Symptoms, causes and treatment of hypertrophic pulpitis. Symptoms and treatment of various forms of chronic pulpitis: fibrous, gangrenous, hypertrophic Chronic hypertrophic pulpitis treatment

It has two clinical forms: granulating (growth of granulation tissue from the cavity of the tooth into the carious cavity) and pulp polyp- a later stage of the course of the disease, when the overgrown pulp tissue is covered with oral epithelium. Epithelial cells are transferred from the gums, cover the entire surface of the protruding pulp and adhere tightly to it.

Complaints:

Aching pain from mechanical (when chewing) and sometimes temperature stimuli;
On the growth of "wild meat", bleeding during meals.

Anamnesis

Previously, spontaneous pain may be noted, which then decreased or disappeared completely.

Objectively:

Sounding:

The tooth cavity is opened, the carious cavity is filled with an overgrown pulp polyp;
Probing the polyp is not painful, but it bleeds heavily, probing the pulp in the cavity of the tooth is sharply painful;
When examining the legs of the polyp with a probe or trowel, the leg goes into the tooth cavity.

The color of the polyp is initially bright red, then with a pulp polyp it has a pale pink color (the color of a normal mucosa).

Percussion is painless

Palpation is painless

Thermodiagnostics - the reaction to temperature stimuli is not expressed.

On the radiograph - a deep carious cavity communicating with the cavity of the tooth, changes in the periapical tissues and in the region of the interradicular septum are not detected.

Chronic hypertrophic pulpitis more common in children and adolescents.

Differential diagnosis of chronic hypertrophic pulpitis

Chronic hypertrophic pulpitis differentiate from:

1. hypertrophy of the interdental papilla;

2. proliferation of granulation tissue from bifurcation, periodontium.

Differential diagnosis of chronic hypertrophic pulpitis with hypertrophy of the interdental papilla

1. bleeding during meals in the area of the causative tooth;

2. the presence of a carious cavity;

3. proliferation of soft tissue.

Differences:

1) the overgrown gingival papilla can be displaced with a tool or a cotton ball from the carious cavity and its connection with the interdental gum can be detected, and the hypertrophic pulp grows from the perforation of the roof of the tooth cavity;

2) on the radiograph with pulpitis, you can see the message of the carious cavity with the cavity of the tooth.

Differential diagnosis of chronic hypertrophic pulpitis with proliferation of granulation tissue from bifurcation, periodontium

1. the presence of granulation tissue protruding from the cavity of the tooth;

2. absence of spontaneous pains, spontaneous pains could be noted in the anamnesis;

3. carious cavity communicates with the cavity of the tooth, there is an overgrown soft tissue;

4. percussion is painless;

5. Probing is slightly painful or painless.

Differences:

1) probing in the area of perforation is less painful (like an injection into the gum) than in chronic hypertrophic pulpitis;

2) the level of perforation is most often below the neck of the tooth, and with hypertrophic pulpitis it is higher (at the level of the roof of the pulp chamber);

3) with the growth of granulation tissue from a bifurcation (trifurcation), in the presence of perforation in this area, as a rule, a complicated form of caries is detected at different stages of treatment. With partial necrectomy, the orifices of the canals are previously sealed or empty;

4) on the radiograph in chronic hypertrophic pulpitis, changes in the area of the interradicular septum and periapical changes are not determined, in the presence of granulations from the bifurcation in the hard tissues of the bottom of the tooth cavity - the focus of bone tissue destruction in the area of the bifurcation (interradicular septum), in the presence of granulations emanating from the periodontium , - focus of bone tissue destruction in periapical tissues;

5) indicators of EDI from tubercles with pulpitis are less, and with periodontitis more than 100 μA.

Complaints:

Aching pain from mechanical (when chewing) and sometimes temperature stimuli;
On the growth of "wild meat", bleeding during meals.

Anamnesis

Previously, spontaneous pain may be noted, which then decreased or disappeared completely.

Objectively:

Sounding:

The tooth cavity is opened, the carious cavity is filled with an overgrown pulp polyp;
Probing the polyp is not painful, but it bleeds heavily, probing the pulp in the cavity of the tooth is sharply painful;
When examining the legs of the polyp with a probe or trowel, the leg goes into the tooth cavity.

The color of the polyp is initially bright red, then with a pulp polyp it has a pale pink color (the color of a normal mucosa).

Percussion is painless

Palpation is painless

Thermodiagnostics - the reaction to temperature stimuli is not expressed.

On the radiograph - a deep carious cavity communicating with the cavity of the tooth, changes in the periapical tissues and in the region of the interradicular septum are not detected.

Chronic hypertrophic pulpitis more common in children and adolescents.

Differential diagnosis of chronic hypertrophic pulpitis

Chronic hypertrophic pulpitis differentiate from:

1. hypertrophy of the interdental papilla;

2. proliferation of granulation tissue from bifurcation, periodontium.

Differential diagnosis of chronic hypertrophic pulpitis with hypertrophy of the interdental papilla

1. bleeding during meals in the area of the causative tooth;

2. the presence of a carious cavity;

3. proliferation of soft tissue.

Differences:

2) on the radiograph with pulpitis, you can see the message of the carious cavity with the cavity of the tooth.

Differential diagnosis of chronic hypertrophic pulpitis with proliferation of granulation tissue from bifurcation, periodontium

1. the presence of granulation tissue protruding from the cavity of the tooth;

2. absence of spontaneous pains, spontaneous pains could be noted in the anamnesis;

3. carious cavity communicates with the cavity of the tooth, there is an overgrown soft tissue;

4. percussion is painless;

5. Probing is slightly painful or painless.

Differences:

1) probing in the area of perforation is less painful (like an injection into the gum) than in chronic hypertrophic pulpitis;

2) the level of perforation is most often below the neck of the tooth, and with hypertrophic pulpitis it is higher (at the level of the roof of the pulp chamber);

5) indicators of EDI from tubercles with pulpitis are less, and with periodontitis more than 100 μA.

Such a chronic form of pulpitis as hypertrophic pulpitis is rare. It develops in the case when timely treatment of fibrous pulpitis has not been carried out and is accompanied by inflammation of the pulp and its growth. Chronic hypertrophic pulpitis does not lead to severe pain, which significantly complicates its detection and timely provision of professional dental care. This is very bad, because pathology can lead to the development of flux or sepsis. Abnormally enlarged pulp tissue protrudes and can be easily infected.

Kinds

It is customary to distinguish two forms of this disease:

Granulating - characterized by the growth of granulation tissues and their germination outward, into the carious cavity;
Polyp - accompanied by oral epithelium covering the pulp tissue protruding from the carious cavity, and occurs as the disease progresses.

Clinical manifestations:

Little manifested pain symptoms arising from exposure to stimuli of various nature;
Pulp bleeding;
An almost completely destroyed tooth crown and a deep carious cavity from which the pulp protrudes;
Halitosis, which occurs due to the impossibility of carrying out full-fledged hygienic procedures of the oral cavity.

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Bagdasaryan Armen Evgenievich dentist-orthopedist-therapist, chief physician Graduated from VSMA them. N.N. Burdenko. Internship on the basis of MGMSU named after A.I. A.E. Evdokimov on "Dentistry of general practice". Clinical internship on the basis of the Moscow State Medical University. A.E. Evdokimov on "Orthopedics". Work experience: more than 16 years.

Sadina Ekaterina Vladislavovna dentist-therapist, surgeon Penza State University Medical Institute specialty "Dentistry" In 2016, she underwent professional retraining in the specialty "Therapeutic Dentistry" at the Moscow State Medical and Dental University named after A.I. Evdokimov Work experience: more than 7 years.

Arzumanov Andranik Arkadievich dentist-orthodontist Education - Graduated from MGMSU. Internship - MSMSU at the Department of Orthodontics and Children's Prosthetics. MGMSU residency at the Department of Orthodontics and Children's Prosthetics. Member of the Professional Society of Orthodontists of Russia since 2010. Work experience: more than 8 years.

Diagnostics

Diagnosis of hypertrophic pulpitis, first of all, involves an examination by a dentist. He collects an anamnesis and analyzes the nature of pain sensations, asking the patient about them. As a result, it is possible to establish that some time ago the patient experienced intense pain symptoms, which almost completely disappeared with time. During the examination, the dentist reveals a deep carious cavity, which contains bleeding granulations, the probing of which is not painful. When probing the pulp, intense pain occurs. When studying a polyp, it can be determined that it originates in the pulp chamber. If the pulpitis is at the initial stage of development, the germinated tissues are bright red in color, while the neglected one is light pink. Diagnostics also includes:

thermal tests (the result of which is negative);
radiography (in the picture of which the absence of a partition between the pulp and the carious cavity is clearly visible);
electroodontodiagnostics (which shows reduced pulp excitability).

Treatment

Treatment of hypertrophic pulpitis is carried out only by partial or complete removal of the pulp, i.e. using surgical techniques. Their choice is carried out individually, depending on the degree of soft tissue damage.

Vital extirpation

This technique involves the partial removal of the pulp from the mouth and crown part. The procedure is performed under local anesthesia and does not cause pain. Partial removal of the pulp allows you to save its functionality, and therefore - the tooth itself keeps alive. An important role is played by how tightly and correctly the medical pad was applied after removal of the pulp. Thanks to it, it is possible to eliminate the risk of infection of the pulp during the filling process and after it.

Devital extirpation

This technique is aimed at the complete removal of the pulp from the crown part, mouth and root part of the tooth. Removal is carried out in two stages using a devital paste, which the dentist applies to the pulp during the first visit. During the second visit, the dead pulp is removed, the dental canals are filled and the crown part of the tooth is restored.

Chronic pulpitis in dentistry is called inflammation that occurs in the pulp (soft tissue component) of the tooth. The abnormal process eventually leads to pathological changes in its structure. Pulpitis mainly affects patients aged 20 to 50 years, while most of the clinical cases are a fibrous or gangrenous form of inflammation, less than 1% of patients suffer from a pathology such as chronic hypertrophic pulpitis.

Causes and mechanism of the development of the disease

The occurrence of chronic hypertrophic pulpitis is associated with the formation of granulations in the lesion, resorption of dentin and its subsequent replacement with osteodentin. In the granulating form of the pathological process, granulation extends beyond the pulp into the carious cavity. If the patient suffers from polyposis HP, during the diagnosis, mushroom-shaped soft tissue growths covered with numerous ulcers are found.

HP can be the result of "local" dental problems or develop against a background of more serious systemic diseases. Exacerbation of hypertrophic pulpitis (hereinafter referred to as HP) without medical intervention leads to pulp gangrene. Chronic inflammation can be an independent pathology or be a consequence (complication) of another disease.

In dentistry, it is generally accepted that the chronicization of the inflammatory process occurs no earlier than 12 weeks after the onset of the acute phase, and is due to the incomplete elimination of "provocative" factors. HP, like any inflammatory process, is primarily caused by "attacks" of pathogens and their waste products (toxins). They enter the dental pulp with blood and lymph through the dentinal tubules.

Among the triggers for the development of chronic hypertrophic pulpitis are:

deep caries (including poorly treated);
tooth trauma (the pulp is exposed, the integrity of the neurovascular bundle is damaged);
periodontitis;
acute pulpitis;
increased tooth wear.

Important! Symptoms of HP can be a complication of other local inflammatory processes in the paranasal sinuses or oral cavity (due to the retrograde penetration of pathogens - pathogenic bacteria - into the pulp).

Signs of HP

Pain syndrome in most cases does not accompany the course of chronic HP. The main complaints of patients are related to the fact that extraneous tissue grows in the tooth, which is injured under functional load (during eating), and also bleeds constantly. Only sometimes a slight pain caused by pressure on the tooth is determined.

The course of GP of polyposis or granulating forms is not associated with bouts of intense pain in the affected tooth.

The color of the overgrown tissue in the granulation form of HP is bright red, even with light probing there is slight pain. Polyps, in turn, have a pale pink hue, are distinguished by a dense texture, do not bleed, and either do not hurt at all on palpation or percussion, or “respond” with slight discomfort.

Diagnostics

The dentist, first of all, is interested in the nature of the pain in the damaged tooth (if any), establishes a connection with such visible causes. An objective examination involves examining the “affected” tooth and probing its hypertrophied soft tissues. With GP, there is necessarily a significantly deepened carious cavity communicated with the pulp chamber. When probing, the soft tissue formation is painful and bleeds.

Depending on the form of the pathological process, polyposis or granulation tissue may protrude from the carious cavity.

An X-ray examination of a damaged tooth reveals changes in the form of an increase in the periodontal gap or detects foci with sparse bone tissue. Chronic GP is differentiated with deep caries, acute pulpitis or exacerbation of the chronic form of periodontitis. In addition, the differential diagnosis of HP is carried out with the growth of the gingival papilla.

Similar manifestations: the presence of a carious cavity filled with overgrown tissue, when probing, the hypertrophied pulp bleeds and slightly “responds” with pain (only if it is not a polyp). The list of differences in these pathological changes includes the following symptoms:

The overgrown papilla of the gums can be “displaced” from the carious cavity with the help of a dental instrument or a cotton swab, its connection with the interdental gum is detected. The hypertrophied pulp, in turn, grows from the opening of the dental crown.
A radiograph with GP shows the relationship between the dental and carious cavities.

GP of the granulation form is also distinguished from overgrown granulations in case of damage to the bottom of the tooth cavity. In both cases, the carious focus is filled with granulation tissue, which, when probed, opens local bleeding. At the same time, chronic GP is associated with acute pain during probing, the level of perforation is localized below the neck of the tooth, and in the case of GP, it is located much higher than that.

Granulating or polypous GP, if left untreated, leads to gangrene (death) of the pulp

Solution

Treatment of hypertrophic pulpitis, first of all, involves the relief of pain attacks (if any), as well as the fight against the local inflammatory process. The list of tasks to be solved by the dentist also includes the prevention of periodontal tissue damage and the restoration of the anatomical integrity and functions of the damaged tooth.

HP involves the vital extirpation of the dental pulp. The operation is performed under local anesthesia, necrotization of the soft tissue formation is not performed. After surgery, the doctor mechanically and with the help of medicinal formulations processes and seals the canals of the tooth, and at the last stage of treatment restores the dental crown.

Prevention and prognosis

Correctly selected timely treatment strategy for chronic GP allows you to save the tooth for many years and not damage its functionality. Advanced forms of the disease can result in a whole range of serious dental complications with unpredictable developments for the patient. The best prevention of HP in both children and adult patients is the treatment of caries and other dental diseases.

In addition, doctors strongly do not recommend enduring intense pain in the tooth for a long time, and immediately seek qualified medical help. Regular visits to the dentist's office, high-quality daily oral hygiene, as well as periodic professional removal of plaque help prevent pulpitis of any form.

Toothache can be caused by many different causes and factors, ranging from traumatic tissue damage to damage to the trigeminal nerve. One of the most common is chronic pulpitis, which can occur as a complication of an acute or as an independent disease. At the same time, there can be a huge variety of varieties and causes of the appearance of inflammatory processes. And the treatment of the disease is always carried out after a thorough diagnosis using modern technologies and examinations. You will learn about how chronic pulpitis is classified and treated from this article.

Disease Definition

The pulp is the inner soft tissue of the tooth, located directly under the enamel. It is made up of connective tissue and also includes nerves and capillaries. If an infection affecting the pulp enters the dental chamber, inflammatory processes develop, the totality of which is called pulpitis. In turn, the progression of chronic pulpitis is characterized by the persistence of inflammation and the alternation of stages of remission and exacerbation. The development of the disease causes tissue necrosis and the death of the pulp itself, as well as the destruction of the tooth crown.

Most often, chronic pulpitis is caused by pathogenic bacteria, as well as toxic substances produced by them in the process of life.

The infection can get directly into the dental chamber through a carious cavity or traumatic damage to the enamel and dentin.

Causes

As stated above, pulpitis is the result of infection of the pulp through the damaged enamel. In turn, a chronic disease is the result of a long absence of therapy for an acute lesion. Usually the process of transition to the chronic stage takes about twelve weeks and occurs if the factors of disease progression are not eliminated or not completely eliminated.

Risk factors increase deep caries, inflammatory diseases of the sinuses, periodontitis, osteomyelitis, periostitis.

Symptoms

Chronic pulpitis has several forms and their corresponding signs of progression. However, with each form there are stages of remission and exacerbation. During remission, the patient does not feel pain, but even during a period of calm, mechanical, chemical or thermal effects can cause an exacerbation. In such situations there are:

In addition, there is often a change in enamel (darkening is characteristic of pulp tissue necrosis), pain during meals.

Kinds

There are five main types of chronic pulpitis: gangrenous, fibrous, ulcerative, hypertrophic, granulomatous.

Gangrenous

In another way, this type of pathology is called ulcerative necrotic pulpitis. is a consequence of the development of acute purulent pulpitis and is characterized by gradual necrosis of the pulp tissue. The pain syndrome in this case occurs when exposed to temperature and disappears immediately after the source of irritation is removed. It can give to the temple, ear, jaw.

On examination, the doctor finds a deep carious cavity and a gray pulp inside. After the death of the crown part of the tooth and the opening of the carious cavity, the patient experiences some relief as soon as the purulent exudate comes to the surface.

The main method of treatment of the disease is the removal of the pulp. The viability of the pulp with gangrenous pulpitis is completely lost.

Fibrous

This type of pulpitis can occur as a complication of acute inflammation or bypassing this phase of progression. The pain syndrome in this case has a long-term course and occurs after the removal of a mechanical or thermal stimulus. On examination, a deep carious cavity is observed, while the pulp horn, as a rule, is not opened. A characteristic feature is the presence of proliferation of fibrous tissue that fills the pathological cavities of the tooth. The patient feels heaviness inside the tooth, as well as pulling pain, gradually turning into a permanent syndrome. In addition, a strong unpleasant odor is a common symptom of the disease. For more information on what fibrous pulpitis is, see.

Treatment of fibrous pulpitis is performed surgically. In this case, not only the overgrown pathological tissue is removed, but also the pulp. A temporary filling can be applied and then replaced with a permanent one.

hypertrophic

Treatment

Therapy of chronic inflammation is carried out with the solution of the following tasks:

elimination of inflammation and pain syndrome;
procedures for restoration of dentine and tissue healing
preventive measures for warning ;
tooth crown restoration using special formulations.

Surgical

Direct surgical complete or partial removal of the nerve is a rather laborious process. The procedure is performed under local anesthesia and involves further medical and instrumental treatment of the canals. The most commonly used methods are:

The method involves the imposition of a composition based on arsenic for two days. After necrotization of the nerve, its direct removal is carried out, followed by cleaning of the canals and the installation of seals.

After the treatment, it is important to visit the dentist's office additionally as a preventive measure to prevent complications.

Possible Complications

There are two possible types of complications of chronic pulpitis:

early complications. They occur immediately after the filling is placed and manifest themselves in constant aching pain and discomfort. Among the main reasons for the appearance of drug treatment, mechanical damage to tissues during treatment, separation of nervous tissue.
Late. Complications of this type occur with poor-quality treatment of the disease and are characterized by further progression of inflammation.

Complications can also occur in the absence of treatment. In this case, fluxes (purulent cavities), cysts, purulent fistulas are formed. These processes are accompanied by sharp and aching pains, general malaise, difficulties while eating.

Prevention

Significantly reduce the likelihood of chronic pulpitis is possible with the following preventive measures:

regularly visit the dental office (at least twice a year);
take multivitamin complexes and minerals to prevent enamel damage;
establish a system of proper balanced nutrition;
eliminate in a timely manner;
Establish proper oral hygiene and, if possible, brush your teeth after each meal;
avoid traumatic situations for the teeth.

Video

For more information regarding the technology of treatment of chronic pulpitis, see the video

Conclusion

Chronic pulpitis is most often the result of the progression of acute inflammation of the nerve, but in some cases it may develop bypassing the acute stage.
A characteristic feature of pulpitis is the occurrence of pain during mechanical and thermal effects. This phenomenon is used to diagnose the disease.
Most often, the treatment of the disease is based on the removal of the pulp, followed by cleaning the canals and placing a seal.
Different types of chronic pulpitis have their own external signs and symptoms that allow them to be diagnosed. Treatment should be based on diagnostic results.
In advanced cases, antibiotics and immunostimulants may be prescribed. Read more about pills for pulpitis.