Pulpal Diseases

CLINICAL CLASSIFICATION OF
PULPAL
AND PERIAPICAL DISEASES
PULP AND PERIAPICAL DISEASES
The inflammatory process in the pulp is basically the
same , as elsewhere in the body c.t in the pulp , there are
several factors that change the response due to:
1-The pulp is a unique c.t
2- lack of collateral circulation
3- the pulp is only organ that can produce reparative dentin
PATHWAY OF THE PULP:
 1- direct extension
 2- extension of periodontal disease
 3- anchoretic
ETIOLOGY OF PULPAL INFLAMMATION
 A- MICROBIAL
 B- IATROGENIC: by dentist
 1. physical: (pressure, speed,size of instrument,depth of
cutting, presence or absence of insulating base, others like
 *loss of enamel by erosion or abrasion
 *high filling
 *hot impression material or wax
 * tooth drifting
 *orthodontic treatment
 2- thermal:
 Same as physical (coolants , metallic filling without
proper insulation, heat produced by setting cement and
polishing of restoration
 3- chemicals :used for cleaning of the cavity:
 * phenol
 *ether and chloroform
 *hydrogen peroxide
 *silver nitrate
 Used for filling the cavity:
 *orthophosphoric acid of zinc phosphate cement
 *acids of acrylic resin and composite.
 C- TRAUMATIC
 Depend of severity of trauma; vary where:
 Some pulps heal with no adverse effect
 Respond to trauma by inc pulpal calcification so teeth
become necrotic
 May cause crack
 D- IDIOPATHIC : internal resorption
Clinical classification of pulpal and periapical diseases
have been developed in order to formulate treatment plan
options.
 This classification is based on objective and subjective
findings.
Pulpal and periapical diseases are classified into:-
A.Pulpal B. Periapical
diseases diseases
:
 Pulpal diseases are:
1.Normal Pulp :
Definition:
It is is a clinical diagnostic category in which the
pulp is symptom free and normally responsive to
pulp testing.
Clinical features:
1. No spontaneous symptoms.
2.Temperature sensitivity will disappear once the
stimulus, such as ice cream, has been removed.
3. The symptoms produced from pulp tests are:
a. b. Do not cause the patient

Mild. distress.
c. Result in a transient sensation that resolves in seconds.
 Radiographical features:
1. There is no evidence of root resorption, caries,
or mechanical pulp exposure.
2. There may be varying degrees of pulpal
calcification.
3.The lamina dura is intact
4.Normal PDL space.
2.Pulpitis
Definition:
 It is a clinical and histologic term denoting inflammation
of the dental pulp.
 Clinically it is described as reversible or irreversible.
Histologically it is described as acute, chronic, or
hyperplastic.
A. Reversible Pulpitis
Definition:
 It is a clinical diagnosis based on subjective and objective
findings indicating that the inflammation should resolve and
the pulp return to normal.
Causative factors include:
1. Caries
2. Defective restorations.
3. Recent restoration.
4. Exposed dentin
5. Vital bleaching.
Symptoms:
a. Mild to moderate sharp transient pain with cold or air or sweet
b. Pain is removed by the removal of stimulus.
c. Pain can not localize the tooth , and sometimes not even the arc
d. A normal periapical
diagnosis.
Treatment.
1. Removal of the irritant.
If the stimulus is not stopped, resolved, or treated, and the
pulp is sufficiently irritated, pulpitis will progress into an
irreversible state.
B. Irreversible Pulpitis
 Can be divided into the subcategories of symptomatic ,
asymptomatic irreversible pulpitis and hyperplasic pulpitis.
Symptomatic Irreversible Pulpitis:

Definition:
It is a clinical diagnosis based on subjective and objective
findings indicating that the vital inflamed pulp is incapable
of healing.
Symptoms:
. Pain is severe , sharp, continuous, diffuse, and stabbing in natur
2.Lingering painful thermal responses, particularly to
cold.
3. The pain is intensified by a stimulus but can be spontaneous.
4.pain persist after the thermal stimulus has been
removed.
5.Referred pain is common.
6. It can be very difficult to isolate and pinpoint the exact
tooth.
7.Normal response to palpation and percussion.
8.Pain exacerbated on bending down or lying down due to
change in intrapulpal pressure.
Radiographical features:
1. Minimal or no changes in the radiographic appearance of
the periradicular bone.
2. Thickening of the PL may become apparent on the

radiograph.
3. Evidence of pulpal irritation.
4. Insult to the pulp, recently or historically, may be
present
 When symptomatic irreversible pulpitis remains
untreated, the pulp will eventually become necrotic.
A symptomatic irreversible pulpitis
Definition:
It is a clinical diagnosis based on subjective and objective
findings indicating that the vital inflamed pulp is
incapable of healing.
Symptoms:
1. Asymptomatic .
Left untreated, the tooth may become symptomatic or the

pulp will become necrotic.
Hyperplasic pulpitis (pulp
polyp)
Definition:
 It is a growth of pulp tissue from the pulp chamber
that is usually covered with epithelium.
 It appears like a reddish cauliflower or a mushroom.
 It is typically seen in a younger population and can be
found in both primary and permanent dentition.
 It is usually occurs in carious crowns.
Symptom:
 It is usually asymptomatic or show signs of irreversible pulpi
3.Pulpal necrosis
Definition:
 It is a clinical diagnostic category indicating death of the
pulp.
When it occurs, the pulpal blood supply is nonexistent
and the pulpal nerves are nonfunctional.
Causes:
1.Subsequent to symptomatic or asymptomatic irreversible
pulpitis.
2.Restorations.
3.Caries.
4.luxation injuries.
5.a longitudinal fracture extending from the occlusal
surface and into the pulp.
Symptom:
1. Usually asymptomatic.
2. Pain on percusion when periapical invlvement occurs
due to bacterial invasion from the infected pulp.
3. No response to vitality test.
4. It can often be very painful to heat stimulation , and is
often relieved by applications of cold.
5. Pulp testing over one root may give no response, whereas
over another root it may give a positive response.
6.The tooth may also exhibit symptoms of symptomatic
irreversible pulpitis.
Radiographic features:
1. Thickening of the PDL space.
2. Appearance of a periapical radiolucent lesion.
Previously Treated
Definition:
It is a clinical diagnostic category indicating that the
tooth has been endodontically treated and the canals are
obturated with various filling materials other than
intracanal medicaments.
Symptom:
1. The tooth may or may not present with signs or
symptoms.
2. No response to pulp testing procedures.
Previously Initiated therapy
Definition:
It is a clinical diagnostic category indicating that the tooth
has been previously treated by partial endodontic therapy
(e.g., pulpotomy, pulpectomy).
The partial endodontic therapy was performed as:
1. An emergency procedure for symptomatic or

asymptomatic irreversible pulpitis cases.
2.Part of vital pulp therapy procedures, traumatic tooth

injuries, apexification, or apexogenesis therapy.
2.Periapical Diseases
Normal Apical Tissues
This classification is the standard against which all of the
other apical disease processes are compared.
Clinical features:
1.The patient is asymptomatic
2.the tooth responds normally to percussion and palpation
testing.
Radiographic finding:
1.Intact lamina dura.
2.Intact periodontal ligament
space.
Periodontitis
Definitio
n:
It is an inflammation of the periodontium. When located
in the
periapical
 tissues it is referred
Apical periodontitis to as apical periodontitis.
can be subclassified to symptomatic
apical periodontitis and asymptomatic apical periodontitis.
Symptomatic Apical
Definitio Periodontitis
n:
It is an inflammation, usually of the apical
periodontium, producing clinical symptoms including a
painful response to biting or percussion or palpation.
Clinical features:
This tooth may or may not respond to pulp vitality
tests
Radiographic
findings:
a. It might or might not be associated with an apical
radiolucent area.
b. a widened periodontal ligament space.
c. May or may not show an apical radiolucency
associated with one or all of the roots
Asymptomatic Apical Periodontitis
Definitio
n:
It is an inflammation and destruction of apical
periodontium that is of pulpal origin.
Clinical features:
1. No clinical symptoms
2.The tooth does not usually respond to pulp vitality
tests. tooth is generally not sensitive to biting pressure but
3.The
may “feel different” to the patient on percussion.
Radiographic
findings:
Appears as an apical radiolucent area.
Acute Apical Abscess
Definitio
n:
It is an inflammatory reaction to Pulpal infection and
necrosis
Clinical features:
1. rapid onset, spontaneous pain.
2.Tenderness to biting pressure, percussion, and
3.palpation.
Pus formation
4.Swelling of associated tissues
5.No response to pulp vitality tests
6.The tooth exhibit varying degrees of mobility
7.The patient will frequently be
febrile.
8.the cervical and submandibular lymph nodes may
exhibit tenderness to palpation.
Radiographic
The radiograph or image can exhibit anything from a
findings:
widened
Periodontal ligament space to an apical radiolucency.
Chronic Apical Abscess
Definitio
n:
an inflammatory reaction to Pulpal infection and
necrosis characterized by gradual onset.
Clinical features:
1.Usually there is no clinical symptoms.
2.No response to pulp vitality tests,
3.Usually the tooth is not sensitive to biting pressure but
can “feel different” to the patient on percussion.
4.intermittent discharge of pus through an associated sinus
tract.
Radiographic
findings:
1.The radiograph or image will exhibit an apical
radiolucency.
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CLINICAL CLASSIFICATION OF

a. b. Do not cause the patient

Symptomatic Irreversible Pulpitis:

2. Thickening of the PL may become apparent on the

Left untreated, the tooth may become symptomatic or the

The partial endodontic therapy was performed as:

1. An emergency procedure for symptomatic or

2.Part of vital pulp therapy procedures, traumatic tooth

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