Pulpitis: Symptoms and Treatment
- Causes of pulpitis
- The process of development of pulpitis
- Symptoms and methods of diagnosis of pulpitis
- Methods of anesthesia in the treatment of pulpitis
- Treatment of pulpitis
The name pulpit comes from the word "pulp". The tooth pulp is a vascular bundle that is located inside the tooth. Some call it a dental nerve.
Pulpitis occurs in dental practice quite often. Patients with such a disease account for about 20% of the total mass of people turning to the dentist.
The pulp is the link between the hard tissues of the tooth (enamel, dentin, cement) and periodontium (hard and soft tissues surrounding the tooth). It is the last biological barrier between cariogenic bacteria and periodontal tissues. After the death of the dental nerve, foreign agents freely attack the mucous and bone tissues of the jaw, causing complications of a different nature.
Causes of pulpitis
The inflammatory process that occurs in the pulp represents a unique response to stimuli penetrating into the neurovascular bundle of the tooth from the carious cavity. It can be pathogenic bacteria and products of their vital activity that fall into the tissues of the pulp along different paths:
- Carious path. Microorganisms penetrate the pulp from the carious cavity, which affects the deep layers of dentin. The protective layer of hard tissues of the tooth becomes thin, and the foreign agents are able to penetrate into the pulp chamber and cause inflammation. If in the treatment of a carious cavity between the walls of a carious cavity and a seal there are micro-gaps, pathogens can enter the dental nerve through it.
- Periodontal path. The sudden appearance of acute pulpitis can be the result of deep curettage, gingivectomy (gum excision), gingivotomy (gum cutting), or plastic surgery on the periodontium with generalized periodontitis.
- Another way - hematogenous - is opened through the lymphatic and blood vessels (arterioles and venules). With the blood flow, the infection "sails" to the tooth and is introduced into the pulp. In such cases, the tooth may externally remain intact (undamaged), and pulpitis occurs due to a descending infection.
There are several other reasons that contribute to the appearance of pulpitis:
- Injury of the tooth (fracture of the crown or part thereof, fracture of the crown or root, accidental dissection of the pulp chamber with tooth grinding under the crown, incorrect orthodontic treatment).
- Therapeutic and operative manipulations on the periodontium (hard and soft tissues surrounding the tooth).
- The effect of low frequency ultrasound, but high intensity.
- Dentikli and petrificates begin to form when there is a metabolic disorder in the pulp. Postponed in the pulp tissues, they can squeeze the nerve endings and blood vessels, contributing to irritation and inflammation of the pulp.
- In addition to bacteria, the inflammatory process can cause chemical (components of filling materials, negative effects of inorganic cements and acids) and temperature stimuli (burning of pulp during tooth grinding). In this case, the effect occurs through the dentinal tubules (dentinal tubules communicating with the dental nerve).
The process of development of pulpitis
Inflammation of the pulp is associated with complex changes in biochemical, structural and functional character. The intensity of the disease, in the first place, is determined by the state of reactivity of the organism. In addition, the nature of the stimulus, the effects of toxins and degradation products of microorganisms possessing biochemical activity, have a sufficient effect on the course of the inflammatory process. The variety of clinical signs and the outcome of the disease depend on these factors.
The peculiarity of pulpitis lies in the fact that the pathological process takes place in a closed space - a pulp chamber - bounded from all sides by solid tooth tissues. It is for this reason that this disease quickly leads to compression of the pulp, trophic disorder, venous congestion and necrosis.
But, regardless of the causes that caused the inflammatory process, the pulpitis develops according to three points:
- Alteration is the primary change and damage to the tissues of the dental nerve.
- Exudation - a violation of blood flow in the microcirculatory bed.
- Proliferation is the multiplication of cellular elements.
Root (part of the pulp, located in the root part of the tooth) and coronal (part of the pulp, located in the crown part of the tooth), the pulp parts, due to the structural features, react differently to the inflammation: in the crown part, exudative phenomena are more pronounced, and in the root part proliferation.
At the very beginning of the development of the disease, stagnant fluid in the pulp is compensated by an increase in the outflow of venous blood, but gradually the vascular permeability becomes too pronounced, plasma and blood cells seep into the cavity of the tooth. Against the background of the inflammatory reaction of the pulp, the acidity decreases, which further accelerates the development of the pathological process. As a result, the cells of the dental nerve are damaged, irreversible denaturation (decomposition) of proteins occurs.
Exudate, at the beginning of the disease, which has a serous character, quickly turns into a purulent discharge.
Swollen tissues, purulent contents and severe hypoxia lead to the appearance of severe pain and the gradual death of the pulp.
The outcome of the acute stage of pulpitis may be different, depending on whether the process is resolved by a purulent meltdown of the neurovascular bundle, necrosis, or a transition to the chronic stage.
But, chronic pulpitis can develop independently, bypassing the acute stage. The patient may not even be aware of its presence, and the disease is detected by contacting the dentist in order to cure cavities .
Symptoms and methods of diagnosis of pulpitis
Recognize pulpitis is not difficult, but it is difficult to determine which form of the disease is present in the patient. Symptoms of inflammation of the pulp, periodontal and periodontium have a certain similarity, which makes the diagnosis more confusing.
To make an accurate diagnosis, dentists are guided by the types of manifestations of pain:
- The fact of the presence of pain;
- Their duration;
- Nature of development;
- The presence or absence of "light" gaps;
- The appearance of unpleasant sensations from temperature stimuli (hot and cold);
- The presence of irradiation (when pain is given in the ear, neck or head).
The methods of objective research are also used:
During the first visit, the doctor, during the survey, finds out the nature of the pain, the history (course) of life and disease, as well as the general well-being of the patient. An anamnesis of life is necessary to determine the factors that can contribute to the development of pulpitis.
The survey allows you to present an approximate course of development of a pathological condition in a particular person.
Methods of anesthesia in the treatment of pulpitis
Taking into account the fact that pulpitis preparation (tooth grinding) is always painful, the doctor needs to take care of the qualitative anesthesia of the tooth before proceeding to treatment.
General and local anesthesia is used in dentistry.
Local anesthesia is carried out with the help of injections, applications, physical and physicochemical methods.
Injection anesthesia can be of several types:
- Conducting anesthesia disables the entire anatomical area of the face when an anesthetic is injected into the area of the nerve plexuses and trunks. This type of anesthesia is used, most often, in the treatment of multi-rooted teeth of the lower jaw, because in this area the jaw bone is too dense and infiltration anesthesia is not effective enough.
- Infiltration anesthesia blocks peripheral and minor nerve endings, impregnating the mucosa in the projection of the causative tooth. Infiltration can be used as a supplement to conductive anesthesia.
- Intraligamentary anesthesia is the introduction of a drug into the circular ligament of the tooth through the periodontal cleft (a gap between the root of the tooth and the bone of the socket). This method is good because a small amount of anesthetic is used and complications such as hematoma, accidental damage of blood vessels and nerves, allergic reactions are excluded.
- Spongy (intraosseous) anesthesia is performed by injecting the drug into the cortical plate using a syringe and a needle.
- Intrasepital anesthesia is a kind of intraosseous, carried out by introducing an anesthetic into the bone septum between the teeth.
Application anesthesia is an additional method of anesthetizing the oral mucosa with lotions, sprays and gels with anesthetic content. With the help of applications, it is possible to achieve loss of sensitivity in the field of small traumatic injuries or a place where infiltration or conductive anesthesia is supposed to be carried out.
Physical methods of anesthesia are most safe, simple, accessible and carried out with the help of:
- Electroanesthesia with direct current;
- Vacuum electrophoresis;
- Diadynamic and fluctuating currents.
To the application of physical methods of anesthesia there is a list of contraindications:
- Individual intolerance;
- Diseases of the central nervous system (CNS);
- Presence of benign and malignant neoplasms in the patient;
- Sclerosis of cerebral vessels and decompensated state of the CCC (cardiovascular system);
- The presence of infectious and viral diseases.
General anesthesia in dentistry is carried out strictly according to indications:
- Absolute contraindications include intolerance to local anesthetics and all other cases when local anesthesia is impossible;
- Relative contraindications: insuperable fear of a patient before dental treatment, CNS and SSS diseases.
Methods of general anesthesia:
- Inhalational anesthesia;
- Non-inhaling (intramuscular, intravenous, rectal, subcutaneous, intrapleural, intraosseous and intraperitoneal);
- Audio anesthesia (zuvukovaya);
- Reflex anesthesia.
Treatment of pulpitis
In therapeutic dentistry, there are two methods for treating pulpitis: surgical and biological.
The biological method is aimed at preserving the pulp, its recovery and restoration of functions.
Indications for the application of the biological method include the initial stages of the acute form of pulpitis:
- Acute focal pulpitis;
- Hyperemia of the pulp;
- Accidental dissection of the pulp chamber;
In some cases it is possible to restore pulp functions in fibrous pulpitis, but with the absence of x-ray and clinical signs of periodontitis.
The age of the patient should also be taken into account (the biological method is recommended for those who are younger than 30 years), the condition of periodontal disease and the absence of diseases of systems and organs.
Contraindications to the method of treatment with preservation of the viability of the pulp are:
- Teeth designed to support bridge and plate prostheses;
- Presence of signs of periodontitis;
- Odontogenic intoxication;
- Age over thirty years;
- Carious cavity in the region of the neck of the tooth or under the gum.
The very process of biological treatment is represented by the use of antibiotics, sulfonamides and their combinations, calcium-containing drugs and corticosteroids.
Antibiotics, as a rule, ensure the elimination of an infectious agent. But antibacterial action is not enough to restore the functions of the pulp. Therefore, antibiotics must be combined with drugs that promote stimulation of the plastic and regenerative functions of the dental nerve.
Corticosteroids safely relieve pain syndrome and have anti-inflammatory properties. Their use helps to reduce the reactivity of the pulp and prevents the formation of granulation tissue. Applying a bandage for a short time does not cause side effects, so you should limit yourself to three or four days with a subsequent replacement for other drugs.
Calcium hydroxide exerts a more favorable effect on the pulp than other preparations. It normalizes the acid-base balance in the tissues of the dental nerve, stimulates the process of remineralization (replenishment of mineral substances) of dentin and the formation of its secondary forms.
Nitrofurans in combination with glycosaminoglycans accelerate the reparative (recovery) functions in the pulp due to biological properties.
The use of enzymes in a complex biological method of treatment is fully justified, since they have the ability to melt dead tissue and cleave microthrombi in the vessels, thereby eliminating the nonviable parts of the pulp and improving the outflow of exudate. At the same time, the inflammatory processes abate and the cells are able to recover.
The method of the biological method of treatment includes strict observance of the following stages:
- Antiseptic treatment of the oral cavity.
- Isolation of a sick tooth with cotton balls and a cofferdam.
- Treatment of the crown of the causative tooth and adjacent teeth with iodine solution.
- Dissection of carious cavity.
- Imposition of drugs on the exposed horn.
- Introduction into the carious cavity of the cotton ball to absorb the exudative fluid.
- Imposition of a temporary seal.
Repeated visits are prescribed after 1-2 days and in the absence of complaints the patient proceeds to the second stage of treatment - applying calcium hydroxide pulp to the horn and closing the carious cavity with a temporary filling.
The third visit is scheduled in a week. In the absence of complaints, a permanent seal can be applied, but with one condition: it is necessary to apply a medical liner on the pulp horn, then insulating, and the seal will be the third layer that seals the carious cavity.
But, there are cases when the biological method of treatment turns out to be ineffective, or inexpedient. In this case, it is recommended to use a surgical method for treating pulpitis.
The surgical method consists in carrying out a vital amputation (amputation of the pulp, pulpotomy, partial removal of the pulp) or vital extirpation (complete removal of the pulp, pulpectomy) of the pulp with subsequent sealing of the root canal and carious cavity.
The choice of this or that method of surgical treatment depends on the state of the neurovascular bundle.
The essence of vital amputation under the influence of anesthetics is that the inflamed area of the coronal pulp is removed, followed by the drug restoration of the remaining stump. The stump is overlaid with a medical paste, and then the cavity is closed in the tooth with a permanent seal.
Indications for pulpotomy:
- Hyperemia of the pulp;
- Focal pulpitis;
- Acute diffuse pulpitis;
- Chronic fibrous pulpitis;
- Chronic hypertrophic form of pulpitis.
- Acute and chronic forms of pulpitis of the milk teeth, and permanent - with incomplete root growth.
The method of pulp amputation consists of several stages.
First of all, the doctor conducts hygienic treatment of the oral cavity and proceeds to dissection of the carious cavity. From the walls of the cavity, all layers of pigmented and softened dentin are removed, since it is from there that toxic substances enter the pulp. Then the cavity is irrigated with a solution containing enzymes and antibiotics.
The second stage is the opening of the pulp chamber. It is very important to correctly perform all manipulations, since insufficient opening threatens incomplete removal of necrotic tissues. In this case, relapse (reappearance) of the disease is inevitable and the tooth will have to be completely re-treated.
The third stage is the actual amputation of the coronal part of the pulp. Manipulation is carried out with a sharp excavator. With its help, gently scrape the inflamed part of the dental nerve, and borax clean the remains of tissues.
The fourth stage involves irrigation of the carious cavity with anti-inflammatory solutions to prevent the infection of pulp residues. Bleeding from the root canals is stopped with a solution of hydrogen peroxide or by diathermocoagulation.
The fifth stage is the imposition on the pulp stump of anti-inflammatory and odontotropic drugs and the closure of the carious cavity with aqueous dentin.
In a few days, in the absence of complaints from the patient and signs of inflammation, you can put a permanent seal.
Vital extirpation differs from pulpotomy in that in this case the vascular bundle is completely and simultaneously removed.
Indications for extirpation are all forms of the disease, in which conservation of viable pulp is impossible. It:
- Traumatic pulpitis;
- Acute purulent pulpitis;
- Congeneous pulpitis;
- Chronic hypertrophic and gangrenous form of the disease;
- Ineffectiveness of vital amputation;
- Pulpitis complicated by lymphadenitis or periodontitis;
- The presence of somatic, viral and infectious diseases in the patient;
- Orthopedic and orthodontic indications.
The method of vital pulp extirpation also includes a certain list of necessary manipulations.
The first stage - hygiene of the oral cavity.
The second stage is the choice of the method of anesthesia and its conduct.
The third stage is the preparation of a carious cavity with the removal of necrotic dentin tissues.
The fourth stage is the opening and / or opening of the dental cavity.
The fifth stage is the removal of the coronal pulp.
The sixth stage is the removal of root pulp with the help of pulp extractors.
In some cases, removal of the pulp by the instrumental method becomes impossible due to the strong curvature of the root canals. The obstruction of the canal serves as an indication to the application of physical methods of extirpation:
- Drug electrophoresis is performed to prevent complications of pulpitis. To this end, a woolen turunda moistened in a solution of potassium iodide or 10% iodine tincture and wrung out and then an active electrode is introduced into the dried and treated dental cavity. The cavity is sealed with wax and for 20 minutes and when a current of 2-3 microampere enters the medicine enters the surrounding tissues. A few days later, in the absence of complaints, the doctor has the opportunity to seal the root canal.
- Depophoresis with copper-calcium hydroxide increases the effectiveness of endodontic treatment of impenetrable and infected channels. In the dried and dilated canal, a suspension is placed on the aqueous basis of this solution and a needle electrode is introduced. Under the influence of electric current, constantly entering the root canal, the medicinal substance penetrates into all micropores and openings of the channel. Gradually, soft tissue decays and copper plugs are formed. The plugs obturate the apical foramen of the tooth, disinfect the lumen and ensure a hermetic closure of the canal.
To stop bleeding from the channels use special hemostatic solutions (hemostab), a solution of hydrogen peroxide or diathermocoagulation.
After complete cleansing of the root canal and stopping bleeding, proceed to the instrumental treatment, which includes:
- Widening of the mouth;
- Full-length passage;
- Determining the size;
- Removal of the parietal, softened dentin.
With the help of instrumental processing, the tooth channel acquires a conical shape with smooth dense walls.
Filling the root canal with pulpitis is the final stage of treatment.
The filling material is of great importance. It must meet certain requirements:
- Possessing antiseptic properties;
- The ability to high adhesion (reliable adhesion to the walls of the root canal);
- Absence of shrinkage and propensity to dissolve in biological fluids;
- Radiopaque (to be clearly visible on the radiograph);
- Absence in the composition of dyes that change the color of the tooth;
- Have a certain degree of plasticity, which makes it easy to insert paste into the canal, and, if necessary, extract it from there without difficulty;
Filling pastes are sometimes used in conjunction with gutta-percha pins for better sealing of the root canal.
The technique of filling the canal is simple, but requires care and attention on the part of the doctor.
The filling material is kneaded on a glass plate, applied to a channel filler (instrument for filling the root canal), inserted into the root canal, the drill is turned on and after a few seconds the tip is removed in the included state.
The procedure is carried out several times until the channel is completely sealed to the anatomical tip.
Then excess material is removed from the carious cavity and an X-ray is taken to check the quality of the filling.
The closure of the gutta-percha channel requires the use of gutta-percha pins.
A small amount of filling paste is inserted into the root canal, and then - pins, one by one, pressing to the walls with special tools, until the channel is completely closed.
You can also enter one pin, corresponding to the size of the tooth canal.
After checking the quality of the filling, the ends of the pins are cut with heated tools and the cavity is sealed with a permanent seal.