Medical conditions with oral symptoms and pulp irritation

medical conditions with oral symptoms:
• pregnancy
• osteoporosis
• diabetes
• heart disease
• pancreatic cancer
• respiratory disease
• kidney disease

infection and inflammation in the mouth have been linked to a variety of systemic conditions. many medical illnesses manifest oral symptoms.

oral indicators:
• swollen gums
• bleeding gums
• ulcers
• bad breath (halitosis)
• metallic taste
• burning sensation
• growths (tumors)
• dry mouth (dry mouth and oral dryness are general terms that encompass two medical entities xerostomia and hyposalivation.

bruxism:
defined as the habitual nonfunctional forceful contact between occlusal tooth surfaces, is involuntary, excessive grinding, clenching or rubbing of teeth during nonfunctional movements of the masticatory system. its etiology is still controversial but the multifactorial cause has been attributed, including pathophysiologic, psychologic and morphologic factors. moreover, in younger children, bruxism may be a consequence of the masticatory neuromuscular system immaturity. complications include dental attrition, headaches, temporomandibular disorders and masticatory muscle soreness. some studies have linked oral parafunctional habits to disturbances and diseases of the temporomandibular joint, mainly bruxism, suggesting its association with temporomandibular disorders in the primary and mixed dentition, whereas other authors did not observed respective relationship in primary dentition. the unreliability for the clinical assessment of bruxism also reduces confidence in conclusions about the relationship with temporomandibular disorders.
bruxism, also known as tooth grinding, is the condition of forcefully sliding the chewing surfaces of the bottom teeth over the chewing surfaces of the top teeth, generally in a sideways, back-and-forth movement. bruxism is often accompanied by clenching which is tightly clamping the top and bottom teeth together. people who grind and clench their teeth are referred to as bruxers and they unintentionally bite down very forcefully subconsciously.
why is bruxism a problem?
over time the complications of bruxism may cause permanent damage to the teeth and uncomfortable oral and facial pain. during sleep the force of bruxing can be up to six times greater than normal waking biting pressure, approximately 250 pounds of force per square inch,
and last for up to 40 minutes per hour of sleep.
the complications of bruxism include:
• damage to the teeth
• broken fillings and other dental work
• worsening of jaw joint problems
• limitation or difficulty in jaw opening and closing
• headaches
• tooth sensitivity
• periodontal signs (gingival recession and tooth mobility)
• dental alterations (wear, fractures and cracks)
what causes bruxism?
the cause of bruxism is not completely agreed upon. consuming stimulants such as caffeine appears to increase the risk of bruxism however a variety of psychological and physical factors are also thought to be responsible. in many cases, bruxism has been linked to stress, however bruxism be the body’s reaction to poor tooth alignment, an uncommon side effect of some psychiatric medications, a complication of severe brain injury or a symptom of certain rare neuromuscular diseases involving the face.
bruxism associated with drugs can be destructive, resulting in severe consequences to health that include destruction of tooth structure, irreversible harm to the temporomandibular joint, severe myofascial pain, and muscle contraction headache. however, reports concerning a possible association between bruxism and various pharmacologic drugs are scarce and mostly anecdotal. there is insufficient evidence-based data to draw definite conclusions concerning the effects of various drugs on bruxism. although certain substances related to the dopaminergic, serotonergic, and adrenergic systems suppress or exacerbate bruxist activity in humans and animals. complex information referring to the association between bruxism and dopamine-related drugs, antidepressant drugs, sedative and anxiolytic drugs, and drugs of abuse.
• stress related bruxism – professional counseling, psychotherapy, biofeedback exercises or other strategies provided by a psychologist or psychotherapist to help you relax may provide more long-lasting relief. muscle relaxants or botulism toxin may temporarily ease spasm in clenched and overworked jaw muscles when more conservative treatments fail.
• dental related bruxism – occlusal therapy or orthodontics may provide relief related to bruxism due to poorly aligned teeth.
• brain injury or neuromuscular illness – cooperation between your dentist and physician may result in combined therapy for these more complicated causes.
• medication related bruxism – your physician may be able to switch you to another medication to counteract your bruxism.
tooth wear:
is one of the most complex processes and involves mechanical, thermal and chemical causes. currently, tooth wear due to the bruxism is increasingly more present in daily clinical practice. this parafunctional habit has been related to stress and the current life style, which have led to an increase of its incidence in the worldwide population. to treat tooth wear resulting from bruxism, the dentist must have knowledge of the dental anatomy and optical behavior of tissue, as well as know how to evaluate and stabilize the temporomandibular joint in centric relation. in this way, the objective of this work was to report a case of generalized tooth wear with boarding for harmonic esthetic rehabilitation. tooth wear was treated by restoration of the anterior guide with composite resin and further occlusal adjustment. this treatment allowed the attainment of a steady harmonic anteroposterior relation, with improvement of the maximal habitual intercuspation. moreover, the adequate passage of the anterior guide was established. the treatment approach accomplished in the present case provided to the patient a pleasant and balanced esthetic smile by means of a reversible, conservative and less costly procedure. in dentistry, it occurs in the cases where little remaining dental structure exists, forcing the dentist to use a root canal post, which will make possible the subsequent setting of the respective crown. the posts can be metallic, casted and later cemented, or can be obtained from distinct materials (either metallic or not), but fabricated from different methods. glass fiber posts are included in this last group. the objective in this work was to address the advantages and limitations of this type of post, as well as present some of its possible clinical applications. glass fiber posts can substitute metallic post advantageously, when esthetics is important, as in case of transparency caused by little thickness of the dental remainder, in the buccal region. the advantages of glass fiber posts are their modulus of elasticity very close to that of dentin and low thermal and electric conductivity. moreover, the material is easy to handle (during fabrication of the core as well as during its eventual removal) and has good cost-effectiveness relation. although glass fiber posts have been extensively used, perhaps due to their clinical ease of fabrication, there are limitations imposed by their properties, such as the small shear and tensile strengths. therefore, this material should only be used when there is a reasonable amount of remaining dentin.

xerostomia:
xerostomia (dry mouth) is defined as a subjective complaint of dry
mouth that may result from a decrease in the production of saliva
( hyposalivation). saliva it keeps the teeth healthy by providing a
lubricant, calcium and a buffer. it also helps to maintain the health of
the gums, oral tissues (mucosa) and throat. it also plays a role in
the control of bacteria in the mouth. antimicrobial factors in human
whole saliva non-immunoglobulin factors origin lysozyme salivary
glands, crevicular fluid lactoferrin salivary glands, maintaining a healthy
mouth is crucial for the kidney disease patients and they need to seek
regular dental care. ionizing radiation can injure the major and minor salivary glands which may lead to atrophy of the secretory components and results in varying degrees of temporary or permanent xerostomia. toxic substances in chemotherapeutic agents. diabetes mellitus patients with poor glycemic control, are more likely to complain of xerostomia and may have decreased salivary flow. dry mouth with strawberry tongue. the oral management of the cancer patient undergoing chemotherapy, bone marrow transplantation and/or radiation therapy to the oral cavity and/or salivary glands. it is neither intended to serve as a comprehensive academic review nor to cover all of the possible complications that develop in the treatment of cancer patients or the morbidity associated with cancer surgery.

clinical presentation
saliva is a crucial protective factor of the oral cavity and enables its normal functioning (speech, alimentation) due to its lubricatory and defensive properties.
• taste perception is facilitated by saliva carrying food particles onto the taste buds in an appropriate dilution.
• salivary amylase and lipase start the digestion of starch and fat.
• saliva is also important in the formation of the food bolus, assisting in food mobility and reducing friction between the different oral structures (teeth, tongue, cheeks, lips) and between these structures and foreign elements (food, dental prostheses).
• salivary lubrication, repair, lavage, antimicrobial and buffering properties contribute significantly to the maintenance of oral hard and soft tissue integrity.


soft tissues changes:
• the mucosal tissues may become painful, “burning”, dry and atrophic. a typical complication of hyposalivation is the occurrence of cracked lips.
• hyposalivation may trigger a painful salivary gland infection called “sialoadenitis”, characterized by facial swelling, pain and, in certain cases, fever. the most frequent salivary gland infection is located on the parotid glands and is therefore named “parotitis”.
• another frequent oral infection in patients affected by hyposalivation is candidosis. it is a fungal infection due to the candida species of fungi, which can clinically present as white patches, redness (erythema and/or atrophy) and burning of the oral mucosa. candidosis is more common in denture wearers.

hard tissues changes:
an increased rate of dental caries with a distinctive cervical pattern of decay, which is extremely difficult to treat, is typically seen.
other symptoms:
• denture wearers often complain of severe discomfort with their dental appliance.
• decreased salivary secretion often leads to difficulties in chewing, swallowing and speaking and a diminished taste sensation. furthermore, patients frequently have to wake up at night repeatedly to sip water.
• another relevant symptom that have been related to hyposalivation is halitosis (bad breath oral malodour)

list of xerogenic medications:
•cardiovascular agents, including antihypertensives drugs
•tranquilizers and hypnotics
•antidepressants
•anti-psychotic agents
•amphetamine derivatives
•anticonvulsants
•anti-parkinsonian drugs
•some gastro-intestinal and genitourinary systems agents
•respiratory system and anti-allergic agents, including antihistamines
•some steroidal and nonsteroidal anti-inflammatory drugs, anti-infective agents and narcotic analgesics
•anti-neoplastic agents


medical conditions with oral symptoms:
• pregnancy:
1. pregnancy gingivitis
2. pregnancy tumors
3. pre-term delivery and low-birth weight

• osteoporosis:
1. bone loss is associated with both gum disease and osteoporosis
2. estrogen deficiency and osteoporosis speed the progression of oral bone loss following menopause, which could lead to tooth loss
3. estrogen supplementation may lower gingival inflammation and help to protect teeth.

• diabetes:
1. diabetics are at higher risk for developing infections, including gum diseases
2. inflammatory diseases such as gum disease can increase insulin resistance, thereby affecting glycemic (blood sugar) control
3. poorly controlled type 2 diabetic patients are more likely to develop gum disease than diabetics under control with medication
4. more than 50% of people in the united states diagnosed with diabetes are not achieving control of the disease, as defined by an a1c or blood sugar count of less than 7%.

• heart disease:
1. theory 1:oral bacteria can affect the heart when entering the blood stream, attaching to the fatty plaques and contributing to clot formation.
2. theory 2:the inflammation caused by gum disease increases plaque build-up, contributing to swelling of the arteries.

• pancreatic cancer:
1. established risk factors for pancreatic cancer are cigarette smoking and chronic pancreatitis.
2. the role of inflammation from gum disease may promote the cancer.

• respiratory disease:
1. gum disease increases bacteria in the mouth.
2. inhaling germ-filled dropinglets from the mouth and throat into the lungs may cause bacterial infections.
3. people suffering from chronic obstructive pulmonary diseases (copd) typically lack protective systems making it difficult to eliminate bacteria from the lungs.
4. patients with respiratory diseases are more at risk for pneumonia.

• kidney disease:
1. patients with kidney disease are considered an “at risk” population and are more prone to infections.
2. oral symptoms of kidney disease: bad breath or a “metallic” taste in the mouth, dry mouth.
3. maintaining a healthy mouth is crucial for these patients and they need to seek regular dental care.

in summary, the consequences of a reduced salivary flow compromise not only the biological integrity of the individual and the oral health status but also the general quality of life and well-being and can lead to reclusion and loneliness.

pulp reaction:
pulpal reactions to caries.• to local anesthetics.• to restorative procedures to restorative materials to laser procedures.• to cavity preparation using air abrasion techniques.• to vital bleaching techniques.• to periodontal procedures.• to orthodontic surgery.• to implant placement and function.
there are several hurtful stimuli responsible for pulp damage, inflammation and necrosis, these stimuli can be summarized into the following:1-microbial.2-physical.3-chemical.
microbial irritants: a- coronal ingress (dental caries, crown fracture). b- radicular ingress. f- root caries. g- retrograde infection.
a- coronal ingress:
1-dental caries: the main cause of pulp injury in which carious dentin and enamel contains numerous amount of bacteria, recently it has been shown that deep carious dentin contains predominantly anaerobic bacteria.
2-crown fracture: complete crown fracture seldom devitalizes the pulp immediately however pulp death is the result of bacterial ingress through the fracture the same can be said about incomplete fracture ( infraction).
b- radicular ingress:
1-root caries: is less frequent than coronal caries, these type of lesions which can occur bucco-gingivally or inter-proximally are the result of poor oral hygiene accompanied with periodontal problems.

2- retrograde infection: periodontal pocket, is not frequently a cause of pulp damage unless there is involvement of the apical foremen or the accessory canals. periodontal abscess, pulp infection, either immediately following or during an acute periodontal abscess is also an infrequent cause of pulp necrosis.

physical or mechanical irritants: a- operative procedures. b- trauma. c- orthodontic movement. d-deep periodontal curettage. e- thermal irritation. f- irradiation irritants.

a- operative procedures:
if proper operative procedures are not taken during cavity preparation the adjacent odontoblast will be damaged leading finally to pulp infection, this damage can result from the following : heat generation, cavity depth, pulp exposure and pin insertion.

b- trauma:
a- acute trauma: fractures ( coronal or radicular ):

1- coronal fracture: expose the dentinal tubules to bacterial invasion which if untreated leads pulpal inflammation.
2- radicular fracture is associated with disruption of the vascular supply to the pulp which results in its calcification or death. luxation , the most common type of dental trauma in which the tooth is displaced rather than completely coming out of it socket in such case the condition is known as ( avulsion ). with these types of trauma the integrity of the pulp tissues depends on the integrity of the blood vessels supplying the pulp.

b- chronic trauma:
1- bruxism, the increased severity of the trauma may eventually cause pulpal necrosis.
2- attrition, incisal wear rarely causes pulpal inflammation because the reparative power of the pulp usually overcome this chronic stimuli.

orthodontic movement: a-orthodontic movement. b-deep periodontal curettage.

a- orthodontic movement, can lead to devitalization of the pulp and pulpal hemorrhage.
b- deep periodontal curettage, leads to damaging the pulpal vessels, so it should be done after r.c.t.

e- thermal irritation:
when we cut the tooth , heat will generate which causes dehydration to dentine and aspiration of moisture through dentinal tubules. this unbalance in water content in dentin is believed to contribute to sensitivity and pulp pathology the followings are to be avoided:
- prolonged application of blasts of warm air.
- excessive cutting of tooth without coolant especially with diamond burs.
- placement of irritating filling materials such as filling , lining or sub-lining.
- polishing of teeth with rubber cup and polishing of amalgam with pumice will produces heat if exceeds the speed and time , so water should be directed to the tooth to prevent damage due to heat.
thermal irritation affected by type of bur ,speed ,pressure ,way of use (intermittent ) ,width and depth of the cavity
- air abrasive cutting its started in 1950 , the disadvantages of it are :
1- generating heat.
2- difficult for operator to determine the cutting progress within the cavity preparation.
3- it s difficult to prevent abrasive dust inhalation by patient.
4- the abrasive dust interferes with visibility.
at the present time , air abrasive equipment is being used for stain removal , cleaning pit and fissure before sealing. this technique doesn t be used in cavity preparation.
f- irradiation irritants
the pulp of human teeth are affected in patients who are eposed to deep radiation therapy form alignant growth in oral cavity and neek region. in time , the odontoblasts and other pulp cells become necrotic.the salivary glands affected resulting in decreasing of salivary flow. radiation causes:
1- pulp necrosis which should be endodontically treated.
2- reduction in the blood supply of the bone so,extraction of teeth may cause osteoradionecrosis involved bone.
3- radium is found in human dental tissue for many years after medical or occupational exposure.
laser
laser is a device which produces beams of very high intensity light. the word laser is for light amplification by stimulated emission of radiation the effects of the laser depend on:
1- power of beam.
2- extent to which beam absorbed.
there are several types available based on wave lengths. at the moment , laser is used for soft and hard tissues. for soft tissue , it can produce completely blood. free incisions followed by rapid pain-free healing with no underlying inflammation. uses of laser in periodontology and surgery and for gingival retraction before impression taking particularly in the presence of hypertrophied tissue. used in fissure sealing. used in caries treatment. used in composite curing. used in root canal cleaning and root sealing. for hard tissue , its not widely used as cavity preparation for cutting enamel and dentine because the process would generate heat, which might affect the pulp.

chemical irritants: a-dental materials. b-antibacterial agents.
a- dental materials:
1- final restorations:
a- composite resin has been regarded as irritant to the pulp in which it is important to place a suitable base material in order to minimize the irritation.
b- amalgam some of its content showed pronounced cytotoxic effects.
c- cements some cement materials has potential irritation to the pulp tissues.
d- etching agents if placed over 15 second in dentin can cause chronic inflammation of the pulp. potential irritation to the pulp tissues.

b- antibacterial agents as silver nitrate, phenol and eugenol which was used to sterilize the cavity preparation have shown cytotoxic effects and causes inflammatory changes.

the pulp is subjected to chemical irritation from :
-materials generally used in dentistry, drinks used with low ph. and the fumes of acids which are deletingrious to the teeth.
a- liners and bases:
1- calcium hydroxide: its used extensively for pulp protection under all restorative materials , also effective in promoting the formation of secondary dentine.
2- varnishes: most are produced by drying solutions of copal or other resins in a volatile solvent. a thin film 2-5 ?m is formed over smear layer along the cavity walls. because there is some moisture in the smear layer and varnishes are hydropinghobic , the film does not wet the surface well , so a second thin layer is recommended for better sealing of the surface. the primary purpose of it is to provide a protective seal on the exposed dentine surface. it blocks the gap between the amalgam and the walls of the cavity until corrosion products form and block this gap because the varnish dissolved by the oral fluids. so it reduce the postoperative sensitivity and prevents discoloration of tooth by retarding ion migration into the dentin.
3- resin bonding: the light activated, unfilled resins may be used as cavity primers or bonding agents with composite resins and they seal dentine more effectively after the smear layer has been removed. most are relatively viscous and do not set through loss of solvent but by either chemical action or light activation.
4-zinc oxide eugenol: zoe is a useful part of pulp therapy in the management of deep, active carious lesions and has also been used as a lining and base material(re-enforced type). it provides an effective antibacterial seal, probably because any gap between the cement and dentine will contain a high concentration of eugenol. which is strongly bactericidal any available eugenol may also inhibit bacterial metabolism within dentine, and if the material is placed on intact dentine it is unlikely to harm pulp cells. it is also possible for it to develop local anesthetic and anti-inflammatory reactions in adjacent pulp tissue (sedative effect).
5-poly carboxylate cement: it is biologically accepted by the pulp. the first of the cements to be regarded as adhesive to tooth structure. less irritation because of large particles size of the poly acrylic acid , recommended for cementation of full crowns and as a base , other cements may cause post insertion sensitivity. varnish should not be used with polycarboxylate cement because it would neutralize the adhesion potential of the cement.
6-glass ionomer cement: it has- ant cariogenic property because they continuously release fluoride throughout the life of restoration. they are also reasonably biocompatible with pulp. they bond to enamel and dentin, when placed without pressure on intact dentine, poses no chemical risk to the pulp and, with the development of the ion exchange layer, it creates an effective antibacterial seal. it shows a very low solubility, and therefore appears to be the material of choice for use as a base, or dentine substitute, beneath all plastic restorations
7- zinc phosphate cement: its used as an insulating base material under metallic restorations and as a luting agent. its acidic in nature , well tolerated by the pulp if placed on intact dentine. there may be immediate and short-term pain if its placed on the dentine of un anaesthetized tooth
8-resin cement: lightly filled resin cements can be used for luting crowns and inlays and they have a very low solubility and can be regarded as durable at the margin. however, they do not flow well so the ultimate film thickness is generally greater than desirable. if the dentine is etched there will be a micro-mechanical adhesion but they do not unite chemically with dentine so they are not proof against future microleakage. also, cleaning and acid treatment of dentine before crown cementation will open the tubules and increase the chance of resin components being forced down tubules under the hydraulic pressures involved with cementation, thus damaging the pulp .if it properly applied they reduce the potential for ingress of bacteria or their byproducts enhancing the seal against microleakage
the filling materials:
1- silicate filling material: is extremely damaging to pulp tissue specially when they are used without liners. its rarely used as a restorative material today.
2- acrylic filling material: it has a high polymerization shrinkage, high coefficient of thermal expansion and , lacks of abrasion resistance. these could result in :marginal leakage.pulp injury.recurrent caries.color changes.excessive wear. so its rarely used today.
3- composite filling materials:the source of irritation are:
-irritation caused by acid etching which affected by the time and the location
-dentin conditioning and smear layer removal
-monomer of matrix and undercuring
-placement of an unfilled bonding resin against deeply etched dentine because of the release and
diffusion through dentine of toxic chemicals from the resin, pulpal damage will result if placed directly on pulp floor.
4-amalgam filling: the source of irritation are:
-if there is no lining there will be sensitivity and pulpal irritation.
-defect in marginal integrity leads to microleakage , sensitivity and pulpal irritation and future caries.
-the insufficient condensation.
-the heat generation during polishing.
-the high spot(occlusal trauma and fracture of the filling ).
5- accumulative effect of all (caries ,attrition ,abrasion, erosion, cavity preparation, lining ,filling ,polishing )
c-erosion:
other irritant of chemical in nature is what we ingest of acidic nature which will cause erosion. erosion is the superficial loss of dental hard tissue due to chemical process not involving bacteria. the clinical appearance may vary. the causes of erosion are:
1- extrinsic factors
a- industrial acids can be carried in gaseous form in the air in heavily polluted areas and may cause demineralization of the labial surface of anterior teeth.
b- variety of food and drink of acidic nature with frequent ingestion may cause problems e.g. low ph cola drinks (including diet cola), fruits juices may cause erosion. however individual variation in the method of consumption of these liquids before swallowing may lead to different patterns, e.g. if you drink from the bottle itself , this will facilitate the seepage of the liquid on the labial and buccal surfaces of the teeth.
c- certain medications: a lack of gastric acid may be compensated for by the oral administration of concentrated hydrochloric acid with advice that it should be taken through a straw or glass tube. erosion on the lingual surface of the upper teeth is evidence of this problem.
2- intrinsic factors
such as gastric acids, are the most common causes. chronic vomiting will affect the palatal surface of the upper teeth.
treatment:
in the presence of reduced salivary flow both extrinsic and intrinsic factors effects will be exacerbated and increased. routine use of a fluoride mouthwash will assist in reducing the damage, stop the irritation to the pulp by the acid. active erosion will demineralize the dentine surface and may lead to sensitivity through the open dentinal tubules. this may be treated by topical fluoride , fluoride rinse , dentinal bonding agents, sealants, desensitizing tooth paste. all of these methods have met with varying degree of success and non has been totally effective. when these methods fail to provide relief, restorative treatment is indicated.

response defense reactions of pulp depends on:
a-rate of caries attack: small or slowly progressing lesion forms more reactionary dentin than large or rapidly progressing lesion.
b-pulp vitality: if the pulp supply is poor the reactionary dentin is not formed for these reason the young teeth may form reactionary dentin more readily than old teeth.
response defense reactions of pulpal:
tubular sclerosis, tertiary dentin formation and pulp inflammation.
1. tubular sclerosis reactionary dentin:
a- if the injury to the tooth is mild and primary odontoblast survive, they are stimulated to synthesize reactionary dentin, which resembles primary dentin matrix and has a tubular pattern.
b- it is a process in which mineral is deposited within the dentinal tubules, reducing the permeability of the dentine and making it impermeable to bacteria and toxic products. intratubular dentin is the result of odontoblast activity.
c- in case of dental caries, some of the dissolved mineral salts are reprecipitated within the subjacent dentinal tubules, blocking them. t
ertiary dentin - reparative dentin:? as a response to various external stimuli, such as dental caries, attrition and trauma, tertiary dentin is synthesized.? it is a layer of dentin formed at the interface between dentin and pulp, and its distribution is limited to the area beneath the stimulus.? tertiary dentin provides extra protection for odontoblast and other cells of the pulp by increasing the distance between them and the injurious stimulus.? is usually shiny and more darkly colored, but feels hard to the explorer tip (more mineral content) and often can be seen radiographically in the form of a more radiopaque (lighter) area.

2. tertiary dentin formation(reparative dentin):
a- as a response to various external stimuli, such as dental caries, attrition and trauma, tertiary dentin is synthesized.
b- it is a layer of dentin formed at the interface between dentin and pulp, and its distribution is limited to the area beneath the stimulus.
c- tertiary dentin provides extra protection for odontoblast and other cells of the pulp by increasing the distance between them and the injurious stimulus.
d- is usually shiny and more darkly colored, but feels hard to the explorer tip (more mineral content) and often can be seen radiographically in the form of a more radiopaque (lighter) area.
if the injury is severe and causes odontoblast cell death, odontoblast-like cells synthesize specific reparative dentin just the beneath the site of injury to protect pulp tissue. the morphology of the reparative dentin varies greatly, and is often irregular, with cellular inclusions.? the tubular pattern of the reparative dentin varies from a discontinuous to an atubular nature, and thus the reparative dentin matrix permeability is reduced and diffusion of noxious agents from the tubules is prevented.
3. pulp inflammation:
a- the first inflammatory reactions within the pulp occurs when caries from an enamel lesion invades the dentin.
b- neutrophils, granulocytes, lymphocytes, and macrophages are seen in the odontoblastic layer.
c- the enzymes released by damaged granulocytes and macrophages cause necrosis of the endothelial cells and this results in increased vascular permeability and extracellular edema.
d- pain, if the treatment is performed at this stage, the pulp inflammation is reversible.