|Year : 2015 | Volume
| Issue : 1 | Page : 68-71
Pulp polyp - A periapical lesion: Radiographic observational study
Kandagal V Suresh1, Nidhi Bajaj1, Ajay G Nayak1, D Mounesh Kumar Chapi2, Snehal Patil3, Ashwini Rani1
1 Department of Oral Medicine and Radiology, School of Dental Sciences, Krishna Institute of Medical Sciences, Deemed University, Karad, Maharashtra, India
2 Department of Oral and Maxillofacial Surgery, School of Dental Sciences, Krishna Institute of Medical Sciences, Deemed University, Karad, Maharashtra, India
3 Department of Public Health Dentistry, School of Dental Sciences, Krishna Institute of Medical Sciences, Deemed University, Karad, Maharashtra, India
|Date of Submission||03-Mar-2015|
|Date of Acceptance||14-Sep-2015|
|Date of Web Publication||12-Oct-2015|
Kandagal V Suresh
Department of Oral Medicine and Radiology, School of Dental Sciences, Krishna Institute of Medical Sciences, Deemed University, Karad, District - Satara, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Pulp polyp (PP) is a chronic hyperplastic condition resulting in formation of granulation tissue and proliferative mass. The radiographic appearance of PP has innumerable presentations. Diagnosing and treatment planning of periapical lesions, heavily relies on the radiographic changes surrounding the root structures. Objective: To evaluate different radiographic periapical changes in clinically detected PP patients. Materials and Methods: Patients reporting to Department of Oral Medicine and Radiology and who were clinically diagnosed with PP by an oral diagnostician were subjected to radiographic examination. Digital intraoral periapical radiographs of 50 patients with PP were taken. Various periapical changes in the digital radiographs were recorded by a skilled oral radiologist. The data obtained was subjected to statistical analysis using SPSS ver 17.0 and P-value was set at <0.05 as significant. Result: Periapical changes like periodontal space widening (PDLW), loss of lamina dura, periapical abscess, periapical granuloma, hypercementosis, condensing osteitis and root resorption were noted. Periodontal space widening was seen in all patients (100%), loss of lamina dura was noted in 72%, periapical rarefying osteitis in 56%, condensing osteitis in 8%, hypercementosis, periapical granuloma, and root resorption were seen in 4% of PP patients. Majority of PP were asymptomatic (66%). Pulp polyp was commonly seen in mandibular first molar followed by mandibular second molar and maxillary first molar. Statistically significant difference was noticed between periapical changes in PP patients (P value <0.0001). All PP patients showed definite periapical changes suggesting it to be a periapical lesion. Conclusion: Pulp polyp is confined to the pulpal portion of the tooth which, may or may not cause changes in periapical region. The results of the present study showed that majority of the PP patients were associated with definite periapical changes. This observation suggests that clinically detected PP are radiographically associated with definite periapical changes suggesting it to be a periapical lesion.
Keywords: Hyperplastic pulpitis, lamina dura, periapical pathologies, peridontitis, pulp polyp
|How to cite this article:|
Suresh KV, Bajaj N, Nayak AG, Chapi D M, Patil S, Rani A. Pulp polyp - A periapical lesion: Radiographic observational study. J Indian Acad Oral Med Radiol 2015;27:68-71
|How to cite this URL:|
Suresh KV, Bajaj N, Nayak AG, Chapi D M, Patil S, Rani A. Pulp polyp - A periapical lesion: Radiographic observational study. J Indian Acad Oral Med Radiol [serial online] 2015 [cited 2020 Jun 2];27:68-71. Available from: http://www.jiaomr.in/text.asp?2015/27/1/68/167085
| Introduction|| |
Pulp polyp (PP) is also known as chronic hyperplastic pulpitis or proliferative pulpitis. Clinically it appears as proliferative red mass seen in the occulsal portion of the molars in individuals with higher immunity.  It is the protective response against the tissue inflammation resulting in hyperplastic changes. It is occasionally associated with mild pain along with large carious cavitated lesions and may be associated with rare history of bleeding. Histologically it shows abundant granulation tissue with numerous blood vessels.  A tooth with a PP and periapical involvement presents many difficulties in diagnosis and treatment. It is believed that radiographically, the pulpal lesion does not show any periapical changes. A delay in treatment of PP usually leads to spread of inflammation into the periodontal ligament space through the apical foramen. ,
Periapical lesion occurs due to the extension of micro-organisms, and their metabolic products, toxins, enzymes from pulpal tissue into the periapical space. All periapical lesions represent two factors, firstly the consequences of an untreated acute inflammatory process and secondly an unsuccessful attempt of the protective reaction of the organism in neutralizing the harmful factors which subsequently perpetuate the inflammatory process. The inflammatory process in chronic periapical lesions is still not fully understood. Humoral and cellular immunological system plays a role in the occurrence, development and perpetuation of these lesions.  Histologically, chronic periapical lesion represents granulational tissue, with inflammatory cells; leukocytes, T and B lymphocytes, macrophages, mast cells and plasma cells.
The radiographic picture of PP is variable. It can be represented radiographically as normal periapical tissues or as a widened periodontal ligament space or as a small to large radiolucency indicative of a long-standing disease process.  Rarefaction of periapical regions may be seen in radiographs in chronically inflamed PP. This occurs because chronic PP does not end at the apical foramen but involves the periapical tissues resulting in destruction of the periapical bone. However, the conventional radiographs are not sensitive enough to detect small regions of chronic inflammation in the periapical tissues at an early stage. 
Pulp polyps has always been categorized as pulpal inflammatory lesions, hence its effect of the periapical structures has largely been ignored which is also reflected in the limited information available in the literature regarding periapical radiographic changes in PP patients. Hence in this study an attempt has been made to evaluate the various periapical changes in PP patients. Various researchers evaluated the prevalence of different periapical pathologies in decayed teeth. However, the occurrence of these changes has not been studied in a PP patient. So, there is increasing need of understanding the prevalence of these conditions in patients having PP.
| Materials and Methods|| |
Present radiographic observational study was conducted in the Department of Oral Medicine and Radiology. The subjects who participated voluntarily and signed a written informed consent form were included in the study. Ethical clearance was obtained from the institutional ethics committee. Patients who were clinically diagnosed with PP by an experienced oral diagnostician were subjected to further radiographic examination. Digital intraoral periapical radiographs were taken with long cone paralleling technique in intraoral X-ray machine at 70 kVp and 8 mA (AMS 6010 AC intraoral radiology unit) and radiovisiography sensor (KODAK 5000) in 50 patients. Exposure time was constantly maintained at 0.6 seconds. All the digital intraoral radiographs were interpreted by a single experienced oral radiologist. Various periapical changes in PP patients were recorded.
Inclusion criteria constituted the subjects clinically diagnosed with PP in any tooth irrespective of age and gender. Exclusion criteria constituted subjects with advanced periodontitis, teeth without antagonist and mesial or distal drifting. Subjects with systemic diseases were also excluded from the study. Diagnosis of PP was made on clinical examination; clinically PP shows chronic inflammation with a pedunculated or sessile mass of tissue protruding from large pulp exposure. The data obtained was subjected to statistical analysis by using SPSS Ver 17.0. ANOVA was used to compare various periapical lesions. P-value was set at <0.05 as significant
| Results|| |
A total of 50 subjects (24 male and 26 female) were included in the study. Out of which, 44% of PP subjects were symptomatic [Table 1]. All 50 patients showed definite periapical changes. Out of which PDL space widening was seen in all 50 cases (100%), lamina dura discontinuity was observed in 36 cases (72%), periapical rarefying osteitis was noted in 28 cases (56%), condensing osteitis was accounted in four cases (8%), periapical granuloma, hypercementosis and root resorption was observed in two cases each (4%) [Table 2]. On comparison of different periapical changes in PP subjects by using ANOVA test, it was observed that there was a statistically significant difference among the periapical changes (P-value <0.0001). Out of 50 subjects, 20 cases showed involvement of mandibular first molar (40%), 14 cases in mandibular second molar (28%), 14 cases in maxillary first molar (28%) and two cases showed involvement of mandibular third molar (4%). Hence PP was commonly seen in mandibular molar followed by mandibular second molar and maxillary first molar [Table 3]. In age-wise prevalence of PP among the 50 subjects, the age group with highest prevalence was between 21 and 30 years of age accounting for 16 cases giving a percentile of 32%. The age group of 11-20 years and 31-40 involved 14 cases each accounting for 28% each and age group of 0-10 years accounted the least of six cases (12%). Hence, pulp polyp is commonly seen in the age group of 21-30 years [Table 4].
| Discussion|| |
PP is a common and specific type of chronic irreversible pulpitis that most often occurs in young adults. Majority of the PP are asymptomatic which causes delay in seeking the treatment. PP is usually an incidental finding that occasionally mimics reactive and neoplastic diseases of the gingiva and adjacent periodontium.  When pulp involvement is long standing, periapical radiography may reveal an incipient chronic apical periodontitis. , Pulpoperiapical periodontitis is the term given to the group of lesions which radiographically shows periapical changes in a tooth whose pulp is vital.  The PP results from both mechanical irritation and bacterial invasion into the pulp. The exposure of pulpal tissue to the oral environment and bacterial invasion results in a chronic inflammatory response that stimulates an exuberant granulation tissue reaction. This 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. 
No previous studies are available to discuss the periapical changes in PP patients. However, many studies have evaluated the most commonly occurring periapical changes in decayed tooth. Pulp polyp is common in the Indian population, and no epidemiologic studies specifically document the frequency of this entity. Although this lesion is reported to be common, the true prevalence of this reactive pulpal disease is underestimated because it is a well-recognized sequel of extensive dental caries in children and young adults. No racial predilection is recognized for PP; however, it is more common in individuals of lower socioeconomic background who have limited access to dental care than in other people. No sexual predilection has been documented for this oral lesion. , This pulpal disease occurs almost exclusively in children and young adults, and it can occur in both the primary dentition and the permanent dentition. These findings were consistent with the results of the present study. 
Intraoral periapical radiographs (IOPARs) are the usual screening tool and routinely employed method for evaluation, diagnosis and planning the treatment for pulpal and periapical diseases. Although there are numerous advanced imaging modalities to visualize the periapical region, IOPARs still remain the best.  Intraoral periapical radiographs are needed for diagnosis and to determine the extent of tooth and bone destruction. Radiographically, PP appears as 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. , The present study results showed widening of PDL space in all cases and discontinuity of lamina dura in 72% cases. This could be because, in chronic PP, microorganisms and their metabolic products, from the pulpal tissue extend to the periapical area leading to inflammatory responses and bone destruction at the periapical area. Severity of radiographic changes in periapical lesions depends on the duration of PP, virulence of microorganism and bacterial activity.
Dayal et al. evaluated the radiographic changes in teeth with pulpitis. They found that, 76.5% chronic pulpitis cases showed radiographic changes and 82.6% of PP had periapical radiographic changes. In contrast, present study showed radiographic periapical changes in all the PP patients. Raphael Carlos Comelli et al., conducted a radiographic evaluation of chronic inflammatory periapical lesions in decayed teeth. They found that, 43.29% were chronic apical periodontitis, 35.98% as inflammatory cysts and 20.73% had no definite diagnosis.  This was in accordance with the present study results which showed that the majority of PP patient had periapical changes. Estrela et al., evaluated common causes of pain in periapical infections. They concluded that, most frequent cause of pulpal pain were symptomatic pulpitis (28.3%) and hyper-reactive pulpalgia (14.4%), and the most frequent periapical pain was symptomatic apical periodontitis of infectious origin (26.4%).  In the present study 44% of PP were symptomatic and few cases were associated with occasional bleeding.
In this study PP has shown radiographic periapical pathologies in all the cases right from the initial PDL space widening to periapical granuloma. The limitation of the present study was that, external factors like (anatomical noise and poor irradiation geometry), which are not in the clinician's control and which might affect the detection of periapical lesions could not be controlled for. Other limitation was the small sample size due to the limited study duration. The imaging technique like CBCT removes these external factors; in addition, it allows the clinician to select the most relevant views of the area of interest resulting in improved detection of the presence and absence of periapical lesions. 
| Conclusion|| |
PP is one of the most common pulpal pathology in young patients. The results of the present study provide information on the distribution of various periapical pathologies in PP patients. Periapical lesions are significantly seen higher in PP patients. A complete knowledge of the radiographic appearances of periapical diseases under normal and pathologic conditions is mandatory for the radiographic diagnosis of periapical diseases. The present study was a radiographic observational study conducted in a small sample. Further studies with larger sample size and considering various socioeconomic variables would be required to make a clear distinction.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Dayal PK, Subhash M, Bhat AK. Pulpo-periapical periodontitis. A radiographic study. Endodontolgy 1999;11:60-4.
Neville BW, Damm D, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. Philadelphia: W.B. Saunders Company; 1995. p. 97-8.
Škaljac-Staudt G, Galiæ N, Katunariæ M, Ciglar I, Katanec D. Immunopathogenesis of chronic periapical lesions. Acta Stomatol Croat 2001;35:127-31.
Ingle JI, Simmon JHS, Walton RE, Pashley DH, Bakland LK, Heithersay GS, et al
. Pulpal pathology: Its etiology and prevention. In: Ingle JI, Bakland LK, editors. Endodontics. London: BC Decker Inc; 2002. p. 157-9.
Caliskan MK. Success of pulpotomy in the management of hyperplastic pulpitis. Int Endod J 1993;26:142-8.
Dummer PM, Hicks R, Huws D. Clinical signs and symptoms in pulp disease. Int Endod J 1980;13:27-35.
Caliºkan MK, Oztop F, Caliºkan G. Histological evaluation of teeth with hyperplastic pulpitis caused by trauma or caries: Case reports. Int Endod J 2003;36:64-70.
Montgomery S, Ferguson CD. Endodontics. Diagnostic, treatment planning, and prognostic considerations. Dent Clin North Am 1986;30:533-48.
Seltzer S, Bender IB, Ziontz M. The dynamics of pulp inflammation: Correlations between diagnostic data and actual histologic findings in the pulp. Oral Surg Oral Med Oral Pathol 1963;16:969-77.
Suyambukesan S, Perumal GC, Somasundaram E, Pandian NJ, Manigandan T. Analyzing periapical lesions on intraoral periapical radiographs: Incongruity in diagnosis. J Indian Acad Oral Med Radiol 2013;25:5-9.
Byers MR, Taylor PE, Khayat BG, Kimberly CL. Effects of injury and inflammation on pulpal and periapical nerves. J Endod 1990;16:78-84.
Eliasson S, Halvarsson C, Ljungheimer C. Periapical condensing osteitis and endodontic treatment. Oral Surg Oral Med Oral Pathol 1984;57:195-9.
Lia RC, Garcia JM, Sousa-Neto MD, Saquy PC, Marins RH, Zucollotto WG. Clinical, radiographic and histological evaluation of chronic periapical inflammatory lesions. J Appl Oral Sci 2004;12:117-20.
Estrela C, Guedes OA, Silva JA, Leles CR, Estrela CR, Pécora JD. Diagnostic and clinical factors associated with pulpal and periapical pain. Braz Dent J 2011;22:306-11.
Patel S, Dawood A, Mannocci F, Wilson R, Pitt Ford T. Detection of periapical bone defects in human jaws using cone beam computed tomography and intraoral radiography. Int Endod J 2009;42:507-15.
[Table 1], [Table 2], [Table 3], [Table 4]