Pulpitis

Photograph showing Pulpal hyperaemia. While bacteria are still some distance from the pulp, acid permeating along the dentinal tubules gives rise to dilation of the blood vessels, oedema and a light cellular inflammatory infiltrate in the pulp [1]

What is Pulpitis?

Pulpitis is the inflammation of the pulp. It is the most common cause of pain in young persons.

Types

It is of two types.

1. Reversible

2. Irreversible

Irreversible pulpitis has been divided into further two types

1. Acute pulpitis

2. Chronic pulpitis

Causes of Pulpitis

1. Dental caries

2. Traumatic injuries

3. Traumatic exposure of the pulp

4. Thermal or Chemical irritation/injury

5. Fracture of a crown or cusp

Clinical Features

The pulps of individual teeth are not precisely perceived on the sensory cortex in the brain. Therefore, pulpal pain is poorly localised by the patient and may be felt in any of the teeth of the upper or lower jaw of the affected side. Sometimes, pain may be referred to a more distant site, for example, the ear. Pulp pain can not be provoked by pressure on the tooth as it is not transferred to pulp tissues. The patient can chew in comfortably unless there is a large open cavity allowing food to distort or stimulate the dentin.

Reversible Pulpitis

1. Pain-short and sharp stabs.

2. Stimulated by hot, cold or sweet.

3. Pain subsides in seconds or few minutes (2-5 Minutes) after removal of

stimulus.

Irreversible Pulpitis

1. Constant throbbing pain with sharp exacerbation.

2. It may exacerbate spontaneously, with hot & cold or sweet.

3. In late stage, cold may relieve the pain.

4. Pain persists minutes or hours after stimulus removal.

Acute Pulpitis 

In the early stages the tooth is hypersensitive to very cold or hot food. They may cause a burst of pain that stops as soon as the irritant is removed. As the inflammation progresses, pain lasts longer after the stimulus removal. There may be prolonged attacks of toothache. The pain may start spontaneously, usually when the patient is trying to get to sleep.

The Mechanism Behind the Pain

The pain is due to two reasons

1. It is partly due to the pressure on the irritated nerve endings being exerted by the

exudate within rigid pulp chamber.

2. It is partly due to the pain-producing mediators from the damaged tissue and

inflammatory cells.

At its worst stage, the pain is excruciatingly severe, sharp and stabbing in nature. Simple analgesics provide little relief. The outcome of acute pulpitis can not be predicted. Acute pulpitis may be considered irreversible on the basis of various features. Even then, the pulp sometimes survives. Although pulp death is the most probable outcome, acute pulpitis may progress to chronic pulpitis, and early treatment can still preserve pulp vitality. A diagnosis of irreversible pulpitis is considered an indication for extirpation of the pulp.

Chronic Pulpitis 

Chronic pulpitis may develop without episodes of acute pulpitis, but usually it follows

acute pulpitis, if not treated at an early stage. In other instances, many pulp dies

painlessly under large carious painlessly.

The first indication of chronic pulpitis is the development of periapical periodontitis,

either with pain or seen by chance in a radiograph. In other cases, there are bouts

of dull pain, brought on by hot or cold stimuli or occurring spontaneously. There are

often prolonged remissions, and recurrent acute exacerbations.

Table: Symptoms and signs of pulpitis in Nutshell
Symptoms	Acute pulpitis	Chronic Pulpitis	Reversible Pulpitis	Irreversible Pulpitis
Nonspecific Pain	Intense, throbbing	Low, dull ache	Moderate	Intense, throbbing
Sensitivity of tooth	Very painful	Short & sharp	Pain resolves after stimulus removed in seconds or few minutes	Last for several minutes or hours after stimulus
Swelling near tooth	Present	Rarely	Rarely	Present
Increase in pain while lying down	Present	Absent	Absent	Present
Malodour	Probable	Probable	absent	Present
Fever	Present	Very rare	Very rare	Present

Management of Pulpitis

The chances of the survival of an inflamed are poor are poor, and we do not have many treatment options. As mentioned previously, the concept of irreversible pulpitis is considered useful for treatment planning, but criteria are poorly defined. Open pulpitis is usually associated with gross cavity formation, and it is rarely possible to save the tooth, despite the vitality of the pulp. Following are the treatment options for pulpitis:

1. If the tooth is fractured or cracked, stabilised the fracture and seal the pulp temporarily

2. Removal of caries, obtundent or steroid dressing for acute pulpitis if one feels that the pulp vitality can be preserved

3. Removal of caries and pulp capping, if the caries is near pulp

4. Pulpotomy of deciduous tooth, to maintain arch integrity

5. Endodontic treatment-for irreversible pulpitis

6. Extractions-for pulp open pulpitis with large carious lesion

Ref: 

1. Cawson's essentials of oral pathology and oral medicines 9th Ed.

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