Pulpitis treatment. Modern classifications of pulpitis
Reproducing in dentin, microorganisms produce enzymes that affect cells, fibers and the main substance of the pulp, destroying, inactivating or modifying them. Irritation of the autonomic nerves leads first to a slowdown in blood flow, then to the expansion of blood vessels due to their overflow with blood. Plasma begins to seep through the walls of the capillaries into the surrounding tissues and spreads between the odontoblasts. Gradually accumulating fluid separates the odontoblasts from the dentin, and on the preparations one can observe a rupture of the pulpodentinal membrane. In odontoblasts, changes occur due to an increase in the number of metabolites and shifts in osmotic pressure. With a serious injury, the core is also damaged. The cell swells, its structures are injured: the cytoplasm turns from a gel-like form into a solution, leading to the release of cellular ingredients into the main substance. Metabolites secreted by damaged cells excite nerve fibers, which, acting on the muscle elements of blood vessels, cause their expansion. The permeability of capillaries that do not have muscle cells also increases. Increased vascular permeability allows plasma proteins and leukocytes to move from the bloodstream to the inflammatory focus, neutralizing, weakening the action of the stimulus and exposing microbial cells and toxins to phagocytosis. A weak inflammatory process can be stopped due to the fact that tissue regeneration occurs simultaneously with the decay.
If the stimulus is not completely eliminated, a kind of equilibrium is established between the protective factors of the tissue and the stimulus. It is characterized by the presence of cells of a special kind - protective (small round cells). In the future, there is a proliferation of fibroblasts that produce collagen fibers. At the same time, new blood vessels form, creating an extensive blood supply system. This tissue is called granulation tissue.
With a strong influence of pathogenic factors, cells are damaged, die, producing autolysis products, which, in turn, have a harmful effect on other cells, fibers and the main substance. Polymorphonuclear leukocytes, which neutralize the action of the stimulus, disintegrate themselves within a short time, releasing enzymes. All damaged tissue is digested. The resulting pus contains necrotic particles, microorganisms, etc. The condition qualifies as purulent inflammation, which characterizes an irreversible process in the pulp.
If dental caries is chronic, the pulp reacts with the deposition of sclerosed dentin in the primary dentinal tubules, as well as the formation of reparative (protective) dentin under the area of the affected tubules. If the progression of caries is not balanced by the formation of reparative dentin, the pulp vessels dilate, signs of chronic inflammation appear. The reaction is initially weak, but as the pulp is irritated by decay products, a pronounced damage to the pulp occurs. In superficial ulceration, deep layers of tissue can remain intact due to the formation of a demarcation line. This zone is infiltrated by leukocytes, as well as fibroblast proliferation of collagen fibers. In some areas, this boundary is not sufficiently reliable, then the damage to the pulp extends deeper.
The progression of the inflammatory process causes colliquatative tissue necrosis in the central region. Insufficient collateral blood circulation and unyielding walls of the pulp chamber impede the outflow of inflammatory exudate, which leads to a local increase in tissue pressure. The products of autolysis freely diffuse into the surrounding fluids, and eventually the cells disappear. If necrosis proceeds with an open cavity of the tooth, then only scanty remnants of the pulp can be clinically detected.
Disruption of the blood supply to the pulp without primary infection (for example, in trauma) can lead to ischemic necrosis. Cells do not die immediately, but intercellular enzymes cause coagulation of the cytoplasm and nuclei (cell pycnosis). In this case, the main structure of the pulp is preserved for a long period of time. Accession of infection destroys the demarcation line and leads to collication necrosis.
Necrosis can occur without clinical symptoms of pulpitis under a carious lesion with a loose seal due to the fact that thousands of dentinal tubules provide centrifugal movement of the CSF from the pulp to the oral cavity. The outflow of fluid reduces the pain reaction. A similar situation is typical for a tooth with an open pulp chamber in the absence of irritants. Pulp inflammation is clinically evident after the filling material seals the dentinal tubules.
International classification of dental diseases based on ICD-10 (WHO, Geneva, 1997)
K04 Diseases of the pulp and periapical tissues
K04.0 Pulpitis
K04.00 Initial (hyperemia)
K04.01 Acute
K04.02 Purulent (pulp abscess)
K04.03 Chronic K04.04 Chronic ulcerative
K04.05 Chronic hyperplastic (pulp polyp)
K04.08 Other specified pulpitis K04.09 Pulpitis, unspecified
K04.1 Pulp necrosis
Pulp gangrene
K04.2 Pulp degeneration
Denticli
Pulp calcifications Pulp stones
K04.3 Improper formation of hard tissues
her in the pulp
K04.3X Secondary or irregular dentin Excluded: pulpal calcifications (K04.2), pulpal stones (K04.2)
K04.4 Acute apical periodontitis of pulpal origin
Acute apical periodontitis
K04.5 Chronic apical periodontitis
Apical granuloma
K04.6 Periapical abscess with fistula
K04.7 Periapical abscess without fistula
K04.9 Other and unspecified diseases of pulp and
riapic tissues
The manual provides formulations corresponding to ICD-10, as well as clinical diagnoses adapted to them, specifying the localization, etiotropic factor, pathogenetic mechanisms, severity and nature of the course. Thus, the extended diagnosis "Acute partial serous pulpitis" explains the possibility of treating a tooth while maintaining the viability of the pulp, and the diagnosis "Chronic pulpitis complicated by periodontitis" characterizes both the need for anesthesia and the level of canal filling at a distance of 1.0-1.5 mm from the radiographic tops.
Initial pulpitis (hyperemia). Complaints of acute pain in the tooth arising from irritants (often thermal, mechanical). After elimination of the factor, the pain is retained for a short time. Unpleasant sensations persist after eating. There may be complaints about the presence of aesthetic defects: a cavity, a change in the color of the enamel, a poor-quality filling. In history - symptoms of caries of the dentin: strictly causal pain, disappearing after the removal of the stimulus. Examination reveals a carious cavity of considerable depth. The tooth can also be sealed, rarely intact. The bottom and walls of the cavity are light or pigmented. Probing the cavity is painful at one point or along the entire bottom. A directed jet of refrigerant or the introduction of a swab moistened with cold water into the cavity causes pain, which is retained for a short time after the removal of the irritant. The reaction to percussion of the tooth is negative. Electrical excitability is reduced to 12-15 μA. On the radiograph, an area of enlightenment is found at the site of the carious cavity, there is no communication between the cavity and the pulp chamber, there are no changes in the periodontal gap.
Acute pulpitis. The main symptom is acute, spontaneous, paroxysmal pain. The attack is also provoked by thermal and mechanical stimuli, does not disappear after the removal of the influencing factor. Night pain is typical. The disease lasts from 1 day to 2-3 days. In the anamnesis, the symptoms of caries most often predominate: short-term causative pain; possible severe trauma to the tooth. On examination, a carious cavity, a filling, an intact tooth, an artificial crown can be determined, and the tooth is at the stage of treatment, for example, with a temporary filling. In any case, the pulp does not communicate with the carious cavity. Probing the bottom of the cavity is painful, the reaction to thermometry is positive. The electrical excitability of the pulp is reduced. No changes in the periodontium are noted on the radiograph.
Partial serous pulpitis. Complaints of acute, paroxysmal, spontaneous pain. Night pains are typical. Attacks are short-term (minutes last), light intervals are long (hours). Exposure to mechanical stimuli, as well as cold and hot, causes an attack of pain. The tooth disturbs no more than 1 day. History of short-term, strictly causal pain. Possible acute injury (impact or iatrogenic factors). If a cavity is found during examination, then probing is painful at one point of the thinned dentin near the pulp. There is no communication of the carious cavity with the pulp. Thermometry is painful. Pain does not disappear after removal of the irritant. In all cases, the pain is strictly localized - the patient points to the causative tooth. Percussion is negative. The electrical excitability of the pulp is reduced to 20 μA.
General serous pulpitis. Complaints of acute, spontaneous, paroxysmal pain. The attack is also provoked by thermal and mechanical stimuli. Night pain is typical. The attack can last up to an hour or more, light intervals are short (minutes). The duration of the attack gradually increases, the light intervals are reduced. The pain radiates along the branches of the trigeminal nerve. The patient cannot pinpoint the exact causative tooth. In history - symptoms of partial pulpitis more often due to caries.
Trauma, preparation, filling, prosthetics are possible.
On examination, a carious cavity, a filling, an intact tooth crown, an artificial crown can be determined, and the tooth may be at the stage of treatment. In any case, the pulp does not communicate with the carious cavity. Probing the bottom of the cavity is painful. The reaction to thermometry is sharply positive. The pain persists after the elimination of irritants. Percussion is negative or slightly positive (vertical). The electrical excitability of the pulp is reduced to 30-40 μA. The differential diagnosis is based on the main symptoms: spontaneous attacks of pain that increase over time; reduced electrical excitability of the pulp.
Purulent pulpitis. Complaints of sharp, throbbing, unbearable pain. Seizures are long. Moreover, the pain does not disappear completely, but only subsides for a short period of time (minutes). Worse from hot (warm). Characterized by a decrease in pain from cold. The irritation spreads to the surrounding areas, radiates along the branches of the trigeminal nerve, so the patient does not indicate the causative tooth. In the anamnesis, as a rule, causative pains are initially short-term, then spontaneous, paroxysmal, nocturnal. The development of pulpitis from 1 to 3 days.
Examination can reveal a varied picture. More often there is a carious cavity of considerable size or a filling. The tooth is in the stage of treatment, rarely intact, depending on the ways in which the infection spreads. The reaction to thermal stimuli is characterized by a decrease in pain from applying a swab moistened with cold water. Probing the bottom of the cavity is painless. The pulp chamber is closed. Perforation of the bottom of the carious cavity leads to the appearance of a drop of pus and a decrease in the intensity of toothache. Vertical percussion of the tooth is painful as a result of perifocal inflammation in the periodontium. The electrical excitability of the tooth is reduced to 60 μA. X-ray shows no changes in the apical periodontium. On the part of the general condition, irritability, fatigue can be noted - the result of a sleepless night. It is necessary to differentiate purulent pulpitis with purulent periodontitis, neuralgia. Leading in the diagnosis are signs from the pulp: the paroxysmal nature of the pain, decreasing from the cold. The electrical excitability of the pulp is reduced, but partially preserved.
Chronic pulpitis. Pain in the tooth is causal (from thermal, mechanical stimuli). After elimination of the factor, the pain does not disappear, remaining for some time. The nature of the sensations is aching pain, strictly localized. The patient easily points to the diseased tooth. During the examination, the reaction to probing and thermometry is positive. The electrical excitability of the tooth is reduced.
Chronic (fibrous) pulpitis. Complaints are characterized by the appearance of aching pain after exposure to thermal stimuli (for example, cold, hot or mechanical factors - food bolus entering the carious cavity). After elimination of the irritating factor, the pain lasts for several minutes. In the anamnesis, the appearance of a carious cavity is noted, treatment or prosthetics may have been carried out. On examination, a cavity of considerable size, filled with carious dentin, is most often determined. The tooth may be filled or the caries treatment has not been completed. In the presence of a cavity, probing the bottom is sharply painful at one point. In this case, a drop of blood may appear if there is a communication between the carious cavity and the pulp chamber. The tooth reacts to cold, and the pain does not immediately disappear after the removal of the stimulus. Percussion of the tooth is painless. The electrical excitability of the pulp is reduced to 20-30 μA. On the roentgenogram, there are no changes in the periodontal fissure, communication of the carious cavity with the pulp chamber can be detected. Simple chronic (fibrous) pulpitis must be differentiated from caries. The leading symptom is a causative aching pain that continues after the elimination of the irritating factor.
Chronic hyperplastic pulpitis. Complaints of aching pain from mechanical and thermal stimuli. Sensation of a foreign body or soft tissue growth in the tooth. Mechanical influences, including eating, brushing teeth, cause bleeding. In the anamnesis, there may be acute pain from irritants, as well as pain that occurs spontaneously (paroxysmal). The tooth can be treated for caries or pulpitis, but the treatment is not complete.
On examination, a carious cavity filled with pink or gray granulation tissue is always found. Probing is painful to varying degrees, causing bleeding from hyperplastic tissue. The reaction to thermometry can be more or less pronounced. Percussion of the tooth is usually painless, in some cases sensitive. The electrical excitability of the pulp varies considerably from 2 to 20 μA. On the radiograph, a wide communication of the carious cavity with the tooth cavity is found. There may be no changes in the periodontal gap, less often bone tissue resorption is determined in the region of the root apex. In this case, chronic pulpitis complicated by periodontitis is diagnosed.
It is necessary to carry out differential diagnostics with the growth of the interdental papilla into the carious cavity or the germination of the connective tissue from the periodontium through the perforation of the bottom of the tooth cavity. The growth of the interdental papilla into the cavity of the tooth occurs only when it is localized on the proximal surface. When you try to circle the probe around the neck of the tooth, the formation is forced out of the carious defect. On the radiograph, no fistulas of the carious cavity with a pulp chamber are found. In the clinic, there are cases when hyperplasia of the gingival papilla and dental pulp are combined. The germination of connective tissue through the perforation of the bottom of the pulp chamber is diagnosed on the basis of the x-ray picture: dentin resorption in the area of bifurcation or trifurcation.
Chronic ulcerative pulpitis. The pains are aching in nature, arising from thermal and mechanical stimuli. Getting a food lump into the tooth causes a feeling of pain and fullness. There is an unpleasant smell, especially when "sucking from the tooth." In the anamnesis, both causative and spontaneous acute paroxysmal pains are noted. Often, unfinished tooth treatment is found out. On examination, a carious cavity communicating with the pulp chamber is often determined. However, the cavity may be closed. Painfully deep probing of the coronal pulp. When exposed to thermal stimuli, aching pain occurs, which does not disappear after the removal of the stimulus. Percussion of the tooth is painless, rarely slightly sensitive. The electrical excitability of the pulp is reduced to 40 μA. On the radiograph, the message of the tooth cavity and carious defect is often determined. Changes in the periodontal gap is not detected.
Ulcerative pulpitis must be differentiated from chronic (fibrous) pulpitis. The main diagnostic features are mild pain during surface probing and electrical excitability of more than 40 μA. It is difficult to diagnose pulpitis in a sealed tooth. In the first place are aching pains from thermal stimuli, reduced electrical excitability, radiologically intact periodontium.
Pulp necrosis (gangrenous pulpitis). Complaints of aching pain from thermal (especially hot) and mechanical stimuli. Getting into the tooth of a food lump causes a feeling of fullness. An unpleasant odor is characteristic, especially when “sucking from the tooth”, a change in color of the tooth is possible. In the anamnesis, both causative and spontaneous acute paroxysmal pains are noted. Often, the fact of incomplete tooth treatment is clarified.
When examining the tooth, a carious cavity is determined, widely communicating with the pulp chamber. Painfully deep (in root canals) probing. When exposed to thermal stimuli, aching pain occurs, which does not disappear after the removal of the stimulus. Percussion of the tooth is painless or slightly sensitive. The electrical excitability of the pulp is below 60 μA. The radiograph reveals a wide communication of the tooth cavity and carious defect. In 30% of cases, changes in the periodontium are found in the form of bone tissue resorption in the apical region. Diagnosis of pulpitis of a sealed tooth is difficult. Significant symptoms are aching pain from thermal stimuli (especially hot), reduced electrical excitability.
Gangrenous pulpitis must be differentiated from chronic periodontitis. The main diagnostic signs are aching pains in response to thermal stimuli, painful deep probing, electrical excitability of about 60 μA.
Pulp degeneration (concremental pulpitis). Complaints about short-term acute pain attacks in the tooth that occur with sudden movements of the head, which is associated with the formation of mineralized dentine-like inclusions in the pulp - denticles. The illness can last for months or even years. Symptoms increase or decrease with time depending on the location of the denticle (free, parietal, at the mouths of the canals).
On examination, the tooth is intact, there is no abrasion due to the high mineralization of tissues, however, increased abrasion of enamel and dentin is possible. Denticles are often formed against the background of periodontitis, especially with severe dystrophic disorders. Probing of exposed dentin, tooth thermometry can be painful due to hyperesthesia of exposed tissues. Percussion is painless. The electrical excitability of the tooth is normal or reduced (20 μA). Changing the position of the head provokes a short-term pain attack. A “chair symptom” is described: when the patient is sitting, tilting back the back of the dental chair causes pain in the tooth (this test is contraindicated for patients with vascular diseases, disorders of the vestibular apparatus, etc.). On the radiograph in the cavity of the tooth, areas characterized by the presence of dense inclusions are found. The latter are more often single, can lie freely or are attached to the walls. Their boundaries are clear, even or blurry. In some cases, denticles fill the entire cavity of the tooth.
Concremental pulpitis must be differentiated from acute pulpitis, which is characterized by a rapid increase in clinical manifestations. It is difficult to distinguish between the symptoms of pulp degeneration and trigeminal neuralgia. However, neuralgia is characterized by the presence of trigger (starting) zones that are absent in pulpitis.
Exacerbation of chronic pulpitis. Complaints of acute, spontaneous, paroxysmal pain. The attack is provoked by thermal and mechanical stimuli. Night pain is typical. The duration of the attack gradually increases, light intervals are reduced, complaints of sharp, throbbing, unbearable pains appear, which do not disappear completely, but only subside for a short period of time (minutes). Typically reduced pain from cold. The irritation spreads to the surrounding areas, radiates along the branches of the trigeminal nerve, so the patient does not indicate the causative tooth. In the anamnesis, complaints characteristic of chronic pulpitis are noted: causative aching, slowly subsiding pains.
On examination, a carious cavity, a filling, an intact tooth or an artificial crown can be determined. The tooth may be in the process of being treated. Communication of the carious cavity with the pulp chamber is possible. Probing the bottom of the cavity is painful. The reaction to thermometry is sharply positive. A situation is possible when the reaction to thermal stimuli is characterized by a decrease in pain from applying a tampon moistened with cold water. Vertical percussion of the tooth is painless or sensitive as a result of perifocal inflammation in the periodontium. The electrical excitability of the pulp is reduced to 40-60 μA. X-ray shows no changes in the apical periodontium. An exception is the complication of pulpitis with periodontitis, which may be accompanied by bone resorption in the periapical region of the root.
It is necessary to differentiate the exacerbation of chronic pulpitis from acute forms of pulpitis, purulent periodontitis, and neuralgia. The leading symptoms in the diagnosis are aching causal pain in history, its paroxysmal nature in the present. The electrical excitability of the pulp is reduced, but partially preserved.
According to WHO statistics, every fifth inhabitant of the Earth at least once faced such a problem as pulpitis. Pulpitis is the case when the disease itself “pushes” the patient to the doctor, and rarely anyone succeeds in ignoring these signals, because almost always this problem signals its appearance with pain, often unbearable. Therefore, even those patients who are ready to drink "packs" of painkillers, just to bypass the dental office, with such symptoms still strive to get an appointment with a dentist as soon as possible. Pulpitis requires immediate medical intervention, since the further development of this disease promises serious complications, up to the complete loss of the tooth. This disease has been sufficiently studied and, thanks to modern technologies and methods, can be effectively treated.
History reference
In ancient times, humanity did not yet know the term "pulpitis", but they were familiar with toothache on "YOU" in different parts of the world. The main means of getting rid of it was the extraction of a tooth. In some countries, "with a curative purpose" were used conspiracies and rituals with sacrifices. In ancient Egypt, according to information found in ancient papyri, doctors were looking for ways to help the patient with anti-inflammatory ointments containing the juice of various plants, and pastes made from myrrh, ashes, pumice and eggshells.
In the 1st century A.D. The personal physician of the Roman emperor Trajan, the surgeon Archigen, drilled a tooth for therapeutic purposes. Approximately in the 150-160s. the famous physician and philosopher of antiquity, Claudius Galen, described in his writings the differences between pulpitis and periodontitis, but this knowledge was forgotten for a long time. In the 9th century in the Middle East, the physician and pharmacist Mohammed al Rashid advised using arsenic to destroy the dental nerve that causes pain to the patient. But in European countries, this method became known much later.
In the 11th century, in some European countries, caries and the pulpitis caused by it were “treated” with laxatives and enemas, and if this did not help, they cauterized the pulp with a hot iron with “anesthesia” in the form of using alcohol-containing compounds before manipulations or even hitting the head through a plank , the so-called Rausch anesthesia (Rausch).
In the 15th century, a professor at the University of Bologna repeated the experiment described by Archigen - he removed the affected dental tissue by drilling, after which he cauterized the pulp and sealed the tooth cavity with gold.
Pierre Fauchard, a French doctor who lived in the 18th century, learned to identify 102 types of toothache, studied and practiced various methods for its elimination, and became the founder of the “dental” patient fit. Before him, the patient was laid on a table or sat on the floor, holding his head between his knees, and P. Fauchard insisted that the patient in this position experiences unwanted nervousness and it is necessary that he sit in a chair, and the doctor should stand next to him.
After 1871, when James Morrison patented the dental drill, restorative dentistry began to develop rapidly. Tools, equipment, drugs for pain relief, technologies began to appear, some of them are still actively used by dentists. To date, modern dentistry has effective methods, modernized tools, advanced technologies, with the help of which dental diseases, including pulpitis, can be effectively treated.
Pulp Anatomy
In the bowels of the tooth, under the layer of dentin, there is a pulp, which consists of soft, loose, fibrous connective tissue, dotted with blood and lymphatic vessels, as well as nerve endings that go from the jaw through the root canal through the apical foramen.
pulp ( lat. pulpis dentis) - the "heart" of the tooth, reliably protected by powerful dental walls of bone tissue from external factors, nourishing the tooth with minerals, ensuring its growth, restoration, and vitality. It is important to note that the pulp is not only a space of soft tissue (pulp chamber), but also a dental canal connected to it. The pulp chamber is a loose amorphous colloidal system containing loose, fibrous connective tissue, as well as a large number of elastin and collagen fibers. The cellular composition of this system contains histocytes, mast cells, macrophages, as well as collagen-producing and intercellular communication fibroblasts. The superficial layers of the fibrous structure of the pulp contain odontoblasts - cells with long processes located in the dentinal canals. These processes make the dentin sensitive to any irritants. A little deeper are stellate cells, and the central layer contains collagen and nerve fibers and blood vessels. If an inflammatory process begins in the pulp, then leukocytes appear in the structure, lymphocytes and plasma cells are activated.
In addition to providing nutrition to the tooth, the pulp performs several other important functions. Plastic, which is responsible for the delivery of "building" proteins, is provided by the activity of odontoblasts involved in the formation of dentin: before the eruption of the primary tooth, after eruption - the secondary one. The protective function of the pulp is carried out by macrophages, lymphocytes and fibroblasts. Macrophages “utilize” dead cells and, together with lymphocytes, are responsible for immune responses, while fibroblasts produce and maintain the required balance of the intercellular substance of the pulp, which is responsible for metabolic processes in it. In general, the protective function of the pulp is to create a barrier for the penetration of pathogenic bacteria that have got through the dentin further, along the root canal into the periodontium, and then to the soft tissues surrounding the tooth. In addition, the protective function includes the regeneration of the so-called replacement (tertiary) dentin: when caries occurs, this dentin prevents it from spreading deep into the tooth. The trophic function of the pulp, affecting the metabolism and nutrition of the tooth, supporting the vital activity of tooth enamel, is ensured by the activity of a developed vascular system, characterized by thin vessel walls, high blood flow velocity and, accordingly, higher pressure than in other organs. The sensory function of the pulp is carried out due to the activity of a large number of nerve fibers, which, like a fan, diverge from the apical opening to the periphery of the pulp.
Very often, the pulp is called the “dental nerve”, because its sensitivity to any irritants is so high that inflammation, as a response to a bacterial, viral, infectious attack, occurs almost immediately. Such inflammation in medical terminology is called pulpitis.
Pulpitis: definition, causes, signs, consequences
Pulpitis is an inflammation of the pulp that occurs due to an infection entering it through the crown of the tooth (intradental infection) or through the apical opening located at the top of the tooth (retrograde infection). Most often, pulpitis is the result of a long-term developing caries.
But there are other factors that provoke the appearance and development of this disease. Modern dentistry divides them into 3 main groups:
To physiological include overheating of the pulp and / or accidental opening of the tooth cavity during preparation, fracture of the coronal part with the opening of the pulp chamber, the presence of decalcified formations in the pulp - calcifications (denticles and petrificates), which, being deposited in it, irritate nerve endings, compress blood vessels, disrupt blood flow cause swelling, discomfort and pain.
To chemical factors include iatrogenic factors caused by doctor's mistakes in the treatment process: the use of strong antiseptic solutions for treating the carious cavity, incomplete removal of the etching gel, etc.
Biological factors include factors that create conditions for infection to enter the pulp: secondary, the spread of infection from the carious cavity through the dentinal tubules, retrograde pulpitis, when the infection penetrates the pulp through the apical opening in sepsis, osteomyelitis, through the lateral branches of the root canal - when (after curettage).
The most common symptom of pulpitis is an intolerable throbbing pain as a reaction to one or another stimulus: temperature, chemical (sweet food intake), mechanical (teeth brushing, etc.). Such pain does not go away on its own, and pain medications often do not help. However, such pain is characteristic not only for pulpitis, but also for other diseases. Therefore, it is very important that if pain occurs, you should immediately contact your dentist to determine the cause of the pain and begin treatment. If the disease is not treated, the inflammatory process becomes more intense and spreads to the periodontium, which leads to periodontitis. Remember: acute toothache requires immediate medical attention, without attempting self-treatment.
Types of pulpitis
To date, the main classification that defines diseases, including pulpitis, and its types, is the International Classification of Diseases and Related Health Problems, developed by the World Health Organization of the tenth revision (ICD-10). Also, the authoritative classification among dentists in Russia is MMSI, developed in 1989 at the Research Institute. N. A. Semashko. one
According to the international classification of ICD-10 accepted clinically and legally, pulpitis (K04.0) as a disease is distinguished by several types, but this classification has some discrepancies with the MMSI classification:
K04.00- initial (pulp hyperemia) / according to MMSI - deep caries
K04.01- acute / according to MMSI - acute focal pulpitis. Acute pulpitis is a frequent complication of deep caries and is characterized by severe pain, aggravated by exposure to the tooth. According to the MMSI classification, the first stage of acute pulpitis is focal pulpitis, which lasts no more than 2 days. Due to the proximity of the carious cavity to the pulp, there is a sharp “shooting” short-term (10-30 minutes) pain of a spontaneous and cyclical nature: it occurs arbitrarily, without affecting the tooth, and also arbitrarily disappears to reappear after some time. It "covers" one tooth, not spreading to neighboring teeth and tissues.
K04.02- purulent (pulp abscess) / MMSI - acute diffuse pulpitis. This is the next stage of the disease, when the inflammation spreads to the root of the pulp. The pain becomes radiating - spreading along the branches of the trigeminal nerve, it “gives” to the area of \u200b\u200bother teeth, to different parts of the jaw, to the cheekbones, to the temples, to the back of the head, to the ears, its attacks become more frequent (especially at night), and the intervals between them are shorter (30-40 minutes) - d diffuse pulpitis. If the patient notes that hot food and drink increase pain, and cold food and drink relieve it, this often indicates that a purulent stage of pulpitis or a pulpal abscess has come. This stage lasts a maximum of 14 days, after which the pulpitis passes into the chronic stage.
K04.03- chronic / according to MMSI - chronic fibrous pulpitis: this is a long inflammatory process, lasting from 2-3 weeks to several years. Toothache at this stage becomes less pronounced, "blunts", aggravated during chewing, bleeding of the pulp and fragility of the hard tissues of the tooth may appear. This also correlates with the first stage of chronic pulpitis according to the MMSI classification - fibrous pulpitis, which often proceeds secretly, does not show itself in any way, or signals mild discomfort and pain. On examination at this stage, a large carious cavity is almost always found, which in many cases is connected to the pulp chamber. The pulp is painless, pain appears only when you touch it, slight bleeding is possible.
K04.04- chronic ulcer /according to MMSI - chronic gangrenous pulpitis. This stage of the development of the disease is characterized by atrophy of the nerve fibers of the pulp, a change in its color to dirty gray, increased pain, and the appearance of bad breath. Examination also reveals an extensive and deep carious cavity.
K04.05- pulp polyp / according to MMSI - chronic hyperplastic pulpitis. FROM stage, on which the connection of the carious cavity with the pulp is always found, tissue growth, the formation of a painful and bleeding polyp when pressed, filling the free space of the pulp chamber.
K04.08- other specified pulpitis (retrograde, traumatic, residual)
K04.09- pulpitis, unspecified
K04.1- Pulp necrosis (pulp gangrene). It is considered to be the final stage of chronic pulpitis, which is characterized by signs of acute and chronic diseases at the same time. Attacks of acute pain intensify and become more frequent, soft tissues are affected by necrotic changes, the bone tissue of the tooth is intensively destroyed, periodontal infection is often detected during examination.
K04.2- pulp degeneration (denticles, pulp petrifications)
K04.3- improper formation of hard tissues in the pulp(secondary or irregulatory dentin) 2 .
Pulpitis, as well as most diseases in principle, progresses and worsens, moving from one stage to another, but at present, modern dentistry has methods that allow in some cases to treat this disease, while maintaining the viability of the pulp. Chronic pulpitis in 90% of cases is irreversible and the only way out is to remove the pulp.
Pulpitis treatment methods
All methods of treatment of pulpitis can be divided into two main ones - biological, aimed at treating and restoring the pulp, and operative, involving its partial or complete removal in order to save the tooth. Only a qualified dentist can determine which method to use in each specific case on the basis of a thorough diagnostic examination.
biological method- This is a method of conservative treatment, with the help of which the inflammatory process is eliminated, and the pulp retains its viability. So, the affected pulp is subjected to alkalization, after which secondary dentin begins to be produced in it again. The biological method is effective only if the patient comes to the dentist-therapist immediately after the onset of a pain symptom. The treatment of pulpitis with a biological method is more effective in people at a young age (up to 30 years), when the pulp is capable of self-healing, in the absence of chronic diseases and sufficient caries resistance (resistance to caries). The treatment takes place according to the following algorithm: the pulp is opened, treated with an antiseptic solution, a bandage with calcium hydroxide is applied on top, the cavity is closed with a temporary filling, which after some time changes to a permanent one.
The biological method is rather complicated in execution and requires high professionalism of the attending physician. In general, this technique is characterized by low predictability of a positive treatment outcome. And even with rich clinical experience, this method is not always effective. Because of these reasons, this method of treatment is not very popular, and often doctors, bypassing it, immediately proceed to a more radical and predictable surgical method for treating pulpitis.
Operational Method consists in removing the affected pulp, cleaning the canals, sanitation from infection and subsequent filling of the canals of the tooth. The operational method combines several methods.
Amputation is prescribed in cases of acute pulpitis or accidental pulp injury and involves the removal of the coronal part of the pulp while maintaining the viability of its root section. This technique is suitable only for the treatment of pulpitis of multi-rooted teeth. Amputation happens vital("life-saving") is when part of the "dental nerve" is removed under anesthesia immediately. In this case, a necessary condition for the operation is a completely healthy periodontium. And devital(“stopping life”) - when the pulp is mummified using a special paste. After that, one section of the “dental nerve” is removed, and the second is subjected to mummification so that in the future this part does not become a source of pulpitis recurrence. This technique is rarely used in clinical practice, since this method is quite controversial and the possibility of relapse is not excluded. Therefore, for a more effective treatment of pulpitis, a more radical method of treating pulpitis is often used. - extirpation.
Extirpation -
complete removal of the pulp when it is impossible to maintain its viability. Extirpation, as well as amputation, is of 2 types - vital and devital. At vital extirpation, which is carried out under anesthesia in one visit, the pulp is not mummified before being removed from the cavity. The dentist removes carious dental tissue, after which he penetrates the canals with the help of special thin needles and removes the affected “dental nerve”, after which he treats the cavity with antiseptics. This technique is used for all forms and stages of pulpitis.
At devital extirpation the pulp is first mummified with a paste containing arsenic, paraformaldehyde, or another similar substance. On single-rooted teeth, the paste should remain for at least 24 hours, on multi-rooted teeth - at least 48. Some soft-acting pastes can be left for 7-14 days. The cavity of the tooth is closed with a temporary filling. After the expiration date of the paste, the doctor removes the pulp, cleans the channels and installs a permanent filling.
Method devital extirpation pulpitis can be cured in 2-3 visits, depending on the number of roots in the diseased tooth. Devital extirpation is suitable for the treatment of all types and stages of pulpitis, except for purulent and necrotic, and is also not used in the treatment of milk teeth. With the development of technology, this method in modern dentistry is also becoming less popular and, perhaps, can be found in remote areas from the centers of regions.
The final stage of endodontic treatment of a tooth is filling (obturation) of tooth canals, which requires high qualification of the attending physician. Regardless of which method of vital or devital extirpation the pulp is removed, special attention is paid to canal filling. After all, the main task is to prevent periodontal infection. Obturation of the root canal of the tooth can be carried out by the following methods - filling with one paste without pins and using gutta-percha pins in various variations, filling using heated gutta-percha with its vertical seal, on a carrier (thermophile), using the System B device, a combined technique , or filling with gutta-percha from a syringe. The choice of methodology and materials always remains with the attending physician based on his preferences, clinical experience, level of training and the possibilities of the clinic.
After carrying out all medical manipulations with the tooth, the final event is the imposition / installation of a permanent filling in accordance with the aesthetic, individual and clinical features.
Attention:
A temporary filling that covers the cavity of the tooth, where the active substance “killing the dental nerve” is located in the root canals, can be very durable and can last for several months. At the same time, the pain that disturbed disappears and the patient does not experience any discomfort, and therefore postpones the next visit to the doctor for an indefinite period. Remember, in no case should such funds be allowed to remain in the pulp chamber for a longer period than was established by the doctor. It is necessary to come to the dental office on the appointed date and complete the treatment!
Also, each patient must remember and know that it is necessary to appear without fail for a control appointment after depulpation, strictly on the appointed day by the attending physician. Since the patient himself is unable to independently distinguish the normal physiological state of the tooth after the treatment of pulpitis from the pathological one.
Complications: pain of a pulpless tooth
After removing the pulp, followed by filling the canals and restoring the crown of the tooth, the patient may still experience pain, especially when biting. If the pain disappears within a week, this is normal. If the pain after 5-7 days continues to disturb, this may indicate poor-quality treatment and / or filling. For example, the filling material was removed beyond the top of the root and got into soft tissues, or during the removal of pathologically affected tissues, the tooth root was accidentally damaged, or the patient is allergic to filling materials. Also, with insufficiently thorough processing and / or filling of the dental canals, pulpitis can turn into.
Methods used in the clinic
We are adherents, first of all, of effective and then modern methods of treatment that are able to quickly, qualitatively and radically eliminate the cause of pulpitis and its consequences. But, in our work, we always try to "save" the pulp and preserve its viable properties by conservative methods and use them in all cases when possible. 
At the same time, if the removal of the dental nerve seems to be the only solution according to indications, in many cases we apply effective anesthesia of the “dental nerve”, after which we carry out its removal. We are convinced that advanced methods do not negate classical methods, but only complement, optimize, and improve them. That is why in our clinical practice we always try to follow the “classic” treatment algorithm. Its first stage is a full complex clinical diagnostics.
The treatment is carried out using and with the use of, perhaps, the most modern instruments, which makes it possible to eliminate carious lesions without missing a single micron of the affected tissue, flexible and thinnest endodontic needles, for the most effective cleaning of the canals, and, of course, the safest filling materials.
It is worth noting that filling includes work in the canals and in the crown part of the tooth. If suddenly the patient has some deviations from the normal course of the adaptation process, patients can be prescribed conservative anti-inflammatory therapy, physiotherapy with ozone or laser treatment.
Age restrictions
Pulpitis can occur in anyone at any age. The conservative method of treatment of this disease has no age restrictions. When choosing a surgical method in patients older than 45 years, it is necessary to take into account the condition of periodontal tissues.
Treatment of pulpitis in children with milk teeth has its own characteristics. So, the inflammatory process in milk teeth arises and spreads rapidly and does not always depend on the depth of the carious lesion and the visible tissues affected by caries. In this case, it is extremely important to stop the spread of infection to the periodontal tissue, since the rudiments of already molars are formed in this tissue. However, those affected by pulpitis are used only in rare cases, since the absence of each dental unit has a negative effect on the formation of bite. In the treatment of pulpitis of milk teeth, filling pastes are used that do not affect the rudiments of molars, but are absorbed along with the “milk” roots when the change of teeth begins. Anesthesia should be carried out with the obligatory consideration of possible allergic reactions.
Indications
Indications for manipulations with the dental pulp are: a pulp horn accidentally opened during the preparation of a carious cavity, acute pulpitis, chronic pulpitis, pulp injuries, including, sometimes, the need to prepare teeth for prosthetics. Depending on the established diagnosis, the dentist-therapist determines which set of therapeutic measures to use in a particular case.
Contraindications
There are no absolute contraindications in the treatment of pulpitis. Severe general somatic conditions, diseases after time and / or appropriate training, with the involvement of highly specialized specialists, can be eliminated, leveled, after which the treatment of pulpitis can be successfully carried out.
Price
Many factors influence the cost of pulpitis treatment. First of all, these include the form and stage of pulpitis, diagnostic measures that allow you to establish an accurate diagnosis and choose the most appropriate method of treatment. In addition, the medicines, materials, equipment and instruments used during treatment are important. Not the last role is played by the qualification of the doctor, additional consultations of narrow specialists, as well as therapeutic measures accompanying the main treatment, if necessary.
Many patients think that toothache is a temporary "little thing in life" that can be overcome with the use of modern pain medications. But this illusion is quickly dispelled as soon as a person experiences unbearable pain ... Remember that the sudden appearance of a toothache is in all cases a serious signal that warns of the presence of some kind of pathology in the maxillofacial system. In many cases, this pathology turns out to be pulpitis - a disease that, if not treated in a timely manner, can lead to many complications, including tooth loss. But only a qualified doctor can establish the exact cause, after a thorough diagnostic examination. Therefore, visit the dentist's office as soon as possible. Your efficiency, combined with modern methods of treatment and the professionalism of a doctor, is a guarantee that the disease that caused the pain will be completely cured and will not deprive you of the beauty of a full-fledged smile.
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1
Therapeutic dentistry. Diseases of the teeth: textbook: in 3 hours / ed. E.A. Volkova, O.O. Yanushevich. - 2013. - Part 1.).
2 http://mkb-10.com
* Images:
- Domenico Ricucci, José Siqueira, “Endodontology. Clinical and biological aspects”, Publishing house “Azbuka”, Moscow, 2015. A book for dentists - endodontists. Edition in Russian, translated from English, 415 pages, 1682 illustrations, hardcover. The original edition of Endodontology: An Integrated Biological and Clinical View (Ricucci, Domenico and Siqueira Jr, Jose) was published in 2013.
- Database of clinical photo protocols of Dr. Edranov; Personal archive of S.S. Edranova.
Pulpitis- inflammatory disease of pulp tissues (Fig. 5.1). By origin, infectious, traumatic and drug pulpitis are isolated.
Rice. 5.1. Chronic hyperplastic pulpitis
5.1. CLASSIFICATION OF PULPIT
In the literature, there are several dozen systematizations of diseases of the pulp. This number can be explained by the variety of types of pulp lesions, etiology, clinical manifestations and pathomorphological signs. Classifications of diseases of the pulp can be divided according to the following criteria.
1. According to the etiological factor: infectious (microbial), chemical, toxic, physical (thermal, traumatic, etc.), hemato- and lymphogenous, iatrogenic.
2. According to morphological features: hyperemia of the pulp, exudative (serous, purulent), alterative (ulcerative, gangrenous, pulp necrosis), proliferative (hypertrophic, fibrous, granulating, granulomatous), dystrophic (pulp atrophy).
3. Topographic and anatomical:
a) partial, limited, local, superficial, coronal;
b) general, total, diffuse, spilled, etc.
4. Clinical (pathophysiological): acute, chronic, aggravated, open, closed aseptic, complicated by periodontitis.
One of the first common classifications is the classification of E.M. Gofunga (1927). It is built taking into account the fact that in different clinical manifestations of pulpitis there is a single pathological process: inflammation of the pulp with the transition from the serous stage to the purulent stage in the acute course, to proliferation or necrosis in the chronic course.
Classification E.M. Gofunga (1927)
1. Acute pulpitis: partial, general, purulent.
2. Chronic pulpitis: simple, hypertrophic, gangrenous.
Classification E.E. Platonov (1968)
2. Chronic pulpitis: fibrous, gangrenous, hypertrophic.
3. Exacerbation of chronic pulpitis. MMSI classification (1989)
1. Acute pulpitis: focal, diffuse.
2. Chronic pulpitis: fibrous, gangrenous, hypertrophic, exacerbation of chronic pulpitis.
3. Condition after partial or complete removal of the pulp.
International classification of dental diseases ICD-C-3, created on the basis of ICD-10
K04.0. Pulpitis.
K04.00. Initial (hyperemia).
K04.01. Spicy.
K04.02. Purulent (pulp abscess).
K04.03. Chronic.
K04.04. Chronic ulcer.
K04.05. Chronic hyperplastic (bullets paired polyp).
K04.08. Another specified pulpitis.
K04.09. Pulpitis, unspecified. K04.1. Pulp necrosis.
Pulp gangrene. K04.2. Pulp degeneration.
Denticli.
pulpal calcifications.
pulp stones.
5.2. PULPIT PATHOGENESIS
5.3. DIAGNOSIS OF PULPITIS
Pulp necrosis (pulp gangrene) (K04.1) (chronic gangrenous pulpitis)
Chronic hyperplastic (pulp) polyp (K04.05)_ (chronic hypertrophic pulpitis) _
5.4. DIFFERENTIAL DIAGNOSTICS OF PULPITS
5.5. METHODS OF TREATMENT OF PULPITS
In the treatment of pulpitis, it is necessary to solve the following tasks: eliminate the pain symptom, eliminate the focus of inflammation, protect periodontal tissues from damage, restore the integrity, shape and function of the tooth.
All methods of treatment of pulpitis can be systematized (Scheme 5.1).
Scheme 5.1. Pulpitis treatment methods
Table 5.1. Calcium containing preparations for dental pulp capping
Table 5.2. Medications for drug treatment and washing of root canals
CLINICAL SITUATION 1
Patient V., 24 years old, came to the clinic with complaints of severe spontaneous paroxysmal pain in tooth 36, prolonged pain from temperature stimuli, pain in this tooth at night.
According to the patient, the tooth hurts for the 2nd day. Previously noted the presence of a cavity in this tooth.
On examination: on the chewing surface of tooth 36 there is a deep carious cavity filled with softened dentin. Probing the bottom of the cavity is sharply painful at one point, the reaction to cold is long, percussion of the tooth is painless.
Make a diagnosis. Perform differential diagnosis. Make a treatment plan.
CLINICAL SITUATION 2
Patient K., 37 years old, came to the clinic with complaints of severe prolonged pain in the teeth of the upper jaw on the left, radiating to the temple. Attacks occur both in the daytime and at night, the pain is aggravated by temperature stimuli.
From the anamnesis: about a week ago, there was an acute pain in tooth 24. He did not go to the doctor, he took analgesics, which relieved the pain for a short time. The attacks became longer, and pain appeared in neighboring teeth, the pain began to radiate to the temple.
On examination: in tooth 24 there is a deep carious cavity on the posterior contact surface, filled with softened dentin. Probing the bottom of the cavity is sharply painful throughout the bottom, the reaction to temperature stimuli is long, percussion is painful.
Make and justify the diagnosis. Define the stages of endodontic treatment. Name the dental preparations used at the stages of treatment.
GIVE ANSWER
1. The peripheral zone of the pulp is formed by cells:
1) pulpocytes;
2) odontoblasts;
3) osteoblasts;
4) fibroblasts;
5) cementoblasts.
2. Complete preservation of the dental pulp is possible with:
1) acute focal pulpitis;
2) acute diffuse pulpitis;
3) acute periodontitis;
4) chronic gangrenous pulpitis;
5) chronic hypertrophic pulpitis.
3. To make a diagnosis of pulpitis, an additional research method is used:
1) clinical blood test;
2) serological blood test;
3) blood test for glucose content;
4) electroodontodiagnostics;
5) bacterioscopy.
4. Pulp electrical excitability in purulent pulpitis (μA):
1)2-6;
2)10-12;
3)15-25;
4)25-40;
5) more than 100.
5. In acute pulpitis, probing the carious cavity is most painful in the area:
1) enamel-dentine connection;
2) the neck of the tooth;
3) projections of one of the processes of the pulp;
4) enamel;
5) the entire bottom of the carious cavity.
6. Persistence of pain after elimination of the irritant is typical for:
1) dentine caries;
2) pulp hyperemia;
3) acute pulpitis;
4) acute periodontitis;
5) chronic periodontitis.
7. Attacks of spontaneous pain occur when:
1) enamel caries;
2) dentine caries;
3) pulp hyperemia;
4) acute pulpitis;
5) chronic pulpitis.
8. Differential diagnosis of purulent pulpitis is carried out with:
1) dentine caries;
2) acute pulpitis;
3) chronic periodontitis;
4) chronic gangrenous pulpitis;
5) chronic hyperplastic pulpitis.
9. Chronic fibrous pulpitis is differentiated from:
1) dentine caries;
2) necrosis (gangrene) of the pulp;
3) enamel hypoplasia;
4) chronic periodontitis;
5) radicular cyst.
10. The method of vital pulp extirpation is to remove the pulp:
1) under anesthesia;
2) without anesthesia;
3) after the use of arsenic preparations;
4) after applying paraformaldehyde paste;
5) after the use of antibiotics.
11. Detection of the mouths of the root canals is carried out using:
1) root needle;
2) boron;
3)probe;
4) an example;
5) K-file.
12. To expand the mouths of the root canals use:
1) K-file;
2)H-file;
3)probe;
4) Gates glidden;
5) root needle.
13. Immediately before filling, the root canal is treated:
1) hydrogen peroxide;
2) ethyl alcohol;
3) sodium hypochlorite;
4) distilled water;
5) camphor-phenol.
14. The root canal with inflammation of the pulp is sealed:
1) to the anatomical top;
2) to the physiological top;
3) outside the opening of the top of the tooth;
4) not reaching 2 mm to the opening of the top of the tooth;
5) 2/3 length.
RIGHT ANSWERS
1 - 2; 2 - 1; 3 - 4; 4 - 4; 5 - 3; 6 - 3; 7 - 4; 8 - 2; 9 - 2; 10 - 1; 11 - 3; 12 - 4; 13 - 4; 14 - 2.
A COMMON PART
DIAGNOSTICS
Diagnostics (end)
TREATMENT
Treatment (end)
MANAGEMENT PLAN INFORMATION SUPPORT
Justification of the management plan: evaluation of the effectiveness of recommended diagnostic and therapeutic measures
DIAGNOSTICS
Diagnostics (end)
TREATMENT
Treatment (continued)
Treatment (end)
Ensuring patient safety
PATIENT SAFETY: WHAT NOT TO DO IN WHEN PULP DEGENERATION K04.2
Patient safety: what not to do with pulp degeneration K04.2 (denticles, pulpal calcifications, pulpal stones) (end)
Brief information note
Pulpitis (K04.0 according to ICD-10)- this is inflammation of the dental pulp (pulpitis from lat. pulpitis): a complex vascular, lymphatic and local reaction to an irritant. The prevalence of pulpitis, according to different authors, is 30% or more. In the general structure of dental care in terms of negotiability, pulpitis occurs in all age groups. Untimely treatment of this disease leads to the development of apical periodontitis, radicular cysts and, as a result, to the extraction of the causative tooth.
Main symptoms. K04.2 pulp degeneration (denticles, pulpal calcifications, pulpal stones) is usually asymptomatic. It is determined only when the pulp chamber is opened or by an accidental X-ray examination.
Etiology. The etiological factor leading to such a response of the dental pulp is inflammation of the pulp with the influence of exotoxins of microorganisms during a long-term carious process, abrasion of teeth, and chronic trauma. All this affects the function of odontoblasts. However, there is no final opinion on the etiology and pathogenesis of degenerative changes in the pulp today. Pulp stones can also form in an intact tooth with a live, normal pulp. You can see them only on a histological preparation. The denticle located in the pulp chamber and pulpal calcifications in the root canal can be seen on an x-ray or computed tomography. The formation of degenerative changes in the pulp does not depend on age.
Level of evidence (source)
Many are familiar with the situation when the fear of dental treatment makes you postpone visiting the dentist indefinitely. It may not disturb anything for a while, but suddenly there is such an unbearable toothache that the sufferer immediately consults a doctor. Often the diagnosis is pulpitis. Pulpitis is called inflammation of the neurovascular bundle of the tooth. It has a certain classification.
- infectious;
- traumatic;
- retrograde;
- aggravated.
Basically, pulpitis occurs with complicated caries, when the hard tissue of the teeth is very strongly destroyed. The infection in the carious cavity contributes to the inflammation of the pulp.
In addition, this disease is often occurs as a result of medical error, for example, if the filling is installed poorly or during the treatment of caries, the pulp was opened carelessly. Also, the tooth can be injured due to impact.
Very rarely, but the infection can penetrate the vessels along with the blood from the side of the root.
Inside the tooth itself, a hard formation called a denticle may appear. It also promotes inflammation of the pulp.
Symptoms
Inflammation of the pulp is accompanied by unbearable pain, which sometimes subsides. The pain is especially annoying at night and the body temperature may rise.
In the initial stage of inflammation, periodic aching pains occur. The advanced stage is characterized by an increase in pain, which gradually becomes longer and pulsating. For the chronic form of inflammation, pain is characteristic only during exacerbation. Pus is formed, and if you press a little on the aching tooth, pain immediately arises.
Classification
Modern dentistry has several dozens of the most diverse classifications of pulpitis. This happens because There are many types of pulp lesions., as well as the ways of their formation. Many in their own way define the classification of pulpitis.
The following classifications are considered the most popular:
- Platonov's classification;
- classification according to ICD-10;
- Gofung classification.
Platonov's classification.
As a result of this classification, pulpitis is divided into the following types and forms:
- acute (focal and diffuse);
- chronic (fibrous, gangrenous and hypertrophic);
- chronic in the acute stage.
Acute pulpitis is characterized by intense throbbing pains that occur in attacks. At first, the pain is short, and the period of calm can last a long time. Then inflammation of the pulp begins to progress, the pain becomes stronger and longer, and the period of calm is getting shorter. A sick tooth begins to hurt from interaction with hot water.
Chronic pulpitis proceeds sluggishly, almost painlessly. External irritants do not greatly disturb the aching tooth. The color of the tooth changes, the pulp is significantly exposed, you can even see the orifices of the root canals.
Exacerbation of chronic pulpitis has all the symptoms of acute. The only difference is that the pain practically does not go away. Outwardly, the tooth looks the same as with chronic inflammation of the pulp.
Classification according to ICD-10.
The World Health Organization proposes the following classification:
- pulp inflammation;
- diseases of the pulp and periapical tissues;
- pulp hyperemia;
- spicy;
- chronic;
- purulent, pulpy abscess;
- chronic ulcerative pulpitis;
- pulp recrosis;
- pulp polyp;
- other specified pulpitis;
- unspecified pulpitis;
- improper formation of hard tissues in the pulp;
- pulp degeneration.
This qualification has a distinctive feature - changes in the pulp of the tooth, before the appearance of systematic pain, were identified as a separate category.
Gofung classification.
The most popular classification of pulp inflammation among dentists. It perfectly reflects all stages of the course of the disease.
Acute pulpitis.
Partial. If there is an acute partial inflammation, then the changes in the pulp are completely reversible. If you immediately consult a doctor as soon as the pain appears, then it is possible to heal a tooth and save the nerve.
General. Acute general inflammation of the pulp is characterized by diffuse inflammation that completely covers the pulp. According to the characteristic features, acute general pulpitis almost impossible to distinguish from the onset of purulent destruction therefore resort to the surgical method of treatment.
O general purulent. This stage is characterized by the development of pathology of an irreversible nature, it is because of this that vital extirpation is considered a method of treatment. The doctor should pay special attention to the prevention of periodontitis.
Chronic pulpitis.
Simple.
Hypertrophic. Both this and the first form are successfully treated surgically, preserving the root sections of the pulp.
Gangrenous. The most severe form of chronic inflammation. The treatment here is extirpation. This form is characterized by the maximum saturation of the walls of the root canals with pathogenic microflora. Treatment is carried out in several stages. it contributes to the prolonged action of antiseptics which reduce the risk of complications after filling.
MMSI classification.
It is very similar to the Gofung classification, only some points of exacerbation of chronic inflammation of the pulp are added and the peculiarities of the occurrence of inflammation in a previously treated tooth are taken into account.
- acute (serous, focal purulent, diffuse purulent);
- chronic (fibrous, gangrenous, hypertrophic);
- exacerbation of chronic pulpitis (fibrous, gangrenous);
- condition after removal of the pulp - partial or complete.
Exacerbation of fibrous pulpitis usually does not have such a destructive effect as an exacerbation of gangrenous. In the latter option, there is a high degree of periodontal complication.
The tooth begins to strongly resist filling the channels, severe pain appears when it is sealed with a temporary filling. This is due to the fact that the anaerobic microflora feels great when isolated from the external environment.
It often happens that removing part of the pulp does not relieve inflammation. This happens due to the fact that the diagnosis is incorrect or the treatment technology is violated. In this case, the complete removal of the tooth along with the roots helps.
Thus, we conclude that the treatment of pulpitis at an early stage contributes to the preservation of the nerve which nourishes the tooth and ensures its vital activity. Therefore, at the very first signs of pulpitis, you should immediately consult a doctor.
