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Pulpitis: treatment
Last reviewed: 23.04.2024
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[Indications for hospitalization
- The course of uncomplicated pulpitis does not involve hospitalization of the patient.
- Individual rare cases:
- decreased reactivity of the organism;
- Multiple lesion of the teeth with pathological fear in the patient;
- treatment of pulpitis under anesthesia in the hospital.
Non-pharmacological treatment of pulpitis
In a number of cases, physiotherapy methods of pulpitis treatment are used: laser therapy, fluctuarization, apexforesis, diathermocoagulation.
Drug medication for pulpitis
When carrying out conservative treatment of pulpitis (biological method), a clinical cure of early forms of inflammation is observed. According to A. Inla (2002) "The best treatment of pulp hyperemia is its prevention."
The determining step in the treatment of pulpitis by a biological method is the effect on the inflamed pulp. By the way of influence, indirect and direct coating of the pulp are distinguished. The direct is performed through a tooth cavity uncovered at one point (an accidentally exposed pulp during the treatment of deep caries), indirect through a layer of near-pulp dentin. There comes a complete recovery, including the elimination of morphological changes. Acute serous-purulent (especially diffuse purulent) pulpitis leaves various irreversible morphological changes. Such teeth do not regenerate the functional capacity of the pulp; produce partial (amputation) or complete (extirpation) removal of the pulp. An exception is the initial change.
Acute pulpitis is treated with the biological method, the vital pulp amputation method, the vital and devital pulp extirpation.
Stages of indirect pulp coating
Preparatory stage
Excision of the softened pigmented dentin by means of a micromotor with a spherical boron with water cooling and high torque.
Main Stage
Cleaning of the dentin from the blood, the remnants of the filling material. It is advisable to use a heated antiseptic (chlorhexidine 2%), drying, coating the bottom with a drug that has a reparative and antiseptic effect. Currently, there are two drugs known to have these properties: based on zinc oxide eugenol and calcium hydroxide. An additional advantage of the preparation on the basis of CEE is an anesthetic effect on C-type nerve fibers. Eugenol gradually penetrates and dentin, being an antiseptic in combination with zinc oxide, affects the production of prostaglandins in the tooth, thus, having an anti-inflammatory effect. Reliably and hermetically closes the cavity of the tooth, protecting against the penetration of microorganisms. Despite the low toxicity of calcium hydroxide, it causes damaging effects, the drug is well known in dental practice, has a strong antibacterial and anti-inflammatory effect, has a pH of 12.5. Further restoration of composite materials can only be done with their complete removal. In modern practice, adhesives have been used for the same purpose, however, due to patients' complaints about the sensitivity to the drugs and subsequent endodontic problems, their use has not been supported by dentists.
Direct pulp coating
This procedure since 1930 was carried out with the use of calcium hydroxide. Success was achieved through the creation of a calcified barrier, the dentin bridge, under which a healthy, non-inflamed tissue was preserved.
The essence of the method is the use of sterile instruments, isolation from saliva to prevent contamination by microbes, medical treatment with a warm solution of antiseptic so as not to irritate the tissue. Dissection of dentin begins from the walls of the cavity, passing to the bottom, which prevents excessive traumatization and invasion of microbes into the tooth. Then apply the drugs to the dissected pulp. Apply preparations based on TSOE and calcium hydroxide. In this case, it is recommended to use calcium hydroxide, which is mixed with water. Of the latest developments - the material MTA PRO POOt. Which has in its composition silicate cements.
Histologically, after the application of such drugs, a zone of necrosis appears in the tissue. Usually, up to 6 months, a dynamic observation is necessary, with the necessary removal of EDI and X-ray images. If the pulp meets within 2-4 μA, it is possible to make a permanent restoration of the crown part, previously isolating the perforation area of the bottom of the tooth cavity with a gasket of glass-ion-cement cement.
Vital amputation
Vital amputation (pulpotomy or partial removal of pulp) - removal at the level of the mouth, high amputation - a cut produces more apical to viable tissues. The procedure is recommended in the teeth with incomplete root formation, however, there are studies confirming the use of this method in the case of partial, acute and chronic forms of pulpitis. Removal of it is carried out under local anesthesia with boron in the turbine tip or just a sharp excavator. Calcium hydroxide and the form of an aqueous suspension are applied to the wound surface, then the level is increased to a thickness of 2 mm. Bleeding should be stopped. With poor hemostasis, a bush is formed under the paste, which subsequently can cause pulpitis and internal resorption, the rest of the cavity is filled with zinc oxide and eugenol to seal the pulp chamber. Evaluate the long-term results of pulpitis treatment at 3, 6 and 12 months after treatment, then 1 time and year.
Pulpotomy (vital extirpation)
Despite the inflammation, as a rule, the tooth is sterile, so the forces are not aimed at fighting the infection, but on preventing the infection of the root canal in the process of preparation. During the first visit to the dentist, a filling with biocompatible material is possible, but in some cases it is advisable to temporarily impregnate the root canal with calcium hydroxide or use strong antibacterial agents. The access cavity is closed with a drug based on the TSOE. Subsequently, the root canal is hermetically sealed by conventional methods. Dynamic monitoring is necessary at 6, 12 months and then 1-2 times a year under radiological control. Very often teeth with chronic pulpitis are met with root canals with petrifications, areas of obliteration that make it difficult to carry out medicamentous and instrumental processing.
Endodontic treatment of pulpitis with pulp necrosis. Primarily all teeth are subject to traditional conservative treatment.
Three principles for the treatment of pulpitis:
- careful mechanical and medicamentous treatment of the root canal with removal of necrotic tissue;
- optimal (adequate) disinfection of the root canal;
- hermetic oturirovanie.
Complete instrumental and medicamentous treatment is carried out at the first visit, partial treatment can lead to a disturbance of biological balance and a change in the microbial landscape with a predominance of pathogenic microorganisms. In 5% of cases of effective treatment of pulpitis, iatrogenic infection of the root canal occurs. The apical part of the root has a complex structure, as a rule, it is in the lower third of the root canal that the largest number of additional tubules and delta is located. It is also recommended to temporarily close the lumen of the root canal with paste on the basis of an isotonic solution and calcium hydroxide with a prolonged dosed antibacterial effect. In the third visit, the root canal is obturated.
In the case of post-pilling, complications, or a severe inflammatory reaction, a pulpitis medication is administered. Assign desensitizing drugs (desloratadine), antibiotics (roxithromycin), metronidazole, anesthetics (non-steroidal anti-inflammatory drugs).
Chronic pulpitis is treated by extirpation of the pulp or its residues. A successful prognosis of any kind of pulpitis treatment depends on correct timely diagnosis of pulpitis based on knowledge of etiology, morphology, pathogenesis, clinical manifestations. The share of the pulp-preserving (biological) method of pulpitis treatment is 2.6-7.71%, which can be explained by insufficiently accurate diagnosis of the disease, non-compliance with the technology, misunderstanding in the clinical and pathoanatomical diagnosis, incorrect choice of indications for its conduct. This method of treatment of pulpitis gives a positive effect (up to 90%) in case of observing the main criterion - accurate diagnosis of the initial state of tissues. Some authors believe that the biological method of treatment of pulpitis is not a method of choice because of very narrow indications for use and long-term results of pulpitis treatment with frequently detected pulp necrosis. In addition, none of the known materials used to conduct the biological method, does not form a dentine bridge.
The method of vital amputation (high amputation) is recommended for teeth with incomplete formation of the apex. If in such a tooth there is inflammation in the pulp, it is necessary to determine its localization (coronal or root pulp). The reliability of diagnosis is 50-60%. Therefore, this method is not the final choice. The favorable outcome of treatment is only 40% of cases from the total number of cases of pulpitis treatment.
Vital pulpal extirpation (pulpectomy) is performed to remove the pulp of the root canal under anesthesia: it is easy to carry out and, with the observance of the latest technological and scientific developments, it is possible to achieve a fairly high result (up to 95% success), taking into account the complexity of the structure of the root system. The key to success is the use of sterile instruments, isolation of the working field to reduce or eliminate contamination by microorganisms; prolonged and hermetic isolation of the root filling (dense obturation of the apical part of the root canal, filling at the level of the physiological opening, constant closure of the root canal mouth and subsequent restoration of the crown part of the tooth). The main task of pulpectomy surgery is complete removal of the pulp. A necessary condition for this process, first of all, is the penetration of the end of the instrument into the root of the root pulp, after which in most cases it can be easily removed. At this stage, it is advisable to use irrigation of the root canal system with special substances serving as a lubricant, dissolving organic pulp residues that have an antibacterial effect. The greatest effect is achieved by a combination of sodium hypochlorite (NaOCL) and ethylene dimethyl tetraacetic acid. Extirpation of pulp can be combined with passive passage of a thin file to apex, which facilitates the work of the main tool - pulp extractor. Pulp extractor is a toothed tool with about 40 teeth on a conical rod with an oblique arrangement and low mobility, which facilitates penetration into the root canal. The tool should be commensurate with the internal volume of the root canal. Too thin does not ensure full capture of the pulp and can break it into fragments, which will complicate the cleansing of the root canal, a large size can become stuck in the narrow channel.
Selecting an adequate size of the pulp extractor so that it does not touch the walls, it is inserted into the canal approximately 2/3 of the length of the root, not leading to the apical third, to avoid clamping it between the walls of the root canal. Rotate 1/4 turn, winding the pulp and taking it out with some effort. An alternative method of extirpation is the use of a thin H-file. With a necrotic pulp, a pulp extractor is used to extract the large fragment. For more effective cleaning - the endodontic tip of the Piezon-Master apparatus with needle No. 10 and simultaneous irrigation with sodium hypochlorite solution.
Classical pulpectomy is completed in the apex of the root, in the area where the pulp tissue connects with the periodontal tissue (1-1.5 mm before reaching the apical opening). Deep penetration of the instrument, especially beyond the root of the tooth, traumatizes the periodontium, so some dentists prefer to remove the pulp after its coagulation.
Diathermocoagulation has a more powerful effect, allowing you to coagulate the bulk of the pulp. This method of treating pulpitis uses special diathermic apparatuses and electrodes of special purpose. The passive electrode of the apparatus is applied to the patient's arm and attached with a rubber bandage. The doctor uses an active electrode in the form of a root needle to coagulate the pulp. The final removal of the pulp is achieved with a pulp extractor. The negative side of this method is the formation of a powerful scab, when it falls off, bleeding sometimes occurs. In connection with this, the current must be dosed for work in the apical region (current strength 50-60 mA and jerky movements within 1-2 s).
Devital extirpation is a method carried out using mummifying or devitalizing substances with a high success rate. The percentage of ineffective treatment of pulpitis depends on non-compliance with the technology, inappropriate choice of medicines and their overdose or individual intolerance.
Treatment of chronic forms of pulpitis with non-viable pulp by endodontic interventions is effective in 95% of cases. Components of success - compliance with the rules for antiseptic treatment, the choice of an adequate medication, the qualification of a dentist. Treatment of pulpitis with the same initial data, but with apical changes is effective in 80-85%. Some authors consider the conduct of conservative treatment in this case impossible because of the peculiarities of periapical microflora. However, to date, the use of a preliminary molecular genetic study of microorganisms by PCR allows avoiding complications (exacerbation) of the process and shortening the treatment period for pulpitis.
Methods of treatment of acute and chronic pulpitis are held in two or more stages (visits), and therefore it is appropriate to talk more about calcium hydroxide used for this purpose.
Surgical treatment of pulpitis
Surgical tooth-saving operations in the treatment of pulpitis are not performed, excluding complications after traditional treatment, not given to conservative treatment. The aim of the intervention is to remove pathologically altered apical tissue with excision of 1-3 mm of the tooth root and retrograde filling with biocompatible material (zinc-valene cement) using ultrasound special attachments for this purpose (satelkc).
Errors in the treatment of pulpitis
The use of arsenic paste for the treatment of pulpitis is now considered a passed stage in the work of a practical physician, however, arsenic devitalization is a legitimate method that has its drawbacks and advantages. Long stay devitalizuyuschey paste in the cavity of the tooth, its many applications or overdose cause intoxication of the apical periodontal. Periodontitis of similar origin is quite long and difficult to treat. Another complication of the application of devitalization is arsenic necrosis of the gingival papilla, which can cause changes in the underlying bone tissue, down to sequestration.
An error is the accidental exposure of the pulp of the tooth during the preparation of hard tissues in caries, which occurs when there is no diagnostic image and the boron moves irregularly in the carious cavity. Insufficient accounting of indications and contraindications to the treatment of pulpitis by the biological method, vital amputation of the coronal pulp is the main error of treatment of various forms of pulpitis.
Perforation of the walls and the bottom of the crown cavity occurs with poor knowledge of the topographic features of its structure, improper access (displacement of the hole away from the longitudinal axis of the tooth, insufficient or excessive expansion of the mouth and trephination hole). The prerequisites for perforating the bottom of the tooth cavity are a decrease in the height of the crown of the tooth due to a significant erasure of the masticatory surface, the deposition of a large number of substitute dentin. The use of high-speed tips with fiberglass optics, special burs that prevent damage to the bottom, adherence to the principles of preparation and knowledge of the topography of the tooth cavity reduces the possibility of perforation and avoids errors in the subsequent zondodontics treatment of pulpitis.
Perforation of the root wall can occur in any of the three parts of the root canal. In the case of bending in the crown third, more dentin is removed on its inner side. Stripping is the lateral (longitudinal) perforation in the middle third on the inner surface of the root, which occurs when attempts are made to enlarge curved, poorly traversed, thin root canals for various reasons in the case of an inconsistency of the axis of the endodontic extension instrument to the direction of the canal, and, as a rule, excessive instrumentation of less curvature of the root channel.
The fascination with the rotational movements of the hand tools leads to overexpansion of the apical third of the root canal, while its middle part remains practically unchanged. If you do not consider the curvature of the root canal during instrumental processing, you can create the ledges in the apical third (Zipping), which later turns into perforation and leads to fragmentation of the tip.
When a perforation is detected, it must be closed. Classical materials - amalgam, glass ionomer cement, in the case of fresh perforation - calcium hydroxide, surgical method.