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According to Grossman
1.Physical
A. Mechanical
i.Trauma ii. Pathologic Wear iii.Cracked tooth Syndrome iv.Barodontalgia
B.Thermal
2.Chemical
A. Phosphoric Acid, Acrylic monomers B.Erosions
3.Bacterial
A.Toxins B.Direct invasion of pulp C.Anachoresis
II. Traumatic
A. Acute
1. Coronal fracture 2. Radicular fracture 3. Vascular stasis 4. Luxation 5. Avulsion
B. Chronic
1. Adolescent female bruxism 2. Traumatism 3. Attrition or abrasion 4. Erosion
B. Radicular ingress
1. Caries
III. Iatral
A. Cavity preparation 1. Heat of preparation 2. Depth of preparation 3. Dehydration 4. Pulp horn extensions 5. Pulp hemorrhage 6. Pulp exposure 7. Pin insertion 8. Impression taking B. Restoration 1. Insertion 2. Fracture a. Complete b. Incomplete 3. Force of cementing 4. Heat of polishing C. Intentional extirpation and root canal filling D. Orthodontic movement E. Periodontal curettage
F. Electrosurgery G. Laser burn H.Periradicular curettage I. Rhinoplasty J. Osteotomy K. Intubation for general anesthesia
IV. Chemical
A. Restorative materials 1. Cements 2. Plastics 3. Etching agents 4.Cavity liners 5. Dentin bonding agents 6. Tubule blockage agents B. Disinfectants 1. Silver nitrate 2. Phenol 3. Sodium fluoride
C. Desiccants
1. Alcohol 2. Ether 3. Others
V. Idiopathic
A. Aging B. Internal resorption C. External resorption D.Hereditary hypophosphatemia E. Sickle cell anemia F. Herpes zoster infection G.Human immuno deficiency virus (HIV) and Acquired Immuno Deficiency Syndrome (AIDS)
1.Grossmans Classification
I) Pulpitis (Inflammation)
A) Reversible pulpitis
1) Symptomatic (acute) 2) Asymptomatic (chronic)
B) Irreversible pulpitis
1) Acute a) Abnormally responsive to cold b) Abnormally responsive to heat 2) Chronic a) Asymptomatic with pulp Exposure b) Hyperplastic pulpitis c) Internal resorption
2. Ingles classification
1) Hyperreactive pulpalgia
a) Hypersensitivity b) Hyperemia
2) Acute pulpalgia
i) Incipient (reversible) ii) Moderate (referred) iii) Advance (relieved by cold)
3) Chronic pulpalgia
4) Hyperplastic pulpitis
5) Pulp necrosis
1) Atrophic pulposis 2) calcific pulposis
5.According to Shafer's:
Acute
Pulpitis Chronic
Total/gen eralized
Pulpitis
1.Focal Reversible Pulpitis/ Initial pulpitis/ Pulpal Hyperemia
Earliest form Mild.., localized..
Def: H/P:
Mild to moderate hyperemia, inflammatory changes restricted to area of involved dentinal tubules
scopy Reparative dentin Disruption of odontoblasts Dilated b/v Extravasations of edema fluid Few acute infl. cells along with chronic infl cells present
Etiology:
Trauma Thermal shock Recent oral prophylaxis Dehydration/ desiccation of the cavity Deep caries or restorations Chemicals
Symptoms:
Unilateral sharp stabbing pain, intermittent & of immediate onset on application of the stimulus Pain only on stimulation, responds more to cold than hot stimuli Short duration & does not linger.. Difficulty in localization
Signs:
Large intra/ extra coronal restoration Carious lesion involving the pulp Pin placed close to the pulp/ involving
Diagnosis:
Percussion Vitality tests Color Radiograph
Treatment:
Removal of the cause Use of Ca(OH)2 liner, ZOE temp.filling Review repeat vitality tests Serial radiographs @ 3,6 & 12 months ,monitoring apical condition & sclerosis!!.....
Prognosis:
Favorable if irritant is removed early enough.
2.Acute Pulpitis
Usually a squeal of focal rev. pulpitis Usually irreversible & leads to suppurative pulpitis
Def: H/P:
Presence of chronic ´ inflammatory cells
Congestion of post capillary venules
Attracts PMNLs
chemotaxis Acute Inflammation
Etiology:
Bacterial involvement of the pulp through caries Trauma / chemical / thermal irritation Progression of rev. pulpitis
Symptoms:
Unilateral pain initially piercing, shooting, stabbing sharp pain becoming dull or throbbing type with time. Exaggerated response to hot stimuli Longer duration & lasts >15 sec.,(even up to several Hours) after removal of the stimulus. Radiation Spontaneous, worsens at night & on lying down Cold reduces .temp relief! Sudden stoppage..! Poorly localized until!
Signs:
Pain increases by heat & decreases by cold although.! Large carious lesion/ restoration, # or discolored tooth Initially may not be tender to bite on.!
Diagnosis:
Diagnostic LA injection may be required for localization> Vitality tests: Exaggerated response to heat & initially.later.!! Vitality in multiple root?? Percussion:----- periodontitis! Radiographs:
Treatment:
Complete removal of pulp / Pulpectomy Posterior tooth.. Extraction as the last resort!!!!
Differential Diagnosis
One must distinguish between Reversible & irreversible Pulpitis
Prognosis: Favorable if the pulp is removed & if the tooth undergoes proper endodontic therapy & restoration
A. B.
C.
Inflammatory cell.
3.Chronic Pulpitis:
May arise on occasion through quiescence of a previous acute pulpitis / more commonly as the chronic type of disease from onset
H/P:
Chronic infl. Cells Prominent capillaries, collagen bundle gathering towards an attempt to ward off the infection
B.Destruction of odontoblasts.
Ulcerative Pulpitis
Granulation tissue formation on the surface of pulp tissue in a wide open exposure organisms in pulp present.
Diagnosis:
Vitality: A gradual reaction Reaction to thermal changes & electrical stimulus is dramatically reduced Percussion: Radiograph:sclerosis of alveolar bone!
Etiology:
Slow progressive carious exposure A large open cavity .. Mechanical irritation too acts as a stimulus. Dental neglect
Symptoms:
Signs:
Seen in! Visible polyp in.! Coronal tooth !
Diagnosis: C/F
Appearance of the polyp Sensitiveness.! Bleeding..! Origin! Tooth involved!
Radiograph:
Large open cavity with direct access to pulp chamber Vitality: Thermal-feeble or no response EPT- more current required
H/P:
Result of osteoclastic activity Lacunae seen filled with osteoid tissue! Profuse bleeding on removal of the pulp Multinucleated giant cells..! Chronic infl. Cells & metaplastc cells
Symptoms:
Asymptomatic usually Pink Spot in the crown
Diagnosis:
May involve crown / root Usually max. ant tooth. Routine radiographic examination. Appearance of Pink spot
R/F:
Change in the wall.! A round/ oval radiolucent area
Treatment:
Extirpation of the pulp stops the receptive process Routine endodontic therapy is indicated Difficulty in obturation of the defect thermo plasticized GP is used. In perforation Ca(OH)2 paste calcific barrier complete obturation .
Prognosis:
Best before perforation In perforation cases it is guarded &depends on the formation of calcific barrier.
Pulp Degeneration:
Usually seen in teeth of older people sometimes young teeth with persistent mild infection may show degeneration. At an early stage- No definite clinical symptoms At a later stage discoloration of the tooth pulp does not respond to stimuli
Calcific Degeneration:
A part of the pulp tissue is calcified i.e. deposition of Ca salts in dead & degenerating tissues
Larger, well outlined, more commonly in the pulp chamber, laminated, large enough at times!
Classification:
Free a. According to location Attached Embedded
b.According to structure
true false
Diagnosis:
R/F:
calcified or radio opaque mass Difficult to distinguish 3 type R/f
Treatment:
Usually pose problem in endodontic treatment Use of chelating agents like EDTA is recommended
Atrophic Degeneration:
Atrophy means wasting away or decrease in the size of an organ. It is attributed to faulty nutrition Usually occurs as the teeth grow older Increase in collagen fibers & decrease in the no. of cells No clinical diagnosis exists
Fibrous degeneration:
Replacement of cellular elements by fibrous connective tissue On removal from root canal appears like a leathery fiber No distinguishing diagnostic features
Pulp Artifacts:
Vacuolization of odontoblasts was ounce thought to be a type of pulp degeneration Empty spaces formed by odontoblasts Actually an artifact caused by poor fixation of the tissue specimen Other Ex- Fatty degeneration, Reticular atrophy
Pulp Necrosis:
Def:
Necrosis is death of the pulp partial / total Usually a squeal of inflammation May occur following a traumatic injury.!
Coagulation
Necrosis Liquefaction
Coagulation necrosis:
The soluble portion of tissue is precipitated or is converted into a solid material. Caseation is a type characterized by a cheesy mass.
Liquefaction Necrosis:
Results when proteolytic enzymes convert the tissue into a softened mass, liquid or amorphous debris.
Etiology:
Any noxious stimuli / insult injurious to the pulp, Bacteria, chemicals or trauma.
Symptoms:
No painful symptoms Discoloration is a first indication of pulpal death. Crown--..!
Diagnosis:
Mostly only by chance as no significant findings Radiograph: Large cavity / filling or an open approach to the root canal H/O trauma or severe pain followed by complete cessation of pain at times by patients Vitality tests: no response to thermal / cold or test cavity EPT may give minimum response to max. current due to moisture content / viable apical nerve fibers at times.
H/P:
Necrotic pulp tissue, cellular debris & microbes Periapical tissue may be normal / slight evidence of the inflammation of apical PDL ligament .
A.
B. C.
Necrosis.
Inflammatory cells. Monocytes.
Treatment:
Proper Endodontic therapy
Prognosis:
Favorable if proper endodontic therapy is instituted
Aerodontolgia/ Barodontolgia
Dental pain occurring due to reduced atmospheric pressure
Symptoms:
Acute pulpitic pain , only during decompression / flying at high altitude
Signs:
Recently restored teeth Aerosinusitis may be a contributing factor if max. teeth are involved
Diagnostic tests:
Radiograph : possible antral opacity on paranasal radiograph.
Treatment:
Monitor: pulpitis might prove to be rev./ Irreversiblle. If irreversible institute endodontic therapy/ extract Refer for investigation & treatment of Sinusitis
Galvanism:
Etiology: Symptoms:
Intermittent pain Occurs only after placement of a new metal restoration ,is well localized & does not refer
Signs:
Recent metallic restoration abutting/ opposing an existing metallic restoration. Corrosion deposits or damage may be evident.
Treatment:
Application of varnish over the restoration May diminish over in a few days by formation of corrosion products
Diseases of the Periradicular Tissues Acute periradicular disease Acute alveolar abscess
Chronic alveolar abscess Granuloma Cyst Condensing osteitis External root resorption
Definition:
An acute alveolar abscess is a localized
Symptoms:
The first symptom - mere tenderness of the tooth. Later, - severe throbbing pain, attendant swelling of the overlying soft tissues.
When swelling becomes extensive, the resulting cellulitis may distort the patients appearance grotesquely.
Diagnosis: In the early stages, it may be difficult to locate the tooth because of the absence of clinical
extruded.
PALPATION
PERCUSSION
Differential Diagnosis:
Acute alveolar abscess should be differentiated
with vital rather than with pulp less teeth, in contrast to an acute abscess, in which the pulp is dead, tests for pulp vitally are useful
Treatment: Treatment consists of establishing drainage and controlling the systemic reaction. When
symptoms have subsided, the tooth has been left open for drainage, one must perform careful
nonvital.
By
recently
inserted
restoration
extending
Acute
apical periodontitis
may
also
be
Symptoms: The symptoms of acute apical periodontitis are pain and tenderness of the tooth. The tooth may be slightly sore, some times only when it is percussed in a certain direction, or the soreness may be severe. The tooth may be extruded, making closure painful.
Diagnosis:
The diagnosis is frequently made from a known
palpation.
with breakdown of periapical tissue, rather than merely an inflammatory reaction of the periodontal ligament. The patient;s history, symptoms and clinical test results, symptoms and clinical test results help one to differentiate these diseases.
Treatment: Treatment of acute apical periodontitis consists of determining the cause and relieving the symptoms. When the acute phase has subsided, the tooth is treated by conservative means.
Acute Exacerbation of
a chronic Lesion:
Definition:
This
condition
is
an
acute
granuloma.
Cause: The periradicular area may react to noxious stimuli from a diseased pulp periradicular disease. with chronic chronic
While
Symptoms : At the onset, the tooth may be tender to the touch. As inflammation progresses, the tooth may be elevated in its socket and may become
sensitive.
The mucosa over the radicular area may be
asymptomatic tooth.
In such a tooth, radiographs show welldefined periradicular lesions.
The patient may have a history of a traumatic accident that turned the tooth dark after a period of time or of postoperative pain in a tooth that had subsided until the present
episode of pain.
DIFFERENTIAL DIAGNOSIS
Differential Diagnosis: An acute exacerbation of a chronic lesion causes symptoms similar to those of an acute
Prognosis:
The prognosis for the tooth is good once the symptoms have subsided.
CHRONIC
PERIRADICULAR
DISEASES
WITH
AREAS OF RAREFACTION These diseases are chronic alveolar abscess. Granuloma, and radicular cyst.
Definition:
A chronic alveolar abscess is a long-standing, low grade infection periradicular alveolar bone. The source of the infection is in the root canal.
Cause: Chronic alveolar abscess is a natural sequela of a death of the pulp with extension of the infective
Symptoms: A tooth with chronic alveolar abscess is generally asymptomatic; at times, such an abscess is detected only during routine radiographic
tract.
A radiograph taken after the insertion of a guttapercha cone into the sinus tract often shows the the involved tooth by tracing the sinus tract to its origin. When an open cavity is present in the tooth, drainage may occur by way of the root
canal.
Diagnosis:
A chronic abscess may be painless or only mildly painful. At times, the first sign of osseous breakdown is radiographic evidence seen during routine examination or discoloration of the
When asked, the patient may remember a sudden, sharp pain that subsided and has not recurred, or he may relate a history of traumatic
injury.
The tooth does not react to the electric pulp test or to thermal tests.
Differential Diagnosis:
Clinically, it is practically impossible to establish an accurate diagnosis among the periradicular diseases with radiographs alone.
As a result, a proper and accurate diagnosis can be made only when tissue specimen has been
examined microscopically
A chronic abscess should be differentiated from cementoma or ossifying fibroma, which is associated with a vital tooth and requires no endodontic treatment.
GRANULOMA: Definition: A dental granuloma is a growth of granulomatous tissue continuous with the periodontal ligament resulting from death of the pulp and the diffusion of bacteria and bacterial toxins from the root canal in to the surrounding periradicular tissues
Symptoms: A granuloma may not produce any subjective reaction, except in rare cases when it breaks down and undergoes supuration. Usually, a granuloma is asymptomatic
Diagnosis: The presence of a granuloma, which is symptomless, is generally discovered by routine radiographic examination. The area of rarefaction is well defined, with
Differential Diagnosis:
A granuloma cannot be differentiated from other periradicular diseases unless the tissue is examined microscopically.
Treatment:
Root canal therapy may suffice for the treatment of a granuloma.
B= Bay cyst
C= Granuloma D= Epithelium E= Alveolar bone
F= Dentine
G= Root canal H= Cementum I= Periodontal ligament
Radicular Cyst:
Cause:
A radicular cyst presupposes physical, chemical, or bacterial injury resulting in death of the pulp, followed by stimulation of the epithelial rests of Malassez, which are normally present in the
periodontal ligament:
Symptoms: No symptoms are associated with the
development of a cyst,
Diagnosis: The pulp of a tooth with a radicular cyst does not react to electrical or thermal stimuli, and results of other clinical tests are negative, except the radiograph. The radiolucent area is generally round in outline, except where it approximates adjacent teeth, in which case it may be flattened and may have an oval shape.
Neither the size nor the shape of the rarefied area is a definitive indication of a cyst
Differential Diagnosis:
A cyst is usually larger than granuloma and may cause the roots of adjacent teeth to spread apart
Definition:
Condensing osteitis is the response to a lowgrade, chronic inflammation of the periradicular
radiographic examination.
Diagnosis: The diagnosis is made from radiographs. Condensing osteitis appears in radiographs as a localized area of radiopacity surrounding the affected root.
Prognosis: The prognosis for long-term retention of the tooth is excellent if root canal therapy is performed satisfactorily. and if the tooth is restored
Diagnosis:
External resorption is usually diagnosed by
radiographs.
Treatment:
Internal resorption ceases when the pulp is
Diseases of the Periradicular Tissues of Nonendodontic Origin: Periradicular lesions not only arise as extensions of pulpal diseases, but they may also originate in the remnants of odontogenic epithelium. Such lesions may be manifestations of systemic diseases, such as multiple neurofibromatosis or they may have other causes, such as periodontal diseases.