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Pulp Polyp

Posted 29 September 2004 - 06:23 AM (#1) User is offline   Sub-Zero 

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INTRODUCTION

Background: The pulp polyp, also known as chronic hyperplastic pulpitis or proliferative pulpitis, is an uncommon and specific type of inflammatory hyperplasia that is associated with a nonvital tooth.

Pulpal diseases are broadly divided into reversible and irreversible pulpitis and are based on the ability of the inflamed dental pulp to return to a healthy state once the noxious stimulus has been removed. In the case of the pulp polyp, the disease process is irreversible. In contrast to most cases of irreversible pulpitis, the pulp polyp is usually an incidental finding that occasionally mimics reactive and neoplastic diseases of the gingiva and adjacent periodontium.

Pathophysiology: The pulp polyp is the result of both mechanical irritation and bacterial invasion into the pulp of a tooth that exhibits significant crown destruction. The mechanical causes that may stimulate this response include a tooth fracture with pulpal exposure or loss of a dental restoration. The large exposure of pulpal tissue to the oral environment and bacterial invasion results in a chronic inflammatory response that stimulates an exuberant granulation tissue reaction.

The hyperplastic tissue reaction occurs because the young dental pulp has a rich blood supply and favorable immune response that is more resistant to bacterial infection. Furthermore, because the tooth is open to the oral cavity, transudates and exudates from the inflamed pulpal tissue drain freely and do not accumulate within the restricted and rigid confines of the tooth. Tissue necrosis with destruction of the microcirculation that usually accompanies irreversible pulpitis does not occur due, in part, to this lack of significant intrapulpal pressure. In young teeth where the apex of the root is open, the risk of pulpal necrosis secondary to venous congestion is decreased. The presence of a rich vascular network in the young pulpal tissue is an important protective mechanism against the inflammatory response that significantly decreases with age.

Frequency:

In the US: Pulp polyps are reportedly uncommon in the United States, and no epidemiologic studies specifically document the frequency of this entity. Although this lesion is reported to be uncommon with only isolated references in the literature, the true prevalence of this reactive pulpal disease is likely to be underestimated because it is a well-recognized sequela of extensive dental caries in children.
Internationally: Pulp polyps are uncommon in countries with routine access to dental care, but they are encountered more frequently in developing countries. In a recent study of Vietnamese refugees who sought dental care, the prevalence of pulp polyps was 6%. This high number of cases is an indication of the severity of dental disease in this impoverished population.

Mortality/Morbidity: Pulp polyps tend to be asymptomatic and are not associated with any significant morbidity or mortality except for gross caries destruction with premature tooth loss in many cases.

Race: No racial predilection exists for this sequela of dental caries; however, it is more common in individuals of lower socioeconomic background who have limited access to dental care than in other people.

Sex: No sexual predilection has been documented with this oral lesion.

Age: This pulpal disease occurs almost exclusively in children and young adults, and it can occur in both the primary dentition and the permanent dentition.

CLINICAL

History:

Pulp polyps are usually asymptomatic.
Direct pressure during mastication may cause mild-to-moderate tenderness.
Localized bleeding may occur when the soft tissue is manipulated or traumatized.
All lesions are associated with a history of a long-standing carious lesion or a fractured tooth.
Pulp polyps reach a maximum size within a couple of months and then remain static.

Physical:
A spongy, soft tissue nodule extrudes from the cavitated or fractured surface of a tooth.
The surface varies from pink and smooth to red and white and granular.
Polyps typically enlarge to fill the entire cavitated area or pulpal chamber of the tooth.
Soft tissue may merge with the adjacent attached gingiva.
Polyps usually develop in carious primary molars and first permanent molars.
A pulp polyp is a single lesion, but multiple teeth may be affected.
Teeth with open or incomplete apexification of the root apices are the most susceptible.


Causes: Causes of a pulp polyp include the following:

Carious tooth with significant loss of tooth structure
Loss of a dental restoration that results in pulpal exposure
Fractured tooth due to trauma with a pulpal exposure
Pulpal tissue with access to a good blood supply
Possible hormonal (estrogen and progesterone) influence


DIFFERENTIALS

Pyogenic granuloma
Irritation fibroma (focal fibrous hyperplasia)
Epulis granulomatosum
Parulis (soft tissue abscess)
Neoplastic disease of the jaws with soft tissue extension
Child neglect (Pulp polyps along with other carious teeth found in children or adolescents may indicate child neglect.)

WORKUP

Imaging Studies:
Intraoral radiographs, in particular a periapical film view, are needed to confirm this diagnosis and to determine the extent of tooth destruction and if the inflammatory lesion involves the surrounding alveolar bone.
Radiographic findings demonstrate a large coronal radiolucency that extends to the pulpal chamber with focal loss of tooth structure, while the root apices may be either open or closed.
Although no bony changes are usually observed, the surrounding alveolar bone may reveal either an incipient periapical radiolucency that is consistent with chronic apical periodontitis or a localized radiopacity that is referred to as focal sclerosing osteomyelitis (condensing osteitis).
Radiographic imaging is required to determine the most appropriate treatment for the involved tooth.

Other Tests:

Diagnosis and determination of the most appropriate treatment options are based on adjunctive tests, including response to percussion, thermal stimuli, and electric pulp testing. In most cases, the results of these adjunctive tests are similar to those obtained for healthy teeth, which is in contrast to most teeth that exhibit irreversible pulpitis. The normal responses should not confuse the practitioner that the pulpal tissue is healthy and therefore requires only conservative treatment. In addition, these tests help to differentiate a true pulp polyp from hyperplastic gingivitis that is overlying a cavitation from a nonvital tooth.

Procedures:

Affected teeth and pulpal tissue are occasionally submitted for gross and histopathologic examination. This examination is most important when the pulp polyp is diagnosed in multiple teeth and when the cause for this uncommon pulpal response is not obvious at clinical examination.
Histologic Findings: Microscopic findings reveal a mass of granulation tissue protruding from the crown of a fractured or carious tooth that resembles a pyogenic granuloma. The fibrovascular stroma contains numerous small, delicate vascular channels and a prominent inflammatory infiltrate composed of primarily lymphocytes, plasma cells, and neutrophils. Although the surface may be ulcerated, it is covered by stratified squamous epithelium that resembles oral mucosa in approximately 50% of these inflammatory hyperplastic lesions. The source of this epithelium appears to be from the engraftment of desquamated oral epithelial cells or the migration of the epithelium from the adjacent gingival tissues. In more mature lesions that are covered with squamous epithelium, the granulation tissue is replaced by fibrous connective tissue with minimal inflammation and foci of dystrophic calcification.

Bacteria (primarily gram positive) are found on the surface of the polyp and within the carious lesion. In many cases, the histopathologic changes are limited to the coronal pulp tissue with the apical tissue exhibiting only mild vasodilation and minimal chronic inflammation.

Ultrastructural examination of nerve fibers associated with the pulp polyp exhibits variable findings within the same tooth, ranging from normal to moderate or severe degeneration of both myelinated nerve fibers and unmyelinated nerve fibers.

TREATMENT

Medical Care:

Treatment of a pulp polyp includes either root canal therapy or extraction of the tooth.
The more conservative pulpotomy treatment has been successful in selected cases when only the coronal pulp is affected.
The tooth requires a full-coverage crown following endodontic therapy.
Surgical Care:

The affected tooth is usually extracted when minimal tooth structure is available for restoration or the alveolar bone support is unfavorable.
A surgical crown lengthening procedure may be needed to prepare a tooth for a full-coverage crown.
Healing is uneventful in most cases.

MEDICATION

No medications are recommended for the management of this lesion. Antibiotics are not prescribed for the treatment of the pulp polyp despite a bacterial component.

FOLLOW-UP

Further Outpatient Care:

Periodic dental examinations are recommended to monitor the success of the root canal therapy or to intercept problems associated with the premature loss of a tooth.
Orthodontic treatment may be needed to restore the occlusion.

Complications:

Space discrepancy from crown destruction or premature loss of a tooth may result in a crowded malocclusion or the impaction of a succedaneous tooth.
Without definitive treatment, some of these long-standing, nonvital teeth may progress to symptomatic disease, including periapical inflammatory disease and (rarely) cellulitis and osteomyelitis of the jaws.

Prognosis:

The prognosis is excellent. No risk for recurrence exists once definitive treatment has been rendered.

Patient Education:

Reinforce the importance of routine oral health care to prevent the development of deep carious lesions that may cause inflammatory pulpal disease and more serious sequelae.

MISCELLANEOUS

Special Concerns:

Rampant dental caries with or without pulpal involvement may be an indication of child neglect.
Although not a problem with most cases of pulp polyp, dental caries with symptomatic pulpal involvement may result in school absenteeism, behavioral and emotional problems, sleep deprivation, and inadequate nutritional intake.

Author :Catherine Flaitz, DDS, MS
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