factor in pulp exposure in the oral cavity is that the entrance of bacteria When the exposure happened if there is good isolation, the bacteria will not enter the pulp and maybe there will be no pulpitis. But if there is lot of bacteria in oral cavity when pulp exposure occur bacteria will enter the pulp and will start causing inflammation Filling materials maybe toxic to the pulp if they are placed directly on the pulp and toxic disinfectant or if you are using certain material it may be very toxic to the pulp. These are the Iatrogenic causes: "which are the causes that you induce or you put to the patient" And the doctor said there is a table in your book talking about these causes !!

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Reversible pulpitis
when the patient comes to the clinic complaining of stimulated pain; pain induce by cold or hot drinks or air for example and this pain last for few second or short duration of time and then it will go by it is self , these are the clinical features of reversible pulpitis.

Irreversible pulpitis
When the pain is spontaneous; pain comes by it is self; the pain doesn't need cause (doesnt induce by cold or hot), its lasting for long duration and sometimes disturbing sleep of the patient.

Reversible pulpitis is the mildest form of inflammatory response to something, it may occur with severe attrition, so exposing dentine will cause reversible pulpitis, abrasion, caries when it's not deep this is reversible pulpitis And what happened in reversible pulpitis is just a slight infiltrate of lymphocyte Let's look here there is caries or cavity within the tooth and in the pulp we have a little bit of lymphocytic infiltrate just close to the area of irritant.

Lymphocyte

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Somebody may ask that the caries is not reaching the pulp yet so why we have inflammation? The answer is that the chemicals products of caries will reach the pulp, before the carious exposure of the pulp, through the dentinal tubule then the pulp will start immediately responding by a little or a small layer of lymphocyte it's localized to the irritant area, a little bit of vasodilatation and that's it. No necrosis, no neutrophils, no abscess formation, no extensive involvement of the pulp with lymphocyte. It is just a local collection of lymphocyte and a little bit of vasodilatation.

Reversible pulpitis
Dentine (dentinal tubule )

Odontoblast layer lymphocyt e

Dilated blood vessel

Here is the dentine and the dentinal tubules, here is the dark rounded spots are mainly lymphocyte look how they are localized forming a single layer immediately below the dentine of the affected area , blood vessels maybe slightly dilated and congested I mean engorged with blood , slight distribution of the odontoblast layer; sometimes the odntoblast go inside the dentinal tubule according to stimulus or they may be pushed a little bit forming small clusters of odontoblast so they may be disturbed but it's still there.

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So we can diagnose reversible pulpitis by: Clinical pictures. Symptoms; stimulated pain last for short duration relived by its self The Histopathologic picture; where there is a focal collection of lymphocyte with a little bit of vasodilatation.

Irreversible Pulpitis
It may be acute or chronic even it clinically or microscopically, and the treatment of irreversible pulpitis is removal of pulp, we can't remove the caries because the pulp can't go back to normal unlike the reversible pulpitis we can remove the caries and place restorative materials or whatever.

Acute irreversible pulpitis

Look at the pulp response here; we have focal collection of inflammatory cells, what are these inflammatory cells? These are acute inflammatory cells which are neutrophils, and you know when there is collection of neutrophils that means we have an abscess . The definition of abscess: focal collection of neutrophils , plus necrotic materials and bacteria ..... etc. Note: acute inflammation means that we have neutrophils, chronic inflammation means that we have lymphocyte.

Carious exposure of the pulp

Neutrophils

Dilated blood vessel

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Here (in acute pulpitis) we have focal area of acute inflammation with caries exposure, edema formation and dilated blood vessels, after that what will happen to the pulp? As a result of acute inflammation there will be more vasodilatation, more edema and fluid accumulation within the pulp which will compressed the circulation, and when the blood supply is cut or not reach at a specific area that will cause necrosis, the same applies in the pulp with focal inflammation, mediators of the inflammation, exudates, fluid accumulation then there will be compression of the circulation, why there will be compression of the circulation here? Because there is no space for the pulp to expand (the pulp can't expand), where the fluid will go? It will start taking the space of the blood vessels and compressing them and that lead to cut the blood supply, later on necrosis will start, it starts focally and then it may expand to involve the whole pulp. So Acute Pulpitis: It called acute because 1. There is rapid entrance of bacteria to the pulp, so the immediate response is focal accumulation of neutrophils. This occurs mainly in children and adolescents why? Because there is no secondary dentin formation; with age the thickness of dentin will increase so the caries will take more time to reach the pulp, but in children the thickness of dentin is small so the caries will reach rapidly to the pulp. 2. Another cause of acute response is overheating due to cavity preparation, it is fast and rapid so it is an acute cause.

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Pulp abscess : Here we have an abscess with a core of neutrophils and the pulp start forming granulation tissue surrounding the abscess without forming capsule this one of the outcome of the abscess , another outcome is spreading to involve the whole pulp.

Chronic pulpitis :
It occurs in older tooth with thick layer dentin formation consist of sclerotic dentin and reparative dentin with penetration of the pulp with very low amount of bacteria or in slow manner. Again acute Vs chronic isn't the important factor that determinates your treatment plan , the factor that determinates your treatment plan is reversible Vs irreversible.

Reversible Vs Irreversible You can differentiate reversible and irreversible by clinical symptoms and the histopathological features . What are the clinical symptoms for pulpitis?? Reversible The pain is Elicited (stimulated) , Sharp Irreversible The pain is Spontaneous , Dull

The pain last for 10 15 minutes or The pain last for more than 20 less minutes Unaffected by body posture Affected by body posture

The pain is Poorly Localized What's the difference between stimulated and spontaneous? Stimulated: need stimulus to occur like cold, hot, or air. Spontaneous: doesn't need stimulus to occur it's comes by it self.
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 Sharp Vs dull pain sometimes it's not easy to differentiate between them but the sharp pain is just like electric shock the patient will tell you that )(

In reversible pulpitis the pain last for short duration ; after you drink cold water the pain will last only for 10 minutes may be (actually the pain may last for second only and it will goes) but in the irreversible the pain will last for long period it's not really 20 minutes its sometimes several hours.

Why in the irreversible pulpitis the pain is affected by body posture? Sometimes when the patient sits in a certain condition he will feel relieve of pain because in the irreversible pulpitis we have fluid we have edema inside the pulp so when the patient moves his head to one side the pressure will be relieved slightly or when the patient lowers his head down sometimes the pressure increase in the pulp so the pain will increase So the pulpitis which is affected by the body posture is not reversible (irreversible) because there is a fluid, edema and accumulation. It's difficult to localized pulpitis in general but it's localized in periapical inflammation, when the inflammation goes out of the pulp, the pain is easily localized why? Because in the periodontal ligaments (PDL) there are proprioceptors, there is nerve ending that feels the pressure, and the pain can be localized this in the periapical inflammation, but when there is pulpitis we don't have proprioceptors within the pulp so the pain can't be localized to which tooth.

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Finally the doctor said "The things I want you to understand are the clinical symptoms of reversible and irreversible, how to differentiate between them clinically, how to differentiate between them microscopically ,the pathological out comes which is if you have a localized abscess ether this abscess can be localized or has spread ,the body can form granulation tissue and keep it localized ,or the amount of bacteria entering to the pulp is very huge ,insulting to the pulp that the pulp can't cope with it so complete necrosis may occur . So the response of the pulp depends on the amount of bacteria entering the pulp and the body response to this amount of bacteria Little amount of bacteria can be handled but huge amount of bacteria may induce complete necrosis to the pulp." A student asked: If there is another cause for reversible pulpitis than bacteria?? Reversible pulpitis can be induce by bacteria ,due to caries, can be induce by air causing fluid to move in the dentinal tubules in abrasion or fracture tooth .. suppose your tooth is fracture and there is no caries but there is pulpitis why? because of the fluid movement in the dentinal tubule . sometimes your fracture tooth will allowed the bacteria to enter directly to the pulp from oral cavity from saliva without caries so caries is not the only factors cause pulpitis ether it's reversible or irreversible And how about the treatment ? Method of the treatment is differing: In reversible pulpitis just remove the caries and put filling, if the tooth is fractured repair fracture first, the important thing you have to cover the dentine to isolate the pulp from the surrounding environment but if the pulpitis is irreversible there is several way to treated ether direct pulp capping or partial remove of the pulp or complete removal of the pulp or what ever Reversible is treated by filling, placement, covering the dentine. Irreversible is treated by several ways including direct or indirect pulp capping etc.. "You will take it in Endo insha'allah "
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Now we already know the histology of the reversible and irreversible pulpitis, Here is a comparison between the reversible and irreversible pulpitis :
reversible pulpitis irreversible pulpitis

Inflammation cell Abscess formation Exudates formation Necrosis Treatment

Lymphocyte No Very minimal or No No Remove the caries

Neutrophils Yes yes yes Remove the pulp RCT

The abscess that form in the pulp may be localized or spread to the whole pulp or even go beyond the tooth and spread surrounding tissue, but the abscess will never be capsulated like in the skin and other region. These are the features of the pulp that change the fate of the inflammation compared to the other region: 1. the pulp is contained within a solid chamber and we know now the important of this statement ; the pulp can't expand , the fluid doesn't have space to accumulate except by causing pressure on the adjacent structure . 2. pulp has limited blood supply through the epical foramen , so if the blood supply is cut due to exudates pressure ,blood supply is difficult to come to the pulp , unlike skin ; it have blood supply coming from all around to neutralizing the toxin and inducing healing. The inflammation in the pulp may be destructive by ; 1. mediators of the inflammation may cause edema which means fluid accumulation that may compressed blood supply and induce necrosis. 2. dilated blood vessels cause pressure on the nerves . 3. leakage of fluid from blood vessel leads to accumulate fluid within the pulp , and further complicate the inflammation process .
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4. migration of the cells from the blood vessel may occur , when the neutrophils die and the enzyme will released and spread causing further damage to the surrounding pulp .

Pulp necrosis;
Untreated irreversible pulpitis (infected with bacteria): lose acute and chronic symptoms ; mediator of inflammation will induce fluid accumulation . degeneration of nerve fibers . autolysis ; when neutrophils die there will be release of their enzyme and will start lysis of the surrounding pulp tissue , but it called autolysis because the lysis occur due to the neutrophils from our bodies . Histopathology of pulp disease: In general it is difficult to correlate pulpal finding with a symptoms, sometime the patient have severe pain but the pulpal changes are very minimal. suppose that the tooth was extracted for a patient with severe pain , and then the tooth was taken to the histolopathology. Sometime the inflammation is very minimal compared to the symptoms but it still inducing sever pain because of the special feature of the pulp, again any extra amount of fluid doesn't have a space it will press on the nerves and induce pain or it will press on the blood vessel and induce necrosis. Bacterial entrance leads to dilate and congest blood vessel and that cause exudates formation as a result of inflammatory mediators coming from the inflammatory cells, this exudates formation will compressed the blood vessel and later on the blood supply is cut and cause ischemia followed by necrosis. If there is low caries level the response will be very mild, and what did we say about the very mild response ? What is the type of WBC's? the type of the inflammatory cell is lymphocyte , because the type of the inflammation is reversible ,and there will be a very minimal dilatation of blood vessel but no exudates formation .

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Chronic Hyperplastic pulpitis:

Sometimes the response of the pulp isn't abscess or autolysis or edema formation, but it may be hyperplastic type of pulpitis (there will be increase amount of granulation tissue formation , to extent that project (protruding) out of the cavity) , and this occur in certain circumstances that is : to have big opened cavity to allow this exuberant amount of granulation tissue to protrude out of it . 2. to have an opened apex so that you have very good blood
1.

supply for the granulation tissue to occur.

We need blood supply here; the inflammation and the granulation tissue formation need good blood supply why? Because we need WBC's, so we will get them and why we need WBC's? Because we need the inflammatory mediators to induce this amount of granulation tissue formation.

Where can we have opened apex? In which type of people? In children! Because they still have opened apex with good blood supply and also we need the caries to be widely opened to have this type of response The granulation tissue that protrude out into the oral cavity can't be covered by epithelium and then it will bleed easily, any touch to the polyp will induce bleeding or it may be epithelialized ,the epithelial will come from the surrounding gingival (from the desquamated cells in saliva) and it will reach the surface and cover it with epithelium if it's epithelialized then it doesn't bleed easily. So the granulation tissue can be epithelialized or not epithelialized according to the oral cavity condition .

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So Chronic Hyperplastic Pulpitis (pulp polyp) : It is hyperplastic because there is increase in the amount of the pulp. The features: 1. opened occlusal cavity . 2. opened apex or good blood supply. 3. the patient is usually young with young pulp capacity to regenerate and the features of this pulp polyp is that the nerves aren't prominent so it isn't painful to touch, and the tooth is not painful.

This projected pulp doesn't disappear by itself, and if you cut it you will induce server excessive bleeding, so we can treat this chronic hyperplastic pulpitis (pulp polyp) by removal the whole pulp (RCT). Low grade caries over long period of time allowing the formation of this big cavity.

Pulp calcification and changes of the pulp

Calcification may occur to the pulp with time Pulp stones may form what are the pulp stones? Calcified particles within the pulp (round particles) and they may be true or false. The True pulp stones contain dentinal tubules but the False pulp stones contain layer of calcified material without dentinal tubule

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Here is a pulp stone if I examine it microscopically I should find dentinal tubules to call it True pulp stone, no dentinal tubule False pulp stone. Here also the pulp stone is free, so it can be free or can be adherent to anything or may be interstitial; it mean incorporated within dentine for example lining the pulp. So it may be: Free or, Adherent or, Interstitial (when they have become surrounded by reactionary or secondary dentine) True pulp stone composed of dentine and contain dentinal tubule False pulp stone composed of calcified material but not having dentinal tubule This is one of the features of age changes of the pulp, so the pulp stone will start increasing in number with age There is Dystrophic Calcification , sometimes the mineral can deposit in the pulp forming dystrophic calcification they are irregular in the shape ,they may be just granules or linear area but not forming something rounded (or particles) So Pulp Stone it has a core it's rounded just like a stone, but the granules (Granular deposit) and anything scattered are Dystrophic Calcification!!

Fig. 4.13 Dystrophic calcifications in the radicular pulp "from the text book"

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Why we call it dystrophic calcification? What is the dystrophic calcification? What are the types of calcification? Dystrophic Calcification can occur in the skin or in the kidney or in the liver it can occur anywhere in the body and even in the pulp so in dystrophic calcification the tissue is abnormal, there is something abnormal in the tissue that allowed calcium minerals to deposit over it , there is a change in the tissue; it's may be inflammation or any generative change; and this is abnormal tissue will allowed the calcium minerals to precipitate in it But in the other type of calcification (the doctor forget the name) the calcium level is high in the blood and calcification happened everywhere because the calcium is very high.

The End
(( )) (( )) !. _ _

Done By : SAKHA'A ALI TWAISSI DUAA WALID ABU HMAID

Please read the extra notes in the next page maybe it will help you .. and forgive us for any mistake we really try to do our best..

Some extra notes the doctor pointed to them in the next lecture:
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 in pulpitis clinical features in the book they didn't mentioned anything about localized pain ether in reversible or irreversible pulpitis so We will rely in this chapter that the pain in pulpitis in general is poorly localized you must focus on the importance of bacteria as etiology of pulpitis they found even if the tooth has fractured and bacteria didn't enter the pulp pulpitis will not occur or if there was exposure with no bacteria pulpitis will not occur so the important factor in pulpitis is the entrance or penetrance of bacteria to the pulp From the text book ((Reactionary dentine may continue to form after the onset of pulpitis, providing the odontoblasts and pulp have not been irreversibly damaged, and may in time protect the pulp from further injury by increasing the thickness of calcified tissue between the pulp and the irritant in the dentine.)) rate of progression of pulpitis is vary from individual to individual the severity of pulpitis depends on individual itself (individual response) and amount of bacteria which enter the pulp sometimes amount of bacteria that entrance the pulp is too small but cause excessive response . before bacteria enter the pulp pulpitis(the inflammatory response) will start and when bacteria enter the pulp abscess and exudates formation starts the difference between carious exposure and non carious exposure to the pulp , trauma and the fracture and the excessive force to the tooth this non carious, may start immediately as acute excaudate (pus), in the other hand the carious exposure start with focal inflammation and later it's return to abscess if the bacteria enter the pulp

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 pulp stones increase with age but it's not only present in elderly it may be present in four condition \circumstances: increasing with age ,and as a response for operative procedure ,and in traumatic injury to the apex ,and maybe in Dentin Dysplasia and Dentinogenesis imperfecta from the text book ((Pulp stones increase in number and size with age and are apparently more numerous after operative procedures on the tooth. When large they may be recognized on radiographs. They do not cause symptoms, although neuralgic pain has sometimes been attributed to their presence.)) what happened to the pulp with age it will be narrower why ? Because of dentine deposition and pulp stone and calcification will increases and vascularity and cellularity of the pulp will decrease with age from the text book ((The volume of the pulp gradually decreases with age due to the continued production of secondary dentine. Decreased vascularity, reduction in cellularity, and increase in collagen fiber content have also been reported, and these changes may impair the response of the tissue to injury and its healing potential)) The doctor advised us and said: " please read your text book and rearrange the information . so you can study easily"

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