Pulpitis is inflammation of the dental pulp resulting from untreated caries, trauma, or multiple restorations. Its principal symptom is pain. Diagnosis is based on clinical findings, radiographs, and pulp vitality tests. Treatment involves removing decay, restoring the damaged tooth, and sometimes doing root canal therapy or extracting the tooth.
Pulpitis can occur when
Caries progresses deeply into the dentin
A tooth requires multiple invasive procedures
Trauma disrupts the lymphatic and blood supply to the pulp
Pulpitis is designated as
Reversible: There is limited inflammation; the tooth can be saved with a simple filling.
Irreversible: Swelling inside the rigid encasement of the dentin compromises circulation, making the pulp necrotic, which predisposes to infection.
Complications
Infectious sequelae of pulpitis include apical periodontitis, periapical abscess, cellulitis, and (rarely) osteomyelitis of the jaw. Infection extension from maxillary teeth may cause purulent sinusitis, meningitis, brain abscess, orbital cellulitis, and cavernous sinus thrombosis.
Spread from mandibular teeth may cause Ludwig angina (cellulitis of the floor of the mouth), parapharyngeal abscess, mediastinitis, pericarditis, empyema, and jugular thrombophlebitis.
Symptoms and Signs of Pulpitis
In reversible pulpitis, pain occurs when a stimulus (usually cold or sweet) is applied to the tooth. When the stimulus is removed, the pain ceases within 1 to 2 seconds.
In irreversible pulpitis, pain occurs spontaneously or lingers minutes after the stimulus (usually heat, less frequently cold) is removed. A patient may have difficulty locating the tooth from which the pain originates, even confusing the maxillary and mandibular arches (but not the left and right sides of the mouth). The pain may then cease for several days because of pulpal necrosis. When pulpal necrosis is complete, the pulp no longer responds to hot or cold but often responds to percussion. As infection develops and extends through the apical foramen, the tooth becomes exquisitely sensitive to pressure and percussion. A periapical (dentoalveolar) abscess elevates the tooth from its socket, and the tooth feels “high” when the patient bites down.
Diagnosis of Pulpitis
Clinical evaluation
Sometimes dental radiographs
Testing for dental sensitivity and/or pulp vitality
Diagnosis is based on the history and physical examination, which includes provoking stimuli (application of heat, cold, and/or percussion). Dentists may also use an electric pulp tester, which indicates whether the pulp is alive but not whether it is healthy. If the patient feels the small electrical charge delivered to the tooth, the pulp is alive.
Judicious use of dental radiographs can help determine whether inflammation has extended beyond the tooth apex and help exclude other conditions.
Treatment of Pulpitis
Caries removal and restoration placement for reversible pulpitis
Root canal and crown or extraction for irreversible pulpitis
In reversible pulpitis, pulp vitality can be maintained if the tooth is treated, usually by caries removal, and then restored.
In irreversible pulpitis,1, 2). If symptoms persist or worsen, root canal therapy is usually repeated in case a root canal was missed, but alternative diagnoses (eg, temporomandibular disorder, occult tooth fracture, neurologic disorder) should be considered.
Very rarely, subcutaneous or mediastinal emphysema develops after compressed air or a high-speed air turbine dental drill has been used during root canal therapy or extraction. These devices can force air into the tissues around the tooth socket that dissects along fascial planes. Acute onset of jaw and cervical swelling with characteristic crepitus of the swollen skin on palpation is diagnostic. Treatment usually is not required, although prophylactic antibiotics are sometimes given.
Treatment references
1. Lockhart PB, Tampi MP, Abt E, et al. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling: A report from the American Dental Association. J Am Dent Assoc 2019;150(11):906-921.e12. doi:10.1016/j.adaj.2019.08.020
2. Wilson WW, Gewitz M, Lockhart PB, et al. Prevention of viridans group streptococcal infective endocarditis: A scientific statement from the American Heart Association. Circulation 18;143(20):e963-e978, 2021. doi: 10.1161/CIR.0000000000000969
Key Points
Pulpitis is inflammation of the dental pulp due to deep cavities, trauma, or extensive dental repair.
Sometimes infection develops (eg, periapical abscess, cellulitis, osteomyelitis).
Pulpitis may be reversible or irreversible.
In reversible pulpitis, the pulp is not necrotic, a cold or sweet stimulus causes pain that typically lasts 1 or 2 seconds, and repair requires only drilling and filling.
In irreversible pulpitis, the pulp is becoming necrotic, the stimulus (often heat) causes pain that typically lasts minutes, and root canal or extraction is needed.
Pulpal necrosis is a later stage of irreversible pulpitis; the pulp does not respond to hot or cold but often responds to percussion, and root canal or extraction is needed.
