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Pulpitis: Symptoms and Treatment


The name pulpit comes from the word "pulp". The pulp of the tooth is a neurovascular bundle, which is located inside the tooth. Some call it the dental nerve.

Pulpitis occurs in dental practice quite often. Patients with this disease make up about 20% of the total mass of people applying to the dentist.

Pulp is the link between hard tooth tissues (enamel, dentin, cement) and periodontal tissue (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, the 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 is a kind of response to stimuli that penetrate the neurovascular bundle of the tooth from the carious cavity. These can be pathogenic bacteria and their metabolic products, which enter the pulp tissue in various ways:

  • Cariesogenic way. Microorganisms penetrate the pulp from the carious cavity, which affects the deep layers of dentin. The protective layer of hard tooth tissues becomes thin, and foreign agents can penetrate into the pulp chamber and cause inflammation. If, when treating the carious cavity, microgaps remain between the walls of the carious cavity and the filling, the pathogens can enter the dental nerve through it.
  • Periodontal path. The sudden appearance of acute pulpitis can be a consequence of deep curettage, gingivectomy (gum excision), gingivotomy (gum dissection), or plastic surgery on periodontal disease with generalized periodontitis.
  • Another way - hematogenous - opens through lymphatic and blood vessels (arterioles and venules). With blood flow, the infection “floats” to the tooth and is embedded in the pulp. In such cases, the tooth may externally remain intact (intact), and the pulpitis occurs due to a downward infection.

There are several other reasons contributing to the occurrence of pulpitis:

  • Tooth trauma (breaking off a crown or a part thereof, a crown or root fracture, accidental opening of the pulp chamber when grinding a tooth under the crown, incorrect orthodontic treatment).
  • Therapeutic and operative manipulations on the periodontium (hard and soft tissues surrounding the tooth).
  • Exposure to ultrasound of low frequency but high intensity.
  • Dentikli and petrification begin to form in case of metabolic disorders in the pulp. Being deposited in the pulp tissues, they can squeeze the nerve endings and blood vessels, contributing to the irritation and inflammation of the pulp.
  • In addition to bacteria, the inflammatory process can be caused by chemical (components of filling materials, negative effects of inorganic cements and acids) and temperature stimuli (burns of the pulp when grinding a tooth). In this case, the impact occurs through the dentinal tubules (dentinal tubules, communicating with the dental nerve).

The development of pulpitis

Inflammation of the pulp is associated with complex changes in the biochemical, structural and functional nature. 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 decomposition products of microorganisms with biochemical activity, have a sufficient effect on the course of the inflammatory process. A variety of clinical signs and the outcome of the disease depends on these factors.

The peculiarity of pulpitis is that the pathological process takes place in a closed space - the pulp chamber - bounded on all sides by the hard tissues of the tooth. It is for this reason that the disease quickly leads to pulp compression, disruption of trophism, venous stagnation and necrosis.

But, regardless of the causes of the inflammatory process, pulpitis develops according to three points:

  1. Alteration is the primary change and damage to the tissues of the dental nerve.
  2. Exudation - impaired blood flow in the microvasculature.
  3. Proliferation - the reproduction of cellular elements.

The root (part of the pulp, located in the root of the tooth) and coronal (part of the pulp, located in the crown of the tooth) pulp departments, due to the nature of the structure, respond to inflammation differently: exudative phenomena are more pronounced in the coronal part, and processes in the root proliferation.

At the very beginning of the development of the disease, the stagnation of fluid in the pulp is compensated by the increased outflow of venous blood, but gradually the vascular permeability becomes too pronounced, the plasma and blood cells seep into the cavity of the tooth. Against the background of the appearance of the inflammatory reaction of the pulp, a decrease in acidity occurs, 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 is serous in nature, quickly turns into purulent discharge.

Swollen tissues, purulent contents and severe hypoxia lead to severe pain and a gradual death of the pulp.

The outcome of the acute stage of pulpitis can be different, depending on whether the process is resolved by purulent fusion of the neurovascular bundle, necrosis, or the transition to the chronic stage.

But, chronic pulpitis has the ability to develop independently, bypassing the acute stage. The patient may not even be aware of its presence, and the disease is detected when referring to a dentist to cure caries .

Symptoms and methods of diagnosis of pulpitis

Recognizing pulpitis is not difficult, but it is difficult to determine exactly which form of the disease is present in a patient. The symptoms of inflammation of the pulp, periodontal and periodontal have a certain similarity, which makes the diagnosis more confusing.

For an accurate diagnosis, dentists are guided by the types of manifestations of pain:

  • The fact of having pain;
  • Their duration;
  • Nature of development;
  • Intensity;
  • The presence or absence of "bright" intervals;
  • The occurrence of unpleasant sensations from temperature irritants (hot and cold);
  • The presence of irradiation (when the pain is given to the ear, neck or head).

The methods of objective research are also used:

  • Inspection;
  • Percussion;
  • Palpation;
  • Sounding;
  • Thermometry;
  • Electroodontodiagnosis;
  • X-ray.

During the first visit, the doctor, in the course of the survey, ascertains the nature of the pain, history (course) of life and illness, as well as the general well-being of the patient. Life history is necessary to determine the factors that may contribute to the development of pulpitis.

The survey allows you to provide an approximate course of development of a pathological condition in a particular person.

Objective research methods confirm and clarify the diagnosis made by the doctor, and depending on the form of pulpitis and the nature of its course, treatment is prescribed.

Methods of pain relief in the treatment of pulpitis

Taking into account the fact that during pulpitis the preparation (grinding of the tooth) is always painful, the doctor needs to take care of high-quality anesthesia of the tooth before proceeding with the treatment.

In dentistry, apply general and local anesthesia.

Local anesthesia is carried out with the help of injections, applications, physical and physico-chemical methods.

Injection anesthesia can be of several types:

  1. Conductive anesthesia disables the whole anatomical region of the face when anesthetic is injected into the region of the nerve plexuses and trunks. This type of anesthesia is used most often in the treatment of multi-root teeth of the lower jaw, since in this area the jaw bone is too dense and the infiltration anesthesia is not effective enough.
  2. Infiltration anesthesia blocks peripheral and small nerve endings, infiltrating the mucosa in the projection of the causal tooth. Infiltration can be used as an adjunct to conduction anesthesia.
  3. Intraligamentary anesthesia is the introduction of a drug into the circular ligament of the tooth through the periodontal gap (the gap between the root of the tooth and the bone of the hole). This method is good because a small amount of anesthetic is used and such complications as hematoma, accidental damage to blood vessels and nerves, and allergic reactions are excluded.
  4. Spongy (intraosseous) anesthesia is performed by injecting the drug into the cortical plate with a syringe and needle.
  5. Intra-septal anesthesia is a type of intraosseous, performed by injecting anesthetic into the bony septum between the teeth.

Application anesthesia is an additional method of anesthesia of the oral mucosa with lotions, sprays and gels containing anesthetic substance. With the help of applications it is possible to achieve a loss of sensitivity in the area of ​​minor traumatic injuries or a place where infiltration or conduction anesthesia is expected.

Physical anesthesia methods are the safest, simplest, most accessible, and implemented using:

  • DC electrical anesthesia;
  • Electrophoresis;
  • Vacuum electrophoresis;
  • Diadynamic and fluctuating currents.

To the use of physical methods of pain relief there is a list of contraindications:

  • Individual intolerance;
  • Diseases of the central nervous system (central nervous system);
  • The patient has benign and malignant neoplasms;
  • Sclerosis of cerebral vessels and decompensated cardiovascular system (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 where local anesthesia is impossible;
  • Relative contraindications: the overwhelming fear of the patient before dental treatment, diseases of the central nervous system and cardiovascular system.

Methods of general anesthesia:

  1. Inhalation anesthesia;
  2. Non-inhalation (intramuscular, intravenous, rectal, subcutaneous, intrapleural, intraosseous and intraperitoneal);
  3. Electronarcosis;
  4. Audio anesthesia (zuvukovaya);
  5. Psychotherapy;
  6. Reflex anesthesia.

Pulpitis treatment

In therapeutic dentistry, there are two methods of treatment of pulpitis: surgical and biological.

The biological method is aimed at preserving the pulp, its recovery and restoration of functions.

The indications for the use of the biological method are the initial stages of the acute form of pulpitis:

  • Acute focal pulpitis;
  • Pulp hyperemia;
  • Accidental opening of the pulp chamber;

In some cases, it is possible to restore the functions of the pulp in fibrous pulpitis, but in the absence of radiological and clinical signs of periodontitis.

You should also consider the patient's age (the biological method is recommended for those who are under 30 years old), the state 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 bridges and laminar dentures;
  • The presence of signs of periodontitis;
  • Odontogenic intoxication;
  • Age over thirty;
  • Carious cavity in the neck of the tooth or under the gum.

The process of the biological method of treatment itself is represented by the use of antibiotics, sulfonamides and their combinations, calcium-containing drugs and corticosteroids.

Antibiotics, as a rule, ensure the elimination of the infectious agent. But the antibacterial effect is not enough to restore the functions of the pulp. Therefore, antibiotics must be combined with drugs that promote the stimulation of the plastic and regenerative functions of the dental nerve.

Corticosteroids safely relieve pain 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, followed by replacement with other drugs.

Calcium hydroxide has a more favorable effect on pulp than other drugs. 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 reparative (restorative) functions in the pulp due to their biological properties.

The use of enzymes in the complex of the biological method of treatment is fully justified, since they have the ability to melt dead tissues and break down microthrombs in the vessels, thereby eliminating non-viable parts of the pulp and improving the outflow of exudate. At the same time, inflammatory processes subside and the cells are able to recover.

The method of biological treatment method includes strict adherence to the following steps:

  1. Antiseptic treatment of the oral cavity.
  2. Anesthesia.
  3. Isolation of a sick tooth with cotton balls and cofferdam.
  4. Treatment of the crown of the causal tooth and adjacent teeth with iodine solution.
  5. Discharge of carious cavity.
  6. Overlay on the bare horn of the pulp of medicines.
  7. Introduction of a cotton ball to the carious cavity to absorb exudative fluid.
  8. The imposition of temporary fillings.

A repeat visit is prescribed in 1-2 days and, in the absence of complaints from the patient, they proceed to the second stage of treatment - the imposition of calcium hydroxide pulp on the horn and the closure of the carious cavity with a temporary filling.

The third visit is scheduled in a week. If there are no complaints, a permanent filling can be applied, but with one condition: it is necessary to apply a medical gasket on the pulp horn, then an insulating seal, and the seal will be the third layer sealing the carious cavity.

But, there are cases when the biological method of treatment is ineffective, or inappropriate. In this case, it is recommended to use a surgical method for the treatment of pulpitis.

The surgical method consists of performing a vital amputation (pulp amputation, pulpotomy, partial removal of the pulp) or vital extirpation (complete removal of the pulp, pulpoectomy) of the pulp with subsequent filling of the root canal and carious cavity.

The choice of a method of surgical treatment depends on the state of the neurovascular bundle.

The essence of vital amputation under the action of anesthetics is that the inflamed area of ​​the coronal pulp is removed, followed by medical restoration of the remaining stump. Medical paste is applied on the stump, and then the cavity in the tooth is closed with a permanent filling.

Indications for pulpotomy:

  • Pulp hyperemia;
  • Focal pulpitis;
  • Acute diffuse pulpitis;
  • Chronic fibrous pulpitis;
  • Chronic hypertrophic form of pulpitis.
  • Acute and chronic forms of pulpitis of dairy teeth, and permanent - with unfinished root growth.

The method of pulp amputation consists of several stages.

First of all, the doctor performs a hygienic treatment of the oral cavity and proceeds to the preparation of the carious cavity. All layers of pigmented and softened dentin are removed from the walls of the cavity, 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 considered the opening of the pulp chamber. It is very important to carry out all the manipulations correctly, since insufficient opening threatens with incomplete removal of necrotic tissue. In this case, the recurrence (recurrence) of the disease is inevitable and it will be necessary to completely over-treat the tooth.

The third stage is the actual amputation of the coronal part of the pulp. Manipulation is carried out with a sharp excavator. With it, gently scraping the inflamed part of the dental nerve, and with a bur clean out the remnants of tissue.

The fourth stage involves irrigation of the cavity with anti-inflammatory solutions to prevent infection of pulp residues. Bleeding from root canals is stopped with hydrogen peroxide solution or using diathermocoagulation.

The fifth stage - the imposition of anti-inflammatory and odontotropnyh drugs on the stump of the pulp and the closure of the carious cavity with aqueous dentin.

A few days later, 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 neurovascular bundle is removed completely and simultaneously.

The indications for extirpation are all forms of the disease in which the preservation of a viable pulp is impossible. It:

  • Traumatic pulpitis;
  • Acute purulent pulpitis;
  • Pulp calculitis;
  • Chronic hypertrophic and gangrenous forms of the disease;
  • The ineffectiveness of the vital amputation;
  • Pulpitis complicated by lymphadenitis or periodontitis;
  • Наличие соматических, вирусных и инфекционных заболеваний у пациента;
  • Ортопедические и ортодонтические показания.

Методика витальной экстирпации пульпы так же включает в себя определенный перечень необходимых манипуляций.

Первый этап – гигиена полости рта.

Второй этап – выбор метода анестезии и его проведение.

Третий этап – препарирование кариозной полости с удалением некротизированных тканей дентина.

Четвертый этап – вскрытие и/или раскрытие зубной полости.

Пятый этап – удаление коронковой пульпы.

Шестой этап – удаление корневой пульпы с помощью пульпоэкстракторов.

В некоторых случаях удаление пульпы инструментальным методом становится невозможным ввиду сильного искривления корневых каналов. Непроходимость канала служит показанием к применению физических методов экстирпации:

  1. Лекарственный электрофорез проводится с целью предотвращения осложнений пульпита. Для этого в высушенную и обработанную зубную полость вводится ватная турунда, смоченная в растворе йодида калия или 10% настойке йода и отжатая, а следом за ней – активный электрод. Полость герметизируется воском и в течение 20 минут и при поступлении тока силой 2-3 микроампер лекарство поступает в окружающие ткани. Через несколько дней, при отсутствии жалоб, врач имеет возможность запломбировать корневой канал.
  2. Депофорез с гидроксидом меди-кальция повышает эффективность эндодонтического лечения труднопроходимых и инфицированных каналов. В высушенный и расширенный канал помещают суспензию на водной основе данного раствора и вводят игольчатый электрод. Под действием электрического тока, постоянно поступающего в корневой канал, лекарственное вещество проникает во все микропоры и отверстия канала. Постепенно происходит распад мягких тканей и образуются медные пробки. Пробки обтурируют верхушечное отверстие зуба, обеззараживают просвет и обеспечивают герметичное закрытие канала.

Для остановки кровотечения из каналов используют специальные кровоостанавливающие растворы (гемостаб), раствор перекиси водорода или диатермокоагуляцию.

После полного очищения корневого канала и остановки кровотечения приступают к инструментальной обработке, которая включает:

  • Расширение устья;
  • Прохождение во всю длину;
  • Расширение;
  • Определение размера;
  • Удаление пристеночного, размягченного дентина.

С помощью инструментальной обработки канал зуба приобретает конусовидную форму с гладкими плотными стенками.

Пломбирование корневого канала при пульпите является завершающим этапом лечения.

Важное значение имеет пломбировочный материал. Он должен отвечать определенным требованиям:

  1. Обладание антисептическими свойствами;
  2. Способность к высокой адгезии (надежному прилипанию к стенкам корневого канала);
  3. Отсутствие усадки и склонности к растворению в биологических жидкостях;
  4. Рентгеноконтрастность (быть четко различимым на рентгенограмме);
  5. Отсутствие в составе красителей, изменяющих цвет зуба;
  6. Обладать определенной степенью пластичности, которая позволяет легко вводить пасту в канал, а при необходимости извлекать его оттуда без затруднений;

Пломбировочные пасты иногда используются в совокупности с гуттаперчевыми штифтами для лучшей герметизации корневого канала.

Методика пломбирования канала проста, но требует осторожности и внимательности со стороны врача.

Пломбировочный материал замешивают на стеклянной пластинке, наносят на каналонаполнитель (инструмент для пломбирования корневого канала), вводят в корневой канал, включают бормашину и через несколько секунд извлекают наконечник во включенном виде.

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.

Closing the gutta-percha channel requires the use of gutta-percha pins.

A small amount of filling paste is introduced into the root canal, and then - pins, one by one, pressing to the walls with special tools, until the canal is completely closed.

You can also enter one pin corresponding in size to the tooth channel.

After checking the quality of the filling, the ends of the pins are cut off with heated instruments and the carious cavity is filled with a permanent filling.

| 18 March 2014 | | 2 975 | Uncategorized
Leave your feedback

Musaab Rustom: thx for your effort but how come that the tooth is vital and has sympt. apical periodontitis and you said perviously that it's an extension of necrotic pulp

Spring Shah: Hi Rayan thanks again for your really helpful series I just need to know what if patient is chewing on an ice and it makes the pain goes away I heard from another lecture this is a sign for none reversible pulpitis as due to inflammation there is a pain but putting cold on tooth will ease off that inflammation is that correct?

gravijiga: I have been having tooth pain that lasts about 10-20 minutes from slight pressure. It's on a tooth that has recently has a deep restoration. My tooth was fine for about 3 weeks then due to some pressure and I started having these longer 15 minutes tooth aches about once a day since then. (About 5 days now) my dentist did some X-rays and said I seem fine and to stay off the tooth for a few weeks. Is it possible to recover or does the pulp become more and more damaged with each ache?

rose quartz: For pulpal diagnosis -Normal pulp -Reversible pulpitis -Symptomatic irreversible pulpitis -Asymptomatic irreversible pulpitis -Pulp necrosis -Previously treated pulp Thanks dr.

Mina Moheb: Is it normal to be pain on percussion (sap) after RCT ( the day after RCT up to a week) in some cases and may extend to a year in other cases ...cause and ttt please ?? Thanks

Benijamin Kozica: If the response on cold stimuli for a ireversible asimptomatic pulpitis is equal to normal pulp , how u are going to distinguishe between those two diagnoses ?

Ithri Netlleli: Hello, thank you for this helpful video. I have a question: how can we differentiate clinically between a sound pulp state and an asymptomatic irreversible pulpits?