Pulpitis of permanent teeth in children. Patterns of clinical manifestations in children of all ages. The clinic, diagnosis, differential diagnosi.The method of treating pulpitis of permanent teeth in children depending on the form of pulpit and stage of development of the tooth. Treatment of pulpitis of permanent teeth in children. Conservative method. Indications, methods of implamentation, monitoring performance prediction. The dentin–pulp complex: structures, functions and responses to adverse. The extent to which the dental pulp will sustain impairment in the clinical setting depends on its potential to oppose bacterial challenges and withstand injury by various forms of trauma. To understand the biological events that operate and most often prevent the pulp from suffering a permanent breakdown, the specific biological functions of both dentin and pulp under pathophysiological conditions will be addressed in this chapter. These two tissue components of the tooth form a functional unit that often is referred to as the dentin–pulp complex .Constituents and normal functions of the dentin–pulp complex Dentin and dentinal tubules. Dentin provides elasticity and strength to the tooth that enable it to withstand loading forces by mastication and trauma. Dentin also elicits important defense functions aimed at preserving the integrity of the pulp tissue.
Under normal, healthy conditions, when dentin is covered by enamel and cementum, fluid in the dentinal tubules can contract or expand to impinge on the cells in the pulp in response to thermal stimuli applied on the tooth surface. Hence, dentin of the intact tooth can transform external stimuli into an appropriate message to cells and nerves in the pulp – a feature that is useful clinically to test its vital function. A sensory transducer function triggered by elastic deformation is also in effect to detect overload resulting in reflex withdrawal and sharp transient pain. When enamel and cementum are damaged for any reason, the exposed dentinal tubules serve as pathways to the pulp for entry of potentially noxious elements in the oral environment including bacterial macromolecules, which may provoke inflammation . The deeper the injury the more tubules become involved. In the periphery there are about 20 000 tubules per square millimeter, each having a diameter of 0.5 μm. At the pulpal ends the tubular apertures occupy a greater surface area because the tubules converge centrally and become wider (2.5–3 μm) (20). Thus, at the inner surface of dentin there are more than 50 000 tubules per square millimeter. In root dentin, especially towards the apex, the tubules become more widely spaced. Also, in the pulpal portion of root dentin they are thinner and have a smaller diameter (ca. 1.5 μm). There are extensive branches between the tubules that allow intercommunication. Movement of particulate matter and macromolecules by way of the dentinal tubules may occur not only from the external environment to the pulp but also in the opposite direction. Hence, following injury which has resulted in disruption of the tight junctions that normally hold the odontoblasts together , fluid in the pulp may enter the tubules and bring plasma proteins with antimicrobial properties . The potential for elements to permeate the dentinal tubules is normally greatly restricted by a variety of tissue structures, including collagen fibers and cellular processes. The odontoblasts normally extend cytoplasmic processes into the tubules. Controversy exists, however, as to how far.
While some believe that these processes extend all the way to the enamel or cementum junctions others contend that only the innermost part (0.5–1 mm) of dentin is filled . A large number of the tubules also contaierve terminals. Furthermore, cells belonging to the immunosurveillance system of the pulp extend dendrites into the tubules of the predentin layer .Consequently, the space available in the tubules for the transport of particulate matter and macromolecules is normally much smaller than the tubular space per se. This is especially true at their pulpal ends.The odontoblast – a multifunctional cell
The most recognized function of the odontoblasts is to form and maintain dentin. Like many other tissue supporting cells, odontoblasts also contribute to hostdefense. By lining the periphery of the pulp with cellular extensions into dentin they are, thus, in the unique position of being the first cell to encounter and react to noxious elements entering dentin from the oral environment. Upon challenge the odontoblasts generate and release a multitude of molecules that can help todefeat invading microorganisms. The response also gives rise to activation of specific receptors present on adjacent cells, vessels, nerves and on the odontoblast itself. Thus, the odontoblasts, together with local resident defense cells and blood-borne invading cells, have a broad repertoire of response patterns and play important roles in activating both innate and adaptive immune responses of the pulp .
Dentin formation
The original odontoblasts, here also termed primary odontoblasts, produce dentin both during tooth development and after completion of root formation. The fact that intratubular cellular processes stay behind makes dentin tubular iature. Owing to the continued function of the odontoblasts, the pulpal space gradually narrows over time and in old individuals it may become so small that endodontic treatment is difficult. The odontoblasts may also produce new dentin at an increased rate in response to mild stimuli: e.g. during initial precavitated stages of enamel caries; by slowly progressing caries in general; or following a shallow preparation for restorative purposes. This type of new dentin has been termed reactionary dentin.
Nerves
Pulpal nerves monitor painful sensations. By virtue of their peptide content they also play important functions in inflammatory events and subsequent tissue repair. In addition, they control dentin formation . There are two types of nerve fiber that mediate the sensation of pain: A-fibers conduct rapid and sharp pain sensations and belong to the myelinated group, whereas C-fibers are involved in dull aching pain and are thinner and unmyelinated. The A-fibers, mainly of the A-delta type, are preferentially located in the periphery of the pulp, where they are in close association with the odontoblasts and extend fibers to many but not all dentinal tubules. The C-fibers typically terminate in the pulp tissue proper, either as free nerve endings or as branches around blood vessels. Nerves belonging to the autonomic nervous system, such as sympathetic vasoconstrictor fibers, are also present . They enter the pulp together with blood vessels and sensory axons. Histochemically, they can be traced in the pulp via their content of noradrenaline and neuropeptide Y. Upon release, these substances result in contraction of the smooth-muscle sphincters in arteries and small arterioles apical to and within the pulp. Both sensory and sympathetic nerves stimulate dentin formation as evidenced by reduced dentin formation in the absence of sensory nerves and after sympathectomy, respectively. Sensory and sympathetic nerves also interact in pulpal inflammation. For example, an intact innervation is significant for recruitment and activation of cells of the immune system . As yet, there is little evidence that parasympathetic vasodilator blood flow control plays an important role in the local function and defense of the pulp.
Vascular supply
Current knowledge of the vascular architecture of the pulp has been influenced greatly by the use of the microvascular resin cast method. This techniqueallows resin to fill up even the smallest capillaries of the pulp(Fig. 2.11). A vascular cast is then obtained, which, following corrosion of surrounding tissue structures, can be examined in the scanning electron microscope. In all developmental stages the crown pulp shows a larger vascular network than the root pulp. In more central portions of the pulp the vascular network is less dense than in peripheral pulp. Anastomosis between incoming and outgoing blood vessels has been observed in the central pulp of adult animal teeth and seems to be more frequent in the apical pulp than in the crown pulp. Shunt connections between supplying and draining pulpal vessels have also been found just outside the apical foramen in the periodontal ligament . It is reasonable to assume that these shunts provide control of blood perfusion through the pulpal tissue. Hence, in the case of a local inflammatory event causing increased resistance to pulpal blood flow, arteriovenous shunts may come into play and redirect incoming blood.
Fig. Series of microphotographs of the vascular network in the pulp of teeth. (a) In the young tooth of dogs there is a dense terminal capillary network in
the pulp–dentin border zone. (b) The superficial capillary network in the odontoblast region in a view perpendicular to the pulpal surface. (c) Blood vessels in the distal root canal of a mature dog premolar. The superficial capillaries drain directly into large venules (V). In the mature tooth, continuous dentin formation and narrowing of the pulp cavity lead to remodeling of the vascular tree. (d) The vascular network of an adult human tooth. With a narrow apical foramen, the number of arterioles is reduced to 5–8 and venules to 2–3 (40). The number of main vessels, arterioles and venules in the central pulp is also reduced and the typical hairpin loops of the terminal capillary network become less pronounced. The detailed vascular architecture of the pulp is similar in cat, dog and human teeth. (Courtesy of Dr K. Takahashi.)
Pulpitis: What’s the Difference Between Reversible Pulpitis and Irreversible Pulpitis? There are lots of different reasons why you might feel pain coming from your tooth. One of the more common reasons is called pulpitis. Pulpitis is an inflammation of the dental pulp. Dental pulp is the portion of your tooth that has blood vessels and nerves in it. It is the core of your tooth that nourishes the hard parts of the tooth. Normally when parts of our body get hurt, they get red. This is a process called inflammation. Our body sends blood and defense cells to the site of injury so that our body can begin the healing process. This works great on most parts of the body. However, sometimes it’s not so good when it happens inside our teeth.
When the dental pulp gets irritated, our body responds by sending extra blood and defense cells to the pulp. When inflammation occurs on any other part of our body, there is room for expansion. For example, if we hurt our finger, our finger gets a red and puffy as it starts to heal. When we irritate our teeth and the pulp gets inflamed, the pulp doesn’t have anywhere to go — the pulp is surrounded by a very strong and hard tooth. This increase in pressure can push on the nerves that run inside the dental pulp. Since the nerves in the pulp are only capable of sending the signal of pain our brains, we feel pain. The inflammation also makes our teeth more sensitive. Things that normally wouldn’t hurt a tooth all of the sudden start to cause pain. For example, breathing in cold air, drinking hot drinks or chewing food can cause pain. This is pulpitis, an inflammation of the dental pulp. There are two types of pulpitis: irreversible and reversible.
Reversible Pulpitis
Reversible pulpitis is simply a mild inflammation of the dental pulp. It can be caused by anything that irritates the pulp. Some common causes of reversible pulpitis are:
• Cavities that haven’t reached the nerve yet.
• Erosion of the tooth that reaches the dentin
• Drilling done by a dentist when doing a filling or crown preparation on the tooth
• A fracture of the enamel layer of the tooth which can expose the dentin
Getting your teeth cleaned (scraped!) by a dental hygienist, especially when they clean the roots if you have periodontal disease. The symptoms of reversible pulpitis can range from nothing at all to a sharp pain when they are stimulated by things that otherwise wouldn’t cause pain to your teeth. When you eat ice cream, and the cold causes a sharp pain in a tooth that quickly goes away when you swallow the ice cream, chances are that you have reversible pulpitis. Unlike in irreversible pulpitis, the pain usually goes away a few seconds after the stimulus is removed.
Luckily, reversible pulpitis gets its name due to the fact that it is reversible – it can go away if the cause of it is taken away. For example, if you brush, floss and use a restoring mouthwash, you could re-mineralize the cavity that is just beginning and heal it. If this was causing your reversible pulpitis, then the reversible pulpitis will go away.
All you have to do to cure reversible pulpitis is to find the cause of the inflammation, and get rid of it. Irreversible pulpitis is a severe inflammation of the dental pulp. Irreversible pulpitis is often occurs after reversible pulpitis when the cause of the pulpitis has not been removed. So, irreversible pulpitis can be caused by everything that causes reversible pulpitis and the following:
• When a dentist needs to remove lots of dentin due to big cavities and gets really close to the pulp.
• When the blood flow to the pulp gets decreased or removed. This could be caused by orthodontic treatment, such as braces, that makes the tooth move so fast that the blood vessels can’t keep up and the pulp’s blood supply gets cut off. It could also be caused by trauma that severs the blood vessels and slowly kills the pulp.
• Very deep cavities that go through the enamel and all the way through the enamel right into the pulp. The bacteria then cause inflammation in the pulp. The more the body tries to fight off the bacteria, the higher the pressure gets inside the tooth until the pressure may strangle the blood vessels and cause the pulp to die. The symptoms of irreversible pulpitis can range from no symptoms at all to an excruciating spontaneous pain. The tooth can be very sensitive to the slightest temperature change, such as breathing in room-temperature air. The pain usually lingers as well. For example, if you’re eating ice cream and the pain stays for longer than five to ten seconds after you’ve swallowed the ice cream, it could be a sign of irreversible pulpitis.
Back in February 2007, I had a bad case of irreversible pulpitis. I had a deep cavity that the dentist filled, but it was so deep that a little bit of bacteria had made it into the pulp. At first, my tooth was slightly sensitive to cold. It would hurt in the morning when I would drink orange juice. After a few weeks, it got so bad that I woke up in the middle of the night with a throbbing pain in my mouth. A few days later, I went to an endodontist and had a root canal performed. Once you have irreversible pulpitis, there’s no cure. The only way to fix it is to have a root canal treatment performed (wehre the dentist or endodontist removes the dead pulp and fills it up with a rubber material) or to have the tooth extracted.
Conclusion
If you start to feel pain, it is best to get in touch with your dentist. A small amount of pain (like that seen in reversible pulpitis) is normal following a filling or deep cleaning. If the pain persists, you may want to meet with your dentist to try to figure out the cause of the pain before your pulpitis progresses to irreversible pulpitis and you have to have a root canal treatment or get the tooth extracted.
Pulpitis
This is the inflammation of the pulp, or nerve chamber inside the tooth creating pain and pressure. The pressure created can cause problems with the nerves of the tooth. The pulp is the inner part of your tooth that protects the nerve endings. This problem can be treated if caught early, and usually doesn’t result in further problems once addressed.
Causes of Pulpitis:
• Bacteria reaches deep into the structure of the tooth
• Trauma to the tooth
• Lots of treatments such as dental tooth fillings or dental crowns
Symptoms of Pulpitis
There usually pain when a stimulus is placed near the tooth. The tooth normally reacts to heat or sugar. When the pulpitis is not too advanced the pain disappears as soon as the problem is taken away. When the pulpitis is advanced, and potentially irreversible, the pain lingers for some time. You may not be able to locate the exact tooth causing the problem. In severe cases pain will be found in areas seemingly unconnected with the affected tooth, such as the face. Dental abscesses can occur when pulpitis is advanced.
Pulpitis Treatment
Reversible pulpitis is treated in the same way as a normal filling would be. The affected area is treated, decay is removed via drilling and then the cavity left is filled. You will be given antibiotics to kill off any infections. Irreversible pulpitis requires a root canal and a crown to rectify the problem. This is sometimes not always possible and the tooth might need to be removed and replaced with a dental implant. The best way to avoid pulpitis is to maintain a good oral hygiene routine, prevention is better than the cure.
ACUTE PULPITIS
Acute pulpitis is an inflammation of the pulp caused by injury to the pulp, usually from dental caries or trauma. It is the most frequent cause of severe tooth pain. The pain is caused by the pressure of fluids building up inside the pulp chamber or root canal.
Symptoms
A patient with acute pulpitis may complain of the following: Spontaneous, continuous, or intermittent pain that lingers Piercing and pulsating pain in the affected area. Increased pain when lying down
Signs
Upon examination for acute pulpitis, you may observe one of the following signs: A large carious lesion affected tooth can manifest in a healthy, noninvolved tooth; this is called referred pain.
Treatment
As a part of the emergency treatment plan, you may perform the following duties:
• Perform emergency treatment guidelines.
• Gently remove all debris from the cavity with a spoon excavator .
• Flush the cavity with warm water.
• Isolate the tooth with cotton rolls or gauze.
• Carefully dry the cavity with cotton pellets
• Mix a temporary filling (zinc oxide eugenol, IRM, etc.).
• Gently fill the cavity with the temporary filling material .
• Check the occlusion. Make sure the temporary restoration does not touch the opposing tooth.
• Instruct the patient to return for definitive treatment on the next work day.
Pain symptoms and pulpal diagnosis
At its worst, pulpitis can cause extremely intense pain. On the other hand, it is a common clinical finding that a large number of teeth develop total pulp necrosis without being painful and with no symptoms. As described above, local mechanisms affecting nociceptor activation in the pulp and regulation of the impulse transmission in the central nervous system have significant modulatory effects on the development of pain in pulpitis. The poor correlation between the pain symptoms and the actual condition of the pulp in inflamed teeth has been established in histopathological studies. From a diagnostic point of view, the greatvariation of symptomology in pulpal inflammation is important to note. The nerve fibers in the pulp may maintain their structural identity even in advanced pulpitis where there is considerable destruction of the other components of the pulp tissue. It is not known if the remaining axons are capable of impulse transmission under such conditions but clinical experience shows that pain can be evoked in connection with endodontic treatment of teeth where most of the pulp tissue is necrotic. Comparison of the electrical thresholds of single intradental nerve fibers and those of human teeth also indicates that activation of only a few intradental axons is sufficient to evoke prepain or pain sensations in human teeth. With pulp diagnosis such results are significant because they indicate that a few surviving nerve fibers in a pulp with advanced tissue necrosis may give a positive sensory response to dental stimulation. Thus, evoked sensations in response to electrical stimulation with a pulp tester do not necessarily mean that the pulp is healthy. In fact, dentin can be sensitive in spite of considerable tissue damage in the underlying pulp tissue. All these findings indicate that the correlation between the dental sensory responses and the condition of the pulp tissue is poor. Accordingly, it should be noted that pain symptoms are not a reliable basis for pulp diagnostics. In inflammatory lesions, mediators such as histamine and bradykinin activate C-fibers . After reduction of the pulpal blood flow by periapical adrenaline injections they maintain their functional capacity better than A-fibers, where the impulse conduction is blocked, probably because of hypoxia in the pulp tissue. This means that during the progress of pulpitis, pulpal C-fibers may maintain their capability for nerve impulse conduction longer than A-fibers. In fact, they can become even more active in the advanced stages of pulpal inflammation owing to their susceptibility to inflammatory mediators and lowered pH . The functional properties of the two pulp nerve fiber groups may explain the changes in the quality of pain symptoms during pulpitis: from rather sharp or shooting and quite well localized, to dull and lingering. Thus, the type and duration of symptoms in patients with pulpal inflammation are of diagnostic value and may give some indication of the pulp’s condition. However, it must be underlined again that the correlation between the symptoms and histopathological changes in pulpitis is poor and determination of the type and extent of the inflammatory changes on the basis of the symptomology is inaccurate.
Chronic fibrous pulpitis (pulpitis chronica fibrosa).A chronic fibrous pulpitis is a form of pulpitis which meets most often, which is the result of sharp pulpitis. For people with low reactivity of organism sometimes a chronic fibrous pulpitis can arise up and without the previous clinically expressed sharp stage of inflammation.
A patient produces complaints about pains from temperature and chemical irritants, which do not pass right after removal of reason. Pain can arise up and from the sharp change of temperature. The patient of complaints does not produce often enough, and a chronic fibrous pulpitis appears at a review during sanation of cavity of mouth. It is explained that localization of some carious cavities (for example, subgingival) is un accessible to the irritants, and also by the presence of good drainage of connection with the cavity of tooth). Complaints about involuntary pain at the chronic forms of pulpitis are absent and arise up only at acutening of chronic process. At a review a doctor finds out a deep carious cavity. The cavity of tooth is exposed in one point probing of which sharply painfully. If a peccant tooth is under stopping, after the delete of the last it is more frequent succeeded to find out everything sickly connection with the cavity of tooth. It is set that a point is exposed more frequent localized at the vestibular horn of pulp (63,5%), rarer near oral (24,09%) or between them. On occasion after necrectomy the area of lighter dense dentine appears with a barely noticeable point in a center, which does not bleed, but sickly at probing. Consisting is given possibly of tooth which before treats oneself odontogenic facilities as a medical gasket. Probing on a dentin – enamel border, as a rule, painlessly, that is why necrectomy needs to be conducted, beginning from the walls of carious cavity. A reaction on a cold is sickly and not at once passes after the removal of reason. A tooth can be changed in a color — more dark comparatively with intact teeth. Percussion of tooth is not sickly, but sometimes comparative percussion helps to define a peccant tooth, that it is possible to explain a change in periodontium (on a sciagram they appear in 30% cases). A transitional fold is without pathology (an exception is made by children). ЕОD at a chronic fibrous pulpitis — 35 mcA, but from a intact hump can be within the limits of 17—20 mcA. A chronic fibrous pulpitis must be differentiated with a deep caries, sharp hearth pulpitis and chronic gangrenous pulpitis. Differential diagnostics of chronic fibrous pulpitis and deep caries General:
1. Presence of deep carious cavity;
2. Complaints are on pain from all types of irritants.
Difference:
1. at a chronic fibrous pulpitis a pain reaction on an irritant disappears not right after removal of reason, but at a deep caries — in that moment;
2. at a chronic fibrous pulpitis there is connection with a pulp chamber probing of which sharply painfully, and at a deep caries the bottom of carious cavity is dense, probing is painfully even on all bottom and dentino-enamel border;
3. it is possible to find out from anamnesis, that at a chronic fibrous pulpitis a tooth was ill before, and at the deep caries of involuntary or aching pains was not;
4. indexes of ЕОD at a chronic fibrous pulpitis — to 35—40 mcA, and at a deep caries — to 12—18 mcA;
5. on a sciagram at a chronic fibrous pulpitis it is possible to find out connection of pulp chamber with a carious cavity and sometimes expansion of periodontal crack in the area of apex of root, what is not at a deep caries.
Differential diagnostics of chronic fibrous and chronic gangrenous pulpitis
General:
1. without symptoms ran across on occasion;
2. pains are from temperature irritants;
3. presence of deep carious cavity which is reported with the cavity of tooth.
Difference consist in that at a chronic gangrenous pulpitis:
1. the crown of the tooth is darker, than at a chronic fibrous pulpitis, connection with the cavity of tooth wider;
2. probing of bottom of carious cavity, perforation opening and mouth of root channel painlessly or poorly sickly, pulp does not bleed;
3. a tooth reacts anymore on hot, what on cold, and at a chronic fibrous pulpitis — on cold;
4. indexes of ЕОD at a chronic gangrenous pulpitis — 60—100 mcA, and at a chronic fibrous pulpitis — 35— 40 mcA.
Chronic fibrous pulpitis in the stage of acutening
A patient produces complaints about involuntary aching pains which increase from temperature and chemical irritants. Pains are periodic, alternated incomplete “light” and more frequent arise up in evening and nightly time. Cold more frequent than other irritants causes the protracted pain reaction. A characteristic irradiation of pain is for the step of branches of trigeminal nerve.
At a review a deep carious cavity or tooth appears under stopping. The cavity of tooth is exposed in one point. Probing of pulp of sharply painfully. Pulp bleeds at probing. A reaction lasted on a cold, pain did not pass after the removal of reason. Percussion of tooth can be poorly sickly. A transitional fold is without pathology. On a sciagram on occasion possibly expansion of periodontal crack in the area of apex of root, there is connection of carious cavity with the cavity of tooth.ЕОD = 35—45 mcA. Chronic fibrous pulpitis in the stage of acuteening it is necessary to differentiate with a sharp partial pulpitis, sharp diffuse pulpitis, chronic gangrenous pulpitis in the stage of acuteening, sharp apex periodontitis and chronic periodontitis in the stage of acuteening. Differential diagnostics chronic fibrous pulpitis in the stage of acuteening and sharp partial pulpitis
General:
1. presence of deep carious cavity; the sickly probing is in one point;
2. provocation of the protracted aching pain a cold;
3. involuntary pain incomplete “light”.
Difference:
1. presence of pains, that irradiation, at a chronic fibrous pulpitis in the stage of acuteening, what is not at a sharp hearth pulpitis;
2. presence of involuntary or protracted aching pains from different irritants in the past, and a sharp partial pulpitis exists not more than 1—2 days;
3.presence of sickly at probing connection of carious cavity with the cavity of tooth, and at a sharp partial pulpitis the cavity of tooth is not exposed (except for a traumatic pulpitis);
5. at a sharp initial pulpitis never there are changes in periapical fabrics;
6. percussion at a sharp initial pulpitis is never un sickly.
Differential diagnostics chronic fibrous pulpitis in the stage of acuteening and sharp diffuse pulpitis
General:
1) complaints about involuntary aching pain incomplete “light”, that irradiation for the step of branches of trigeminal nerve;
2) the protracted pain is provoked by chemical and temperature irritants;
3) presence of deep carious cavity, sickly at probing;
4) percussion can be sickly.
Difference:
1) a presence of involuntary pains is in the past at a chronic fibrous pulpitis in the stage of acuteening. A sharp diffuse pulpitis can exist not more than 2—14 days;
2) probing at a chronic fibrous pulpitis in the stage of acuteening painfully in one point, the cavity of tooth is exposed. At the sharp diffuse pulpitis of probing painfully on all bottom of carious cavity and there is connection with the cavity of tooth;
3) at a sharp diffuse pulpitis a cold can quiet pain, what is not observed at a chronic fibrous pulpitis in the stage of acuteening. At presence of in the cavity of mouth of plenty of teeth with the complicated caries a doctor must be predisposed to the diagnosis of chronic fibrous pulpitis in the stage of acuteening, as a sharp diffuse pulpitis meets more frequent for people with the low index of CSR. Differential diagnostics of chronic fibrous pulpitis in the stage of acuteening and sharp or acuteening of apex periodontitis
General:
1) protracted aching pains;
2) a tooth is changed in a color;
3) presence of deep carious cavity (or tooth under stopping);
4) percussion is sickly.
Difference:
1. at a pulpit necessarily presence of “light” without pains intervals, and at sharp forms periodontitis pain is permanent, increasing in time;
2. at a pulpitis pain arises up from temperature irritants, what is not at periodontitis;
4. at a pulpitis a transitional fold at palpation is sickly, and at the sharp forms of periodontitis she was swollen, hyperemia, sickly;
5. indexes of ЕОD at any periodontitis more than 100 mcA, that talks about complete death of pulp;
6. sciagraphies are given also help correctly to diagnose, at periodontitis destructive changes appear in periapical fabrics, except for sharp periodontitis in the stage of intoxication. Chronic gangrenous pulpitis (pulpitis chronica gangraenosa). Complaints for a patient at this form of pulpitis absent more frequent in all, however there can be pains which arise up from different irritants, more frequent in all from hot. Characteristic pains which appear at the change of temperatures (on leaving from a warm apartment on a cold and vice versa). Sometimes a patient is disturbed by an unpleasant smell from a tooth. It is possible to discover from anamnesis, that a tooth in was strongly ill the past, but then pains calmed down gradually. At a review a deep carious cavity appears more frequent in all. The color of tooth has a grey tint. Usually the cavity of tooth is exposed widely enough. At lasted current process of probing painfully only in the deep layers of crown pulp or at back of channels of roots. Superficial layers of mash dirtily – grey color, not bleeding. The action of temperature irritants (especially thermal) causes slow growth pains and its gradual fading. Percussion of tooth is not sickly. On a sciagram in periapical fabrics often expansion of periodontal crack or resorption of bone appears with unclear contours (at deep necrosis of pulp). Electro-excitability of pulp is reduced 60-100 mcA.
A chronic gangrenous pulpitis must be differentiated with a chronic fibrous pulpitis (look differential diagnostics of chronic fibrous and chronic gangrenous pulpitis) and chronic apex periodontitis. Differential diagnostics chronic gangrenous pulpitis and chronic apex periodontitis
General:
1) without symptoms ran across sometimes (out of acuteening);
2) complaints are about a putrid smell from a carious cavity;
3) the painless probing of superficial layers is in the cavity of tooth;
4) changes are on a sciagram in periapical fabrics.
Difference consist in that at chronic apex periodontitis:
1. from anamnesis it is possible to find out appearance of the slight swelling on gums and pain at biting on a peccant tooth during acuteening;
3. at the review of transitional fold it is possible to find out fistula, scar from fistula or stagnant hyperemia;
4. probing is painlessly along the whole length of channel, except for those cases, when granulation from periodontium grows in a channel, but in this caseon trailer appears brightly is red blood, that not characteristically for a gangrenous pulpitis;
5. granulation at probing is less sickly, than pulp which was saved, in a channel at a gangrenous pulpitis;
6. indexes of ЕОD of more than 100 mcA.
Chronic gangrenous pulpitis in the stage of acuteening. A patient produces complaints about involuntary aching pains incomplete “light” short. Sometimes pain takes undulating character, only a little calming down and again increasing. Hotter provokes pain, the cold of her calms for a short time. Pain can appear at bite. It turns out from anamnesis that a tooth hurts not first time. At a review: a tooth is changed in a color, there is a deep carious cavity which is reported widely enough with the cavity of tooth. Probing of superficial layers of pulp painlessly, pulp does not bleeding, the color of her dirtily – grey. A putrid smell appears. A sickly reaction appears at probing of more deep layers of crown pulp or mouths of channels of roots. A reaction on a cold can be painless. Percussion of tooth is sickly. On a transitional fold hyperemia of mucus shell appears in the area of peccant tooth. ЕОD — 60—100 mcA. On a sciagram changes can appear as expansion of periodontal crack or resorption of bone fabric with unclear contours. Chronic gangrenous pulpitis in the stage of acuteening it is needed to differentiate with a chronic fibrous pulpitis in the stage of acuteening (see differential diagnostics of chronic fibrous pulpitis), by a sharp diffuse pulpitis, sharp apex periodontitis and chronic apex periodontitis in the stage of acuteening. Differential diagnostics of chronic gangrenous pulpitis in the stage of acuteening and sharp diffuse pulpitis
General:
1) a presence of the protracted involuntary aching pains is almost without “light” intervals;
2) hotter provokes pain, cold calms her;
3) sickly percussion.
Difference:
1. at a chronic gangrenous pulpitis in the stage of acuteening it turns out from anamnesis, that this tooth was ill and before, and at the sharp diffuse pulpitis of involuntary pains in was not the past, as he exists not more than two weeks;
2. at a gangrenous pulpitis there is connection of carious cavity with the cavity of tooth, at sharp — the cavity of tooth is usually closed;
3. presence of changes in periapical fabrics on a sciagram at a gangrenous pulpitis, what is not at a sharp general pulpitis.
Differential diagnostics of chronic gangrenous pulpitis in the stage of acuteening and sharp or acuteening of apex periodontitis
General:
1) presence of the protracted aching pains;
2) pain at biting, sickly percussion;
3) there is connection with the cavity of tooth superficial probing of which painlessly;
4) there is a putrid smell from a tooth;
5) on a sciagram changes appear in periapical fabrics.
Difference:
1) pains at a pulpitis take periodic character, and at the sharp forms of apex periodontitis — increasing, without “light” intervals;
2) biting on a tooth at this form of pulpit not such painfully, as at the sharp forms of periodontitis, when to the tooth very even to touch, and palpation of transitional fold is sharply sickly;
3) deep probing at gangrenous pulpitis painfully, and at periodontitis — painlessly;
4) a pain reaction is expressed on hot temperature irritants at a gangrenous pulpitis, and at a periodontitis reaction is;
5) indexes of ЕОD are at a pulpitis to 100 mcA, and at periodontitis — more than 100 mcA. Chronic hypertrophy pulpitis (pulpitis chronica hypertrophic)
A chronic hypertrophy pulpitis has two clinical forms:
• that granulates (excrescence of granulation fabric is from the cavity of tooth in a carious cavity)
• a polypus of pulp is more late stage of motion of disease, when fabric of pulp which overgrew is covered a mouth epithelium. The cages of epitheliums are carried from gums, cover all surface of bursting pulp and densely with her accustomed to drinking.
Chronic hypertrophy pulpitis
A patient produces complaints about bleeding from a tooth at mastication, pain at a hit in the tooth of hard meal. Sometimes a patient is disturbed by original appearance of tooth from the carious cavity of which “something bursts”. At a review a carious cavity is determined, partly or fully filled fabric which overgrew. At a granulation form the color of fabric is bright red, bleeding appears at the easy probing, moderate pain. The polypus of pulp has a pinky color (color of normal mucous), at probing bleeding is absent, pain weak, consistency of polypus is dense. Abundant dental deposits appear on the side of peccant tooth, as a patient spares this side at mastication. A reaction on temperature irritants is expressed poorly. On the sciagram of changes in periapical fabrics, as a rule, does not appear. A chronic hypertrophy pulpitis more frequent meets for children and teenagers. A chronic hypertrophy pulpitis must be differentiated with excrescence of gingival papilla and with granulation which overgrew, from the perforation of bottom of cavity of tooth.
Differential diagnostics of chronic hypertrophy pulpitis and excrescence of gingival papilla
General
1. for these diseases there is original appearance of carious cavity, filled fabric which overgrew, probing of which causes bleeding and weak pain (except for the polypus of pulp).
Difference:
1. a gingival papilla which overgrew can be forced out an instrument or wadding marble from a carious cavity and to find out his connection with interdental gums, and hypertrophy pulp overgrows from the perforation opening of roof of cavity of tooth;
2. on a sciagram at a pulpitis it is possible to see connection of carious cavity with the cavity of tooth. Differential diagnostics of chronic hypertrophy pulpitis and granulation that overgrew from the perforation of bottom of cavity of tooth (bifurcation)
General:
1) a carious cavity is filled granulation fabric;
2) there is bleeding at probing of granulation.
Difference:
1) probing in the area of perforation less painfully (like a prick in gums), what at a chronic hypertrophy pulpitis;
2) a level of perforation more frequent in all is below thaeck of tooth, and at a hypertrophy pulpitis — higher (at the level of roof of pulp chamber);
3) at excrescence of granulation fabric from bifurcation at presence of in this area of perforation, as a rule, the complicated form of caries appears on the different stages of treatment. At partial necrectomy the mouths of channels appear before stopped or empty;
4) on a sciagram connection of cavity of tooth is determined from periodontitis bifurcation and dilution of bone fabric in this area, and at the hypertrophy pulpit of changes in periodontium does not appear;
5) indexes of ЕОD from humps at a pulpitis less, and at periodontitis more than 100 mcA.
TREATMENT OF PULPITIS
At treatment of pulpitis it is necessary to decide the followings problems:
1) to remove a pain symptom;
2) to liquidate the hearth of inflammation in pulp;
3) to guard fabrics of periodontium from a damage with the purpose of warning of development of periodontium;
4) to enable formed scold at treatment of pulpitis for a child;
5) to pick up thread an anatomic form and function of tooth as to the organ.
The existent methods of treatment of pulpitis can be divided on
• conservative
• surgical
• conservatively – surgical.
The biological (conservative) method of treatment of pulpitis is directed on the removal of inflammation in pulp by medicinal preparations and methods of physiotherapy without the subsequent delete of vascular-nervous bunch, or partial delete of pulp under anesthesia with the subsequent saving of its part which remained (methods of congratulatory and deep congratulatory amputation). Surgical methods of treatment of pulpitis (vital and devital extirpation) are the mashes directed on a delete under anesthesia or after its devitalization.
Biological methods of treatment of pulpitis
A biological method of treatment of pulpitis is a method, directed on the complete saving of pulp in the viable state. Saving viability of all pulp is possible at the circulating forms of its inflammation.
There are indications for the choice of this method:
• Sharp partial pulpitis.
• The casual baring of intact pulp is at preparing of carious cavity or tooth under a crown, breaking off of crown of the tooth at a trauma. In last case it is necessary to be convinced from data of ЕОD, that the complete break of vascular-nervous bunch did not take place in the area of apex of root.
• Chronic fibrous pulpitis at the indexes of ЕОD of not more than 25 mcA and in default of in anamnesis of information about acuteening of this form of pulpitis.
• Low intensity of caries (not more than 7 and the constant of S — stopping predominates).
• Young age (to 30) and absence of heavy concomitant chronic diseases, and also sharp diseases of respirators the day before and during treatment.
• Absence of changes is on a sciagram in the area of apex of root.
• Absence of allergic reactions is on common medicinal preparations.
A tooth is not subject prosthetics.
Direct coverage of pulp is at a biological method treatment of pulpitis
1 is pulp:
2 is a medical gasket;
3 is a dentine;
4 is a cement gasket;
5 —is stopping.
A carious cavity must not be localized in a cervical area, as in this case inflammation of crown pulp can quickly pass to the root, and also it is very difficult technically to execute this method of treatment from the closeness of gingival edge and in relation to the small depth of carious cavity for imposition of multi-layered gaskets. A biological method allows prevent inflammation in pulp, to stimulate forming of dentine, the same keeping a reliable biological barrier to penetration of microorganisms in fabric of periodontium that keeps him intact. Unsuccessful results after application of this method it is possible to explain the followings reasons:
• an error is in a diagnosis at determination of the state of pulp;
• expansion of testimonies is to application of biological method;
• violation in the technique of implementation of method (failure to observe of rules of asepsis and antiseptics, traumatic interference, disparity of common preparations, careless imposition of gaskets and other).
Stages of biological method of treatment (look lecture material)
Medical gaskets
A medical gasket is imposed a thin layer (
a) high рН (to 12) on occasion can bring to necrosis of pulp;
b) calcification is possible in pulp, formation of denticles, that will bring cavities over of tooth to obliteration.
Medical gaskets must own next properties
• to stimulate the reparative function of pulp;
• to own bactericidal and antiinflammation actions;
• to operate anaesthetizing;
• not to annoy pulp of tooth;
• to own good adhesion;
• to be plastic;
• to maintain pressure after hardening;
• to be adapted to modern composite materials.
Preparations which contain the hydroxide of calcium: Dycal (firm Dentsply); Calcipulpe (firm Septodont); Life (firm Kerr); Calcimol (firm Voco); Reocap (firm Vivadent) and other to pasture, that contain eugenol, also odontogenic own and by antiinflammation actions. Eugenol – containing pastes: biodent; zinc – eugenol paste (not recommended for direct coverage of pulp); Cavitec (firm Kerr); Eugespad (firm SPAD).
Their failings are the followings moments:
• they are not adapted to modern composite materials, that is why during work with these medical gaskets it is necessary to avoid their hit on the walls of carious cavity and carefully to insulate them from the permanent stopping indifferent insulating gaskets;
• an allergic reaction is possible from the side of pulp on eugenol.
Method of vital amputation
Saving of viable pulp in the channels of roots after the delete of crown pulp is named “by the method of vital amputation”. A method is based on the capacity of root pulp for reparative processes.
By shows to the method of vital amputation:
• sharp partial pulpitis;
• casual baring of pulp;
• a chronic fibrous pulpitis is at electro-excitability of pulp to 40 mcA
• a tooth is with the unformed root.
This method is used in the teeth of multiroots, where a border is expressly expressed between crown and by root pulp, at healthy periodontium and paradontium for healthy young people.
Stages of conducting of method of vital amputation (look lecture material)
Surgical methods of treatment of pulpitis
Method of vital extirpation
The method of vital extirpation is based on the delete of all pulp under anaesthetizing without previous imposition of arsenic paste. Advantages of method:
• absence of toxic action is on fabric of periodontium preparations of arsenic;
• treatment is conducted in one session;
• painlessness of manipulations is in a tooth.
Disadvantages of method:
• a risk of complications is during conducting of anesthesia (unbearableness of anesthetic, action of vasoconstrictive preparations, inwardly vascularintroduction and other);
• bleeding from a channel, which can arise up during tearing away of vascular-nervous bunch from fabrics of periodontium;
• absence of reaction is from the side of patient under time of endodontics manipulations;
• an origin of pains is at that which bite as a result of education haematomas in periapical areas or destroying of stopping material for the apex of root.
A method is shown at all forms of pulpitis, especially at gangrenous and hypertrophy, when to use arsenic paste it is contra-indicated.
Location of stopping materials at treatment of pulpit by a surgical method
1. is paste;
2. is an artificial dentine;
3. is a cement gasket;
4. is the permanent stopping.
Choice of anesthetic
For stopping of channels use the followings materials:
1. to pasture, that contain eugenol: Endobtur, Endometpasone (firm Septodont), zinc – eugenol paste;
2. to pasture with the hydroxide of calcium: Biocalex (firm SPAD);
3. to pasture on the basis of epoxides resins: АН-26, AH-Plus;
4. materials are on the basis of formalin of resortsyn: resortsyn – formalin paste, Forfenan (firm Septodont);
5. gutta-percha, thermafil (firm Dentsply).
After stopping of channels it is necessary to do control sciagraphy, argued that channels are sealed on all draught.
Method of devital extirpation
Method of devital extirpation is based on the delete of all pulp after its necrotization and conducted in two visits. By shows to this method there are pulpitis which it is impossible to bring through vital methods on objective reasons (absence of shows and presence ofagainst shows, for example, unbearableness of anesthetics, badly communicating channels through their ramified, large curvature and etc).
Imposition of devitalizing past
1. is pulp;
2. is devitalizing paste;
3. is a tampon with an anesthetic matter;
4. is an artificial dentine.
For necrotization of use preparations of arsenic anhydride and paraformaldehyde. In the first visits after necrectomy of carious cavity one of these preparations is imposed on the exposed horn of pulp under a bandage. Stages of conducting of method of devital amputation (look lecture material)
Combined method of treatment. Shows to application of this method is:
• sharp diffuse pulpitis
• chronic forms of pulpitis of teeth of multiroots from heavily by clock-houses by the channels of roots and one accessible for treatment and stopping a channel. At treatment of pulpitis in such teeth at first conduct the partial delete of the softened and pigmented fabrics of carious cavity, section of cavity of tooth, imposition of devitalized pasts. Iext visits expose the cavity of tooth, delete crown pulp. After antiseptic treatment of cavity of tooth extend the mouths of channels of roots the spherical drill. Then from the palatal channel of molars of overhead jaw and distal channel of molars of lower jaw fully delete root pulp, and a root channel after antiseptic treatment and drying is stopped some hardening paste to the apex opening of root of tooth. Mash which was saved in impassable channels, 2 — 3 times add impregnation, mummify resortsyn – formalin mixture with subsequent abandonment above the mouths of channels of resortsyn – formalin past or to paracyn-cement.
Methods of obturation of root channel
Till recently the basic method of stopping of channels of roots was a method of filling one paste. Thus the very popular were pastes on the basis of oxide of zinc and eugenol, and also preparations which contain resortsyn and formaldehyde in the composition. Technique of stopping of root channel by paste simple enough and does not require considerable temporal and financial charges. However much the row of the substantial failings has stopping of channels one paste:
1. At this method material is fill a main channel only and the numerous forks of the system of root channel remain opened.
2. Very often paste hatches for the apex of root, as there is not adequate control of filling of root channel material.
3. Paste fills a root channel unevenly, abandoning emptinesses and not providing the adequate pressurizing.
4. Pasturing all is given contraction and resolve at a contact with a tissue liquid.
5. Most pastes own an irritable action on periodontium.
X-ray measurement image
The principle of root canal treatment consists in removing infected or devital tissue from the inside of the tooth and to seal the cavity with filling material. Treatment takes place under local anaesthetic if the pulpa is not devital.
Root canal treatment can be divided into:
1. Removal of pulpal tissue
2. Determination of root canal length
3. Preparation of root canals
4. Filling of root canals
First the canal portals have to be found and expanded. Once the portal is found, the diseased tissue is removed from the root canal. If the roots are strongly arched, are very fine or calcified, it may be impossible to reach the apex with the preparation instruments. The result is insufficient root canal treatment, which does not allow the inflammation to abate.
The determination of the root canal length specifies the operational length of the root canal instruments by displaying the length to the foramen apicale. A decisive factor for the correct filling of the canals is its length, previously determined by X-ray. The X-ray displays how far the instrument is away from the root tip and which length the instruments in the canal may have. Determination of canal length can also be performed electrically, whereby a probe is inserted into the canal and the end of the root canals is indicated by a measurement device.
Root canal preparation serves to prepare the root canal for root filling. The canals are extended and planed with flexible, mechanically or manually driven drills and files, which adjust even to arched or bent roots. Canal preparation is also possible with ultrasound.
Canal preparation should be performed up to the foramen apicale.
Unintended lateral penetration of the root is called “via falsa” (the “wrong way” in Latin). The objective of root canal filling is to fill the prepared root canal with special, bacteria-proof paste and matching gutta-percha tips and thus ensure sustainable treatment success. Root canal filling is performed with endogenous substances, which should be tissue-compatible, hardening, fluid, dimensionally stable, parietal, bacteria-proof, non-resorbable and visible on X-ray. A disinfecting effect is also expedient in order to render remaining or newly introduced bacteria harmless.
Insertion of paste and pins into the root canals
In thermoplastic root canal filling, heated and formable gutta-percha is injected into the prepared root canal or inserted as gutta-percha pins. The insertion of several gutta-percha pins with hardening pastes is preferred. While the orthograde root canal filling is normally positioned from the crown, the retrograde root canal filling is performed at the tip of the root (e.g., in root tip resection). A final X-ray is performed to control whether the canals were filled completely and bubble- free. A cavity may not be created, as bacteria could settle there and cause an infection (parodontitis apicalis). The cavity is then either provisionally or terminally closed. Root canal treated teeth have often lost their form and stability die to the disease and its treatment. This indicates the necessity of crowns for their protection.
