Professional Documents
Culture Documents
Carryl F. Sepang
Febe M. K Wangania
Glory V. Pohan
UNIVERSITAS PADJADJARAN
BANDUNG
2017
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TABLE OF CONTENTS
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CHAPTER I
INTRODUCTION
involves blood vessels and the nerves and is one of the most common reasons of tooth
ache. Pulpitis can occur as a result of untreated tooth decay, trauma to the tooth or can
2010)
Pulpal diseases are based on the ability of the inflamed dental pulp to return to a
healthy state once the noxious stimulus has been removed. Condition of the pulp can be
classified into normal pulp, reversible pulpitis, irreversible pulpitis, and necrotic pulp.
This paper will be talking mainly about chronic hyperplastic pulpitis which one
of the form of irreversible pulpitis, a report about unusual case report of it, and
management of the case. In the case of chronic hyperplastic pulpitis, the disease process
is irreversible.
Chronic hyperplastic pulpitis also known as pulp polyps usually occurs in molar
granulomatous tissue into the carious cavity, but there is some unusual case where
chronic hyperplastic pulpitis occurred in matured pulp (Faryabi and Adhami, 2008).
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CHAPTER II
RELATED LITERATURE
The dental pulp consists of vascular connective tissue contained within rigid
dentinal walls, pulp tissue similar to other connective tissue in the human body and
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Nutritive. Preserving the vitality of all the cellular elements
The elaboration of dentin creates a special environment for the pulp. The pulp
space becomes limited by dentin formation in permanent adult human teeth. This
life of the pulp, as well as by the deposition of reparative dentin in response to noxious
1) Odontoblastic Zone
Odontoblasts are the characteristic cells of pulp. They form a single layer at its
periphery, synthesize the matrix, and control the mineralization of dentin. The
morphology of the cell reflects its level of activity; larger cells have a well-developed
synthetic apparatus and the capacity to synthesize more matrix. Odontoblasts can
continue at varying levels of activity for a lifetime. the odontoblast consists of two
The primary function if the odontoblasts throughout the life of the pulp is the
production and deposition of dentin. Because the important and close relationship
2) Cell-free Zone
Thin layer immediately subjacent to the odontoblastic zone that contains very
few cells. This zone, although called cell-free, contains some fibroblasts, mesenchymal
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3) Cell-rich Zone
The cell-rich zone is located central to the cell-free zone. Ground substance,
fibroblasts and their product like collagen fibers, undifferentiated mesenchymal cells,
macrophages are the main components of this zone. Those components will be
(1) Fibroblast
Fibroblasts are the common cell type in the pulp and are seen in greatest
numbers in the coronal pulp. They produce and maintain the collagen and ground
substance of the pulp and alter the structure of the pulp in disease. The more active the
cell, the more prominent the organelles and other components necessary for synthesis
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and secretion. These cells also undergo apoptotic cell death and it will be replaced by
The undifferentiated mesenchymal cells are derived from the mesenchymal cells
of the dental papilla. They retain pluripotential characteristic because of their function
in repair and regeneration. These cells resemble fibroblasts as they are stellate in shape,
with a large nucleus and little cytoplasm. Usually located around blood vessels in the
cell-rich zone and are difficult to recognize (Chandra and Krishna, 2011).
Macrophages are found in the cell-rich zone, especially near the blood vessels.
These cells are blood monocytes that have migrated into the pulp tissue. Their function
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is to phagocytize necrotic debris and foreign materials. Lymphocytes and plasma cells,
if present in the normal pulp, are found in the coronal subodontoblastic region. The
function of these cells in the normal pulp may be immune surveillance (Chandra and
Krishna, 2011).
4) Central zone
The central zone or pulp proper contains blood vessels and nerves that are
embedded in the pulp matrix together with fibroblast. From their central location, the
blood vessels and the nerves send branches to the periphery of the pulp.
Pulpitis refers to inflammation of dental pulp that involves blood vessels and the
nerves and is one of the most common reasons of tooth ache. Pulpitis can occur as a
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result of untreated tooth decay, trauma to the tooth or can occur because of multiple
restorations.
caused by noxious stimuli in which the pulp is capable of returning to the uninflamed
inflammatory changes limited to the area of the involved dentinal tubules, such as
dental caries. Dilated blood vessel, extravasation of edema fluids, disruption of the
moment, that more often cause by cold food and beverages and also cold air when apply
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to the cavity. Pain is not spontaneous usually should be trigger, and will stop as soon as
Management for reversible pulpitis are removal of the noxious stimuli and in
2011).
Based on subjective and objective findings that the vital inflamed pulp is
incapable of healing and that root canal treatment is indicated. Characteristic may
include sharp pain upon thermal stimulus, lingering pain (often 30 seconds or longer
after stimulus removal), spontaneously (unprovoked pain) and referred pain. Typically,
there are minimal changes in the radiographic appearance of the periradicular bone, for
advance irreversible pulpitis thickening of the periodontal ligament may be seen. Dental
history and thermal test are very important and the primary tools for assessment (Ali
Clinical diagnose based on subjective and objective findings indicating that the
vital inflamed pulp is incapable of healing. If its left untreated the tooth may become
possible. These cases have no clinical symptoms and usually respond normally to
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thermal testing but may have had trauma or deep caries that would likely result in
microorganism present if it in the late carious state, along with lymphocytes, plasma
Figure 2.6: Irreversible Pulpitis. A, Advanced caries in the dentin has reached the pulpal
tissue under the occlusal fissure, causing circumscribed pulpal
inflammation. B, Death of odontoblasts without formation of reparative
dentin, and inflammatory cell infiltration into the adjacent pulpal tissue.
C, Penetration of bacteria within the dentinal tubules with chemotactic
attraction of neutrophilic granulocytes (Mrzezo,2015)
Chronic hyperplastic pulpitis is found rarely, despite wide exposure and heavy
infection, the pulp not merely survives but proliferates through the opening. This may
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even happen in fully formed teeth, as there are some case report about chronic
More explanation and discussion about this type of pulpitis will be in chapter 3.
Pulpal necrosis is the term applied to pulp tissue that is no longer living. Pulpal
necrosis occurs slowly over time, as occurs during the course of an untreated
irreversible pulpitis. In this later case the patient may gradually lose the acute and
chronic symptoms, because the nerve fibers in the pulp degenerate from the
Figure 2.7: Pulp with Partial Necrosis. Area with cell nuclei of cells inflammation (Red
arrow), and calcification (Black arrow) (H.E., original magnification 200x)
(Bruno, et al., 2015)
In pulpal necrotic the pulp tissue may be infected with bacteria. Usually it is the
result of dental decay, in which the infection can quickly extend into the apical areas
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and surrounding bone of the tooth. Noninfected necrosis pulpal occurs usually after a
traumatic incident, that sometimes asymptomatic for months. The signs for non-infected
consists of gently tapping on several teeth in the area with a blunt instrument. A tooth
that has undergone pulpal necrosis will be identified, because the pressure from the
tapping will produce intense pain Called percussion test (Sapp, et al., 2004).
iatrogenic (Garg, 2014). There will be brief explanation about each cause, but this paper
will be explaining more about bacteria and the reaction of the pulp to bacteria.
2.3.1 Bacteria
In 1894 W.D Miller suggested that bacteria were the most common cause of
pulp inflammation. Bacteria or their products may enter the pulp through a break in
Once bacteria have invaded the pulp, the damage is almost always irreparable.
The species of bacteria recovered from inflamed or infected pulps are many and varied.
Although lactobacilli are commonly found in carious dentin, they are seldom recovered
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from the pulp because of their low degree of invasiveness. Microorganisms doesnt
Bacteria most often found from infected vital pulp are streptococci,
staphylococci, and other microorganism i.e. anaerobes. The type of organism recovered
usually depends on whether the pulp is cultured in situ or after extraction of the tooth,
whether communicates with the fluids of the mouth, and whether the disease has
progressed to necrosis.
Pulp itself react to the bacterial invasion, the reaction of the pulp is difference
not like other infection in the other part of the body. Once the pulp is exposed by caries
immediately. At first, the infection is localized to a small area of the pulp, just an
infection following a scratch of the arm is localized. Although the coronal area of the
pulp may be involved by a mild or even severe infective process, the body and apical
portion of the pulp may remain normal. The reaction of the pulp in the involved area is
an inflammatory response.
bacteria deeper into the pulp is prevented. Because some microorganisms enter the
dentinal tubules, they may gain a foothold that is difficult to dislodge. In this respect,
injury of the pulp and injury of the arm or some other part of the body differ; in the
latter, microorganisms are more readily reached by tissue defenses. The reaction in an
inflamed pulp also differs from that in an inflamed of other organ in that small limited
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space provided during the inflammatory state for swelling of the pulp because the pulp
is entirely enclosed in a hard, unyielding dentinal wall, except at the apical foramen. If
the inflammatory process is severe, it will extend deeper into the pulp and all the
nutritional supply, many of the polymorphonuclear leukocytes die, and pus forms,
further irritating the nerve cells. If the process is less severe, lymphocytes and plasma
cells will replace the polymorphonuclear leukocytes in numbers, and the inflammatory
with resulting necrosis of the pulp. In most cases the microorganisms survive, and if
virulent, multiply rapidly and reach the periapical tissue, where they continue their
destruction and produce an acute alveolar abscess. Meanwhile, during the process of
bacteria invasion, the dentinal tubules may become infiltrated with products of blood
decomposition, bacteria, and occasionally, food debris, and the dentin becomes
discolored. Such discoloration of tooth structure is sometimes the first clinical sign that
2.3.2 Traumatic
root. Trauma is less frequently the cause of pulp injury in adults than in children.
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Whether the injury is a result of an automobile accident, a sport mishap, the severity
and the type of injury will determine the treatment necessary. There are number of
common injuries that occur to the teeth such as, acute trauma including fracture,
luxation or avulsion of the tooth. Where chronic trauma including parafunctional habits
like bruxism.
2.3.3 Iatrogenic
During dentine preparation, numerous dentine tubules are always exposed and
the odontoblast process cut off at the level of the dentine wound. The mechanical
opening of the dentine tubules and intra-pulp pressure lead to the dentinal fluid flowing
through the dentine tubules to the open dentine surface resulting in dehydration of the
pulp.
Iatrogenic cause pulp inflammation for which the dentists own procedure.
bleaching of enamel, laser beam, etc. that can cause severe damage to the pulp
if not controlled.
2) Orthodontic movement
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CHAPTER III
3.1 Background
specific type of inflammatory hyperplasia that is associated with a non-vital tooth. The
disease process in most cases is irreversible. Often the pulp polyp is an incidental
finding and at times may mimic reactive and neoplastic disease of gingiva clinically.
Most frequently involved teeth are deciduous or permanent molars (Saraf, 2006).
It is usually seen in teeth of children and adolescence in which pulp tissue has
high resistance and large carious lesion permit free proliferation of hyperplastic tissue.
Since it contains few nerve fibers, it is non-painful but bleeds easily due to rich network
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of blood vessels (Garg, 2014). Rather than undergoing necrosis, the pulp tissue reacts in
extrudes through the pulp exposure. This type of reaction is believed to be related to the
open root foramen, through which a relatively rich blood supply flows (Regezi, et al.,
2011).
cauliflower-like outgrowth of connective tissue into caries that has resulted in a large
occlusal exposure, and It said this kind of pulpitis has no symptoms, but if one of these
polyps is found to be symptomatic most likely not of pulpal origin but is instead an
extension of the adjacent gingiva that is overlying the disintegrated tooth crown (Sapp,
et al., 2004).
Epithelium derived from gingiva and freshly desquamated epithelial cells of oral
mucosa or tongue. Granulation tissue projects from pulp into carious lesion.
2011).
case report about unusual chronic hyperplastic pulpitis in an impacted 3rd molar of a 27-
year-old woman. The case report will be explained next in this chapter, it will give more
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Figure 3.2: Pulp Polyp. Microphotograph of a pulp polyp extending from the pulp of a
young tooth. Black arrow: Stratified squamous epithelial, Red arrow:
Chronic inflammatory granulation tissue. (Bergenholtz, et al., 2010)
A 27-year-old woman referred for treatment of left side lesion of the oral cavity.
She gave history of six months for its presence that enlarged gradually and interfered
with eating and occluding the teeth, so that made patient worried about it.
Figure 3.3: Unusual Chronic Hyperplastic Pulpitis in Unique Large Size (Faryabi and
Adhami,2008)
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Intraoral examination showed a large polypoid lesion with 3.5 cm height, 1.5 cm
width and a 5-mm stalk diameter protruded from the carious cavity of partially exposed
crown of the tooth, the lesion overlaid on lingual side of this tooth and obviously
presented itself in left oropharyngeal area. The lesion also covering the crown of the
adjacent teeth beside the infected 3rd molar, makes it really visible clinically.
years ago, and caesarian section three years ago, but both of it had no relation to the
present lesion found in her oral cavity. Laboratory examination including CBC
differential, WBC, platelet count, prothrombin time, and partial thromboplastin time
Figure 3.4: Left Side Semi Impacted Carious Lower 3rd Molar was the Origin of the
Lesion (Faryabi and Adhami, 2008)
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Considering the radiographic and clinical data a large pulp polyp, peripheral
giant cell granuloma, and papilloma were the possible differential diagnoses.
The specimen included the carious 3rd molar with base of the lesion in the
carious cavity and the bulk of the lesion to the pathologist for histopathologic
examination. The results of the biopsy from the laboratory will help in pointing out a
diagnosis of the lesion in order for the medical team to give the patient the right
management.
resembling pyogenic granuloma that protruding from the crown of the carious tooth.
The fibrovascular stroma contained numerous capillary sized blood vessels line
plasma cells and neutrophils. The surface of the lesion was ulcerated and replaced by
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Figure 3.6: Specimen Showing Capillary Blood Vessels and A Mixed Inflammatory
Cell Infiltrate of, Plasma Cells and Lymphocytes (H&E; original
magnification x400) (Faryabi and Adhami,2008)
Figure 3.7: Mixed Inflammatory Cell Infiltrate of Neutrophil, Plasma Cells and
Lymphocytes (H&E; original magnification, x1000) (Faryabi and Adhami,
2008)
Management for this case were surgical procedure for excisional biopsy of the
lesion and surgical removal of badly broken 3rd molar due to the extensive caries.
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3.3 Management of Chronic Hyperplastic Pulpitis and Healing Process Post-
Extraction
and Walton, 2009). The usual treatment of a tooth with pulp polyp is extraction. If the
molar is in the deciduous dentition, sometimes it is not extracted to maintain arch space.
It should be remembered that the polyp cannot be effectively cleaned and that the
remaining tooth structure will continue to decay, producing a chronic septic condition
that can pose a health risk to the patient (Sapp, et al., 2004).
prosthodontic management. In cases of pulp polyp young adults where there is only
coronal pulp tissue involvement pulpotomy has also been suggested as a treatment of
This paper discusses more about the unusual case report of chronic hyperplastic
pulpitis that occurred in permanent tooth. Therefore, the discussion for the healing
process will be on post-extraction following the management that was given in the case
report.
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3.3.2 Healing Process Post-Extraction
The extraction wound also results in disruption of normal anatomic structure and
In this stage the extraction defect is filled with blood and after a series of
physiological events, the clot is formed eventually. The clot is composed of fibrin,
RBCs enmeshed with WBCs. This stage is followed by granulation stage. The
granulation tissue replaces the clot over a 4-5-day period. The granulation tissue in the
3rd stage is connective tissue hat compromises of fibroblasts cells, collagen fibers,
This starts at the base and periphery of the socket. Early osteoid is seen by 7-10 days.
By 6 weeks, the socket is filled with bony trabeculae. In fifth stage the defect further
covered by an epithelium. This occurs after 24-35 days. The bone deposition keep on
taking place between 5-10 weeks and till 16 weeks the filling of extraction socket defect
by bone is complete. Osteoblasts cells are seen laying down the osteoid in maximum
number between 4-6 weeks after extraction wound and 8 weeks thereafter these
As for the bone healing, can be primary or secondary. The primary bone healing
occurs after the fractured ends of bone are aligned perfectly with compression of the
fragments and there should be no gap between the separated or fractured ends.
Obviously, the bone heals without callus formation. To achieve this perfect reduction of
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fractured ends is difficult. At microscopic level, such perfect reduction and alignment is
impossible.
The fracture may not be treated or whenever they are treated, the surgical
A
C
Figure 3.8: Repair Response After Tooth Extraction. A, The tooth in situ. B, after
extraction the socket is filled with clot. C, the clot resolves by (1) the
polymorph response, (2) the macrophage response, and (3) the fibroblast
response. In addition, the bony defect become colonize by new osteoblast
(4) that form new bone as the collagen scar is remodeled (D) (Antonio, 2012)
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CHAPTER IV
DISCUSSION
asymptomatic, patient only feel discomfort during mastication by the pressure caused
due to the food bolus. It is the opposite of acute irreversible pulpitis where it is exhibits
pain usually caused by hot or cold stimulus, or pain that occurs spontaneously
Chronic hyperplastic pulpitis (pulp polyp) is the most visually dramatic of all
pulp response, rising out of the carious shell of the crown and is a mushroom of living
pulp tissue that is often firm and insensitive to touch. The difference in between other
pulpitis and chronic hyperplastic pulpitis is very rare in middle aged adults but it is
more common in teeth of children and adolescents, in which the pulp tissue have a high
resistance and a good blood supply (Faryabi and Adhami, 2008). Any other pulpitis
could happen in any teeth at any age. The other type of pulpitis clinically seen like
badly broken down crown of the tooth unlike chronic hyperplastic pulpitis, where you
can see cherry red of the granulation tissue to opaque whiteness of moist keratinized
epithelium depending on the degree to which the appearance of the granulation tissue is
response. Presumably the young pulp does not become necrotic following exposure,
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because its natural defenses and rich supply of blood allow it to resist bacterial
infection. Transudates and exudates which are inflammatory response products in open
chronic pulpitis, drain into the oral cavity and do not accumulate (Regezi, et al., 2012).
According to chronologic time for development of the lower 3rd molar, there is
no young pulp found in the beginning of formation of this lesion and may consider rich
blood supply to resist bacterial infection and slow process of carious formation due to
occurred in impacted tooth or not. As long as the tooth can resist the bacterial infection
and have rich blood supply that brings the transudates and exudates into oral cavity and
doesnt allow them to accumulate, chronic hyperplastic pulpitis may be takes place.
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CHAPTER V
CONCLUSION
This paper explains general view of chronic hyperplastic pulpitis, but highlight
with the unusual case report presentation about chronic hyperplastic pulpitis which also
known as pulp polyp in a lower third molar of a 27-year-old woman, that not only grow
into carious cavity but also extruded in a very large size that interfered with occluding
of the teeth. The management which is extraction of the lower left third molar.
In treatment planning for oral and maxillofacial lesions, we must consider the
clinical finding, and dental history of the patient and finally the histopathologic report
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