A brief presentation of UG level about diagnosis of various pulpal pathology in pediatric dentistry

1. By:
Shirin
IV year Part I BDS
KMCT Dental College

2. INTRODUCTION
• Dental pulp may be defined as, “ a special organ with a
unique environment of the unyielding dentin surrounding a
resistant,resilient soft tissue of mesenchymal origin
reinforced with a ground substance.”
• It has a close relationship between its peripheral cells,the
odontoblasts and the dentin thereby making it a functional
entity sometimes refered to as „pulp-dentin complex‟.
• The dental pulp is a delicate connective tissue liberally
interspersed with tiny blood vessels,lymphatics,nerves, &
undifferentiated CT cells.
• The enclosure of the pulp tissue within the rigid calcified
walls of dentin precludes the excessive swelling of tissue
that occur in hyperemic phases of inflammation in other
tissues.
• Pulpal injury  frequently irreversible & painful

3. Normal Pulp
• Asymptomatic
• Exhibits mild to moderate transient response to thermal
& electric pulpal stimuli, which subsides almost
immediately with ceasation of the stimuli.
• No pain on percussion or palpation.
• R/G
 clearly delineated canal that tapers toward the
apex.
no evidence of canal calcification.
intact lamina dura.

4. CLASSIFICATION OF PULPAL DISEASES
(Grossman’s Classification)
A. Pulpitis
i)Reversible Pulpitis
ii)Irreversible Pulpitis
a)Hyperplastic Pulpitis
b) Internal resorption
B. Pulp degeneration-Pulp Calcification
C. Pulp Necrosis

5. Reversible Pulpitis
• “Mild to moderate inflammatory condition of the pulp caused by
noxious stimuli , in which the pulp is capable of returning to the
uninflammed state following removal of the stimuli.”
• A Clinical diagnosis based on subjective & objective findings.
• C/F :
 due to direct or indirect injury to pulp
increased response to cold ,hot or sweets
Thermal stimuli cause quick, sharp & transient hypersensitive
response which lasts for a moment & subsides soon after removal of
stimuli.
 respond to electric pulp tester at a lower level of current than
that of adjacent normal teeth.
 Associated teeth usually show deep carious lesions,large metallic
restorations(particularly w/o adequate insulation), or restorations
with defective margins.

6. Irreversible Pulpitis
• “Persistant inflammatory condition of the pulp,which is
symptomatic or asymtomatic caused by a noxious stimulus.”
• A Clinical diagnosis based on subjective & objective findings.
• Normally continuation of reversible pulpitis resulting in
progressive damage to pulp.
• May be acute ,subacute or chronic.
• Clinically, acutely inflammed pulp symptomatic &
chronically inflammed asymptomatic
• Pain occurs as a result of increase in intrapulpal pressure due to
inflammatory exudates.
• C/F :
Irreversible pulpitis may be symptomatic or asymptomatic
Symptomatic Irreversible Pulpitis
spontaneous intermittent or continuous paroxysms of pain
Sudden temperature changes induce prolonged episodes of pain.

7. There may be prolonged painful response to cold which can be relieved by
heat & painful response to heat which is relieved by cold.
Continuous spontaneous pain may occur by change in posture
Pain may be moderate to severe depending on severity of inflammation.
May be sharp or dull ; localized or referred ; intermittent or constant.
Characteristics Potentially reversible Irreversible Pulpitis
Pain Momentary-dissipates readily after
removal of stimulus
Continuous,persistent,throbbing,int
ermittent
Stimulus Require external stimulus spontaneous
Pulp Sensibility Testing Not reliable in primary & young
permanent teeth
unreliable
Percussion - ve May be +ve in advanced cases
Referred pain - ve Common finding
Postural variation - ve Common finding
Color of tooth no change Present-due to tissue lysis &
intrapulpal hemorrhage
Radiographic findings Normal periapex Widening of PDL space

8. Asymptomatic Irreversible Pulpitis
 May develop on conversion of a symptomatic irreversible pulpitis
into a quiescent state,probably because the inflammatory exudate
was quickly vented --- large carious exposure / previous traumatic
injury that resulted in painless pulp exposure of long duration.
 Chronic Hyperplastic Pulpitis (Pulp Polyp)
•a unique form of pulpitis wherin
the inflammed pulp instead of
perishing by continued
suppuration,reacts by excessive &
exuberant proliferation into the
occlusal surface.
•Characterized by development of
granulation tissue,covered by
epithelium,that protrude out of
pulpal chamber
•Occurs in teeth with extensive
carious exposure of pulp,asstd
with long standing ,low grade
irritation.
•Usually asymptomatic but pain
may present during mastication.

9. Internal Resorption
• “Idiopathic slow or fast progressive resorptive process occuring in
dentin of the pulp chamber or pulp canal of the tooth.”
•Exhibit no additional symptoms other than existing pulpitis.
•Crown may appear as pink  „ ,when resorption is in
coronal portion.
•Resorption involving the root canal appears as round to oval R/L
area that extends from pulp canal.

10. Pulpal Necrosis
• Associated with death of the pulp.
• Tooth becomes non-vital.
• May result from untreated irreversible pulpitis or may occur
immediately after a traumatic injury that disrupts the blood supply to
the pulp.
• Necrotic remnants may be liquefied or coagulated.
• May be asstd with periapical abscess.
• Crown of the tooth may be discolored.
Pulpal necrosis presented as
apersistent greyish
discoloration of crown
bcessation of root
development & periapical
radiolucent lesion
-after traumatic injury.

11. DIAGNOSTIC PROCEDURES
• Diagnosis is the process of identifying a medical condition or
disease by proper evaluation of signs & sypmtoms & from the
results of various diagnostic procedures.
• Diagnostic procedure should follow a consistent & logical order
& include review of medical & dental histories ,radiographic
examination & clinical examination.
• Pulp is the essence of the tooth. It is the structure that makes
the tooth vital.
• An understanding of the possible underlying pathological
process ,combined with an exact assessment of pain history &
appropriate clinical tests should aid the practitioner in
determining the nature of the pulpal inflammation.
• Operative diagnosis  there are instances when a final
diagnosis can be reached only on direct evaluation of pulp
tissue & decission about treatment can be made accordingly.
eg:

12. • History
• Recollecting -1st step towards establishing a diagnosis.
• May not determine treatment but may influence modification in
treatment modalities as according to the person‟s health status.
• Detailed history of pain
• Extra-Oral Examination
• For localized swelling,changes in color or bruises,abrasions,cuts or
scars & similar signs of disease,trauma or previous T/t.
• Enlarged lymphnodes important in denoting spread of infection.
• Intra-Oral Examination
• Examination of oral mucosa for any abnormality
• Carious lesions ,discolorations & other obvious abnormalities asstd
with the teethshould be noted.
• Coronal Evaluation
 by using a mouth mirror & explorer and possibly a fiber optic light
source.
Suspected tooth carefully & thoroughly examined for caries,defective
restoration,discoloration,enamel loss or defects that allow direct
passage of stimuli to pulp.
• Pulpal Evaluation
Clinical condition of the pulp evaluated by thermal
stimuli,percussion,palpation & vitality tests.

13. • Pulpal Evaluation + History+ R/G findings Diagnosis
• The various pulpal evaluation methods are:
i) Pulp testing
ii) Percussion
iii) Radiographs
Dental Pulp Testing
• A useful & essential diagnostic aid in endodontics
• An investigation that provide valuable diagnosis & treatment
planning information.
• Help in the assessment of pulp health based on its qualitative
sendory response.
• 3 types
Pulp vitality testing assessment of pulp‟s blood supply
eg: Laser Doppler Flowmetry
Pulse oximetry
Pulp sensibility testing assessment of pulp‟s sensory response.
eg: Thermal & electric pulp testing
Pulp sensitivity condition of pulp being very responsive to
stimuli.

14. • Conventional Pulp Testing
Method Technique/Material Symptom/Interpretation
1. Thermal
Cold
Heat
•Ethyl chloride,ice,air blast
•Hot water,heated gutta parcha
(used for location of
symptomatic tooth)
•Hypersensitivity/subsiding pain-
reversible pulpitis.
•Lingering pain-irreversible pulpitis
•No response-pulpal necrosis
2.Electirc •Odontometer •Respond to lower level of current-
reversible pulpitis
•Respond to higher level of current-
Irreversible
•No response-necrosis
3.Percussion •Vertical
•Lateral
•Apical periodontitis(irreversible
pulpitis if due to caries)
•Lateral periodontal space
inflammation
4.Radiograph •IOPA •Furcation involvement /thickening of
the PDL space-indicates periapical
infection(usually accompanied with
irreversible pulpitis)
Pulp sensibility tests unrelaible in children,recently traumatized & multi rooted
teeth.

15. • Newer Methods
• Laser Doppler Flowmetry
• Developed in 1970s to measure the velocity of RBCs in capillaries.
• A non-invasive,objective,painless alternative to traditional neutral-
stimulation methods promising test for children.
• Vital teeth-produce regular signal fluctuations
• Non-vital teeth-no synchronous signals;produced irregular fluctuations or
very steep spike traces that are attributed to a movement artefact.
• Useful in assessment of post-traumatized incisors aswell.
• Pulse Oximetry
• Direct measurement of pulp circulation-real measure of pulp vitality.
• Pulp oximetry-completely objective estimates blood oxygen saturation
levels by measuring & comparing amplitudes of the ratios of transmitted
infra-red with red light.
• The ratio varies with relative fractions of oxygen saturated to
unsaturated Hb & is used to calculate oxygen saturation.
• Capable of evaluating the blood vasculature status within a tooth &
therefore pulp vitality.
• Disadvantage – dependance on a pulsatile blood flow

16. • Duel Wavelength Spectrometry
• Measures blood oxygenation change within the capillary bed of
dental tissue & tus not dependent on a pulsatile blood flow.
• Hughes Probeye Camera
• Used in detecting temperature change as small as 0.1 C ,hence
,been used to test pulp vitality experimentally.
Odontometer Laser Doppler Flowmeter

17. Pulse Oximeter

18. CONCLUSION
Before initiating treatment one must first assemble all the information
regarding signs,symptoms & history.
That information is then combined with results from the clinical examination &
tests to obtain the diagnosis.
Determination of the etiology of the patient’s chief complaint & a correct
diagnosis is are paramount prior to a recommendation of an endodontic therapy
or any treatment.
A diagnostician must have a working knowledge of examination procedures ,a
knowledge of pathosis .its radiographic & clinical manifestations ,an awarness
of various modalities of treatment and above all a questioning mind .
A methodical & disciplined approach,along with a good measure of patience ,will
help establish an accurate diagnosis.

19. REferences
• Textbook Of Pedodontics by Shobha Tandon,2nd
Edition.
• Principles & Practice Of Pedodontics by Arathi Rao
• Shafer’s Textbook Of Oral Pathology,6th Edition
• Review article –Dental Pulp Testing by Eugene Chen
& Paul V.Abbott ;International Journal Of
Dentistry,Vol. 2009,Article ID 365785
• Clinical Update on Pulpal & Periradicular Diseases
by Naval Post Graduate Dental School,December
2005
• Various Internet sources