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Pulp Polyp
Updated: Nov 5, 2009
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.
Pulp polyps involving the primary, first, and second mandibular molars in a young child with extensive dental caries.
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 due to trauma or caries. The mechanical causes that may stimulate this response include a tooth fracture with pulpal exposure or loss of a dental restoration. Usually, the entire dentinal roof is exposed with the crown of a carious tooth. 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 in part because of this lack of significant intrapulpal pressure. In young teeth in which 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
United States
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.
International
Pulp polyps are uncommon in countries with routine access to dental care, but they are encountered more frequently in developing countries. In a 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 is recognized 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 for 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, a fractured tooth due to trauma, or a combination or these 2 insults.1 Pulp polyps reach a maximum size within a couple of months and then remain static.
- Mobility of the tooth and sensitivity to percussion are usually absent.
- Drainage of a purulent exudate is not a characteristic finding.
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 because, anatomically in young persons, these teeth have large pulp chambers. Less frequently, maxillary central incisors in both dentitions are affected.
- 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.
- Extrusion of the opposing molar or tipping of the adjacent teeth with space loss may be observed when significant destruction of the crown occurs.
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
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References
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Caliskan MK, Oztop F, Caliskan G. Histological evaluation of teeth with hyperplastic pulpitis caused by trauma or caries: case reports. Int Endod J. Jan 2003;36(1):64-70. [Medline].
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Nair RG, Samaranayake LP, Philipsen HP, Graham RG, Itthagarun A. Prevalence of oral lesions in a selected Vietnamese population. Int Dent J. Feb 1996;46(1):48-51. [Medline].
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Smulson MH, Sieraski SM. Histopathology and diseases of the dental pulp. In: Weine FS. Endodontic Therapy. 5th ed. St. Louis: Mo: Mosby; 1996:84-165.
Southam JC, Hodson JJ. Neurohistology of human dental pulp polyps. Arch Oral Biol. Oct 1973;18(10):1255-60. [Medline].
Southam JC, Hodson JJ. The growth of epithelium, melanocytes, and Langerhans cells on human and experimental dental pulp polyps. Oral Surg Oral Med Oral Pathol. Apr 1974;37(4):546-55. [Medline].
Whitaker SB, Singh BB, Weller RN, Bath KR, Loushine RJ. Sex hormone receptor status of the dental pulp and lesions of pulpal origin. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Feb 1999;87(2):233-7. [Medline].
Further Reading
Keywords
pulp polyp, pulp polyps, pulpal diseases, chronic hyperplastic pulpitis, proliferative pulpitis, inflammatory hyperplasia, dental caries, reactive pulpal disease, irreversible pulpitis
