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Pulpitis: treatment
Last reviewed: 07.07.2025
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[ Indications for hospitalization
- The course of uncomplicated pulpitis does not require hospitalization of the patient.
- Individual rare cases:
- decreased reactivity of the body;
- multiple dental lesions with pathological fear in the patient;
- pulpitis treatment under anesthesia in a hospital.
Non-drug treatment of pulpitis
In some cases, physiotherapeutic methods of pulpitis treatment are used: laser therapy, fluctuation, apexphoresis, diathermocoagulation.
Drug treatment of pulpitis
During conservative treatment of pulpitis (biological method) clinical cure of early forms of inflammation is observed. According to A. Ingle (2002) "The best treatment for pulp hyperemia is its prevention".
The determining stage in the treatment of pulpitis by the biological method is considered to be the impact on the inflamed pulp. According to the method of impact, there are indirect and direct pulp capping. Direct is carried out through a cavity of the tooth opened at one point (accidentally exposed pulp during the treatment of deep caries), indirect through a layer of peripulpar dentin. Complete recovery occurs, including the elimination of morphological changes. Acute serous-purulent (especially diffuse purulent) pulpitis leaves various irreversible morphological changes. In such teeth, there is no restoration of the functional capacity of the pulp; partial (amputation) or complete (extirpation) removal of the pulp is performed. The exception is the initial changes.
Acute pulpitis is treated using the biological method, the method of vital pulp amputation, vital and devital pulp extirpation.
Stages of indirect pulp capping
Preparatory stage
Excision of softened pigmented dentin using a micromotor with a water-cooled, high-torque ball bur.
Main stage
Cleaning dentin from blood, remnants of filling material. It is advisable to use a heated antiseptic (chlorhexidine 2%), drying, covering the bottom with a preparation that has a reparative and antiseptic effect. Currently, two preparations with these properties are known: based on zinc oxide eugenol and calcium hydroxide. An additional advantage of the preparation based on CE is a local anesthetic effect on C-type nerve fibers. Eugenol gradually penetrates dentin, being an antiseptic in combination with zinc oxide, affects the production of prostaglandins in the tooth, thereby providing an anti-inflammatory effect, reliably and hermetically closes the tooth cavity, preventing the penetration of microorganisms. Despite the slight toxicity of calcium hydroxide and does not cause 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 from composite materials can be done only after their complete removal. In modern practice, adhesives were used for the same purpose, but due to patient complaints about sensitivity to the preparations and subsequent endodontic problems, their use was not supported by dentists.
Direct pulp capping
This procedure has been performed since the 1930s using calcium hydroxide. Success was achieved by creating a calcified barrier, a dentinal bridge, beneath which healthy, non-inflamed tissue was preserved.
The essence of the method is the use of sterile instruments, isolation from saliva to prevent contamination with microbes, medicinal treatment with a warm antiseptic solution so as not to irritate the tissue. Dentin preparation begins with the walls of the cavity, moving to the bottom, which prevents excessive trauma and invasion of microbes into the tooth. Then, preparations are applied to the exposed pulp. Preparations based on TSEE and calcium hydroxide are used. In this case, it is recommended to use calcium hydroxide mixed with water. One of the latest developments is the MTA PRO ROOT material, which contains silicate cements.
Histologically, after using such preparations, a necrosis zone appears in the tissue. Dynamic observation is usually necessary for up to 6 months, with mandatory recording of EOD indicators and X-ray images. If the pulp responds within 2-4 μA, then permanent restoration of the crown part can be done, having previously isolated the perforation area of the bottom of the tooth cavity with a lining of glass-iomer cement.
Vital amputation
Vital amputation (pulpotomy or partial pulp removal) - removal at the level of the mouths, high amputation - the cut is made more apically to viable tissues. The procedure is recommended for teeth with incomplete root formation, however, there are studies confirming the use of this method in partial, acute and chronic forms of pulpitis. Its removal is carried out under local anesthesia with a bur in a turbine tip or simply a sharp excavator. Calcium hydroxide is applied to the wound surface in the form of an aqueous suspension, then the level is increased to a thickness of 2 mm. Bleeding must be stopped. With poor hemostasis, a bush is formed under the paste, which can subsequently cause pulpitis and internal resorption, the remaining cavity is filled with zinc oxide with eugenol to seal the pulp chamber. Remote results of pulpitis treatment are assessed 3, 6 and 12 months after treatment, then once a year.
Pulpetomy (vital extirpation)
Despite the inflammation, the tooth is usually sterile, so efforts are not aimed at fighting the infection, but at preventing infection of the root canal during the preparation process. During the first visit to the dentist, filling with a biocompatible material is possible, but in some cases it is advisable to temporarily obturation the root canal with calcium hydroxide or use strong antibacterial agents. The access cavity is closed with a preparation based on CE. Subsequently, the root canal is hermetically sealed using conventional methods. Dynamic observation is necessary after 6, 12 months and then 1-2 times a year under X-ray control. Very often in teeth with chronic pulpitis, root canals with petrifications, obliteration areas are encountered, which complicate the implementation of drug and instrumental treatment.
Endodontic treatment of pulpitis with pulp necrosis. Initially, all teeth are subject to traditional conservative treatment.
Three principles of pulpitis treatment:
- thorough mechanical and medicinal treatment of the root canal with removal of necrotic tissue;
- optimal (adequate) disinfection of the root canal;
- hermetic obturation.
Full instrumental and medicinal treatment is carried out during the first visit, partial treatment can lead to disruption of biological balance and change of microbial landscape with prevalence of pathogenic microorganisms. In 5% of cases of effective pulpitis treatment, 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 are located. It is also recommended to temporarily close the lumen of the root canal with paste based on isotonic solution and calcium hydroxide with prolonged dosed antibacterial effect. During the third visit, obturation of the root canal is carried out.
In case of post-filling complications or a strong inflammatory reaction, drug treatment of pulpitis is carried out. Desensitizing drugs (desloratadine), antibiotics (roxithromycin), metronidazole, painkillers (non-steroidal anti-inflammatory drugs) are prescribed.
Chronic pulpitis is treated by extirpation of the pulp or its remnants. A successful prognosis for any type of pulpitis treatment depends on correct and timely diagnosis of pulpitis based on knowledge of the etiology, morphology, pathogenesis, and 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, discrepancies in the clinical and pathological diagnosis, and incorrect choice of indications for its implementation. This method of pulpitis treatment gives a positive effect (up to 90%) if the main criterion is met - accurate diagnosis of the initial state of the tissues. Some authors believe that the biological method of pulpitis treatment is not the method of choice due to very narrow indications for use and remote results of pulpitis treatment with frequently detected pulp necrosis. In addition, none of the known materials used for the biological method form a dentinal bridge.
The vital amputation method (high amputation) is recommended for teeth with incomplete apex formation. If inflammation occurs in the pulp of such a tooth, it is necessary to determine its localization (coronal or root pulp). The reliability of the diagnosis is 50-60%. Therefore, this method is not the final choice. The favorable outcome of treatment is only 40% of cases of the total number of pulpitis treatments.
Vital pulp extirpation (pulpectomy) is performed to remove the root canal pulp under anesthesia: the method is simple to perform and, if the latest technological and scientific developments are followed, it is possible to achieve a fairly high result (up to 95% success), taking into account the complexity of the root system structure. The key to success is the use of sterile instruments, isolation of the working field to reduce or eliminate contamination with microorganisms; long-term 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, permanent closure of the root canal orifice and subsequent restoration of the crown of the tooth). The main goal of the pulpectomy operation is complete removal of the pulp. A necessary condition for this process, first of all, is penetration of the end of the instrument deep into the root pulp, after which in most cases it can be easily removed. At this stage, it is advisable to irrigate the root canal system with special substances that act as a lubricant, dissolve organic residues of the pulp, and have an antibacterial effect. The greatest effect is achieved by combining sodium hypochlorite (NaOCL) and ethylene dimethyl tetraacetic acid. Pulp extirpation can be combined with passive passage of a thin file to the apex, which facilitates the work of the main instrument - the pulp extractor. The pulp extractor is a toothed instrument with about 40 teeth on a conical rod with an oblique arrangement and slight mobility, which facilitates penetration into the root canal. The instrument should be proportionate to the internal volume of the root canal. Too thin will not ensure complete capture of the pulp and can tear it into fragments, which will complicate the cleaning of the root canal, a large size can get stuck in a narrow place of the canal.
Having selected 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 root length, not reaching the apical third, in order to avoid its clamping between the walls of the root canal. Rotate by 1/4 turn, twisting the pulp and removing it with some force. An alternative method of extirpation is the use of a thin H-file. In case of necrotic pulp, a pulp extractor is used to extract large fragments. For more effective cleaning - an endodontic tip of the Piezon-Master device with a #10 needle and simultaneous irrigation with a sodium hypochlorite solution.
Classical pulpectomy is completed in the apical part 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, injures the periodontium, so some dentists prefer to remove the pulp after its coagulation.
Diathermocoagulation has a more powerful effect, allowing to coagulate the main mass of the pulp. This method of treating pulpitis uses special diathermic devices and special-purpose electrodes. The passive electrode of the device is applied to the patient's hand and secured 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, which sometimes causes bleeding when it falls off. In this regard, the current strength must be dosed for work in the apical region (current strength 50-60 mA and jerky movements for 1-2 s).
Devital extirpation is a method performed using mummifying or devitalizing substances with a high success rate. The percentage of ineffective pulpitis treatment depends on non-compliance with technology, incorrect choice of medications 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. The components of success are compliance with the rules of antiseptic treatment, selection of an adequate medication, and the qualifications of the dentist. Treatment of pulpitis with the same initial data, but with apical changes is effective in 80-85%. Some authors consider conservative treatment in this case impossible due to the peculiarities of the periapical microflora. However, today the use of preliminary molecular genetic research of microorganisms using PCR allows to avoid complications (exacerbation) of the process and reduce the time of pulpitis treatment.
Treatment methods for acute and chronic pulpitis take place in two or more stages (visits), and therefore it is appropriate to talk in more detail about calcium hydroxide used for this purpose.
Surgical treatment of pulpitis
Surgical tooth-preserving operations are not performed in the treatment of pulpitis, excluding complications after traditional treatment that are not amenable to conservative treatment. The purpose of the intervention is the elimination of pathologically altered apically located tissues with excision of 1-3 mm of the tooth root and retrograde filling with a biocompatible material (zinc eugenol cement) using special ultrasonic tips for this purpose (satelkc).
Mistakes in pulpitis treatment
The use of arsenic paste for the treatment of pulpitis is currently considered a thing of the past in the work of a practicing physician, however, arsenic devitalization is a legitimate method that has its own advantages and disadvantages. Long-term presence of devitalizing paste in the cavity of the tooth, its multiple use or overdose cause intoxication of the apical periodontium. Periodontitis of this origin lasts quite a long time and is difficult to treat. Another complication of the use of devitalization is "arsenic" necrosis of the gingival papilla, which can cause changes in the underlying bone tissue, up to sequestration.
Error - accidental exposure of the dental pulp during preparation of hard tissues in caries, which occurs in the absence of a diagnostic image and incorrect movement of the drill during treatment of the carious cavity. Insufficient consideration of indications and contraindications for the treatment of pulpitis by a biological method, vital amputation of the coronal pulp is the main error in the treatment of various forms of pulpitis.
Perforation of the walls and bottom of the coronal cavity occurs due to poor knowledge of the topographic features of its structure, incorrect formation of access (displacement of the opening to the side from the longitudinal axis of the tooth, insufficient or excessive expansion of the mouths and trepanation opening). Prerequisites for perforation of the bottom of the tooth cavity - a decrease in the height of the tooth crown due to significant abrasion of the chewing surface, deposition of a large amount of replacement 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 helps to avoid errors in subsequent endodontic treatment of pulpitis.
Perforation of the root wall can occur in any of the three parts of the root canal. In the case of a bend in the coronal third, more dentin is removed on its inner side. Stripping is a lateral (longitudinal) perforation in the middle third on the inner surface of the root, which occurs when trying to expand curved, poorly passable, thin root canals for various reasons in the case of a discrepancy between the axis of the endodontic expansion instrument and the direction of the canal and, as a rule, excessive instrumental processing of a smaller curvature of the root canal.
The passion for rotary movements of hand instruments leads to overexpansion of the apical third of the root canal, while its middle part remains practically unchanged. If the curvature of the root canal is not taken into account during instrumental processing, then ledges in the apical third (Zipping) can be created, which subsequently turn into perforation and lead to fragmentation of the apex.
If perforation is detected, it must be closed. Classic materials are amalgam, glass ionomer cement, in case of fresh perforation - calcium hydroxide, surgical method.