DIAGNOSIS OF PULPAL DISEASES

Presented by: Prakriti Sharma

3rd year,
17th Batch BDS
Department of Conservative Dentistry and Endodontics
 DIAGNOSTIC AIDS
History taking:

a. Chief complaint
b. Medical and dental history
Clinical examination: Extraoral and Intraoral

Symptoms :
a. Subjective symptoms: Most common being pain.
b. Objective symptoms:
i. Visual and tactile inspection: Color, Contour, Consistency.
ii. Thermal tests: Heat tests, Cold tests
iii. Electric pulp testing
iv. Radiographs
v. Percussion tests
vi. Test cavity
 NORMAL PULP
1. Pain: The normal and healthy pulp is free from spontaneous pain.
2. Pulp tests: A normal pulp is vital and gives mild to moderate, transient(1-2 seconds) response to
pulp tests and this response subsides immediately when the stimulus is removed.
3. Radiograph: Radiograph shows intact lamina dura, absence of any pulpal abnormality,
calcifications, and resorption.
 PULPAL PATHOLOGIES- Classification
Clinical classification of diseases of pulp (Grossman) :

1. Inflammatory diseases of the dental pulp

a. Reversible pulpitis : i. Acute reversible pulpitis

ii. Chronic reversible pulpitis

b. Irreversible pulpitis : i. Symptomatic irreversible pulpitis

ii. Asymptomatic irreversible pulpitis

iii. Chronic hyperplastic pulpitis

iv. Internal resorption

2. Pulp Degeneration
a. Calcific degeneration

b. Fibrous degeneration

3. Pulp Necrosis
a. Pulp necrobiosis

b. Pulp necrosis with no signs of infection

c. Necrotic and infected pulp

Clinical classification of diseases of pulp ( suggested by American Association
of endodontics – 2012)
• Reversible Pulpitis
• Irreversible Pulpitis :
- Symptomatic irreversible Pulpitis
- Asymptomatic irreversible Pulpitis
• Pulp Necrosis
• Previously treated
• Previously initiated therapy
Sequelae of Pulpal Diseases
 A. REVERSIBLE PULPITIS
• Reversible pulpitis is a mild to moderate inflammatory condition of the pulp caused by noxious stimuli
in which the pulp is capable of returning to the uninflamed state following removal of the stimuli.
 Causes:

• Dental caries.
• Trauma: as from a blow or from a disturbed occlusal relationship.
• Thermal injuries
• Chemical stimulus: like sweet or sour foodstuff or from irritation of the filling.
• Excessive dehydration of the cavity or irritation of the exposed dentin at the neck of tooth .
Symptoms: (Pain)
• short, sharp pain lasting for a moment.
• This pain is always specific to a stimulus and instantly relieved on removal of the stimulus.
• More often brought on by cold than hot food or beverages and by cold air.
• It does not occur spontaneously and does not continue when the cause has been removed.
• Following insertion of a restoration , patient may complain mild sensitivity to temperature
changes, especially cold. Such sensitivity may last for a week or longer but gradually, it subsides.
This sensitivity is symptom of reversible pulpitis.
Diagnosis:
• Diagnosis is done by a study of the patient’s history, symptoms and by clinical tests.
• Pain: It is sharp, lasts but a few seconds, usually caused by cold, sweet, and sour stimuli. Pain
ceases after removal of stimulus.
• Visual examination and history: It may reveal caries, recent restoration, traumatic occlusion, and
undetected fracture.
• Radiographic examination: Shows normal periapical tissue and Presence of deep dental caries or
restoration.
• Percussion test: Tooth is normal to percussion and palpation without any mobility.
• Vitality test: Pulp responds readily to cold and electric stimuli.
• Mandibular left first molar had deep
occlusal caries and the patient
complained of sensitivity to sweets and
cold liquids. There was no discomfort on
biting or percussion. The tooth was
hyper-responsive to cold with no
lingering pain.
• Diagnosis: reversible pulpitis; normal
apical tissues.
 B. IRREVERSIBLE PULPITIS
• Irreversible pulpitis is a persistent inflammatory condition of the pulp, symptomatic or asymptomatic
in nature with the pulp becoming incapable of healing.
Causes:

Irreversible pulpal inflammation can result from:

• Most common cause of irreversible pulpitis is bacterial involvement of pulp through caries.
• Chemical, thermal, mechanical injuries of pulp.
• Untreated reversible pulpitis may deteriorate into irreversible pulpitis.
 Types:

• Symptomatic irreversible pulpitis

• Asymptomatic irreversible pulpitis
Symptoms: (Pain)
• Rapid onset, caused by sudden temperature change, sweet, or acidic food and pressure from
packing food into a cavity or suction exerted by the tongue or cheek.
• Time: persists for several minutes to hours, lingering after removal of the stimulus.
• Nature: Spontaneous in nature which is sharp, piercing, intermittent, or continuous .
• Exacerbated on bending down or lying down due to change in intra pulpal pressure from standard
to supine position.
• Severity: Pain is so severe that it keeps the patient awake in night.(nocturnal pain)
• Presence of referred pain to adjacent teeth, temple and sinuses.
• In later stages, pain is severe, boring, and throbbing in nature which increases with hot stimulus.
• Pain is relieved by using cold water. Sometimes pain is so severe that patient may report dental
clinic with jar of ice cold water.
• Apical periodontitis develops in later stages when inflammation extends to periodontal ligament.
Diagnosis:
• Visual examination and history: Deep cavity involving pulp or secondary caries under restorations.
The pulp may already be exposed. Grayish, scum-like layer may be seen over the exposed pulp and
the surrounding dentin.
• Radiographic findings: Shows depth and extent of caries. Periapical area shows normal
appearance but a slight widening may be evident in advanced stages of pulpitis.
• Thermal test: Early stages: the thermal test may elicit pain that persists after removal of the
thermal stimulus. Later stages: when the pulp is exposed, it may respond normally to a thermal
stimulus, but generally it reacts feebly to heat and cold.
• Electric test: Less current is required in initial stages. As tissue becomes more necrotic, more
current is required to generate the response.
• Results of examination for mobility, percussion and palpation tests are negative.
• Mandibular left first molar had deep
mesio-occlusal caries. Patient
complained of sensitivity to hot and
cold liquids initially but later pain
became spontaneous. EPT test showed
lingering pain even after removal of the
stimuli. Response to both percussion
and palpation was normal.
• Diagnosis: symptomatic irreversible
pulpitis
• Fractured restoration
with secondary caries
showing clinical signs
of irreversible pulpitis.
 C. CHRONIC HYPERPLASTIC PULPITIS
• Chronic hyperplastic pulpitis or pulp polyp is a productive pulpal inflammation due to an extensive carious
exposure of a young pulp.
Causes:

• Slow, progressive carious exposure of the pulp.

• For the development of hyperplastic pulpitis, a large, open cavity; a young, resistant pulp; and a chronic,
low-grade stimulus are necessary.
• Mechanical irritation from chewing and bacterial infection often provide the stimulus.
Symptoms :

• It is usually asymptomatic .
• Fleshy pulpal tissue fills the pulp chamber.
• It is less sensitive than normal pulp.
• Bleeds easily due to rich network of blood vessels.
• Sometimes this pulpal growth interferes with chewing.
Diagnosis
• This disorder is mostly seen in young adults and children.
• Pain: It is usually absent.
• Visual examination: Hyperplastic form shows a fleshy, reddish pulpal mass which fills most of pulp
chamber or cavity or even extends beyond the confines of the tooth.
• It is less sensitive than normal pulp but bleeds easily when probed.
• Vitality tests : Tooth may respond feebly or not at all to thermal test, unless one uses extreme cold
More than normal current is required to elicit the response by electric pulp tester .
• Radiographic findings : Radiographs generally show a large, open cavity with direct access to the
pulp chamber .
• Differential diagnosis: If pulp tissue extends beyond the cavity of a tooth, it may appear as if the
gum tissue is growing into the cavity. To differentiate a pulp polyp from proliferating gingival
tissue, one should raise and trace the stalk of the tissue back to its origin, the pulp chamber.
Fig: Hyperplastic form of pulpitis showing fleshy Fig: Radiographic appearance of a mandibular
reddish pulpal mass filling the pulp chamber. molar exhibiting chronic hyperplastic pulpitis.
 D. INTERNAL RESORPTION
• Resorption is defined as a condition associated with either a physiologic or a pathologic process
resulting in loss of dentin, cementum, or bone.
• Also called as “Pink tooth of mummery”.
Causes: Exact etiology is unknown. Patient may present history of trauma or persistent
chronic pulpitis, or history of pulpotomy.
 Symptoms:
• Internal resorption in the root of a tooth is asymptomatic.
• In the crown of the tooth, internal resorption may be manifested as a reddish area called pink
spot.
• This reddish area represents the granulation tissue showing through the resorbed area of the
crown.
• Pulp shows either partial or complete necrosis. In actively progressive lesion, pulp is partially
vital and may show symptoms of pulpitis
Diagnosis:
• Clinically: “Pink tooth” appearance. Pink spot is formed during the resorptive process.
• Radiographic changes :Clearly well-defined radiolucency of uniform density which balloons out of
root canal . Original root canal outline distorted.
• Pulp tests: Positive, though coronal portion of pulp is necrotic, apical pulp could be vital.
• It may be a slow, progressive, intermittent process extending over 1 or 2 years; it may develop
rapidly and may perforate the tooth within a matter of months.
• Although any tooth in the mouth can be involved, those most readily recognized are the maxillary
anterior teeth.
Fig: “Pink spot” indicative of an internal resorptive Fig: An extracted tooth showing evidence of
defect seen in the palatal aspect of the crown of the
maxillary central incisor. internal resorption causing root perforation.
Fig: Radiographic image of the maxillary central Fig: Radiograph showing internal resorption
incisor showing an internal resorptive defect with in distal root of mandibular first molar.
intact crown margins.
 E. PULP NECROSIS
• Pulp necrosis or death is a condition following untreated pulpitis. Pulpal tissue becomes nonvital and if
the condition is not treated, noxious materials will leak from pulp space forming the lesion of
endodontic origin.
• It may be partial or total, depending on whether part of or the entire pulp is involved.
 Types :

• Coagulation necrosis : Results in the soluble portion of tissue being precipitated or is converted
into a solid material.
• Liquefaction necrosis results when proteolytic enzymes convert the tissue into a softened mass, a
liquid, or amorphous debris.

 Causes: Necrosis of the pulp can be caused by any noxious insult injurious to the pulp, such as
bacteria, trauma, and chemical irritation.
Symptoms :
• Discoloration(grayish or brownish) of tooth due to extravasation of pulpal blood into dentin as a
result of trauma. 1st indication that the pulp is dead.
• Lack of translucency/dull or opaque appearance .
• Tooth may lack its usual brilliance and luster.
• Tooth is asymptomatic in complete necrosis but teeth with partial necrosis can respond to thermal
changes, owing to the presence of vital nerve fibers passing through the adjacent inflamed tissue.
Diagnosis:
• Pain: It is absent in complete necrosis
• History of patient: History reveals past trauma or past history of severe pain which may have
lasted for some time followed by complete and sudden cessation of pain.
• Radiographic changes: Radiograph shows a large cavity or restoration or normal appearance
unless there is concomitant apical periodontitis or condensing osteitis
• Vitality test: Usually, vitality tests show negative response. But multirooted teeth may show
mixed response because only one canal may have necrotic tissue. Sometimes teeth with
liquefaction necrosis may show positive response to electric test when electric current is conducted
through moisture present in a root canal.
• Visual examination: Tooth shows color change like dull or opaque appearance due to lack of
normal translucency
Fig: Radiograph showing carious lesion in Fig : Radiograph showing a large carious lesion in
mandibular 3rd molar premolar resulting in pulp necrosis
Fig: Photograph showing discolored maxillary Fig: Lack of normal translucency in
left central incisor due to pulpal necrosis nonvital maxillary right central incisor.
 PREVIOUSLY TREATED
• This is a clinical diagnostic category indicating that the tooth has been endodontically treated and
the canals are obturated with various filling materials.
• In this situation, the tooth may or may not present with signs or symptoms but will require
additional nonsurgical or surgical endodontic procedures to retain the tooth.
• In most such situations, there will no longer be any vital or necrotic pulp tissue present to respond
to pulp testing procedures
 PREVIOUSLY INITIATED THERAPY
• This is a clinical diagnostic category indicating that the tooth has been previously treated by partial
endodontic therapy (e.g., pulpotomy, pulpectomy)
• In most instances, the partial endodontic therapy was performed as an emergency procedure for
symptomatic or asymptomatic irreversible pulpitis cases.
• In other situations, these procedures may have been performed as part of vital pulp therapy
procedures, traumatic tooth injuries.
• At the time these cases present for root canal therapy it would not be possible to make an
accurate pulpal diagnosis because all, or part, of the pulp tissue has already been removed.
THANK YOU!