Pulpitis

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

[1], [2], [3], [4]

Epidemiology of pulpitis

Pulpitis is a common disease that occurs in the practice of a dentist. According to different authors, in the structure of dental care, patients with pulpitis account for 14-30% or more, depending on the region of the country.

[5], [6], [7]

What causes pulpitis?

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

The causes of pathological changes, and, accordingly, pulpitis:

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

According to available modern literary data, the pulp reacts to the carious process in the tooth in different ways. It exhibits signs of inflammation 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 stimulation of intratubular dentin occurs in different ways, leading to the sclerosis of dentinal tubules. Deposits of minerals have the appearance of large crystals of hydroxyapatite, needle-shaped or diamond-shaped. A zone of sclerotized dentin is a kind of barrier, so effective that an inverse process can develop in the development of inflammation. However, if the patient is ill or does not cure tooth decay, then eventually the trailer will repeat and become irreversible.

Causes of pulpal hyperemia

• The development of the carious process, in which dentin is involved in the destructive process. As the caries progresses with the formation of ever wider decay zones, the pathological process approaches the pulp. The introduction of decay products along the dentinal tubules leads to a change in the vessels - hyperemia in combination with irrigation.
• Transient states:
  • stress;
  • rise to the height;
  • diving,
  • hypertonic disease.

Bacterial factors

Pulpit is characterized by the presence of polymorphous microbial flora with the predominance of streptococcal associations and with other pyogenic cocci (golden and gray staphylococci), Gram-positive rods, fusospirochete flora and fungi. As a rule, streptococci and staphylococci of 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 P. Gingivals, T, dentkola. A. Actinamycetecomitans, P. Intermedia, Eubacterium, Selenomonas and Actinomyces. Traumatic factors

Traumatic lesions leading to a disease such as pulpitis are divided into acute and chronic. Acute trauma - 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.

Fractures of the tooth (especially if the pulp chamber is opened) open the way for infection with microorganisms from the oral cavity. In the zone of any fracture, a hemorrhage is formed, then the microorganisms penetrate and colonize the injury site, the result is pulpitis and total necrosis. The forecast in this case is unfavorable. However, a traumatic effect on the tooth causes a polar reaction on her part. Instead of the appearance of necrosis, recovery without complications can occur, and enhanced calcification is also possible. Subluxation and complete dislocation of the tooth (with a rupture of the neurovascular bundle and without its rupture) is accompanied by hemorrhage, clot formation and infection of the injury zone, which leads to unavoidable endodontic treatment.

Chronic injuries - bruxism, permanent occlusive trauma, non-carious lesions, for example erosion of enamel often cause pulpitis.

[8], [9], [10], [11],

Iatrogenic factors

These include improper restoration and preparation, namely, drying, dehydration of dentin, the pressure applied to the preparation of enamel over 220 grams, the toxic effect of filling materials and cements, the breaking of the marginal fit and, as a consequence, micro permeability for bacteria. Marginal micro permeability can provoke pulpitis of the tooth. Work by blunt boron also leads to serious changes in the layer of odontoblasts (dislocation of cells, migration of their nuclei), which in the future can affect the state of the pulp. Also, in the process of orthodontic treatment, excessive exposure to teeth exceeding the compensatory possibilities causes damage to it. Recent studies show that modern composite and glass ionomer cements adversely affect the tooth. This question has a discussion question, but many researchers suggest using insulating files before composite restoration and turning teeth to orthopedic structures. The pulp reacts to similar irritants with acute inflammation, which in its nature is reversible in most cases. Usually there is a strong heating of the tissues, coagulation necrosis develops in it, and the formation of an intrapulpural abscess is possible. When conducting 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 the study of the effect of toxic agents of various materials and substances used in dentistry for pulpitis. They include a large number of filling and packing materials (restorative composite materials), cements (zinc-phosphate, glass ionomer, materials for temporary obturation of the carious cavity), acids for total etching of bonding systems, as well as substances such as alcohol, ether, phenols. Unfortunately, almost all of them affect the tooth (from hyperemia to necrosis).

[12], [13], [14]

Idiopathic factors

Very often pulpitis develops because of a variety of, for unknown reasons. For example, internal resorption of the root: as a rule, it is learned about its development by chance during the radiographic examination. During an acute period of herpes zoster, painful sensations, similar to those of pulpitis, may occur. Untypical forms of neuralgia of the trigeminal nerve may also resemble pulpitis pains.

How does pulpitis develop?

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

Circulatory disorders begin with vascular hyperemia, which is considered as the initial stage of inflammation. Expansion of arterioles and capillaries, increased blood flow, adherence of exudation lead to transition to the stage of acute pulpitis. Then there is a purulent exudate, abscessing and then empyema. The loss of the viability of the pulp is also facilitated by the stubbornness 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 (it has the character of immune inflammation). This is confirmed by the possibility of sensitization of microorganisms and their metabolic products, as well as the rate of propagation of exudative necrotic reactions leading to an irreversible state of the pulp. In the pathogenesis of immediate-type hypersensitivity reactions, immune complexes that activate the complement system with the release of inflammatory mediators and complement derivatives that support damage to the vascular wall take the leading place.

For acute serous-hyoid and purulent pulpitis, leukocyte infiltration of focal or diffuse character (lymphoid, histocytic elements) is characteristic. Noticeable fibrotic changes in the main substance (in places fibrinoid necrosis around the vessels), areas of complete decay of the tissue.

The outcome of an acute process is recovery (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 "polyp" of the pulp with hypertrophic pulpitis, the tissues of the pulp itself, vessels, nerve fibers). When the inflammatory process changes into a chronic form, the focus is dominated by lymphocytes, macrophages, and plasma cells. In the pathological focus, there are T and B lymphocytes 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 for pulp. With fibrous pulpitis, a change in the cellular composition of the pulp arises, in the root pulp often occur fibrosis, which can be limited to one area or spread to the entire tissue of the pulp. When hypertrophic pulpitis is characterized by proliferative processes occurring in the pulp.

The polyp of the pulp is often covered with epithelial lining, but its structure is also distinguished from the gingival epithelium. A common symptom is the pockets of ulceration in the surface layer of the polyp, exposing the underlying pulp tissue. With the development of the inflammatory process, the formation of infiltrates is observed, followed by the emergence of microabscesses. In the tissue of the pulp, there are sites consisting of cell decay, with a limited accumulation of white blood cells along the periphery of the focus. For chronic gangrenous pulpitis, a demarche is characterized by a tonal shaft from the granulation tissue, in the coronal pulp there is a decomposition of pulp tissue. Observe multiple foci of micro necrosis, in the underlying pulp, its structure is preserved, the cellular composition is poor, and dystrophic changes in collagen fibers are noted. Exacerbated chronic pulpitis is characterized by the fact that against the background of sclerotic changes there is an acute disorganization of the cellular and tissue elements of the pulp. It should be noted that changes in the pulp can be influenced by factors such as the age of a person, due to the fact that sclerosis and hyalinosis areas can be a natural reorganization of pulp tissue. In the walls of the vessels, edema and accumulation of glycosaminoglycans with disorganization sites of collagen fibers are revealed.

Classification of pulpitis

WHO in the 10th revision of diagnoses and diseases (1997) under the code K04 in the chapter (V "Diseases of the digestive system" proposed the classification recommended since 1998 in the territory of our country STAR.

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

• K04. Diseases of pulp and periapical tissues.
• To 04.0 Pulpit.
• K04.1 Necrosis.
• K04.2 Degeneration.
• K04.3 Wrong 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 Terminical abscess without cavity.
• K04.8 Root cyst.
• K04.9 Other and unspecified diseases of pulp and periapical tissues.

Until recently, the classification of pulpitis was used, which has a pathomorphological justification, and to correlate its subsections with WHO classification, it can be considered that focal and diffuse pulpitis corresponds to acute (K04.01) and purulent (K04.02), chronic forms [fibrotic, hypertrophic (proliferative), gangrenous] correspond to - chronic (К04.03), chronic ulcerative (К04.04), chronic gaperplastic, or pulpal polyp (К04.05), respectively. The newly developed section K04.02 Degeneration (denticles, petrification) reflects the often occurring clinical and morphological changes that lead to a change in the traditional protocol of treatment by dentists. In the clinic, there is a pulpitis of unknown origin and the inclusion in the classification of position K04.09 Pulpitis, unspecified or K04.9. 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, indicated in positions up to K04.02, purulent (pulpal abscess), can be both reversible and irreversible, which, of course, must be confirmed by diagnosis and subsequent treatment with or without preserving the pulp. However, the position "Exacerbation of chronic pulpitis", included in the generally accepted classification in our country, did not find its place in ICD-10. A dentist can differentiate this type of inflammation according to anamnestic data, clinical signs, pathomorphologically. In this case, the alteration process predominates in the pulp.

[15], [16], [17], [18], [19]

How to recognize pulpitis?

Anamnestic data is one of the important components of the clinical examination, which allows you to obtain the information necessary to establish the 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 reflections can be constructed. The history of the disease needs to be formalized, assignments to questions relating to heart disease, endocrine disorders, diseases of internal organs, such as kidneys, surgery, medications. To clarify the diagnosis will require blood tests for the human immunodeficiency virus (HIV), hepatitis. Perhaps, the treatment of a patient is necessary to be carried out by several doctors together.

To diagnose a disease such as pulpitis, the collection of anamnestic data is very useful. When the diagnosis is made, all the nuances of spontaneous pain, its character (spontaneous or caused by the action of any stimuli, pulsating, acute, dull, aching, periodic) are clarified, the period of the appearance of the first pain sensations. When interviewed, the doctor finds out what preceded the painful attack, how long it lasted and what the duration of the "light" intervals, in connection with which the pain resumed, can the patient indicate the causative tooth. The reactivity of the patient's body has an important diagnostic value, frequent exacerbations can occur when working conditions change, stress.

In case of serous diffuse pulpitis, the inflammation spreads over the crown and root pulp for 1 day, therefore the physician must rely on the most important symptom - the time of the appearance of primary pain sensations. Painful paroxysms last more than 24 hours, alternating with "light" painless intervals, purulent pulpitis, which requires appropriate treatment. Based only on the data of the anamnesis (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.

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

Physical examination

During the examination the doctor can resort to EDI tooth pulp, which has undoubted priority in carrying out the dynamic control of the disease. The method makes it possible to take readings from each tooth separately, to compare them during repeated examinations; This is especially useful in traumatic lesions, observation of patients after pulp-preserving treatment. A healthy pulp reacts to an electric current within 2-6 μA. With inflammatory phenomena in the pulp, the values of electroexcitability gradually decrease depending on the degree and phase of the pulpitis. With pulp hyperemia, the EDI values do not change, however, with the development of the inflammatory response of the pulp in the acute condition in the molar, there may be 20-35 μA from one hillock, others within normal limits, and with the transition of inflammation to the whole pulp, the decrease in the sensitivity threshold for the EDI test will be marked from all the hillocks. With a purulent process, EDP values are in the range of 30-50 μA. A tooth with chronic fibrotic pulpitis reacts to a current of less than 50 μA, with pulp necrosis the values will be closer to 100 μA.

A few indications are usually taken from each tooth, after which an average value is determined.

The results are influenced 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; work in gloves (to break the electrical circuit). Wet (colliquated) or partial necrosis of the pulp can "show" the complete death of the pulp, although this is not true.

Objective information on the state of blood flow in the pulp can be obtained with the help of non-invasive research methods - rheodentography and laser Doppler flowmetry (LDF). These procedures allow estimating changes in the blood supply to the pulp of the tooth in response to various effects on the hard tooth tissues, including vasoactive substances, the carious process in the solid tissues of the tooth, 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, a significant decrease (in%) of the LDF signal value occurs; the imposition of co-felding significantly and significantly reduces the recorded signal in the intact tooth, prolonged exposure to orthodontic forces - the beds in the pulp. Along with standard methods (chloroethyl, x-ray transparency of the periapical area and complaints of pain) in diagnosing the pulp vitality, LDF can be used to assess the sensitivity. The signal level in the teeth with necrotic pulp is significantly lower than in the control intact ones. In all teeth with a deep carious cavity before treatment, the blood flow level is higher than in intact control teeth. On the rheodentogram, the amplitude of the pulse oscillations of the pulp vessels is reduced by a factor of 10 compared to the symmetrical intact tooth; in the descending part, a lot of additional waves are recorded.

Laboratory research

Laboratory studies conducted in pulpitis:

• clinical blood test;
• blood chemistry;
• analysis on AIDS, RW and hepatitis;
• PCR;
• the study of the 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, which indicates the patient himself, and then the opposite side. Assess the asymmetry of the face, the presence of edema. When inspecting soft tissues, the "suspiciousness factor" should predominate, which can contribute to a more thorough and methodical examination. Examination of the teeth is carried out using a probe and a mirror. Assess the localization of the carious cavity, the state of the bottom, the degree of soreness in sounding. The localization of the carious cavity is important in the diagnosis of pulpitis due to the fact that in the cavities of Class II it may be difficult to examine the walls and bottom. The condition of the bottom of the carious cavity is an important prognostic sign. When viewed, pay attention to the color of the dentin, its consistency, integrity, soreness, especially in the projection of the horn of the pulp. Studies have shown that the color, consistency, and integrity of the near-pulp dentin are directly proportional to the state of the tooth. The appearance of the bottom of the carious cavity depends on the degree of severity of the disease: when the pulp is hyperemia, the dentin is light gray, dense, without disruption of integrity, is sensitive when probing the bottom in the region of the projection of the horn of the pulp; with more pronounced inflammation, the dentin becomes brownish-black, softened, with areas of perforation, painful during probing.

Pay attention to anatomical and functional features:

• violation of the structure of the vestibule of the oral cavity;
• the location of bridles, mucous bands;
• recession of the gum;
• caries;
• dentoalveolar anomalies - denseness of teeth, occlusion, presence of traumatic nodes, orthodontic manipulations, condition after traumatic tooth extraction. It is important to "appreciate the color of the tooth; enamel tooth with non-viable pulp becomes dull color, gray. Injured teeth change their color more intensively.

An important diagnostic method is the study of the periodontal status, in particular, the study of the depth of the periodontal pocket using a parodental calibration calibration probe, proposed by WHO experts (D = 0.5 mm) with a standard pressure of 240 N / cm. Registering 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 pulp-periodontal connection, while pathological processes have a dual origin and require endodontic and periodontal treatment.

Percussion is a simple accessible diagnostic method that allows you to get information about the presence of inflammation in periodontium. Percussion can be Vertical and horizontal (horizontal teeth react with a predominance of periodontal inflammation, possibly with an abscess, unlike teeth with an apical process).

Palpation study provides information on the state of soft tissues (soreness, edema, fluctuation, densification, crepitus). It is necessary to explore the opposite side, which helps to evaluate the reliability of the results. In some cases, bimanual palpation helps the doctor diagnose.

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

The pulpitis clinic may be similar to the complaints of patients with vertical fractures, so it is necessary to conduct a diagnostic study that identifies such fractures. Clinically, patients have painful sensations arising from chewing. The line of vertical fracture is not always visible on the roentgenogram, therefore it is possible to determine the fracture by biting a cotton roll or labeling it with food coloring.

X-ray examination of patients for pulpitis is an informative, but not a determining method. Pictures can be - Conventional (film shots) and Digital (Visionograms). According to the sightogram, you can only determine the file number but ISO number 15, and according to the X-ray, you can even determine the file number according to ISO No. 10. With a two-dimensional image of the tooth, an incorrect interpretation of the pictures and, as a consequence, a diagnostic error. A doctor with an increased "suspicion factor" should soberly evaluate radiographic images that can be done in parallel technique, which reduces distortions to 3%. At different angles, as this will allow us to find additional channels (roots). Teeth with non-viable pulp do not always have changes in the periapical tissues, they take time to appear. The area of destruction is not necessarily located apically, it can be anywhere along the root. Very demonstrative and interesting are X-ray pictures with gutta-percha pins inserted into the focus (Tracing test).

Differential diagnostics

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

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

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

Shingles is a viral disease, accompanied by a severe pain syndrome. For differential diagnosis, the electrical excitability of the pulp is checked, and thermal samples are carried out. The appearance of characteristic elements facilitates the process of diagnosis. Treatment with a specialist.

Chronic neurogenic pain presents a difficulty for both the patient and the doctor in terms of differential diagnosis. Complaints concern one or more teeth, the pain in this case occurs when you touch the trigger zones, quickly reaches its maximum, then the refractory period comes - "light "A gap during which it is impossible to re-cause pain. This is typical for inflammation of the trigeminal nerve (no night pain and reaction to temperature tests). In this case, carrying out endodontic interventions may not lead to the success of treatment, and sometimes worsen the situation. The detection of hidden cavities can help in choosing the right direction of search. It is necessary to consult and treat the neurologist.

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

Chronic fibrous pulpitis is differentiated from a pathology that has a subjective similarity, for example, deep caries. The methodically collected history helps to establish an accurate diagnosis: the duration of the course of chronic pulpitis, the results of the conducted thermometry (slowly arising pain, open arch of the tooth cavity). Hypertrophic pulpitis (polyp) differentiates from gingival hypertrophy. Carefully cited sounding helps to establish the absence of growth from the cavity of the tooth. Often, the apical periostitis is completely asymptomatic, in which case this condition can be differentiated from the unfinished formation of roots. It is necessary to take into account the history of the patient, the results of the X-ray study, and the age of the patient.

[20], [21], [22], [23]

Indications for consultation of other specialists

In a number of cases, the treatment to other specialists is justified. It is quite obvious that if there is difficulty in differentiation with trigeminal neuralgia, dysfunction of the temporomandibular joint, shingles, consultation and treatment are necessary for a neuropathologist, surgeon, skin diseases specialist.

Patients suffering from pulpitis are shown complex or individual treatment.

How to prevent pulpitis?

Prevention of pulpitis - medical examination of the population for the timely detection of carious lesions in dairy and permanent teeth, the use of water cooling for odontopreparation.

Measures for the prevention of pulpitis and its complications:

• the dispensary examination at the attending physician and, proceeding from the received results,
• drawing up a plan for preventive and curative measures;
• informing the attending physician about his state of health before commencing medical procedures (about the presence of allergies to medicines, chronic diseases, surgical interventions, injuries).

Approximate terms of incapacity for work

When you pulpit, you do not get a certificate of incapacity for work. In the case of a severe course of the disease (exacerbation of chronic pulpitis, multiple foci of inflammation, covering several teeth at the same time), the period for processing the disability sheet is 3-7 days.

Clinical examination

Clinical supervision is carried out 2 times a year. X-ray dynamic observation allows you to monitor the process in the root canal and periodontium. Timely removal of defective restorations to prevent the penetration of microorganisms into the cavity of the tooth and the root canal impedes the development of complications.

[24], [25], [26],