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Pulp & Periapical Diseases
Dr. Ashraf Refai
BDS MSc DD HMD
Associate Professor of Endodontics

Normal Response of Tissue to Irritants
Goals of Inflammation
1. Dilute the irritant
2. To destroy the irritant
3. To set the stage for healing and
repair
Sequence of the Inflammatory Process
Pulpal
Irritation
Infammatory
Mediators
Increased
Vascular
Premeability
Increased
Vascular
Premeability
Tissue
Damage
Exudate
Formation
Uniqueness of Pulpal
Inflmmation
1. Non-Compliant environment
(Dentinal Walls)
2. Lack of collateral circulation
3. Reparative dentin formation
Pulpal Disease
Classification of Pulpal Disease
❖ Reversible Pulpitis
❖ Irreversible Pulpitis
❖ Acute Pulpitis
❖ Chronic Pulpitis
❖ Chronic Ulcerative Pulpitis
❖ Chronic Hyperplastic Pulptis
❖ Pulp Necrosis
❖ Other Causes
Etiology
Reversible Pulpitis
(Hyperemia)
Due to mild stimulus
• Incipient caries
• Cavity preparation
• Cervical erosion
• Leaking restorations
1. Sharp transient pain which
subsides after removal of the
stimulus
2. Pulp Test: Normal
3. Radiograph: Normal
4. Palpation & Percussion: Normal
Signs & Symptoms
Reversible Pulpitis
(Hyperemia)
1. Vasodilatation
2. Mild infiltration of
inflammatory cells
Histopathological PIcture
Reversible Pulpitis
(Hyperemia)
Classification of Pulpal Disease
❖ Reversible Pulpitis
❖ Irreversible Pulpitis
❖ Acute Pulpitis
❖ Chronic Pulpitis
❖ Chronic Ulcerative Pulpitis
❖ Chronic Hyperplastic Pulptis
❖ Pulp Necrosis
❖ Other Causes
Etiology
Acute Pulpitis

(Irreversible Pulpitis)
Due to increased intrapulpal pressure
• Symptoms vary according to
degree of inflammation
• Can be Initial, Moderate or
Severe
Pain
Initially mild shooting pain that
increases when patient lies down
Signs & Symptoms
Acute Pulpitis

(Irreversible Pulpitis)
Pain
Initially it is initiated with cold
stimulus and lasts for awhile after
removal of stimulus in later stages
it is spontaneous
Signs & Symptoms
Acute Pulpitis

(Irreversible Pulpitis)
Pain
• Initially it is intermittent but in later
stages becomes continuous
• Diffuse not localized hard to identify
offending tooth
Signs & Symptoms
Acute Pulpitis

(Irreversible Pulpitis)
Pain
• Initially cold stimulus causes pain in
the later stages heat as well. (Hot tooth)
• Pain can be referred to adjacent of
opposing teeth
Signs & Symptoms
Acute Pulpitis

(Irreversible Pulpitis)
Signs & Symptoms
Acute Pulpitis

(Irreversible Pulpitis)
1. Pulp Test: Exaggerated response
2. Radiograph: Normal or slight
widening in PD membrane
space
3. Palpation & Percussion: Normal
Histopathological Picture
Acute Pulpitis

(Irreversible Pulpitis)
1. Increased infiltration of
inflammatory cells (Neutrophils)
2. Formation of Micro-abscesses
lymphocytic infiltration around
abscess as well macrophages &
plasma cells
Classification of Pulpal Disease
❖ Reversible Pulpitis
❖ Irreversible Pulpitis
❖ Acute Pulpitis
❖ Chronic Pulpitis
❖ Chronic Ulcerative Pulpitis
❖ Chronic Hyperplastic Pulptis
❖ Pulp Necrosis
❖ Other Causes
Etiology
Chronic Ulcerative Pulpitis

(Irreversible Pulpitis)
• Can occur after a period of acute
pulpitis
• Or can occur from the onset
• Usually due to low grade stimulus
• Large carious exposure pulp
appears ulcerated
Signs & Symptoms
Chronic Ulcerative Pulpitis

(Irreversible Pulpitis)
• Pain: Mild or absent no intrapulpal
pressure
• Large carious lesion with exposed area of
the pulp
• Pulp testing: Responsive
• Radiograph: Normal or slight widening of
PD membrane space
• Palpation & Percussion: Normal
Histological Picture
Chronic Ulcerative Pulpitis

(Irreversible Pulpitis)
• Zone of necrosis
• Zone of leukocytic infiltration
• Zone of proliferation fibroblasts
Classification of Pulpal Disease
❖ Reversible Pulpitis
❖ Irreversible Pulpitis
❖ Acute Pulpitis
❖ Chronic Pulpitis
❖ Chronic Ulcerative Pulpitis
❖ Chronic Hyperplastic Pulptis
❖ Pulp Necrosis
❖ Other Causes
Etiology
Chronic Hyperplastic Pulpitis

(Irreversible Pulpitis)
• Usually occurs in young patients
• Mild inflammatory low grade
response
• Overgrowth of granulomatous
tissue from a large pulp
exposure
Signs & Symptoms
Chronic Hyperplastic Pulpitis

(Irreversible Pulpitis)
• Presents as a pulp polyp extruding out of a
carious exposure
• Polyp is not painful but easily bleeds
• Pain: Mild pain
• Pulp Test: Responsive
• Radiograph: Normal or slight widening of
PD membrane space
• Palpation & Percussion: Normal
Histopathological Pictures
Chronic Hyperplastic Pulpitis

(Irreversible Pulpitis)
Pulp polyp is made up of:
• Proliferation of fibroblasts
• New capillaries
• Inflammatory cells
• Few nerve cells
Classification of Pulpal Disease
❖ Reversible Pulpitis
❖ Irreversible Pulpitis
❖ Acute Pulpitis
❖ Chronic Pulpitis
❖ Chronic Ulcerative Pulpitis
❖ Chronic Hyperplastic Pulptis
❖ Pulp Necrosis
❖ Other Causes
Etiology
Pulp Necrosis
• The inflammation progresses
due to acute or chronic pulpitis
results in pulp disintegration
and necrosis.
Signs & Symptoms
Pulp Necrosis
• Pain: Mostly very mild or absent.
• Pulp Test: Negative
• Radiograph: Normal of
Widening of PD membrane space
• Palpation & Percussion: Negative
Histopathological Picture
Pulp Necrosis
• Liquefaction necrosis
Classification of Pulpal Disease
❖ Reversible Pulpitis
❖ Irreversible Pulpitis
❖ Acute Pulpitis
❖ Chronic Pulpitis
❖ Chronic Ulcerative Pulpitis
❖ Chronic Hyperplastic Pulptis
❖ Pulp Necrosis
❖ Other Causes
Etiology
Other Causes
• Pulp atrophy
• Calcification
• Internal resorption
Periapical Disease
Classification of Periapical Disease
❖ Acute Periapical Disease
❖ Acute Apical Periodontitis
❖ Acute Apical Abscess
❖ Recrudescence Absecess (Pheonix
Abscess)
❖ Chronic Periapical Disease
❖ Chronic Aical Periodontitis
❖ Chonic Apical Abscess
❖ Condensing Osteitis
Etiology
Acute Apical Periodontitis
• Localized inflammation of the apical
area
• Due to either
• Toxic component of pulp necrosis
• Mechanical irritation
• Chemical causes (irrigant & filling
materials)
1. Tooth is tender and slightly elevated
2. Patient can localize pain
3. Pain can be mild to severe
4. Pulp test: Postive or Negative
5. Radiograph: Slight Widening
6. Palpation & Perscussion: Positive
Signs & Symptoms
Acute Apical Periodontitis
1. Connective tissue shows
migration of inflammatory cells
into the interstitial tissues
2. Beginning of bone resorption
Histopatholog
Acute Apical Periodontitis
Classification of Periapical Disease
❖ Acute Periapical Disease
❖ Acute Apical Periodontitis
❖ Acute Apical Abscess
❖ Recrudescence Absecess (Pheonix
Abscess)
❖ Chronic Periapical Disease
❖ Chronic Aical Periodontitis
❖ Chonic Apical Abscess
❖ Condensing Osteitis
Etiology
Acute Apical Abscess
• Localized collection of pus in an a
cavity formed by disintegration of
tissues
• Advanced exudative inflammatory
response
• Neglected apical periodontitis (Same
Eitology)
1. Severe throbbing & tooth is elevated
2. Localized or diffuse swelling
3. May present with fever & lymph node
affection
4. Pulp test: Negative
5. Radiograph: Slight Widening or large
lesion
6. Palpation & Perscussion: Positive
Signs & Symptoms
Acute Apical Abscess
Classification of Periapical Disease
❖ Acute Periapical Disease
❖ Acute Apical Periodontitis
❖ Acute Apical Abscess
❖ Recrudescence Abscess (Pheonix
Abscess)
❖ Chronic Periapical Disease
❖ Chronic Aical Periodontitis
❖ Chonic Apical Abscess
❖ Condensing Osteitis
Etiology
Recrudescence Abscess
(Pheonix Abscess)
• It is an acute exacerbation of chronic
periapical lession. It occurs when there
is an imbalance between the host
response & irritant.
• Symptoms are similar to an acute
apical abscess
• Usually large lesion related to the tooth
Classification of Periapical Disease
❖ Acute Periapical Disease
❖ Acute Apical Periodontitis
❖ Acute Apical Abscess
❖ Recrudescence Abscess (Pheonix
Abscess)
❖ Chronic Periapical Disease
❖ Chronic Aical Periodontitis
❖ Chonic Apical Abscess
❖ Condensing Osteitis
Etiology
Chronic Apical
Periodontitis
• It can develop from acute apical
periodontitis
• Or it can develop independently
without previous symptoms
1. Usually no significant pain
2. Pulp test: Negative
3. Radiograph: Lesion related to
the tooth
4. Palpation & Perscussion: Mild
or none
Signs & Symptoms
Chronic Apical
Periodontitis
1. Growth of granulation tissue around root apex
2. 4 Zones:
1. Zone 1: Necrosis zone (Neutrophills)
2. Zone 2: Contamination zone (Multi
Nucleated Giant Cells
3. Zone 3: Irritation zone (Neutrophills,
lymphocytes & macrophages
4. Zone 4: Stimulation zone (Fibroblasts &
Osteoblasts)
Histopatholog
Chronic Apical Periodontitis
(Periapical Granuloma)
1. Considered a granuloma with a fluid
filled center & an epithelium lined cavity
2. Epithelial cells originate from the cells of
Malassez
3. The fluid in the center maybe clear or
viscous yellow (fatty degeneration).
Contains cholesterol crystals.
Histopatholog
Chronic Apical Periodontitis
(Periapical Cyst)
Classification of Periapical Disease
❖ Acute Periapical Disease
❖ Acute Apical Periodontitis
❖ Acute Apical Abscess
❖ Recrudescence Abscess (Pheonix
Abscess)
❖ Chronic Periapical Disease
❖ Chronic Aical Periodontitis
❖ Chonic Apical Abscess
❖ Condensing Osteitis
Etiology
Chronic Apical Abscess
• Condition after an acute apical
abscess has drained
1. Usually very mild pain
2. Usually a draining sinus tract
3. Pulp test: Negative
4. Radiograph: Lesion related to the
tooth (Not well defined)
5. Palpation & Perscussion: Mild or
none
Signs & Symptoms
Chronic Apical Abscess
1. Could be either periapical
granuloma or periapical cyst.
2. Usually looks like a periapical
granuloma with pus in the
center
Histopatholog
Chronic Apical Abscess
Classification of Periapical Disease
❖ Acute Periapical Disease
❖ Acute Apical Periodontitis
❖ Acute Apical Abscess
❖ Recrudescence Abscess (Pheonix
Abscess)
❖ Chronic Periapical Disease
❖ Chronic Aical Periodontitis
❖ Chonic Apical Abscess
❖ Condensing Osteitis
Etiology
Condensing Osteitis
• Low grade long standing irritation
• Resulting in unusual body response
by increased density of periodical
bony tissue due to hyperactive
osteoblastic activity
• Young patients with large carious
session
1. Usually no pain
2. Pulp test: Negative
3. Radiograph: Radioopacity
related to the root apex
4. Palpation & Perscussion:
Negative
Signs & Symptoms
Condensing Osteitis
“Thank You”

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Pulp & periapical disease

  • 1. Pulp & Periapical Diseases Dr. Ashraf Refai BDS MSc DD HMD Associate Professor of Endodontics

  • 2. Normal Response of Tissue to Irritants Goals of Inflammation 1. Dilute the irritant 2. To destroy the irritant 3. To set the stage for healing and repair
  • 3. Sequence of the Inflammatory Process Pulpal Irritation Infammatory Mediators Increased Vascular Premeability Increased Vascular Premeability Tissue Damage Exudate Formation
  • 4. Uniqueness of Pulpal Inflmmation 1. Non-Compliant environment (Dentinal Walls) 2. Lack of collateral circulation 3. Reparative dentin formation
  • 6. Classification of Pulpal Disease ❖ Reversible Pulpitis ❖ Irreversible Pulpitis ❖ Acute Pulpitis ❖ Chronic Pulpitis ❖ Chronic Ulcerative Pulpitis ❖ Chronic Hyperplastic Pulptis ❖ Pulp Necrosis ❖ Other Causes
  • 7. Etiology Reversible Pulpitis (Hyperemia) Due to mild stimulus • Incipient caries • Cavity preparation • Cervical erosion • Leaking restorations
  • 8. 1. Sharp transient pain which subsides after removal of the stimulus 2. Pulp Test: Normal 3. Radiograph: Normal 4. Palpation & Percussion: Normal Signs & Symptoms Reversible Pulpitis (Hyperemia)
  • 9. 1. Vasodilatation 2. Mild infiltration of inflammatory cells Histopathological PIcture Reversible Pulpitis (Hyperemia)
  • 10. Classification of Pulpal Disease ❖ Reversible Pulpitis ❖ Irreversible Pulpitis ❖ Acute Pulpitis ❖ Chronic Pulpitis ❖ Chronic Ulcerative Pulpitis ❖ Chronic Hyperplastic Pulptis ❖ Pulp Necrosis ❖ Other Causes
  • 11. Etiology Acute Pulpitis
 (Irreversible Pulpitis) Due to increased intrapulpal pressure • Symptoms vary according to degree of inflammation • Can be Initial, Moderate or Severe
  • 12. Pain Initially mild shooting pain that increases when patient lies down Signs & Symptoms Acute Pulpitis
 (Irreversible Pulpitis)
  • 13. Pain Initially it is initiated with cold stimulus and lasts for awhile after removal of stimulus in later stages it is spontaneous Signs & Symptoms Acute Pulpitis
 (Irreversible Pulpitis)
  • 14. Pain • Initially it is intermittent but in later stages becomes continuous • Diffuse not localized hard to identify offending tooth Signs & Symptoms Acute Pulpitis
 (Irreversible Pulpitis)
  • 15. Pain • Initially cold stimulus causes pain in the later stages heat as well. (Hot tooth) • Pain can be referred to adjacent of opposing teeth Signs & Symptoms Acute Pulpitis
 (Irreversible Pulpitis)
  • 16. Signs & Symptoms Acute Pulpitis
 (Irreversible Pulpitis) 1. Pulp Test: Exaggerated response 2. Radiograph: Normal or slight widening in PD membrane space 3. Palpation & Percussion: Normal
  • 17. Histopathological Picture Acute Pulpitis
 (Irreversible Pulpitis) 1. Increased infiltration of inflammatory cells (Neutrophils) 2. Formation of Micro-abscesses lymphocytic infiltration around abscess as well macrophages & plasma cells
  • 18. Classification of Pulpal Disease ❖ Reversible Pulpitis ❖ Irreversible Pulpitis ❖ Acute Pulpitis ❖ Chronic Pulpitis ❖ Chronic Ulcerative Pulpitis ❖ Chronic Hyperplastic Pulptis ❖ Pulp Necrosis ❖ Other Causes
  • 19. Etiology Chronic Ulcerative Pulpitis
 (Irreversible Pulpitis) • Can occur after a period of acute pulpitis • Or can occur from the onset • Usually due to low grade stimulus • Large carious exposure pulp appears ulcerated
  • 20. Signs & Symptoms Chronic Ulcerative Pulpitis
 (Irreversible Pulpitis) • Pain: Mild or absent no intrapulpal pressure • Large carious lesion with exposed area of the pulp • Pulp testing: Responsive • Radiograph: Normal or slight widening of PD membrane space • Palpation & Percussion: Normal
  • 21. Histological Picture Chronic Ulcerative Pulpitis
 (Irreversible Pulpitis) • Zone of necrosis • Zone of leukocytic infiltration • Zone of proliferation fibroblasts
  • 22. Classification of Pulpal Disease ❖ Reversible Pulpitis ❖ Irreversible Pulpitis ❖ Acute Pulpitis ❖ Chronic Pulpitis ❖ Chronic Ulcerative Pulpitis ❖ Chronic Hyperplastic Pulptis ❖ Pulp Necrosis ❖ Other Causes
  • 23. Etiology Chronic Hyperplastic Pulpitis
 (Irreversible Pulpitis) • Usually occurs in young patients • Mild inflammatory low grade response • Overgrowth of granulomatous tissue from a large pulp exposure
  • 24. Signs & Symptoms Chronic Hyperplastic Pulpitis
 (Irreversible Pulpitis) • Presents as a pulp polyp extruding out of a carious exposure • Polyp is not painful but easily bleeds • Pain: Mild pain • Pulp Test: Responsive • Radiograph: Normal or slight widening of PD membrane space • Palpation & Percussion: Normal
  • 25. Histopathological Pictures Chronic Hyperplastic Pulpitis
 (Irreversible Pulpitis) Pulp polyp is made up of: • Proliferation of fibroblasts • New capillaries • Inflammatory cells • Few nerve cells
  • 26. Classification of Pulpal Disease ❖ Reversible Pulpitis ❖ Irreversible Pulpitis ❖ Acute Pulpitis ❖ Chronic Pulpitis ❖ Chronic Ulcerative Pulpitis ❖ Chronic Hyperplastic Pulptis ❖ Pulp Necrosis ❖ Other Causes
  • 27. Etiology Pulp Necrosis • The inflammation progresses due to acute or chronic pulpitis results in pulp disintegration and necrosis.
  • 28. Signs & Symptoms Pulp Necrosis • Pain: Mostly very mild or absent. • Pulp Test: Negative • Radiograph: Normal of Widening of PD membrane space • Palpation & Percussion: Negative
  • 30. Classification of Pulpal Disease ❖ Reversible Pulpitis ❖ Irreversible Pulpitis ❖ Acute Pulpitis ❖ Chronic Pulpitis ❖ Chronic Ulcerative Pulpitis ❖ Chronic Hyperplastic Pulptis ❖ Pulp Necrosis ❖ Other Causes
  • 31. Etiology Other Causes • Pulp atrophy • Calcification • Internal resorption
  • 33. Classification of Periapical Disease ❖ Acute Periapical Disease ❖ Acute Apical Periodontitis ❖ Acute Apical Abscess ❖ Recrudescence Absecess (Pheonix Abscess) ❖ Chronic Periapical Disease ❖ Chronic Aical Periodontitis ❖ Chonic Apical Abscess ❖ Condensing Osteitis
  • 34. Etiology Acute Apical Periodontitis • Localized inflammation of the apical area • Due to either • Toxic component of pulp necrosis • Mechanical irritation • Chemical causes (irrigant & filling materials)
  • 35. 1. Tooth is tender and slightly elevated 2. Patient can localize pain 3. Pain can be mild to severe 4. Pulp test: Postive or Negative 5. Radiograph: Slight Widening 6. Palpation & Perscussion: Positive Signs & Symptoms Acute Apical Periodontitis
  • 36. 1. Connective tissue shows migration of inflammatory cells into the interstitial tissues 2. Beginning of bone resorption Histopatholog Acute Apical Periodontitis
  • 37. Classification of Periapical Disease ❖ Acute Periapical Disease ❖ Acute Apical Periodontitis ❖ Acute Apical Abscess ❖ Recrudescence Absecess (Pheonix Abscess) ❖ Chronic Periapical Disease ❖ Chronic Aical Periodontitis ❖ Chonic Apical Abscess ❖ Condensing Osteitis
  • 38. Etiology Acute Apical Abscess • Localized collection of pus in an a cavity formed by disintegration of tissues • Advanced exudative inflammatory response • Neglected apical periodontitis (Same Eitology)
  • 39. 1. Severe throbbing & tooth is elevated 2. Localized or diffuse swelling 3. May present with fever & lymph node affection 4. Pulp test: Negative 5. Radiograph: Slight Widening or large lesion 6. Palpation & Perscussion: Positive Signs & Symptoms Acute Apical Abscess
  • 40. Classification of Periapical Disease ❖ Acute Periapical Disease ❖ Acute Apical Periodontitis ❖ Acute Apical Abscess ❖ Recrudescence Abscess (Pheonix Abscess) ❖ Chronic Periapical Disease ❖ Chronic Aical Periodontitis ❖ Chonic Apical Abscess ❖ Condensing Osteitis
  • 41. Etiology Recrudescence Abscess (Pheonix Abscess) • It is an acute exacerbation of chronic periapical lession. It occurs when there is an imbalance between the host response & irritant. • Symptoms are similar to an acute apical abscess • Usually large lesion related to the tooth
  • 42. Classification of Periapical Disease ❖ Acute Periapical Disease ❖ Acute Apical Periodontitis ❖ Acute Apical Abscess ❖ Recrudescence Abscess (Pheonix Abscess) ❖ Chronic Periapical Disease ❖ Chronic Aical Periodontitis ❖ Chonic Apical Abscess ❖ Condensing Osteitis
  • 43. Etiology Chronic Apical Periodontitis • It can develop from acute apical periodontitis • Or it can develop independently without previous symptoms
  • 44. 1. Usually no significant pain 2. Pulp test: Negative 3. Radiograph: Lesion related to the tooth 4. Palpation & Perscussion: Mild or none Signs & Symptoms Chronic Apical Periodontitis
  • 45. 1. Growth of granulation tissue around root apex 2. 4 Zones: 1. Zone 1: Necrosis zone (Neutrophills) 2. Zone 2: Contamination zone (Multi Nucleated Giant Cells 3. Zone 3: Irritation zone (Neutrophills, lymphocytes & macrophages 4. Zone 4: Stimulation zone (Fibroblasts & Osteoblasts) Histopatholog Chronic Apical Periodontitis (Periapical Granuloma)
  • 46. 1. Considered a granuloma with a fluid filled center & an epithelium lined cavity 2. Epithelial cells originate from the cells of Malassez 3. The fluid in the center maybe clear or viscous yellow (fatty degeneration). Contains cholesterol crystals. Histopatholog Chronic Apical Periodontitis (Periapical Cyst)
  • 47. Classification of Periapical Disease ❖ Acute Periapical Disease ❖ Acute Apical Periodontitis ❖ Acute Apical Abscess ❖ Recrudescence Abscess (Pheonix Abscess) ❖ Chronic Periapical Disease ❖ Chronic Aical Periodontitis ❖ Chonic Apical Abscess ❖ Condensing Osteitis
  • 48. Etiology Chronic Apical Abscess • Condition after an acute apical abscess has drained
  • 49. 1. Usually very mild pain 2. Usually a draining sinus tract 3. Pulp test: Negative 4. Radiograph: Lesion related to the tooth (Not well defined) 5. Palpation & Perscussion: Mild or none Signs & Symptoms Chronic Apical Abscess
  • 50. 1. Could be either periapical granuloma or periapical cyst. 2. Usually looks like a periapical granuloma with pus in the center Histopatholog Chronic Apical Abscess
  • 51. Classification of Periapical Disease ❖ Acute Periapical Disease ❖ Acute Apical Periodontitis ❖ Acute Apical Abscess ❖ Recrudescence Abscess (Pheonix Abscess) ❖ Chronic Periapical Disease ❖ Chronic Aical Periodontitis ❖ Chonic Apical Abscess ❖ Condensing Osteitis
  • 52. Etiology Condensing Osteitis • Low grade long standing irritation • Resulting in unusual body response by increased density of periodical bony tissue due to hyperactive osteoblastic activity • Young patients with large carious session
  • 53. 1. Usually no pain 2. Pulp test: Negative 3. Radiograph: Radioopacity related to the root apex 4. Palpation & Perscussion: Negative Signs & Symptoms Condensing Osteitis