Pulp Disease – Part 3

Chronic Hyperplastic Pulpitis:

Definition: Chronic hyperplastic pulpitis or”pulp polyp” is a productive pulpal inflammation due to an extensive carious exposure of a young pulp.

This disorder is characterized by the development of granulation tissue, covered at times with epithelium and resulting from long-standing, low – grade irritation.

Slow, progressive carious exposure of the pulp is the cause. For the development of hyperplastic pulpitis, a large, open cavity, a young, resistance pulp, and a chronic, low grade stimulus are necessary. Mechanical irritation from chewing and bacterial infection often provide the stimulus.

 1) Clinically:
This disorder is generally seen only in the teeth of children and young adults. The appearance of the polypoid tissue is clinically characteristic; a fleshy, reddish pulpal mass fills most of the pulp chamber or cavity or even extends beyond the confines of the tooth.

At times, the mass is large enough to interfere with comfortable closure of the teeth, although in the early stages of development it may be the size of a pin. Polypoid tissue is less sensitivity than normal pulp tissue and more sensitive than gingival tissue.

Cutting of this tissue produces no pain, but pressure thereby transmitted to the apical end of the pulp does cause pain.

This tissue bleeds easily because of a rich network of blood vessels. If the hyperplastic 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.

2. Radiograph:
Radiographs generally show a large, open cavity with direct access to the pulp chamber.

3. Thermal Test:
The tooth may respond feebly or not at all to the thermal test, unless one uses extreme cold, as from an ethyl chloride spray.
4. EPT:
More current than normal may be required to elicit a response by means of the electric pulp tester.

Differential Diagnosis:
The appearance of hyperplasic pulpitis is characteristic and should be easily recognized. The disorder must be distinguished from proliferating gingival tissue.

Efforts at treatment should be directed toward elimination of the polypoid tissue followed by extirpation of the pulp, provided the tooth can be restored.

The prognosis for the pulp is unfavorable. The prognosis for the tooth is favorable after endodontic treatment and adequate restoration.

Internal Resorption:

Internal resorption is an idiopathic slow or fast progressive resorptive process occurring in the dentin of the pulp chamber or root canals of teeth.

The cause of internal resorption is not known, but such patients often have a history of trauma.

Internal resorption in the root of a tooth is asymptomatic.

Clinically, 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. Condition known as “pink tooth of mummery”.

2. Radiographs:
The radiograph usually shows a change in the appearance of the wall in the root canal or pulp chamber, with a round or ovoid radiolucent area.

Differential Diagnosis:
When internal resorption progresses into the periodontal space and a perforation of the root occurs, it is difficult to differentiate from external resorption. In internal resorption, the resorptive defect is more extensive in the pulpal wall than on the roof surface; this defect usually is recognized by means of a radiograph.

Extirpation of the pulp stops the internal resorptive process. Routine endodontic treatment is indicated.

The prognosis is best before perforation of the root crown occurs. In the event of a root-crown perforation, the prognosis is guarded and depends on the formation of a calcific barrier or access to the perforation that permits surgical repair.


Although degeneration of the pulp, as such, is seldom recognized clinically, the types of pulp degeneration should be included in a description of diseases of the pulp. Degeneration is generally present in the teeth of older people.

Degeneration may also be the result of persistent, mild irritation in teeth of younger people, however, as in calcific degeneration of the pulp. The specific types of pulp degeneration are

Calcific Degeneration:
In calcific degeneration, part of the pulp tissue is replaced by calcific material; that is, pulp stones or denticles are formed. This calcification may occur either within the pulp chamber or root canal, but it is generally present in the pulp chamber.

Atrophic Degeneration:
In this type of degeneration, observed histopathologically in pulps of older people, fewer stellate cells are present, and intercellular fluid is increased. The pulp tissue is less sensitive than normal.

Fibrous Degeneration:
This form of degeneration of the pulp is characterized by replacement of the cellular elements by fibrous connective tissue. On removal from the root canal, such a pulp has the characteristic appearance of a leathery fiber.
This disorder causes no distinguishing symptoms to aid in the clinical diagnosis.

Necrosis of Pulp:

Necrosis is death of the pulp it may be partial or total, depending on whether part of or the entire pulp is involved. Necrosis, although a sequel to inflammation, can also occur following a traumatic injury in which the pulp is destroyed before an inflammatory reaction takes place,
Necrosis is of two general types: coagulation and liquefaction
Necrosis of the pulp can be caused by any noxious insult injurious to the pulp, such as bacteria, trauma, and chemical irritation.
An otherwise normal tooth with a necrotic pulp causes no painful symptoms. Frequently, discoloration of the tooth is the first indication that the pulp is dead. The dull or opaque appearance of the crown may be due merely to a lack of normal translucency.
Teeth with partial necrosis can respond to thermal changes, owing to the presence of vital nerve fibers passing through the adjacent inflamed tissue.
Radiograph generally show a large cavity or filling, an open approach to the root canal, and a thickening of the periodontal ligament, Some teeth have neither a cavity nor a filling, and the pulp has died as a result of trauma a few patients have a history of severe pain lasting from a few minutes to a few hours, followed by complete and sudden cessation of pain.
A tooth with a necrotic pulp does not respond to cold, the electric pulp test, or the test cavity. In rare cases, however, a minimal response to the maximum current of an electric pulp tester occurs when the electric current is conducted through the moisture present in a root canal following liquefaction necrosis to neighboring vital tissue.