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
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)
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
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
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
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
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
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
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)
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
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