Pulpitis

Pulpitis is inflammation of the dental pulp, usually from bacterial invasion through caries, and also from trauma, cracked teeth, deep restorations, thermal injury during cavity preparation, and periodontal disease. It is the commonest cause of acute dental pain. The pulp is enclosed in rigid dentine, so inflammatory oedema increases pressure, compresses vessels, and leads to necrosis (low compliance environment).

Two stages are clinically recognised: reversible pulpitis (inflammation that resolves when the stimulus is removed, with a pulp capable of healing) and irreversible pulpitis (inflammation that cannot heal, symptomatic with spontaneous or lingering pain, or asymptomatic). Progression to pulp necrosis follows, and then periapical periodontitis. Pulp necrosis is relieved of pain, which the patient may misread as improvement. Dental caries prevalence exceeds 50 percent in adults in many settings, so pulpitis is a frequent cause of emergency visits.

• Reversible pulpitis: brief sharp pain (seconds) to cold, sweet or hot stimuli that stops when the stimulus is removed; no spontaneous pain; tooth not tender to percussion.
• Symptomatic irreversible pulpitis: spontaneous throbbing pain that wakes the patient at night, lingers for minutes to hours after cold or heat, worsens on lying down, referred pain to the ear, temple or opposite jaw; heat sensitivity relieved by cold.
• Asymptomatic irreversible pulpitis: deep caries or pulp polyp (hyperplastic pulpitis) without symptoms.
• Percussion tenderness appears when inflammation reaches the periapical tissues.
• Red flags: facial swelling, fever, trismus, spreading infection, and pain with systemic symptoms.

• History: character, duration, provoking and relieving factors, spontaneous pain, nocturnal pain, referred pain.
• Clinical examination: deep caries, defective restorations, cracks, fractured cusp, and tooth wear; visual exposure of pulp.
• Pulp sensibility tests: cold test (refrigerant spray applied with a cotton pellet) and electric pulp test; reversible pulpitis shows a brief response, irreversible pulpitis shows a lingering response of over 10 seconds, and necrosis shows no response.
• Percussion and palpation to identify periapical involvement; bite test with a bite stick for cracked tooth.
• Periapical and bitewing radiographs: depth of caries, periapical widening or radiolucency (normal in early pulpitis).
• Anaesthetic test (selective infiltration) to localise the source of referred pain.
• Exclude cracked tooth syndrome, dentine hypersensitivity, maxillary sinusitis, trigeminal neuralgia, atypical odontalgia, and periodontal abscess.

• Reversible pulpitis: remove caries, place a sedative base (calcium hydroxide or glass ionomer lining), restore with composite or glass ionomer; fluoride varnish 22 600 ppm every 3 to 6 months; pain settles over days to weeks.
• Deep caries with possible pulp exposure: stepwise or selective caries removal, indirect or direct pulp capping with calcium silicate cement (mineral trioxide aggregate) and restoration; success is about 80 to 90 percent in carefully selected cases.
• Irreversible pulpitis: pulpectomy (complete removal of the pulp) with root canal treatment, chemomechanical preparation with sodium hypochlorite 2.5 to 5.25 percent, intracanal dressing with calcium hydroxide, and obturation; or pulpotomy in young teeth with open apices, or extraction.
• Emergency pain relief: local anaesthetic (lidocaine 2 percent with adrenaline 1:80 000, inferior alveolar nerve block 1.8 mL; supplement with intraligamentary or intraosseous injection because inflamed mandibular molars are resistant), opening and pulpotomy under rubber dam.
• Analgesia pre-treatment: ibuprofen 400 mg orally 1 hour before the visit with paracetamol 1 g, increasing anaesthetic success; for later pain, ibuprofen 400 mg every 8 hours with food for 3 days and paracetamol 1 g every 6 hours (children: ibuprofen 5 to 10 mg/kg every 8 hours, paracetamol 15 mg/kg every 6 hours).
• Antibiotics do not relieve pulpitis and are not indicated unless there is systemic involvement or spreading infection: amoxicillin 500 mg orally every 8 hours for 5 days.
• Restoration of the treated tooth with a cuspal coverage crown after root canal treatment of posterior teeth to prevent fracture.
• Follow up: review at 1 to 2 weeks after pulp therapy, radiograph at 6 and 12 months; vitality testing after pulp capping.
• Prevention: sugar reduction, fluoride toothpaste 1450 ppm twice daily, fissure sealants, regular dental review.