Diseases of the Dental Pulp

Diseases of the Dental Pulp

Pulp is a vital formative organ that promotes dentin formation through various stages of
tooth development and eruption. It is also responsible for reparative dentin formation as a
response to stimuli. The maintenance of a vital pulp and protection of the pulp against various
insults is of prime importance to the clinician. There is a poor co relation between clinical
symptoms and histopathology of the pulp which makes accurate diagnosis very difficult .36
Pulpal injuries are due to physical, chemical and bacterial agents. Physical causes are
trauma, attrition, abrasion, erosion, cracked tooth syndrome and barometric changes. Chemical
causes are erosion, action of phosphoric acid, monomer etc. Thermal changes like heat induced
from cavity preparation, exothermic heat from setting of cement, frictional heat from polishing
and from conduction of heat through deep fillings without a protective base. Bacterial injuries
are principally due to toxins associated with caries, direct invasion of pulp from caries or trauma
and by microbial colonization in the pulp by blood borne organisms .71
The principal cause of pulpal injury is bacteria and bacterial by products that invade the
pulp. Once bacteria have invaded the pulp, the damage is irreparable and the byproducts of
bacteria are enough to produce an inflammatory reaction. On exposure to caries or trauma,
microorganisms gain access to pulp and are confined to small area of pulp exposure and result in
an inflammatory response. Polymorphonuclear leucocytes reach the pulpal area and prevent
further bacterial dissemination. If the inflammatory process becomes severe, bacterial
penetration is deeper and results in an acute inflammatory reaction. 36 Accumulation of
inflammatory exudates causes pain due to pressure from the nerve endings. Disturbances in
nutritional supply cause pulpal necrosis, many of the polymorphonuclear leucocytes die and pus

12

Diseases of the Dental Pulp

formation occurs. If the reaction is less severe, lymphocytes and plasma cells replace the
polymorphonuclear leucocytes and the inflammatory reaction is confined to the surface of the
pulp. This chronic inflammatory state is quiescent and gets flared up when an acute reaction
develops by bacterial penetration.
The necrotic pulp formed may remain quiescent for years, but in most cases the virulent
microorganisms survive and rapidly multiply to reach the periapical tissue and produce an acute
alveolar abscess. If the microorganisms are less virulent, they remain in the root canal, and by the
action of their byproducts produce a chronic abscess without any subjective symptoms.
Meanwhile, the dentinal tubules become infiltrated with products of blood decomposition,
bacteria and food debris and dentin becomes discoloured indicating pulpal death.36
Reversible Pulpitis
It is a mild to moderate inflammatory condition of the pulp caused by noxious stimuli
usually dental caries and operative procedures in which the pulp is capable of returning to the
normality on removal of the stimulus.38
Trauma

from a sharp blow or deranged occlusal relationships, thermal shock during

prolonged cavity preparation or excessive dehydration of a cavity is usually the physical causes.
Chemical stimuli are sweet or sour foodstuffs, irritation from a filling, caries.36
Sharp pain that lasts for a moment more often by cold beverages is a characteristic
feature. The clinical difference between reversible and irreversible pulpitis is that the severity is
greater and duration of the pain is longer in irreversible pulpitis. Asymptomatic reversible
pulpitis can result from incipient caries and is resolved on removal of the caries and proper
restoration of the tooth.36

13

Diseases of the Dental Pulp

The pulp is sensitive to temperature changes and application of cold is an excellent
method of localizing and diagnosing the involved tooth. A tooth with reversible pulpitis reacts
normally to percussion, palpation, mobility and the periapical tissue appears normal on
radiographic examination. The patients description of the pain, its onset, character, duration is
important for differential diagnosis. The electric pulp test done using less current than on control
tooth is an excellent corroborating test. Removal of the noxious stimuli returns the pulp status
back to normality. Prevention is the best treatment option. Periodic care to prevent development
of caries , early restoration, use of cavity varnish or a cement base before insertion of filling,
adequate care while cavity preparation

and polishing are recommended as preventive

measures.16
Irreversible Pulpitis:
It is a persistent inflammatory condition of the pulp, symptomatic or asymptomatic
caused by noxious stimuli. The initial reaction is a very sharp pain to hot or cold stimuli which
linger for minutes to hours after the stimulus is removed. Spontaneous throbbing pain may wake
the patient at night and may become worse when lying down, is a feature of irreversible pulpitis.
The patient may completely avoid eating on the side of the mouth due to the severity of the
pain.79
Patients with irreversible pulpitis often need strong analgesics to relieve pain and may
have difficulty locating the precise tooth that is the source of the pain. They may even confuse
the maxillary and mandibular arches (but not the left and right sides of the mouth) because of the
extensive branching of dental nerve axons and perhaps fewer proprioceptive fibres in the pulp.
Information provided by the patients and the results of pulp sensibility tests are helpful in pain

14

Diseases of the Dental Pulp

localization and diagnosis. Dynamic changes occur in the irreversibly inflamed pulp and it may
move from being chronic and asymptomatic to having acute pain within few hours.16
Acute Irreversible Pulpitis
Acute irreversible pulpitis usually has a sudden onset that may wake the patient at night.
The pain is spontaneous with moderate to very severe intensity, and it lingers in response to
temperature changes. The pain may be intensified by posture changes such as when lying down
or bending over. Common analgesics are rarely effective in controlling the pain. In most cases,
radiographs are not useful in diagnosis but they can be helpful in identifying the possible cause
of the disease (e.g., deep caries, an extensive or fractured restoration, pins etc.). The tooth may
be tender to biting pressure and/or percussion and, if present, this usually indicates spread of the
inflammatory process to the periapical tissues. In some cases, the biting or percussion pain may
indicate a crack in the tooth and this is particularly noticeable when the crack is undermining a
cusp.2
Chronic Irreversible Pulpitis
Chronic irreversible pulpitis will have similar signs and symptoms but they will be much
less severe than those in the acute cases. Patients may complain of moderate pain, which is more
intermittent rather than continuous and it may be controlled by common analgesics. In the early
stages of the disease process, the diagnosis may be difficult because the tooth may not show any
demonstrable periapical change on the radiographs or a definitive sign of tenderness to
percussion. However, information from the patient and pulp sensibility tests should be useful. As
the disease progresses to involve the periapical tissues, periapical changes are more likely to be
evident radiographically.36

15

Diseases of the Dental Pulp

Pulp Necrosis
Necrosis may occur following irreversible pulpitis or trauma that disrupts blood supply to
the pulp. A necrotic pulp should be suspected when the tooth does not respond to pulp sensibility
tests. However, this will not always be the case since teeth with pulp canal calcification, previous
root fillings or pulpotomies will also not respond to pulp sensibility tests. Likewise, some teeth
or patients just do not respond to such tests for no apparent reason. When pulp necrosis is
present, history may reveal past trauma, previous episodes of pain or history of restorations and
caries.79
Radiographically, a tooth with a necrotic pulp may have signs (such as untreated caries,
an extensive restoration, previous pulp capping) or there may be no such signs (e.g., following
trauma). Trauma to a tooth may cause pulp necrosis as a result of severing the apical blood
supply if the tooth has been displaced from its normal position (e.g., luxations, avulsion) or if
there has been significant damage and inflammation to the apical periodontal ligament (e.g.,
subluxation). No significant radiographic changes are evident at the root apex unless there is also
periapical involvement, and this only occurs once the necrotic tissue becomes infected. It is
important to realize that a necrotic pulp per se does not cause apical periodontitis unless it is
infected. Pain usually does not present unless the periodontal ligament is affected. In this
situation, the canal is infected and leads to apical periodontitis. Once necrotic pulp is invaded by
bacteria, then the bacteria will spread throughout the entire root canal system. The necrotic pulp
acts as a source of nutrients for the bacteria which ingest the necrotic tissue and render the tooth
pulpless .36

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Diseases of the Dental Pulp

Degenerative Changes
The pulp will usually respond to noxious stimuli by becoming inflamed, but it may also
respond by degeneration which includes atrophy and fibrosis, calcification, root resorption, or
hyperplasia.36
Atrophy
Atrophy is a normal physiologic process that occurs with age and is asymptomatic. Pulp
sensibility tests responses may be normal or delayed. As the pulp atrophies, there will also likely
be fibrosis of the pulp tissue and the extent of this will be largely determined by the number of
irritant episodes suffered by that particular pulp throughout its history. The size of the pulp
chamber may be reduced. No treatment is required .79
Pulp Canal Calcification
Teeth with pulp canal calcification (commonly referred to as pulp canal obliteration) may
or may not have any symptoms. There are usually no responses to thermal tests but an electrical
test may elicit a normal or delayed response. Radiographically, there is no evidence of the usual
pulp chamber outline and the root canal may appear narrow or it may not be evident at all. Pulp
canal calcification may appear radiographically to be partial or complete but it is not possible to
assess the extent of calcification from a clinical or radiographic examination. It is feasible, and
likely, that the canal may only be a few cells wide and therefore will not be evident
radiographically, but may still contain viable and healthy tissue. Hence, the term obliteration is
not ideal since this term implies that there is no canal remaining and instead the term
calcification is preferred.2

Hyperplasia

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Diseases of the Dental Pulp

Hyperplasia of the pulp occurs almost exclusively in young teeth with an abundant blood
supply and a large carious lesion. It is essentially an overgrowth of granulation tissue and may
result in the development of a pulp polyp. The hyperplasic tissue is relatively insensitive to touch
due to having only a few nerves present. It may bleed easily depending on the degree of the
tissue vascularization and the degree of ulceration. Occasionally it may cause mild discomfort
during mastication. It has been suggested that the inflammation may be limited to the pulp
chamber and that the apical pulp tissues may be normal, except for some vasodilation and
minimal chronic inflammation. The tooth will respond to pulp sensibility testing but often with
an exaggerated response to cold tests. No significant radiographic changes except for the cause
of the problem .For example, caries, and fractured restoration are evident unless there is also
periapical involvement presenting as radiolucency or radiopacity.Sometimes, the gingival tissues
may grow into the carious lesion and this may be suggestive of a hyperplasic pulpitis. In these
cases the distinction may be made by careful examination of the tissue mass, so as to determine
if it is connected to the pulp or to the gingivae.2

Internal Resorption (Pink Tooth)

There are three forms of internal resorption surface, inflammatory and replacement.
Internal surface resorption is unlikely to ever be diagnosed since it is defined as minor areas of
resorption of the surface of the root canal wall. It is unlikely to be noticed radiographically and
there will be no clinical signs or symptoms. No treatment is required, which is fortunate since it
cannot be clinically or radiographically diagnosed. Inflammatory resorption can occur at any
point along the length of the pulp space that is coronally within the pulp chamber or within the
root canal. It is believed to occur in teeth with necrobiosis and it is probably due to a metaplastic

18

Diseases of the Dental Pulp

19

change or activation of dentinoclasts within the inflamed pulp tissue that is in contact with the
coronal pulp which is necrotic and infected. This condition is usually asymptomatic and often
only recognized during a routine radiographic examination. If symptoms are present, they are
usually indicative of an infected canal or pain when perforation of the crown occurs and the
metaplastic tissue is exposed to oral fluid and bacteria. Initially, part of the pulp (i.e., the apical
portion) is alive and still contains nerve fibres so a response to pulp sensibility testing is possible.
However, as the lesion progresses, the entire pulp become necrotic and infected, and overtime
the canal will become pulpless and infected, hence there will be no response to pulp sensibility
testing.16
Radiographically, internal inflammatory resorption will have an oval shaped increase in
the size of part of the root canal system. Periapical changes may be noted after the canal has
become infected and apical periodontitis develops. Internal replacement resorption is an
uncommon condition that occurs when the pulp undergoes metaplastic changes and the dentine is
resorbed and replaced by bone like hard tissue. Radiographically, internal replacement resorption
will have an irregular enlargement of the pulp space that is filled with bone like hard tissue.
Periapical changes do not usually occur with internal resorption.2
Accurate diagnosis of pulpal diseases is the key to all endodontic treatments. The
clinician should have an understanding of the various causative factors of pulpal diseases, collect
information about the presentation and history of symptoms and conduct many practical tests
before formulating the final diagnosis.36

WHO (1985)

Weine (1989)

Ingle (1965)

Walton &
Torabinejad (2002)

Diseases of the Dental Pulp

( note normal pulp not
mentioned )
Pulpitis

( note normal pulp not

mentioned )
Pulpitis

Healthy pulp

Initial (hyperaemia)

( reversible Pulpitis)
Hypersensitive Dentin
Hyperemia

Hyper reactive
pulpalgia

Acute suppurative
(pulpal abscess)
Chronic
Chronic ulcerative
Chronic hyperplastic
( pulp polyp )
Other unspecified
pulpitis
Pulpitis unspecified

Necrosis of the pulp

Pulpitis

20

( note normal pulp not

mentioned )
Pulpitis
Reversible pulpitis
Irreversible pulpitis
Hyperplastic pulpitis

Hypersensitivity
Painful pulpitis
Acute pulpalgia
(acute pulpitis )
Chronic pulpalgia
(chronic pulpitis)

Hyperaemia
Acute pulpalgia
Incipient
Moderate
Advanced

Non painful pulpitis

Chronic ulcerative pulpitis
Chronic pulpitis (no caries )
Chronic hyperplastic
pulpitis ( pulp polyp)

Hyperplastic pulposis

Pulp necrosis

Pulp necrosis

Pulp necrosis

Liquefaction sicca

Pulpal calcification
Internal (intracanal
resorption )

Chronic pulpalgia

Pulp Degenerations

Pulp Degeneration

Pulp Degeneration

Denticles
Pulp calcification
Pulp stones

Atrophy
Dystrophic calcification

Atrophic pulposis
Calcific pulposis

Abnormal Hard tissue

formation in pulp

Internal Resorption

Internal Resorption

Secondary or irregular
dentin
Comparative terminology and classification of pulp diseases used by various authors/organizations 2

Diseases of the Dental Pulp

Seltzer and Bender

21

Cohen and Burns (1998)

Tronstad (1991)

Grossman (1978)

( note normal pulp not

mentioned)

Within normal limits

Normal pulp
Calcific Metamorphosis

Healthy pulp

( note normal pulp not

mentioned)

Pulpitis

Pulpitis

Pulpitis

Hyperaemia Pulpitides

Incipient form of chronic

pulpitis
Acute pulpitis
Chronic partial pulpitis
with partial necrosis
Chronic total pulpitis with
partial liquefaction
necrosis
Chronic partial pulpitis
(hyperplastic form )

Reversible
Irreversible
Asymptomatic irreversible
Pulpitis
Hyperplastic pulpitis
Internal resorption
Canal Calcification
Symptomatic
Irreversible pulpitis

Asymptomatic pulpitis
Symptomatic pulpitis

Acute pulpitis
Chronic ulcerative pulpitis
Chronic ulcerative pulpitis

Pulp necrosis

Necrosis

Necrotic pulp

Necrosis

(1984)

Partial
Complete

Pulp Degeneration

Pulp Degeneration

Atrophic pulp
Dystrophic mineralization

Calcific
Fibrotic
Atrophic
Internal Resorption

Diseases of the Dental Pulp

22

Amercian association of
endodontists
Glossary (2003)

Harty (1990)

Castellucci (2004)

Stock (2004)

( note normal pulp not

mentioned)

Normal Pulp

Healthy pulp

Normal Pulp

Pulpitis

Pulpitis

Pulpitis

Concussed Pulp

Reversible pulpitis
Irreversible pulpitis

Reversible pulpitis
Irreversible pulpitis

Hyperemia
Pulpitis Irreversible

Reversible pulpitis
Irreversible pulpitis

Pulp necrosis

Necrosis

Necrosis

Pulp necrosis
( Internal resorption )