PULP DISEASES IN CHILDREN

DR. ALOK DUBEY

ASSOCIATE PROFESSOR, DIVISION OF PEDODONTICS,
COLLEGE OF DENTISTRY, JAZAN UNIVERSITY
 Contents
 Introduction
 Pulp-dentin Complex
 Clinically Normal Pulp
 Nerve Fibres Of Pulp
 Etiology Of Pulpal Pathology
 Classification Of Pulpal Disease
 Description Of Each Pulpal Disease
 Periapical Pathosis
 Description Of Periapical Pathosis
 Steps In Pulpal Diagnosis
 Conventional & Advanced Vitality Test
What is Dental Pulp?
The dental pulp is a loose connective tissue, containing
blood vessels, lymphatic, nerves and undifferentiated C.T.
cells.

PULP-DENTIN COMPLEX
Pulp has a close relationship between its peripheral cells, the
odontoblasts and the dentin thereby making it a functional
entity sometimes referred to as pulp-dentin complex‟.
 PULP IS UNIQUE
HOW?

• surrounded by hard tissue

• small apical foramen

 THE CLINICALLY NORMAL PULP

• Vital to testing procedures

• Percussion, palpation, and bite tests
elicit no pain
• Radiographic appearance is normal.
• Free of spontaneous symptoms !!!
ASYMPTOMATIC
 NERVE FIBRES OF THE PULP
Features Aδ-fibres C-fibres

1 Conduction speed Fast conducting Slower conducting

2 Myelin presence Myelinated Unmyelinated

3 Elicited pain Responsible for the acute Attribute to the “dull,
“sharp, piercing and gnawing, and
lancinating” pain excruciating” pain with
slower onset
4 Onset of pain acute slower onset

5 Size Larger diameter Aδ-fibres Smaller diameter C-

fibres

C fibres do not respond to electric pulp testing. Because of their high threshold, a stronger
electric current is needed to stimulate them.
The A-delta fibres are more affected by the reduction of pulpal blood flow than the C fibres
because the A-delta fibres cannot function in case of anoxia.
 TERMINOLOGIES
Pulp Vitality Testing (Assessment of the Pulp’s Blood Supply)
• Laser Doppler Flowmetry and Pulse Oximetry

Pulp Sensibility Testing (Assessment of the Pulp’s Sensory Response)

• Defined as the ability to respond to a stimulus
• Thermal and electric tests
• They do not detect or measure blood supply to the dental pulp
Thermal sensitivity Testing & Electrical Pulp Testing are NOT very
reliable in primary teeth

Pulp Sensitivity (Condition of the Pulp Being Very Responsive to a Stimulus)

• Thermal and electric pulp tests can be used as sensitivity tests
• When attempting to diagnose a tooth with pulpitis - such teeth are more
responsive than normal
AETIOLOGY OF THE PULP AND PERIAPICAL PATHOSIS
Physical
 Mechanical
 Trauma – accidental or Iatrogenic
 Pathologic wear
 Cracked tooth syndrome
 Barometric changes
Thermal
 Heat from cavity preparation
 Exothermic heat from setting of cement
 Conduction of heat and cold through deep fillings without base
 Frictional heat caused by polishing a restoration
Electric
 Galvanic current from dissimilar metallic fillings
 AETIOLOGY OF THE PULP AND PERIAPICAL PATHOSIS
… continued

Microbial - Bacterial
 Direct invasion of pulp from caries or trauma
 Microbial colonization in the pulp by blood-borne
microorganisms – anachoresis
 Toxins associated with dental caries

Chemical
 Phosphoric acid
 Acrylic monomer
 Erosion (acids)
 PATHWAYS OF BACTERIAL INVASION OF THE PULP

1. Opening in dental hard tissue wall

caries
clinical procedures
trauma induced fractures
microcracks
2. Bacteria from the gingival sulcus/ pocket
3. Endodontic reinfection
4. Extension of a periapical infection from adjacent infected teeth
 FACTORS AFFECTING RESPONSE OF PULP

• Severity and duration of irritant.

• Nature of irritant.
• Health condition of the pulp or pre-existing state of the
pulp
• Apical blood flow
• Local anatomy of the pulp chamber
• Host defence
 CLASSIFICATION
I. According to pathological condition
- Focal or acute reversible pulpitis (Pulp hyperaemia)
- Irreversible pulpitis
II. According to its duration
- Acute pulpitis
- Chronic pulpitis
III. According to presence of dentin covering the pulp chamber
- Open pulpitis
- Closed pulpitis
 CLASSIFICATION contd.
IV. According to extension of inflammation in pulp tissue
- Partial pulpitis
- Complete / total pulpitis

V. According to amount of pus formation

- Exudative pulpitis
- Suppurative pulpitis (pus forming)
The pathway of the pulp and periapical pathosis set
out from caries, dental trauma etc
 PULPAL PATHOSIS
• General symptoms of inflammation
– Rubor (temperature)
– Calor (color)
– Tumor (oedema)
– Dolor (pain)
– functio laesa (loss of function)

• The special anatomical aspects of the pulp: enclosed

chamber
 Classification of pulpal diseases
(according to symptoms and treatment)

removal of the
1. Reversible pulpitis stimulating agent

2. Irreversible pulpitis

– Hyperplastic pulpitis root canal

treatment
3. Degeneration of pulp

4. Pulpal necrosis
 TYPES OF PULP DISEASES
GROSSMAN CLASSIFICATION
 Pulpitis
Definition:
Inflammation of pulp tissue as a response to surrounding
environment
 I. PULPITIS

a. REVERSIBLE PULPITIS
- Symptomatic (Acute)
- Asymptomatic (Chronic)

b. IRREVERSIBLE PULPITIS
i. Acute
- Abnormally responsive to cold
- Abnormally responsive to heat
ii. Chronic
- Asymptomatic with pulp exposure
- Hyperplastic pulpitis
- Internal resorption
 II. PULP DEGENERATION
• ETIOLOGY:
• Aging- condition is usually seen in older people
• Persistent mild irritation
• may be induced by the attrition of the teeth, bacteria, erosion etc.
• An important gene associated with Pulp Degeneration is DSPP
(Dentin Sialophosphoprotein)

• TYPES:
a. Calcific degeneration (confirmed by radiographic diagnosis)
b. Other (confirmed by histo-pathologic diagnosis
 Calcific metamorphosis
Process where there is extensive formation of hard tissue on dentin walls
Etiology:
Response to irritation or death and replacement of odontoblasts.
Progression:
• As irritation increases, the amount of calcification may also increase,
leading to partial or complete radiographic (but not histologic)
obliteration of the pulp chamber and root canal
Clinical manifestation:
• A yellowish discoloration of the crown is often a manifestation of
calcific metamorphosis
• The pain threshold to thermal and electrical
stimuli usually increases - often the teeth are
unresponsive

Calcific metamorphosis does not represent

pathosis per se and may occur with aging or
low-grade irritation.
 Internal (Intracanal) Resorption
Pathogeneis:
Inflammation in the pulp may initiate resorption of adjacent hard tissues
Pulp becomes a vascularized inflammatory tissue with dentinoclastic
activity
CLINICAL MANIFESTATION:
1. There is resorption of the dentinal walls - advancing
from its center to the periphery
2. Intracanal resorption are asymptomatic
3. Advanced internal resorption involving the pulp
chamber is often associated with pink spots in the
crown – Hence called as Pink Tooth
Hard tissue resorption that causes disappearance
of normal radiographic evidence of the root canal
usually indicates an internal resorption defect
 III. PULP NECROSIS
What is it?
Death of the pulp
Types:
Partial (necrobiosis) or total
Etiology:
• Inflammation
• Traumatic injury
Pathogenesis:
• Coagulation necrosis or Liquefaction necrosis.
• end result of irreversible pulpitis
• In sickle cell anemia, blockage of pulp vessels due to defective RBC
results pulp necrosis.
 PULPAL NECROSIS … continued

Anamnesis:
– asymptomatic
Clinical examination:
– vitality test: negative
Treatment:
– root canal treatment (It is associated with foul odor when pulp is
opened for endodontic treatment.)
– or extraction followed by space maintainer if indicated
 REVERSIBLE PULPITIS
Hyperemia – Hyperactive pulpalgia
• Etiology –
Exposure of dentinal tubules
 incipient caries,
 cervical erosion or occlusal attrition
 most operative procedures
 deep periodontal curettage
 enamel fractures
Clinical Presentation:
 usually asymptomatic
 application of stimuli, such as cold or hot liquids, as well as
air and sweets may produce sharp, transient pain
 pain resolves within seconds of removal of the stimulus
 no response to percussion or palpation of the alveolus
 radiographic appearance is generally normal

Diagnosis based on Clinical examination

 pain from cold test does not linger more than 30 seconds
 no percussion sensitivity
 no spontaneous pain
 no heat sensitivity
 vitality test: positive, “short” respond
• Treatment
 The removal of irritants
 sealing and insulating the exposed
dentin or vital pulp usually results
in diminished symptoms and
reversal of the inflammatory
process in the pulp tissue
 making a filling (or pulp capping)

A. Mechanically exposed pulp horns of a mandibular

molar with signs of reversible pulpitis were capped
with mineral trioxide aggregate.
B. On recall, a follow-up radiograph 5 years later
shows no calcific metamorphosis in the pulp
chamber, closure of apexes, and the presence of
normal responses during clinical examination
 IRREVERSIBLE PULPITIS
Pathogenesis:
• implies the presence of a more severe
degenerative process that will not heal
Progression:
• if left, untreated, will result in pulpal
necrosis followed by apical periodontitis
• Etiology
 Deep caries or restorations
 Pulp exposure
 Cracks
 Orthodontic movement of teeth
 or any other pulpal irritants
Types:
• Classified as symptomatic or asymptomatic
Clinical Presentation:
 generally asymptomatic
 mild or severe spontaneous pain (symptomatic)
 intermittent or continuous episodes of spontaneous pain - with no
external stimuli
Type & Duration of pain
 may be sharp, dull, localized, or diffuse pain and can last anywhere
from a few minutes up to a few hours

Effect of external stimuli:

 Application of external stimuli, such as cold or heat, may result in
prolonged pain
 Application of cold in patients with painful irreversible pulpitis may
cause vasoconstriction - a drop in pulpal pressure and subsequent
pain relief
 IRREVERSIBLE PULPITIS contd.
• Diagnosis
 Pain from cold test lingers more than 30
seconds
 May get pain from heat test
 May have spontaneous pain
 May be percussion sensitive
 Radiographically or clinically visible deep
caries
• Pain at night
• Postural pain – bending over or lying down
as result of change in intrapulpal pressure
• It might be localized or referred
• Pain is increased by heat
Clinical examination
 vitality test: “long”, sharp respond
 lingers after removal of a stimulus

Response to palpation and percussion

 If inflammation is confined to the pulp and has not extended
periapically, teeth respond within normal limits to palpation and
percussion
 The extension of inflammation to the Periodental ligament causes
percussion sensitivity and allows better localization of pain
Treatment:
 root canal treatment
 extraction followed by space maintainers when indicated
DIFFERENCE BETWEEN REVERSIBLE & IRREVERSIBLE PULPITIS
 CHRONIC OPEN HYPERPLASTIC PULPITIS PULP POLYP
- in young people and children, chronically inflamed pulp

ETIOLOGY:
1. Slow progressive carious exposure of the pulp
2. A large open cavity, a young resistant pulp and a
3. chronic low grade stimulus are necessary

Anamnesis or history:
– Usually asymptomatic
 Hyperplastic pulpitis… continued

Clinical examination:
vitality test: positive
Polypous tissue within open pulp chamber
Pulp is relatively insensitive because few nerves in hyperplastic tissue.

Tooth affected:
-Most commonly affected are deciduous molar & First permanent molars.
Treatment:
root canal treatment/extraction followed by space maintainer if
indicated
Does any radiological symptom link to
“simple” pulpal pathosis?

No, it doesn’t

Rare exceptions: calcification and internal resorption

PERIAPIAL PATHOSIS
 AETIOLOGY

• non-treated pulpal disease

• trauma (hyperocclusion)

• irrigants

• instrumentation
 GENERAL SYMPTOMS OF PERIAPICAL
PATHOSIS
Anamnesis or history:
– acute: pain, swelling
– chronic: mild or no symptoms
Clinical examination:
– vitality test: usually negative
• Radiological symptoms
CLASSIFICATION OF PERIAPICAL PATHOSIS

1. Acute apical periodontitis

2. Chronic apical periodontitis
• Condensing osteitis

3. Acute apical abscess (“closed”)

4. Suppurative apical periodontitis (“open”)
 ACUTE APICAL PERIODONTITIS
• Anamnesis:
– symptoms of pulpitis or necrosis + pain on bite
• Clinical examination:
– pain on percussion
• X-ray:
– thickening of periodontal ligament space
• Treatment:
– root canal treatment, (adjustment of occlusion)
followed by SSCs
 CHRONIC APICAL PERIODONTITIS

• Anamnesis:
– asymptomatic or slight discomfort
• Clinical examintaion:
– little or no pain on percussion
• X-ray:
– interruption of lamina dura or
apical radiolucency
• Treatment:
– root canal treatment

Condensing osteitis: radiopaque

 ACUTE APICAL ABSCESS “CLOSED”

Anamnesis:
– severe discomfort, swelling, fever
Clinical examination:
– swelling, localisation
– lymphadenopathy
X-ray:
– radiolucent lesion (localisation)
Treatment:
– root canal treatment, drainage, (antibiotics) with stainless steel crowns
– Extraction with space maintainers
 SUPPURATIVE APICAL PERIODONTITIS
“OPEN”

Anamnesis:
– asymptomatic (drain), swelling
Clinical examination:
– fistula, swelling
X-ray:
– radiolucent lesion (localisation with guttapercha)
Treatment:
– root canal treatment
 Steps in diagnosing Pulpal Lesions
• Anamnesis - Health history (medical, dental)
– Fever
– Pain (subjective examination, tentative diagnosis)
• Oral investigation
– Inspection (fistula, swelling, open pulp chamber)
– clinical tests
vitality tests
percussion
– Mobility
– X-ray
– selective anesthesia
CONVENTIONAL VITALITY TEST
DrawBack of Eletrical Pulp Test:
Electric pulp testing has shown to be unreliable or rather non effective
in deciduous teeth and immature permanent teeth

Why Unreliable?
Relationship between odontoblasts and nerve fibers of the pulp has yet
to develop.
Nerve fibers are the last to develop and first to degenerate in these
teeth
 AGENTS USED FOR COLD TEST

AGENT TEMPRATURE
Ice sticks 0C
Ethyl chloride -50 C
Frozen Carbon dioxide -78.5 C

Which test is more Reliable in primary teeth?

In pediatric patients, application of CO2 snow produces a low
intrapulpal pressure and is far more effective and reliable even in
immature tooth.
 Advanced Pulpal Diagnostic Aids

1. Laser Doppler Flowmetry

2. Pulse Oximetry
3. Dualwave Spectrophotometry
4. Plethysmography
5. Liquid Crystal Testing
6. Time-temperature Graph
7. Electronic Thermography
8. Ultrasonic Imaging
9. Xeroradiography
10.Digital Imaging
11.Subtraction Radiography
12.Computed Tomography.
 LASER DOPPLER FLOWMETRY
How does it assess the vitality of teeth ?
Detects the presence or absence of pulpal blood flow.

ADVANTAGE OF LASER DOPPLER FLOWMETRY IN TRAUMATIZED ANTERIOR TEETH

1. Early detection of pulp vitality:

Identifies vitality correctly at earlier time periods following injury than conventional
tests.

2. Reliability for assessing pulpal status:

Reliable method for assessing the pulpal status of traumatized anterior teeth than
standard pulpal diagnostic tests.
 REFERENCE
• Endodontics Principles and Practice; Mahmoud Torabinejad
and Richard E. Walton
• Grossman's Endodontic Practice - 12th edition