Transcript m5zn_08025a2c78c5dfc

Open Pulpitis
By : Mohammed El-Said Abu El-Naga
Oral and Maxillofacial Surgery
By:Dr/M.Abuelnaga
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CLASSIFICATION OF PULPITIS
Pulpitis
Depending on direct
communication
between
pulp and oral cavity.
Depending upon the
extend of involvement
Partial pulpitis
(Focal)
Subtotal pulpitis
(Generalized)
Open pulpitis
(pulpitis aperta)
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Closed pulpitis
(pulpitis clausa)
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Chronic open pulpitis.
The extension of a carious lesion or
trauma may result in a connection
between the oral cavity and the
pulp tissue .
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Chronic open
pulpitis.
Granulomatous
open chronic
pulpitis
Ulcerative open
chronic pulpitis
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Ulcerative open chronic pulpitis
Ulcerative open chronic pulpitis is associated with
an ulcerative pulp surface in the area of exposure
of the pulp cavity, ie healing prospects are poorer
in this area.
The pulp tissue lying beneath this surface either
presents as a diffuse chronic inflammation or
merely shows signs of hyperaemia.
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Clinically
Chronic ulcerative pulpitis sharp probes
have to wear marrow cavities deep
exploration hole, a moderate degree of
exploration can be painful; diagnosis or
electric hot and cold reaction diagnosis can
be slow or sensitive; percussion may have
mild discomfort.
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X-rays examination may have the
periodontal ligament space widened
periapical plate blurred or hard to
change.
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Granulomatous open chronic pulpitis
)pulp polyp(
If the blood supply is sufficient, open chronic
pulpitis can change to granulomatous open chronic
pulpitis (pulp polyp).
Granulation tissue sprouts from the ulcerative
surface tissue and slowly grows to an enlarging mass
of tissue from the pulp cavity through the opening of
the pulp roof into the oral cavity.
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Pulp polyp
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Pulp polyp
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History
Pulp polyps are usually asymptomatic .
Direct pressure during mastication may cause mild-tomoderate tenderness .
Localized bleeding may occur when the soft tissue is
manipulated or traumatized .
All lesions are associated with a history of a longstanding carious lesion, a fractured tooth due to
trauma, or a combination or these 2 insults .
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Pulp polyps reach a maximum size
within a couple of months and then
remain static .
Mobility of the tooth and sensitivity to
percussion are usually absent .
Drainage of a purulent exudate is not a
characteristic finding .
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Physical
A spongy, soft tissue nodule extrudes from the cavitated or
fractured surface of a tooth .
The surface varies from pink and smooth to red and white and
granular .
Polyps typically enlarge to fill the entire cavitated area or pulpal
chamber of the tooth .
Soft tissue may merge with the adjacent attached gingiva .
Polyps usually develop in carious primary molars and first
permanent molars because, anatomically in young persons,
these teeth have large pulp chambers.
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Less frequently, maxillary central incisors in both
dentitions are affected .
A pulp polyp is a single lesion, but multiple teeth may
be affected .
Teeth with open or incomplete apexification of the root
apices are the most susceptible .
Extrusion of the opposing molar or tipping of the
adjacent teeth with space loss may be observed when
significant destruction of the crown occurs .
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Causes
Causes of a pulp polyp include the following :
Carious tooth with significant loss of tooth structure .
Loss of a dental restoration that results in pulpal
exposure .
Fractured tooth due to trauma with a pulpal exposure .
Pulpal tissue with access to a good blood supply .
Possible hormonal (estrogen and progesterone)
influence .
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Differential Diagnoses
Pyogenic Granuloma (Lobular
Capillary Hemangioma )
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Imaging Studies
Intraoral radiographs, in particular periapical and bite-wing film
views, are needed to confirm this diagnosis and to determine the
extent of tooth destruction and if the inflammatory lesion
involves the surrounding alveolar bone .
Radiographic findings demonstrate a large coronal radiolucency
that extends to the pulpal chamber with focal loss of tooth
structure, while the root apices may be either open or closed .
Although no bony changes are usually observed, the surrounding
alveolar bone may reveal either an incipient periapical
radiolucency that is consistent with chronic apical periodontitis
or a localized radiopacity that is referred to as focal sclerosing
osteomyelitis (condensing osteitis).
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In addition, vertical alveolar bone height may be
decreased surrounding the involved tooth,
which is indicative of periodontitis .
Radiographic imaging is required to determine
the most appropriate treatment for the involved
tooth .
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Pulp polyp radiographically
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Other Tests
Diagnosis and determination of the most
appropriate treatment options are based on
adjunctive tests, including response to percussion,
thermal stimuli, and electric pulp testing.
In most cases, the results of these adjunctive tests
are similar to those obtained for healthy teeth,
which is in contrast to most teeth that exhibit
irreversible pulpitis.
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Electrical pulp tester
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The normal responses should not confuse
the practitioner that the pulpal tissue is
healthy and therefore requires only
conservative treatment.
In addition, these tests help to differentiate
a true pulp polyp from hyperplastic
gingivitis that is overlying a cavitation
from a nonvital tooth .
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Correlation between Pulp Vitality &
Chronic Open Pulpitis
Examination of human non-epitheliated and
epitheliated pulp polyps, using paraffin
sections stained with Holmes' silver stain,
showed nerve fibers present in the
connective tissue of the pedicle region, in
the granulation tissue of the polyp, and in
the epithelium.
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A similar innervation was present in some of
the epitheliated polyps to that described in
the oral mucosa.
Pulp nerves never innervate epithelium under
normal circumstances, so that the
innervation of epithelium covering a pulp
polyp is a unique example of innervation of
a newly formed mature tissue after fetal life
(Southam et al, 1973).
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An electron microscope study of ultra-thin
sections of hypertrophic pulps removed from
human teeth showed that the epithelial cells
which covered the oral surface of the polyps
were closely related to one another by
“intercellular bridges” and desmosomes.
Structures resembling half desmosomes attached
the epithelial cells to the underlying basement
membrane and were a prominent feature of the
scalloped boundary zone between epithelial
and connective tissue elements .
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Although somatic myelinated nerve fibres were not seen, small
bundles of unmyelinated nerve fibres were observed in the
connective tissue of the polyps (Dixon et al, 1965).
Chronic inflammation is often associated with irreversible
destruction of parenchymal tissue, and fibrous connective
tissue fills the resultant defect.
Proliferation of fibroblasts, collagen production, and
neovascularization are enhanced by the secretion of cytokines
by T cells and macrophages. It may be concluded that
epithelium of pulp polyps show morphologic characteristics
similar to the epithelium of oral mucosa .
The connective tissue shows characteristics of chronic
inflammation of varied intensity (Trowbridge, 1990).
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Presumably the young pulp does not become necrotic
following exposure, because its natural defenses and
rich supply of blood allow it to resist bacterial
infection.
Transudates and exudates which are inflammatory
response products in open chronic pulpitis, drain into
the oral cavity and do not accumulate.
Thus intra-pulpal pressure, which may consequently cause
tissue damage and destruction of the microcirculation,
does not develop (Faryabi & Adhami, 2008).
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Histologic Findings
Microscopic findings reveal a mass of granulation tissue
protruding from the crown of a fractured or carious tooth
that resembles a pyogenic granuloma.
The fibrovascular stroma contains numerous small, delicate
vascular channels and a prominent inflammatory infiltrate
composed of primarily lymphocytes, plasma cells, and
neutrophils.
Although the surface may be ulcerated, it is covered by
stratified squamous epithelium that resembles oral
mucosa in approximately 50% of these inflammatory
hyperplastic lesions.
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The source of this epithelium appears to be from
the engraftment of desquamated oral epithelial
cells or the migration of the epithelium from
the adjacent gingival tissues.
In more mature lesions that are covered with
squamous epithelium, the granulation tissue is
replaced by fibrous connective tissue with
minimal inflammation and foci of dystrophic
calcification .
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Bacteria (primarily gram positive) are found on the
surface of the polyp and within the carious lesion. In
many cases, the histopathologic changes are limited
to the coronal pulp tissue with the apical tissue
exhibiting only mild vasodilation and minimal
chronic inflammation .
Ultrastructural examination of nerve fibers associated
with the pulp polyp exhibits variable findings within
the same tooth, ranging from normal to moderate or
severe degeneration of both myelinated nerve fibers
.and unmyelinated nerve fibers .
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pulp polyp histologically
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Treatment
Medical Care
Treatment of a pulp polyp in a permanent tooth includes
either root canal therapy or extraction of the tooth .
The more conservative pulpotomy treatment has been
successful in selected cases when only the coronal
pulp is affectedIn immature teeth with incomplete
root development, placement of an apical barrier and
strengthening of the thin root with composite resin
may be indicated prior to root canal treatment .
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Pulp revascularization of an immature
permanent tooth is another new treatment
approach that results in the formation of
vital pulpal tissue .
The tooth requires a full-coverage crown
following endodontic therapy .
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Surgical Care
The affected tooth is extracted when primary teeth are
involved or when minimal tooth structure in
permanent teeth is available for restoration or the
alveolar bone support is unfavorable .
A surgical crown lengthening procedure may be needed
to prepare a tooth for a full-coverage crown .
Healing is uneventful in most cases .
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Medication
Systemic medications are not recommended for
the management of this lesion.
Antibiotics are not prescribed for the treatment
of the pulp polyp, despite a bacterial
component.
However, an antibiotic paste mixture is used
within the canals of the infected tooth when
the revascularization process is performed for
the treatment of the nonvital tooth .
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Further Outpatient Care
Periodic dental examinations are recommended to
monitor the success of the root canal therapy or to
intercept problems associated with the premature loss
of a tooth .
Orthodontic treatment may be needed to restore the
occlusion .
If a tooth is extracted, either a dental implant or fixed
dental prosthesis (bridge) is a treatment option to
restore function and aesthetics .
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Complications
Space discrepancy from crown destruction or
premature loss of a tooth may result in a crowded
malocclusion, supereruption of an opposing
tooth, or the impaction of a succedaneous tooth .
Without definitive treatment, some of these longstanding, nonvital teeth may progress to
symptomatic disease, including periapical
inflammatory disease and (rarely) cellulitis and
osteomyelitis of the jaws .
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Prognosis
The prognosis is excellent.
No risk for recurrence exists once
definitive treatment has been rendered .
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Patient Education
Reinforce the importance of routine
oral health care to prevent the
development of deep carious lesions
that may cause inflammatory pulpal
disease and more serious sequelae .
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Histological evaluation of teeth with
hyperplastic pulpitis caused by trauma or
caries: case reports
AIM The purpose of this histological study was to
examine teeth with hyperplastic pulpitis caused by
trauma or caries.
SUMMARY The pulp tissue of one young permanent
incisor with a complicated crown-root fracture and a
hyperplastic pulpitis, which had been contaminated with
oral microflora for 40 days, and pulp polyps from four
permanent first molars whose crowns were destroyed by
extensive caries were prepared for standard histological
examination.
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Histologically,
Normal pulp tissue organization was observed in
the tooth with a complicated crown-root
fracture in the cervical radicular region. Irregular
calcification was seen in the coronal and
radicular portion of the pulp in the four carious
teeth with pulp polyps.
Radicular pulp tissue in the middle and apical third
of root canals beneath irregular calcification
showed intensive fibrosis but was free from
inflammatory cells.
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KEY LEARNING POINTS
Hyperplastic pulpitis is a type of
irreversible chronic open pulpitis.
Young permanent teeth with hyperplastic
pulpitis caused by trauma or caries have a
great inherent defensive capacity to heal.
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Pulp polyp associated with a natal
tooth: case report
Natal teeth are an infrequent occurrence at birth.
Often these teeth are extracted because they are very mobile and
pose a risk of aspiration.
This is a rare case in which a natal tooth was extracted by the
pediatrician with his fingers.
A root fragment remained and out of this developed a large pulp
polyp.
This relationship has not been previously reported .
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References
Catherine M, Jan 23, 2012
Pulp Polyp Clinical Presentation.
Medscape Reference
Assem M, Jan 2012
Correlation between Pulp Vitality & Chronic Open Pulpitis.
PathXchange / Global Online Pathology Community
Calişkan M.K, Oztop F, Calişkan G, 2003 Jan,
Histological evaluation of teeth with hyperplastic pulpitis caused by
trauma or caries: case reports.
Endod J.; 36 (1):64-70
Vergotine R, Hodgson B, Lambert L, 2010
Pulp polyp associated with a natal tooth: case report.
J Clin Pediatr Dent.; 34 (2):161-3
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