Pulpitis

Pulpitis (inflammation of the dental pulp from the Latin pulpitis) is a complex vascular, lymphatic and local reaction to an irritant.

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Epidemiology of pulpitis

Pulpitis is a common disease encountered in the practice of a dentist. According to various authors, in the structure of dental care by visits, patients with pulpitis make up 14-30% or more, depending on the region of the country.

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What causes pulpitis?

The etiological factor leading to such a disease as pulpitis is irritants (microorganisms, chemical, temperature, physical). The inflammatory response is formed under the influence of microorganisms and their toxins penetrating from the carious cavity or ascending from the periodontium (pulp-periodontal relations).

Causes of pathological changes and, accordingly, pulpitis:

• bacterial:
• traumatic;
• iatrogenic;
• chemical;
• idiopathic.

According to the available modern literature data, the pulp reacts to the carious process in the tooth differently. Signs of inflammation are found in it with minor carious changes, and in some cases, deep carious lesions are not accompanied by an inflammatory reaction and vice versa. This can be explained by the fact that the stimulation of intratubular dentin, leading to sclerosis of dentinal tubules, occurs differently. Deposits of mineral substances have the form of large crystals of hydroxyapatite of needle or diamond shape. The zone of sclerotic dentin is a kind of barrier, so effective that the reverse process in the development of inflammation can occur. However, if the patient poorly or does not treat caries, then over time the trailer will repeat itself and become irreversible.

Causes of pulp hyperemia

• Development of the carious process, in which dentin is involved in the destructive process. As caries progresses with the formation of increasingly wider decay zones, the pathological process approaches the pulp. The introduction of decay products through the dentinal tubules leads to changes in the vessels - hyperemia combined with irritation.
• Transient states:
  • stress;
  • rise to heights;
  • diving,
  • hypertension.

Bacterial factors

Pulpitis is characterized by the presence of a polymorphic microbial flora with a predominance of streptococci associations and other pyogenic cocci (golden and gray staphylococci), gram-positive rods, fusospirochetal flora and fungi. As a rule, streptococci and staphylococci of the inflamed pulp are microorganisms of increased virulence with significant sensitizing properties. The strain Fusobacterium nuckatum, a representative of the gram-negative microbial flora, which is of decisive importance in the infection of the root canal, forms associations with various representatives of the microflora, namely with P. gingivals, T, dentkola. A. actinamycetecomitans, P. intermedia, Eubacterium, Selenomonas and Actinomyces. Traumatic factors

Traumatic lesions that lead to such a disease as pulpitis are divided into acute and chronic. Acute injuries are cracks, fractures of the crown part, root of the tooth, vertical fracture of the tooth, subluxation and complete dislocation of the tooth. Teeth with cracks sometimes have an atypical clinical picture, which complicates timely diagnosis.

Tooth fractures (especially if the pulp chamber is exposed) open the way for infection by microorganisms from the oral cavity. Hemorrhage occurs in the area of any fracture, then microorganisms penetrate and colonize the damaged area, resulting in pulpitis and total necrosis. The prognosis in this case is unfavorable. However, traumatic impact on the tooth causes a polar reaction on its part. Instead of necrosis, uncomplicated recovery may occur, and increased calcification is also possible. Subluxation and complete dislocation of the tooth (with or without rupture of the vascular-nerve bundle) are accompanied by hemorrhage, clot formation and infection of the damaged area, which leads to inevitable endodontic treatment.

Chronic injuries - bruxism, chronic occlusal injuries, non-carious lesions such as enamel erosion often cause pulpitis.

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Iatrogenic factors

These include improper restoration and preparation, namely overdrying, dentin dehydration, pressure force exerted during enamel preparation over 220 g, toxic effects of filling materials and cements, disruption of marginal adhesion and, as a result, micropermeability for bacteria. Marginal micropermeability can provoke dental pulpitis. Working with a blunt vibrating bur also leads to serious changes in the odontoblast layer (disruption of cell arrangement, migration of their nuclei), which can subsequently affect the condition of the pulp. Also, during orthodontic treatment, excessive impact on teeth exceeding compensatory capabilities causes its damage. Recent studies show that modern composite and glass ionomer cements have an adverse effect on teeth. This issue is debatable, but many researchers suggest using insulating files before composite restoration and grinding teeth for orthopedic structures. The pulp reacts to such irritants with acute inflammation, which is reversible in most cases. Usually, strong heating of tissues occurs, coagulation necrosis develops in it, and an intrapulpar abscess may form. During periodontal interventions (curettage), the integrity of the vessels of the deltoid branches of the pulp is destroyed, which is associated with necrobiotic changes in the root zone (ascending pulpitis).

Chemical factors

In the scientific dental community, there are research works devoted to studying the influence of toxic agents of various materials and substances used in dentistry on pulpitis. These may include a large number of filling and lining materials (restorative composite materials), cements (zinc phosphate, glass ionomer, materials for temporary obturation of carious cavity), acids for total etching of bonding systems, as well as such substances as alcohol, ether, phenols. Unfortunately, almost all of them have an effect on the tooth (from hyperemia to necrosis).

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Idiopathic factors

Very often pulpitis develops due to various, unknown reasons. For example, internal root resorption: as a rule, its development is discovered by chance during an X-ray examination. During the acute period of shingles (herpes zoster), painful sensations similar to pulpitis may occur. Atypical forms of trigeminal neuralgia may also resemble pulpitis pain.

How does pulpitis develop?

Pulpitis develops according to the general laws of physiology: in response to a damaging factor, complex biochemical, histochemical and ultrastructural vascular-tissue reactions occur. First of all, it should be noted that the degree of inflammatory reaction is determined by the level of reactivity of the body (altered reactivity is present in patients with general diseases, with hypo- and avitaminosis, anemia), the influence of the nervous system of the body (stress). In acute pulpitis, the initial trigger is alternation. At the beginning of the cellular phase of inflammation, polymorphonuclear neutrophils predominate in the lesion, then monocytes (macrophages), plasma cells. Pulpitis begins as a vascular reaction, a short-term narrowing of arterioles occurs, then their expansion (as well as capillaries and venules), blood flow increases, intracapillary pressure increases, edema appears.

Circulatory disorders begin with vascular hyperemia, which is considered the initial stage of inflammation. Dilation of arterioles and capillaries, increased blood flow, and the addition of exudation lead to the transition to the stage of acute pulpitis. Then purulent exudate, abscess formation, and then empyema appear. The loss of pulp viability is also facilitated by the inflexibility of the walls of the tooth cavity.

The existence of various forms of acute pulpitis reflects the variants of the course of the inflammatory process. As a rule, acute pulpitis is a hyperergic type of reaction (has the nature of immune inflammation). This is confirmed by the possibility of sensitization by microorganisms and their metabolic products, as well as the rate of spread of exudative-necrotic reactions leading to an irreversible state of the pulp. In the pathogenesis of immediate hypersensitivity reactions, the leading place is occupied by immune complexes activating the complement system with the release of inflammatory mediators and complement derivatives that support damage to the vascular wall.

Acute serous-hyoid and purulent pulpitis is characterized by focal or diffuse leukocyte infiltration (lymphoid, histiocytic elements). Fibrous changes in the ground substance (in places fibrinoid necrosis around the vessels), areas of complete tissue disintegration are noticeable.

The outcome of the acute process is restoration (regeneration), necrosis or transition to chronic pulpitis. In the chronic form of pulpitis, morphological changes occur in all layers of the tooth (in the epithelium covering the pulp "polyp" in hypertrophic pulpitis, the tissue of the pulp itself, vessels, nerve fibers). When the inflammatory process becomes chronic, lymphocytes, macrophages, and plasma cells predominate in the lesion. T- and B-lymphocytes appear in the pathological lesion, responsible for the development of the reaction of humoral and cellular immunity. Lymphocytes and macrophages themselves are capable of destroying tissues and the immune response will be even more destructive to the pulp. In fibrous pulpitis, a change in the cellular composition of the pulp occurs; fibrosis is often encountered in the root pulp, which can be limited to one area or spread to the entire pulp tissue. Hypertrophic pulpitis is characterized by proliferative processes occurring in the pulp.

The pulp polyp is often covered with an epithelial lining, but its structure is also different from the gingival epithelium. A frequent sign is ulceration foci in the superficial layer of the polyp with exposure of the underlying proliferating pulp tissue. With the development of the inflammatory process, the formation of infiltrates is observed, followed by the occurrence of microabscesses. In the pulp tissue, areas consisting of cellular decay are found, with a limited accumulation of leukocytes along the periphery of the lesion. Chronic gangrenous pulpitis is characterized by a demarche-ton shaft of granulation tissue, in the coronal pulp, decay of pulp tissue is found. Multiple foci of micronecrosis are observed, in the underlying parts of the pulp, its structure is preserved, the cellular composition is poor, dystrophic changes in collagen fibers are noted. Aggravated chronic pulpitis is characterized by the fact that against the background of sclerotic changes, acute disorganization of the cellular and tissue elements of the pulp appears. It should be noted that changes in the pulp can be affected by factors such as a person's age, due to the fact that areas of sclerosis and hyalinosis can be a natural reorganization of the pulp tissue. Edema and accumulation of glycosaminoglycans with areas of disorganization of collagen fibers are detected in the walls of blood vessels.

Classification of pulpitis

In the 10th revision of diagnoses and diseases (1997), WHO, under the code K04 in chapter (V “Diseases of the digestive system”, proposed a classification recommended since 1998 in our country by StAR.

The classification of the disease is based on the nosological principle,

• K04. Diseases of the pulp and periapical tissues.
• By 04.0 Pulpitis.
• K04.1 Necrosis.
• K04.2 Degeneration.
• K04.3 Abnormal formation of hard tissues.
• K04.4 Acute apical periodontitis of pulpal origin.
• K04.5 Chronic apical periodontitis.
• K04.6 Periapical abscess with cavity.
• K04.7 Terminal abscess without cavity.
• K04.8 Root cyst.
• K04.9 Other and unspecified diseases of pulp and periapical tissues.

Until recently, a classification of pulpitis with a pathomorphological basis was used, and in order to correlate its subsections with the WHO classification, it can be considered that focal and diffuse pulpitis corresponds to acute (K04.01) and purulent (K04.02), chronic forms [fibrous, hypertrophic (proliferative), gangrenous] correspond to chronic (K04.03), chronic ulcerative (K04.04), chronic hyperplastic, or pulp polyp (K04.05), respectively. The new section K04.02 Degeneration (denticles, petrification) reflects frequently occurring clinical and morphological changes that lead to a change in the traditional treatment protocol by dentists. In the clinic, pulpitis of unclear genesis is encountered and the position K04.09 Pulpitis, unspecified or K04.9 is included in the classification. Other and unspecified diseases of periapical tissues can be considered useful from the point of view of the doctrine of nosology. All stages of inflammation designated in positions up to K04.02 purulent (pulp abscess) can be both reversible and irreversible, which, of course, should be confirmed by diagnostics and subsequent treatment with or without preservation of the pulp. However, the position "Exacerbation of chronic pulpitis" included in the generally accepted classifications in our country did not find its place in ICD-10. A dentist can differentiate this type of inflammation by anamnestic data, clinical signs, pathomorphologically. In this case, alterative processes prevail in the pulp.

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How to recognize pulpitis?

Anamnestic data is one of the important components of a clinical examination, allowing to obtain the information necessary for making a correct diagnosis. The doctor needs to accustom himself to studying the general health of the patient. Perhaps, it is from the data obtained that a logical chain of thoughts can be built. The medical history must be drawn up, questions concerning heart diseases, endocrine disorders, diseases of internal organs, such as kidneys, surgical intervention, medications taken. To clarify the diagnosis, blood tests for human immunodeficiency virus (HIV), hepatitis will be required. Perhaps, the patient needs to be treated by several doctors together.

For the diagnosis of such a disease as pulpitis, collecting anamnestic data is very useful. When making a diagnosis, all the nuances of spontaneous pain, its nature (spontaneous or caused by the impact of any irritants; pulsating, sharp, dull, aching, periodic), the time of the first pain sensations are specified. During the survey, the doctor finds out what preceded the pain attack, how long it lasted and what is the duration of the "light" intervals, in connection with which the pain resumed, whether the patient can indicate the causative tooth. The reactivity of the patient's body is of great diagnostic importance, frequent exacerbations can occur with a change in working conditions, stress.

In serous diffuse pulpitis, the inflammation spreads to the coronal and root pulp within 24 hours, so the doctor must rely on the most important sign in the anamnesis - the time of the onset of primary pain. Pain paroxysms last more than 24 hours, alternating with "light" painless intervals - purulent pulpitis, requiring appropriate treatment. Relying only on the anamnesis data (acute pain attacks appeared after previous discomfort, weak pain reactions in the tooth or their absence), it is possible to establish a diagnosis of exacerbation of chronic pulpitis.

In-depth anamnesis collection, if it is carried out taking into account the type of the patient's nervous system, the level of his intelligence, is the basis for the correct diagnosis of pulpitis. In some situations, anamnesis collection is difficult, in these cases the doctor relies on the specific complaints of the patient and clinical manifestations of the disease, becoming the absolute organizer of the treatment process.

Physical examination

During the examination, the doctor may resort to EOD of the dental pulp, which has an undoubted priority in the dynamic control of the disease. The method makes it possible to take readings from each tooth separately, compare them during repeated examinations; this is especially useful in case of traumatic lesions, observation of patients after pulp-preserving treatment methods. Healthy pulp responds to electric current within 2-6 μA. In case of inflammatory phenomena in the pulp, the values of electrical excitability gradually decrease depending on the degree and phase of pulpitis. In case of pulp hyperemia, the EOD values do not change, however, with the development of the inflammatory reaction of the pulp in an acute condition in a molar, there may be values of 20-35 μA from one tubercle, within the normal range on others, and with the transition of inflammation to the entire pulp, a decrease in the sensitivity threshold for the EOD test will be noted from all tubercles. In case of a purulent process, the EOD values are within 30-50 μA. A tooth with chronic fibrous pulpitis reacts to a current of less than 50 μA, with pulp necrosis the values will be closer to 100 μA.

Several readings are usually taken from each tooth, after which the average value is determined.

The results are affected by various factors, which leads to false readings. It is necessary to exclude contact with metal, correctly install the sensor, and isolate the tooth from saliva, give clear instructions to the patient on what to react to; work in gloves (to break the electrical circuit). Wet (colliquation) or partial necrosis of the pulp can "show" complete death of the pulp, although this is not true.

Objective information on the state of blood flow in the pulp can be obtained using non-invasive research methods - rheodentography and laser Doppler flowmetry (LDF). These procedures allow us to evaluate changes in the blood supply to the dental pulp in response to various effects on hard dental tissues, including vasoactive substances, the carious process in hard dental tissues and the inflammatory process in the pulp itself; as well as mechanical forces - orthodontic. When interpreting the results of LDF-grams, it is necessary to take into account that with age there is a reliable decrease (in %) in the LDF signal value; the application of a rubber dam reliably and significantly reduces the recorded signal in an intact tooth, long-term exposure to orthodontic forces - beds in the pulp. Along with standard methods (chloroethyl, radiolucency of the periapical region and pain complaints) in diagnosing pulp vitality, LDF can also be used to assess sensitivity. The signal level in teeth with necrotic pulp is significantly lower than in intact control teeth. In all teeth with deep carious cavity before treatment the blood flow level is higher than in intact control teeth. On the rheodentogram the amplitude of pulse oscillations of pulp vessels is reduced by 10 times compared to a symmetrical intact tooth; in the descending part many additional waves are registered.

Laboratory research

Laboratory tests performed for pulpitis:

• clinical blood test;
• biochemical blood test;
• analysis for AIDS, RW and hepatitis;
• PCR;
• study of general and humoral immunological status;
• determination of immunoglobulins in the patient's oral fluid.

Instrumental research methods

Clinical examination begins with an external examination of the patient, examining the area indicated by the patient himself, and then the opposite side. Facial asymmetry and the presence of edema are assessed. When examining soft tissues, the "suspicion coefficient" should prevail, which can contribute to a more thorough and methodical examination. Examination of the teeth is carried out using a probe and a mirror. The localization of the carious cavity, the condition of the bottom, and the degree of pain during probing are assessed. Localization of the carious cavity is important in diagnosing pulpitis due to the fact that in class II cavities, it may be difficult to examine the walls and bottom. The condition of the bottom of the carious cavity is an important prognostic sign. During examination, attention is paid to the color of the dentin, its consistency, integrity, pain, especially in the projection of the pulp horn. Studies have shown that the color, consistency, integrity of the peripulpar dentin are directly proportional to the condition of the tooth. The appearance of the bottom of a carious cavity depends on the severity of the disease: with pulp hyperemia, dentin is light gray, dense, without damage to integrity, sensitive when probing the bottom in the area of the projection of the pulp horn; with more pronounced inflammation, dentin becomes brown-black, softened, with areas of perforation, painful when probing.

Pay attention to the anatomical and functional features:

• disruption of the structure of the vestibule of the oral cavity;
• location of frenulum, mucous cords;
• gum recession;
• caries;
• dentoalveolar anomalies - crowding of teeth, type of occlusion, presence of traumatic nodes, orthodontic manipulations, condition after traumatic tooth extractions. It is important to "value the color of the tooth; the enamel of a tooth with non-viable pulp becomes dull and turns gray. Traumatized teeth change their color more intensely.

An important diagnostic method is the study of the periodontal status, in particular, the study of the depth of the periodontal pocket using a periodontal calibration graduated probe proposed by WHO experts (D = 0.5 mm) with a standard pressure of 240 N/cm. recording the depth with an accuracy of 1 mm {Van der Velden). In this case, the largest value is taken into account. There is a so-called pulpo-periodontal connection, while pathological processes have a dual origin and require endodontic and periodontal treatment.

Percussion is a simple, accessible diagnostic method that allows obtaining information about the presence of inflammation in the periodontium. Percussion can be vertical and horizontal (teeth with predominant periodontal inflammation, possibly with an abscess, react to horizontal, in contrast to teeth with an apical process).

Palpation examination allows obtaining information about the condition of soft tissues (pain, swelling, fluctuation, compaction, crepitations). It is necessary to examine the opposite side, which helps to assess the reliability of the results obtained. In some cases, bimanual palpation helps the doctor in establishing a diagnosis.

It is known that the most important symptom of pulpitis is the presence of pain syndrome, which often occurs as a response to thermal stimuli. The data of temperature tests can be assessed only in a complex of diagnostic measures. To conduct a thermal test, the irritant is applied to the dried and cleaned surface of the tooth. It is appropriate to check all thermal tests on intact teeth for comparison. The doctor should not forget that the sensitivity threshold is individual, which is reflected in the results. The protective properties of hard tooth tissues can distort the result of the thermal test. Cooling the tooth reduces blood circulation in the pulp due to temporary vasoconstriction, but does not stop it. To conduct a "hot" test, gutta-percha is usually used, which is preheated; in the presence of inflammation, a reaction appears, intensifying and lasting up to 1 minute. The cold test is carried out using a piece of ice, carbon dioxide (-78 ° C), with a ball moistened with difluorodichloromethane (-50 ° C). In asymptomatic chronic inflammatory processes in the dental pulp, it is necessary to provoke a reaction of the pulp. Thermal tests are also used for this purpose, but the thermal test is more effective.

The clinical picture of pulpitis may be similar to the complaints of patients with vertical fractures, so it is necessary to conduct a diagnostic study to identify such fractures. Clinically, patients experience pain when chewing. The line of a vertical fracture is not always visible on an X-ray, so the fracture can be determined by biting a cotton roll or marked with food coloring.

X-ray examination of patients for pulpitis is an informative, but not a definitive method. Images can be Conventional (film images) and Digital (visiograms). A visiogram can only determine the file number according to ISO #15, while an X-ray can even determine the file number according to ISO #10. With a two-dimensional image of a tooth, incorrect interpretation of images is possible and, as a consequence, a diagnostic error. A doctor with an increased "suspicion coefficient" should soberly evaluate X-ray images that can be taken in a parallel technique, which reduces distortions to 3%. at different angles, as this will allow finding additional canals (roots). Teeth with non-viable pulp do not always have changes in the periapical tissues; time is required for them to appear. The area of destruction is not necessarily located apically; it can be anywhere along the root. X-ray images with gutta-percha pins inserted into the lesion are very demonstrative and interesting (Tracing test).

Differential diagnostics

The most indicative diagnostic criterion for diagnosing pulpitis is pain (paroxysm of pain). Differential diagnostics of acute pulpitis is carried out with diseases similar in this criterion: inflammation of the trigeminal nerve, shingles, acute periodontitis, papillitis.

Local inflammation of the gingival papilla resembles periapical inflammation due to the atypical spread of exudate, accompanied by paroxysmal pain, painful probing. Usually, with a single curettage performed under local anesthesia, all complaints disappear.

Inflammation of the sinuses (sinusitis, primarily sinusitis) can manifest itself as pain in the area of one or more teeth. The patient complains of pain when biting, a feeling of a "grown" tooth; cold! The test in this case will be positive. To clarify the diagnosis, an X-ray examination is required, it should also be remembered that sinus disease is accompanied by increased pain when tilting the head forward and, as a rule, pain manifests itself in a group of teeth. Diseases of the temporomandibular joint (dysfunction) can also cause pain in the patient's teeth, usually the upper jaw. Careful palpation, X-ray and tomographic studies will help establish the correct diagnosis.

Shingles is a viral disease accompanied by severe pain syndrome. For differential diagnostics, the electrical excitability of the pulp is checked, temperature tests are carried out. The appearance of characteristic elements facilitates the diagnostic process. Treatment by a specialist.

Chronic pain of neurogenic nature is difficult for both the patient and the doctor in terms of differential diagnosis. Complaints concern one or more teeth, pain in this case occurs when touching trigger zones, quickly reaches its maximum, then a refractory period begins - a "light" interval, during which it is impossible to cause pain again. This is typical for inflammation of the trigeminal nerve (there are no night pains and reactions to temperature tests). In this case, endodontic interventions may not lead to successful treatment, and sometimes even worsen the situation. Identification of hidden cavities can help in choosing the right direction of search. Consultation and treatment with a neurologist is necessary.

Some forms of migraine, heart disease (angina) can lead to pain (in particular, radiating), similar to pulpal pain. Heart pain most often radiates to the lower jaw on the left.

Chronic fibrous pulpitis is differentiated from pathology that has subjective similarity, such as deep caries. A methodically collected anamnesis helps to establish an accurate diagnosis: the duration of chronic pulpitis, the results of thermometry (slowly developing pain, an open vault of the tooth cavity). Hypertrophic pulpitis (polyp) is differentiated from gingival hypertrophy. Careful probing helps to establish the absence of growth from the tooth cavity. Often, apical periostitis is completely asymptomatic, in which case this condition can be differentiated from incomplete root formation. It is necessary to take into account the anamnesis data, the results of the X-ray examination, as well as the age of the patient.

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Indications for consultation with other specialists

In some cases, it is justified to consult other specialists. It is quite obvious that if there is difficulty in making a differentiation in case of trigeminal neuralgia, dysfunctions of the temporomandibular joint, herpes zoster, consultation and treatment with a neurologist, surgeon, or skin disease specialist are necessary.

Patients suffering from pulpitis are prescribed complex or individual treatment.

How to prevent pulpitis?

Prevention of pulpitis - medical examination of the population for timely detection of carious lesions in primary and permanent teeth, use of water cooling during dental preparation.

Measures for the prevention of pulpitis and its complications:

• a medical examination by the attending physician and, based on the results obtained,
• drawing up a plan of preventive and therapeutic measures;
• informing the attending physician about the state of your health before starting treatment procedures (about the presence of allergies to medications, chronic diseases, surgical interventions, injuries).

Approximate periods of incapacity for work

In case of pulpitis, a sick leave certificate is not issued. In case of severe course of the disease (exacerbation of chronic pulpitis, multiple foci of inflammation, covering several teeth at the same time), the period for issuing a sick leave certificate is 3-7 days.

Clinical examination

Outpatient observation is carried out twice a year. X-ray dynamic observation allows monitoring the process in the root canal and periodontium. Timely elimination of defective restorations in order to prevent the penetration of microorganisms into the tooth cavity and root canal prevents the development of complications.

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