How many difficulties and discomfort can dental diseases cause? However, sometimes not only aching or acute pain, but also the appearance of pus in the oral cavity can disturb a person’s life. Do not rush to get upset - most likely, this is purulent pulpitis, the treatment of which can eliminate all the symptoms of the disease and return health to normal. What are the features? How to behave correctly and who to contact in such a situation - let's look at it in detail.
Acute pulpitis of a molar tooth
Disease and information about it
The definition of purulent pulpitis looks like this - it is an infection of the dental pulp, characterized by the presence of pus inside the pulp chamber. The occurrence of the disease is associated with incorrect or unqualified treatment and occurs quite often in representatives of either sex. Pulpitis is in the next place after caries in terms of frequency of occurrence. Acute purulent pulpitis can invade the entire structure of the pulp chamber. It is known that the pulp has nerve endings, blood and lymphatic vessels, and therefore it is logical that it will aggressively respond to such inflammation.
A purulent disease can transform into a chronic disease as a result of spontaneous opening of a purulent area.
The classification of acute pulpitis presents several varieties.
- The focal form of the disease (also called serous, purulent), which is described by short painful attacks, aching pain, which can be intensified by changes in temperature. The pain is most severe at night. Two days are enough to move to the next stage.
- Acute diffuse pulpitis is accompanied by throbbing pain that moves from the nerve to the temple, eyebrows, ear and intensifies when the person is lying down. The pain subsides only in the last stages of the form, as the nerve endings are destroyed.
The etiology of pulpitis is divided into infectious/chemical. Depending on the location, the disease can be coronal, root, or total. Taking into account the outcome of infection, the disease can be reversible or irreversible.
As the acute form of the disease develops, the exudative stage, which is characterized by swelling that increases gradually, as well as serous exudate, comes first.
Focal purulent pulpitis is characterized by inflammation of a focal type, diffuse is characterized by filling the coronal pulp.
The occurrence and development of the disease is influenced by a variety of obvious stimuli:
- taking antibiotics;
- use of medicinal pastes;
- use of low-quality medicinal parts for fillings;
- tooth destruction, when the fracture is located near the pulp;
- dislocation, crack in the tooth, damage to the crown;
- the use of alcohols, essential agents, phenol, etching.
However, the main internal ways of occurrence of pulpitis are considered:
- penetration of microorganisms from the carious area directly into the pulp chamber, causing inflammation;
- penetration of bacteria through gum damage after treatment of periodontitis or as a result of treatment of periodontitis, sinusitis;
- penetration of infection through blood and blood vessels - this path has an external feature, the tooth does not look sick.
Development of pulpitis by stages
Acute diffuse pulpitis is a complex disease, and therefore has other causes. Often, the disease can appear as a complication of one of the forms of caries, which is caused by hemolytic and non-hemolytic streptococci, Staphylococcus aureus, gram-positive bacilli, fusobacteria, actinomycetes and yeast. It is not difficult to get into the pulp - this is facilitated by the softening of dentin and dentinal tubules. As a result of penetration, the infection disrupts microcirculation, leads to hemorrhages, thrombosis and changes nerve fibers and structural elements of the pulp.
Diagnostics
How to determine purulent pulpitis yourself?
It would seem that what could be simpler than identifying a disease in a tooth? It is enough to feel the pain and detect its location. Acute diffuse pulpitis, in addition to pain, is accompanied by the following symptoms:
- the occurrence of causeless painful sensations that are pulsating in nature;
- the appearance of constant pain (especially at night), which subsides only for a while;
- the manifestation of pain when eating hot and cold food (in the second case, the pain may even weaken);
- reaction to food with a clear sour or sweet taste (manifests itself even after stopping consumption);
- sudden bleeding from the gums, darkening of the enamel;
- pain affects the entire oral cavity, head, ears.
Manifestations of pulpitis and a healthy tooth
A significant difference between pulpitis is that it is difficult for the patient to detect the specific place where the pain comes from. General symptoms may include weakness, general malaise, and fever.
How does a doctor diagnose pulpitis?
For an accurate diagnosis and correct diagnosis, it is necessary to visit a dentist, who will be able to see the overall picture during the examination of the patient. How is diagnosis done?
The doctor listens to the patient and then carefully examines the oral cavity. When the examination is accompanied by a painful reaction, the smell of pus, or softening of dentin, the patient is sent for an x-ray, which confirms or refutes the dentist’s suspicions and allows one to find out how deep the process has gone.
Acute pulpitis of anterior tooth
If white plaque, swelling, or pus is detected on the mucous membrane, an x-ray is not required for confirmation.
Additional measures to identify the disease also include electroodontodiagnosis, thermal test, rheodentography, radiovisiographic examination, and flowmetry. Less commonly prescribed are medical tests: blood tests for biochemistry, determination of immunoglobulin levels. To accurately confirm the diagnosis of pulpitis, you should contact doctors dealing with related issues. The patient is referred to neurologists, surgeons, and otolaryngologists.
The dentist must determine in what form and what type of pulpitis it has. Often, it is confused with similar diseases. To be confident in the words of the attending physician, it is worth distinguishing purulent pulpitis from other forms:
- with diffuse and focal pulpitis, when the tooth cavity is opened, there will be no pus at all, and the pain will not last long;
- with purulent periodontitis, a brief, sudden toothache occurs when you eat;
- when trigeminal neuralgia is observed, pain symptoms appear exclusively after touching certain areas of the skin.
If the symptoms are obvious and the dentist’s prognosis is unfavorable, do not hesitate, start immediate treatment.
Differential diagnosis of pulpitis and periodontitis
How to cure purulent pulpitis?
All therapeutic measures to eliminate purulent pulpitis should be aimed at getting rid of inflammation and restoring the functions of the pulp. In order to make the patient's everyday life easier from severe pain, analgesics are often used.
The professional you choose can tell you in detail how and how to treat the problem. But, whatever its technique, the main principle and goal is to eliminate pus from the canals. Before starting treatment, the general condition is assessed, since, most often, the appearance of pus leads to loss of functionality and ability to recover. In such situations, pulp excision is necessary, which is performed under anesthesia. Purulent pulpitis also damages children's developing teeth. Their treatment differs only in the dosage of the chosen drugs and methods of anesthesia.
The most dangerous thing is the development of purulent pulpitis during pregnancy.
It is important to use therapy to a minimum; you need to completely protect the woman from pain and any accompanying symptoms. After treating a pregnant patient, her condition should be monitored for some time. Infection of a wisdom tooth with purulent pulpitis leads to mandatory excision, since there is no point in treatment.
With the development of serous-purulent and ordinary purulent diseases, you need to be prepared for the fact that irreversible changes will occur to the tooth, and the pulp will lose its functionality. Such changes require either amputation or extirpation (complete excision). Depending on which anesthesia was chosen: conduction, infiltration or devitalizing, there are two methods of treating pulpitis.
Tooth extraction due to untimely treatment of pulpitis
Vital method
The use of the vital method (pulpotomy) is only suitable if it is possible to preserve the root pulp in a state of normal functioning. The meaning of the technique is to completely destroy the affected areas of the oral cavity, carefully filling the teeth and canals. The procedure is aimed at preserving pulp. It can be done after opening the tooth. The dentist removes the coronal and ostial pulp, applying dentin-stimulating paste, and performs sealing. The process of carrying out the method itself is divided into several steps:
- administration of anesthesia;
- elimination of affected areas;
- cleansing, disinfection, use of antiviral drugs;
- secondary canal cleaning and filling;
- restorative measures for the tooth or installation of a crown.
Despite the complete destruction of the pulp, with the help of vital extirpation it is possible to completely restore the tooth with a filling.
Devital method
The use of the devital method (pulp extirpation) is suitable for curing acute diffuse pulpitis and is divided into two stages. First, the dentist opens and disinfects the tooth, after which he places a medicinal devitalizing paste on it, which causes the death of the nerve (arsenic and analogues are considered the best means for this). Next, a temporary filling is placed. The final stage is removing the pulp, removing the temporary filling, cleaning the cavity, processing and filling the canals, and installing a new permanent filling. To monitor the result of treatment, radiography is prescribed.
Treatment of acute pulpitis - stages
The choice of method for each specific case depends on the dentist and the individual preferences of the patient. Mostly, patients prefer the first method, since it takes less time. But, the procedure for painless nerve extraction should be trusted only to a qualified specialist, in order to avoid breakage of blood vessels and the occurrence of periodontitis. The danger and complexity of the devital method lies in the use of arsenic. Such a powerful remedy can lead to tooth extraction.
Removal of dental nerve and cleaning of canals
Whatever the method you choose, it will take you some time to restore your normal lifestyle. You need to be prepared for the fact that for three days there will be pain accompanying swallowing and chewing. The pain will go away on its own. Lack of treatment for purulent pulpitis is fraught with consequences detrimental to the human body. If the disease is not cured on time, then:
- pulpitis will transform into acute periodontitis;
- inflammation will occur in the bone marrow and tissues;
- immunity will decrease;
- the soft tissues of the facial skin will be affected;
- Possible blood poisoning, leading to death.
Before and after treatment - pictures
In the case of purulent pulpitis, every minute is precious. To avoid negative consequences, consult a doctor as soon as possible.
How to cure an aseptic form?
Aseptic acute serous pulpitis mainly affects young people and is characterized by the fact that it is easily treatable. Using a conservative biological method, it is possible to preserve pulp tissue.
Treatment occurs in several steps:
- the dentist applies mechanical or medicinal treatment to the mouth;
- applies non-irritating antiseptics, antibiotics, proteolytic enzymes; a special medicated paste is used, which differs
- regenerating as well as anti-inflammatory properties;
- a temporary filling is placed (up to 7 days);
- a permanent filling is installed (in cases where there are no complaints from the patient).
Sometimes special physiotherapy procedures chosen by the dentist are used to treat pulpitis. Most often, these include laser therapy, fluctuarization, and Alex-phoresis.
Is it possible to cure purulent pulpitis with folk remedies?
Any specialist will confidently declare that there is no place for traditional medicine in dental treatment. No matter how common the recipes for getting rid of pain and similar symptoms are, not a single tincture or decoction can resist purulent pulpitis. Despite the fact that sage, garlic, beets, chamomile, vodka, peroxide solution and propolis can anesthetize a tooth, they do this for a short time, which later will not be enough. Neglect of traditional treatment leads to tooth decay, decay and loss.
Dentists advise patients who are unable to get an appointment and undergo surgery to use temporary available painkillers, completely forgetting about traditional medicine and dental healing. Every patient should remember that a professional dentist can save teeth from resorting to surgical forceps.
Treatment of pulpitis using traditional methods is impossible
Alternative treatment will relieve you of pain for a while, but can lead to odontogenic infection. The infection can “encompass” the entire body, even infecting the blood.
Measures to prevent purulent pulpitis
The outcome of the disease is directly related to the nature and extent of inflammation in the pulp. The quality and type of inflammation can only be determined in the dental chair. In this case, there are several options:
- pulp renewal in aseptic serous form;
- development of infection during necrosis;
- transformation into a chronic form.
But, mostly, treatment of pulpitis has favorable prognoses and is not difficult. Having made sure that none of the tinctures and decoctions can provide you with health, it’s time to think about how to prevent the recurrence of inflammation and keep your teeth in order. The insidiousness of purulent pulpitis is that it can affect any person, regardless of age, moment, situation, and so on. That is why oral care for women during pregnancy, as well as for young children, should be thorough and strict. You can avoid the appearance of pulpitis - just maintain hygiene, periodically visit the dental clinic, treat caries of milk and molar teeth, follow the rules of preparation and treat concomitant diseases.
Remember that not only the appearance of your teeth, but also your overall health depends on a timely visit to a specialist. Having learned how negative complications after purulent pulpitis can be, it is impossible to resist going to the doctor. By choosing a professional, you will protect yourself from all sorts of complications and discomfort associated with dental diseases. Take care of your health and do not put off going to the dentist if you find a problem until later.
Despite the recommendations of doctors about the need for regular examinations of the oral cavity and timely treatment of caries at the initial stage, patients with serious problems often turn to the dental clinic, one of which is acute purulent pulpitis. This disease causes a lot of discomfort to a person and can cause serious complications.
Causes of purulent pulpitis
There are several main reasons for the development of acute purulent inflammatory process in the dental pulp:
- Complication of caries – most often occur against the background of a long-term carious process. When deep layers are damaged, cariogenic flora penetrates into the tooth cavity, provoking inflammation in the dental pulp.
- Mechanical damage to the tooth – as a result of injury (for example, a blow to the jaw or a fall), the integrity of the crown part of the tooth is damaged. In some cases, the dental pulp is exposed; in a more serious situation, the neurovascular bundle is torn off. All these factors contribute to impaired blood circulation in the pulp and infection by pathogenic microflora.
- Iatrogenic factor – sometimes purulent pulpitis is a consequence of poorly performed caries treatment, for example, preparation without cooling or accidental opening of the tooth cavity.
- Infection of the pulp through a periodontal pocket – purulent pulpitis can accompany periodontal diseases. When the integrity of the dentogingival junction is violated, pathogenic microorganisms penetrate the pulp through the apical foramen, provoking inflammation.
- The tooth is located close to another source of infection – for example, teeth located next to the maxillary sinus may be involved in the inflammatory process during sinusitis. In this case, the causative agents of the disease spread into the tooth cavity through the blood and lymphatic vessels.
Symptoms of purulent pulpitis
The disease most often begins with a deterioration in general health and the appearance of pain. In addition, the development of acute purulent inflammation can be suspected based on some signs:
- Severe throbbing toothache that has a long lasting character. Painkillers are usually ineffective.
- Pain occurs in the absence of a stimulus, most often at night.
- Any irritants (mechanical, temperature, as well as simple touching the tooth) cause discomfort or the development of a new pain attack.
- Hot foods and drinks provoke pain, while cold ones can help the attack subside.
- The pain radiates (spreads) along the branches of the trigeminal nerve - to the zygomatic region, the opposite jaw, the back of the head, to the temple and to neighboring teeth. Often the patient finds it difficult to accurately indicate the location of the pain.
- Upon examination, the doctor may see a deep cavity filled with softened dentin and food debris. When all infected dentin is removed, the tooth cavity is opened and the pus is separated. Immediately after evacuation of the purulent contents, the pain subsides.
- The mucous membrane of the gums around the causative tooth may be hyperemic, swollen, and covered with a whitish coating.
- Mobility of the affected tooth is observed.
Which doctor treats purulent pulpitis?
The diagnosis and treatment of all forms of pulpitis is carried out by a dentist-therapist. Using special materials and methods, he cleans and fills root canals.
Diagnostics
It is hardly possible to make a diagnosis on your own; this requires an examination using special instruments.
During an examination of the oral cavity, the dentist performs several mandatory procedures:
- Visually assesses the condition of the causative tooth and dentition as a whole. Determines the depth of the lesion and distance from the pulp chamber.
- Performs probing - with a sharp instrument he feels the bottom and walls of the cavity, identifies the location of pain points and the nature of the pain.
- Detects the presence or absence of communication with the tooth cavity. In acute purulent pulpitis it is usually absent.
- Performs percussion - tapping a tooth with a metal object. With its help, the condition of the periapical tissues is determined. Most often it does not cause pain.
Treatment of purulent pulpitis
Treatment of all forms of pulpitis in adults comes down to cleansing the root canals of pulp and infected tissue. As a rule, with a purulent lesion, the pulp already loses its functions and cannot recover. There are two main methods of treating pulpitis – vital and devital.
The vital method is also divided into two subtypes - complete extirpation of the pulp (removal from the root canal) without preliminary killing and amputation, that is, excision of the affected tissue while preserving the root tissue. In acute purulent pulpitis, the viability of the root pulp is extremely rarely preserved, so the doctor almost always performs a complete extraction of the neurovascular bundle.
Vital extirpation is carried out as follows:
- They make the appropriate one.
- The tooth cavity is opened, simultaneously removing infected tissue in the coronal part.
- The pulp is first removed from the coronal part of the chamber, then with special instruments from the root canals.
- The root canals are cleaned and expanded, rinsing with an antiseptic solution (most often sodium hypochlorite) after each instrument.
- If necessary, the root canals are filled with a medicinal substance and the tooth is closed.
- At the next visit (usually after 2-3 weeks), the canals are re-cleaned, washed and filled with permanent materials.
- The coronal part is restored or.
The devital method of treating pulpitis is distinguished by the fact that before extracting the pulp, special preparations are applied on the first visit to promote its death. For this purpose, modern dentistry uses devitalizing pastes without the addition of arsenic - they are much safer than pastes of the old generation. The medicine is applied to the exposed pulp horn, after preliminary anesthesia and cleansing of the cavity from decayed tissue.
During the second visit, the tooth cavity is completely opened, dead tissue is removed and, as with the vital method, the root canals are treated, followed by filling.
Prevention
To prevent the development of purulent pulpitis, caries should be treated in time. It is recommended to visit the dentist twice a year for timely diagnosis of the carious process at an early stage. In addition, you should contact a specialist if you experience such unpleasant symptoms as pain when biting, reactions to temperature and chemical stimuli.
High-quality root canal treatment is manifested in thorough cleaning and filling of the root canals, which is confirmed x-ray, the absence of negative dynamics and complications. In addition, the crown of the tooth should be restored as soon as possible to ensure complete sealing and functionality.
Useful video about the signs and treatment of pulpitis
Purulent pulpitis (or pulp abscess) is an inflammation of the connective tissue of the tooth, in which an abscess forms in the pulp chamber. What are the causes of this disease, why is it dangerous and what treatment methods can modern dentistry offer? The answers to these and other questions are in today's article.
What is a pulp abscess
The pulp chamber is the “heart” of the tooth. It is filled with connective tissue, which contains the entire nutritional system of the tooth - nerve endings, blood and lymphatic vessels. The pulp can be called the control center, because it is it that nourishes dentin, bone tissue, and is responsible for maintaining sterility inside the crown and for tissue regeneration.
Causes of pulpitis
- cariogenic - as the name implies, microbes enter the pulp chamber from the carious area (if it gets too close to its boundaries),
- hematogenous - in which harmful microorganisms enter the pulp chamber from blood or lymphatic vessels,
- periodontal is a complication after treatment of periodontitis, usually arising due to doctor errors.
Important! Purulent pulpitis can also develop on baby teeth, so it is also necessary to treat them so that the infection does not affect the embryos of permanent teeth. The difficulties in treating pulpal abscess in children lie in the anatomical features of the mammary units and in the subtleties of selecting anesthesia.
How does a pulpal abscess manifest?
Like any inflammation, purulent pulpitis is characterized by severe pain and general malaise, but the disease also has characteristic symptoms. Signs of purulent inflammation of the pulp will be as follows:
- severe, throbbing toothache, radiating to the head, ear, eye, jaw joint or not having a clear localization,
- swelling, redness, tenderness of the gums at the site of inflammation,
- an acute reaction of a diseased tooth to hot/cold, sour/sweet food, which does not go away after the stimulus disappears,
- there is a feeling that the tooth is literally pulsating and bursting from the inside,
- increased pain at night,
- darkening of the enamel on one or more crowns,
- increased body temperature, headache, malaise, sleep disturbance,
- in the later stages, pus may begin to “knock out” from the tooth - for example, through holes in the coronal part.
Diagnosis of the disease
To begin treatment, the doctor must establish a diagnosis and at the same time exclude diseases that resemble pulp abscess in symptoms. So, for example, with aseptic pulpitis the pain is less prolonged, with pain arising from mechanical load on the tooth, and with trigeminal neuralgia the pain does not depend on temperature interaction and can occur at any time of the day.
After examining the oral cavity and if purulent inflammation is suspected, the dentist will prescribe it in order, firstly, to confirm the diagnosis, and secondly, to see the degree of growth of the purulent sac and its location. After this, the doctor chooses the most effective treatment tactics in a particular situation.
Attention! Pulp abscess poses the greatest danger to pregnant patients. On the one hand, any inflammatory process in the body can negatively affect the condition of the fetus, and on the other hand, dentists are limited in the choice of drugs in the treatment of this disease, because some of them are contraindicated for use during pregnancy.
How to treat a pulp abscess
The goal of treatment is to remove pus from the pulp chamber as quickly as possible, because the serous substance disrupts the acid-base balance and kills connective tissue. In this case, the pulp loses its function and must be removed. In modern dentistry, there are two most effective methods of treating this disease:
- vital,
- devital.
Important! If there is pus inside the tooth, antibiotic therapy is a mandatory process. It is necessary to stop the development of inflammation and prevent the spread of pus throughout the jaw and throughout the body.
Vital treatment method
Its name comes from the Latin word vitae, which means “life.” This is the essence of the method - to preserve the vital processes in the root system of the tooth, that is, in this case, the doctor removes only part of the pulp affected by pus, trying to preserve the innervation in the root canals. True, this is rarely possible - after all, patients most often come in at an advanced stage, when the abscess has already affected the entire root system.
Stages of the vital method:
- local anesthesia,
- opening the pulp chamber and removing dead tissue,
- with this approach, the clinical situation requires long-term medicinal treatment, then the doctor puts the necessary drugs into the tooth cavity, closes the tooth with a temporary filling and continues treatment after a few days,
- if the patient walks with a medicinal “bookmark” for some time, then the next stage of treatment will be to re-clean the cavity, remove any remaining drug,
- canal filling,
- recreating the original shape using filling material or an artificial crown.
Devital treatment method
From its name it is clear that this method is used when it is impossible to preserve a living root system. It is partly similar to the vital method, but differs from it only in that the therapy is carried out in two large stages.
At the first stage, the tooth is opened, its cavity is cleared of necrotic tissue, after which a special drug (most often arsenic-based) is placed in it, which kills the dental nerve. This takes several days, then the patient comes back for an appointment.
At the second stage, the doctor removes the paste and dead pulp, cleans and disinfects the canals and carefully seals them. This is followed by the same manipulations as with the vital method.
For your information! If purulent pulpitis is diagnosed on a wisdom tooth, then the unit must be removed, because due to its anatomical features, treatment will be ineffective.
Treatment of aseptic (serous) pulpitis
If the patient goes to the clinic immediately after the onset of acute pain, then there is a high probability of diagnosing aseptic (or serous) pulpitis. Most often it turns into purulent (focal) pulpitis, and then the treatment tactics will be different. And at the stage of the aseptic form, when pus has not yet begun to form, drug treatment is possible.
Its essence is that the doctor opens the cavity of the crown and puts inside a medicine that kills microbes, and therefore inhibits the inflammatory process. With this method, neither partial nor complete removal of the pulp is required.
Treatment with folk remedies
Pulp abscess is a fairly serious disease fraught with dangerous complications. If pus enters the bloodstream and spreads throughout the body, blood poisoning may begin or the infection will spread to another organ and continue to develop there. In medicine, there are cases where untreated purulent pulpitis led to the development of pyelonephritis, arthritis, cystitis and even meningitis. There are cases when the infection spreads through the body tissues and leads to inflammation of the facial muscles, bone tissue or bone marrow.
Therefore, it is better not to self-medicate such a complex disease, since folk remedies - compresses and rinses - provide only temporary relief and do not remove the very cause of the pain - pus. In the meantime, the inflammatory process will continue and the unit will have to be removed in the future.
Prevention of purulent pulpitis
The main prevention is timely treatment of caries, because it is the most common cause of purulent inflammation inside the tooth. Careful oral hygiene also plays an important role: it is important to choose the right toothpaste and the stiffness of the bristles of the toothbrush so as not to injure the enamel and gums. The fact is that microtraumas are an excellent opening for germs.
It is also important to monitor your general health. You cannot carry such severe viral diseases as influenza, sore throat, bronchitis, and sinusitis on your feet. Also, you should not use antibiotics uncontrollably, as they kill not only pathogenic, but also beneficial microflora of the body, thereby reducing its resistance to bacteria and viruses.
You should not skimp on treatment. Low-quality, cheap materials do not guarantee tooth protection after therapy. And modern materials are able to withstand chewing loads, are less likely to crack and chip, and do not irritate the tissues of the tooth itself.
Video on the topic
PREFACE................................................... 5
TOOTH PULP. ANATOMICAL AND HISTOLOGICAL STRUCTURE, FUNCTIONAL FEATURES .... 7
ETIOLOGY AND PATHOGENESIS OF PULPITIS.................................... 16
CLASSIFICATION OF PULPITIS.................................... 26
CLINIC, PATHOLOGICAL ANATOMY, DIAGNOSTICS, DIFFERENTIAL DIAGNOSIS OF PULPTIS.......................... 29
ACUTE PULPTIS. CLINIC, PATHOLOGICAL ANATOMY, DIAGNOSTICS, DIFFERENTIAL DIAGNOSTICS........ 30
Pulp hyperemia.................................................... 33
Acute limited pulpitis................................... 34
Acute diffuse pulpitis. . ................................ 35
Acute purulent pulpitis.................................................... 36
Acute traumatic pulpitis.................................... 37
CHRONIC PULPTIS. CLINIC, PATHOLOGICAL ANATOMY, DIAGNOSTICS, DIFFERENTIAL DIAGNOSTICS........ 44
Chronic fibrous pulpitis.................................... 44
Chronic hypertrophic pulpitis........................ 45
Chronic gangrenous pulpitis.................................... 47
Chronic concrementous pulpitis.................................... 49
AWARENESSED CHRONIC PULPTIS..................................... 53
PULPTITIS COMPLICATED WITH PERIODONTITIS.................................... 55
PAIN RELIEF WHEN TREATING PULPTIS.................................... 57
LOCAL ANESTHETICS.................................................... 58
GENERAL ANESTHESIA.................................................... 69
TREATMENT OF PULPTIS.................................................... 73
BIOLOGICAL (CONSERVATIVE) METHOD OF TREATING PULPTIS. . 74
SURGICAL METHOD FOR TREATING PULPTIS...................................82
Vital pulpotomy (pulp amputation)....................................82
Vital pulpectomy (pulp extirpation)....................85
Method of vital pulp extirpation (pulpectomy)...86
Physical methods of pulp extirpation...................................89
Medicinal electrophoresis........................89
Copper-calcium hydroxide depophoresis...................91
Diathermocoagulation of pulp.......................... 97
Instrumental and medicinal treatment of root canals... 98
Methods for determining the working length of the root canal.........99
Apical-coronal technique
root canal treatment.........................115
Coronal-apical technique
root canal treatment................................119
Filling root canals for pulpitis....................................122
plastic filling materials........................126
Filling the root canal with pins
in combination with filler (sealer)..................................129
Filling the root canal with gutta-percha......129
The method of the central pin, or one cone.........131
Sectional method of filling with gutta-percha.........133
Cold lateral condensation of gutta-percha..........134
Hot lateral condensation of gutta-percha...........135
Vertical condensation of hot gutta-percha..........138
Root canal filling
thermoplasticized gutta-percha................139
DEVITAL METHOD OF TREATMENT OF PULPTIS.................................... 141
Devital pulpotomy (pulp amputation) ....................144
Devitalpulpectomy (extirpationpulp) ................149
COMBINED METHOD OF TREATMENT OF PULPTIS............................152
ERRORSANDCOMPLICATIONSATTREATMENTPULPITA
ANDWAYSTHEIRSOLUTIONS ......................... ..........,154
TOOTH PULP. ANATOMICAL AND HISTOLOGICAL STRUCTURE, FUNCTIONAL FEATURES
The pulp, or pulp of the tooth (pulpa dentis), is a complex connective tissue organ with various cellular structures, blood vessels, rich in nerve fibers and receptor apparatus, which together perform its functions and ensure the vital activity of the tooth. The pulp completely fills the tooth cavity, gradually passing into the periodontal tissue in the area of the apical foramen. The general outlines of the pulp to a certain extent repeat the shape and external relief of the tooth. The pulp contained in the cavity of the tooth crown is called coronal; in root canals it is called root pulp. The names “coronal pulp” and “root pulp” reflect not only the anatomical distribution nature, they have certain differences depending on the location, shape, structure and function of these anatomical formations. These differences between the coronal and root pulp are especially significant in multi-rooted teeth, where the anatomically pronounced border in the form of the mouths of the root canals appears quite clearly, especially with the development of pathological processes in it.
According to the morphological structure, the pulp is represented by loose connective tissue, which contains many cells, intercellular substance, blood vessels and nerve fibers. Its peculiarity is that, along with cellular elements, it contains a large amount of gelatinous ground substance. The fibers are represented by collagen and reticular (argyrophilic), elastic fibers were not detected in the pulp. The main cellular elements of the pulp are odontoblasts, fibroblasts, poorly differentiated cells (stellate, pericytes), sedentary macrophagocytes and others. These cells are distributed unevenly in the pulp, forming a certain pattern. Conventionally, this allows us to distinguish three layers in it: the layer of odontoblasts, or peripheral, subodontoblastic, or cambial, central. Each of them performs a specific physiological function or exhibits one or another reaction during the development of various processes (Fig. 1).
Rice. 1. The dental pulp is normal.
1 - primary dentin; 2 - secondary dentin; 3 - predentin; 4 - layer of odontoblasts; 5 - subodontoblastic layer; 6 - central layer.
Microphotograph. Hematoxylin and eosin staining. V.: about. 3, approx. 10
In the peripheral layer of the pulp, which is directly adjacent to the dentin, odontoblasts are located in several rows. These are highly specialized pear-shaped cells with dark, basophilic cytoplasm. Each of these cells has a dentinal process (Toms fiber), which penetrates the dentinal tubule and branches in it according to the branching of the latter. The cell body is rich in cellular organelles: a well-developed intracellular mesh apparatus, a lamellar complex, the Golgi apparatus, numerous mitochondria, the nucleus contains a lot of chromatin and several nucleoli. Towards the apex of the tooth root, the size of cells and the number of rows of odontoblasts in the peripheral layer of the pulp decrease.
The subodontoblastic layer consists of small, poorly differentiated stellate cells, from the body of which numerous processes extend, which are closely intertwined. The cells are located directly under the odontoblasts, connect with their elongated body and processes to the odontoblasts and enter the spaces between them. The cells of this layer have the ability, if necessary, to transform into odontoblasts.
The central layer of the pulp contains cells such as fibroblasts, which are spindle-shaped. For pulp cells of the fibroblast type, a characteristic functional feature is their differentiation into specific pulp cells, preodontoblasts and odontoblasts. In addition to fibroblasts, this layer contains a large number of sedentary macrophagocytes (histiocytes). The presence of these reticuloendothelial cells in the pulp provides its protective role. Both in the subodontoblastic and central layers of the pulp there are a large number of adventitial cells (pericytes) located along the vessels. These cells belong to the poorly differentiated cellular elements of the pulp. During inflammation, adventitial cells progressively change and transform into either fibroblasts or free macrophages. Thus, the presence of poorly differentiated cellular elements in the pulp (stellate and adventitial cells) is associated with the ability of the pulp to regenerate. In addition to cellular elements, this layer contains thin reticular and collagen fibers. Reticular fibers predominate in the odontoblastic and pododontoblastic layers, and collagen fibers predominate in the central layer.
Blood supply to the pulp
Rice. 2. Location of blood vessels and nerves in the dental pulp.
A - vessels in the coronal pulp of the tooth. B - vessels and nerves in the root pulp of the tooth.
Microphotograph. Hematoxylin and eosin staining. UV: vol. 3, approx. 10
Rice. 3. Lymphatic vesselsV pulp of the tooth.
Microphotograph. Hematoxylin staining and
eosin. UV: vol. 9, approx. 10
Innervation of the pulp
The dental pulp of the upper and lower teeth is innervated by the branches of the trigeminal nerve and is a highly sensitive tissue. Bunches of pulpal nerve fibers enter through the apical foramen of the root, forming, together with blood vessels, a neurovascular bundle with almost no branching; later it gives off thinner branches and individual nerve fibers that go in different directions to the periphery of the pulp, forming here the pododontoblastic nerve plexus is Rashkov's plexus. It has a large number of nerve endings, and is most pronounced in the area of the horns of the coronal pulp. A significant portion of the nerve fibers from the central layer of the pulp are directed through the odontoblast layer into the predentine and dentin. Above the layer of odontoblasts, at the border of pulp and dentin, part of the nerve fibers forms a nadodontoblastic nerve plexus, the fibers of which branch in the main substance of predentin. Various receptors are described in the pulp: in the form of branched bushes, brushes, etc. Along the dentinal processes of odontoblasts, nerve fibers can penetrate to a depth of approximately one third of the dentin thickness. Thus, the pulp has a pronounced sensitive innervation, which allows one to perceive sensations not only from the pulp, but also from the hard tissues of the tooth (Fig. 4).
Rice. 4. Rashkov’s plexus in the area of the horn of the coronal pulp of the tooth. Ascending nerve fibers directed through the odontoblast layer into pre-dentine and dentin.
Microphotograph. Silvering with silver nitrate according to Gomori. UV: vol. 9, approx. 10
Functions of the pulp
The dental pulp performs a number of diverse functions. One of the most important factors for the development and life of a tooth is dentin formation. This function is directly provided by highly differentiated pulp cells - odontoblasts. The reserve for constant replenishment of odontoblasts is the poorly differentiated cells of the subodontoblastic layer.
The plastic function of the pulp is most actively and clearly manifested during tooth formation and continues after its eruption. When pathological changes occur in the hard tissues of teeth, for example, caries, the pulp responds to them with the formation of secondary irregular (replacement) dentin. Dentinogenesis continues as long as poorly differentiated pulp cells are capable of differentiating into odontoblasts. Under the influence of factors causing the development of the carious process, along with the formation of secondary irregular dentin, restructuring processes are observed in the dentin directly adjacent to the bottom of the carious cavity. They are accompanied by the active flow of mineral salts through Toms fibers into the dentinal tubules. As a result, obliteration occurs, i.e. complete closure of the lumen of some groups of dentinal tubules. This is the so-called transparent, sclerotic dentin, characterized by increased hardness. Increased deposition of lime salts during caries and increased tooth abrasion can be considered as a tooth reaction to the action of various harmful agents, which protects the pulp from irritation and infection.
The trophic function is important for the pulp; it provides nutrition to dentin and supports the vital activity of tooth enamel. Hard dental tissues receive nutrients with transudate from capillaries, through Toms fibers, which, branching and anastomosing, form a sap-bearing network. Neurohumoral processes in all dental tissues are regulated through the pulp, and their disruption can lead to dystrophic changes in dentin and enamel.
Pulp cells, especially odontoblasts, regulate the trophic function and regenerative capacity of dentin. The presence of elements of reticuloendothelial tissue (sedentary macrophagocytes) in the pulp increases its protective barrier function. It has been established that pulp cells have a high phagocytic ability, which prevents the penetration of microbes into the periapical tissues and inactivates them. This fact is confirmed by the active accumulation of cells in areas located directly at the apical foramina or at a short distance from them. On the one hand, the barrier function of the pulp is enhanced by the presence of hyaluronic acid in it, the astringent properties of which contribute to the retention of bacteria that do not have hyaluronidase-secreting ability. On the other hand, the pulp is rich in a capillary network of blood and lymphatic vessels, which enable the outflow of exudate. One of the features of dental pulp is the high absorption capacity of vascular endothelial cells, as one of the reserve physiological mechanisms of tissue protection, especially during inflammation of the pulp. The rich innervation of the pulp and its receptor apparatus also play an important protective role.
Dental pulp has a significant potential for regeneration as a tissue of the vascular-connective tissue type. It contains a significant number of poorly differentiated cells that can quickly transform into highly differentiated protective cells and specific odontoblasts. An equally important role in this process is played by the rich blood supply and innervation of the pulp, and the high activity of metabolic processes in it. This leads to the fact that even with significant trauma, the pulp can remain viable and form a scar at the site of injury. These features of the structure and function of the pulp provide a specific clinical picture for inflammatory processes in it and lie at the forefront of the choice of treatment methods.
Acute purulent pulpitis The clinical picture of the disease is even more severe. The patient is bothered by tearing, constant, nocturnal, periodically increasing and decreasing pain, which can calm down from exposure to cold and intensify from hot. There are no changes upon external examination. The patient's general condition suffers due to severe pain and lack of sleep at night. Body temperature is normal. A carious cavity is identified in the causative tooth. When probing the bottom of the cavity, the pulp horn is easily opened and a drop of pus with blood is released, which causes relief in the patient’s condition. Percussion of the tooth is painless, but in young people it can be sensitive. The adjacent mucous membrane is pale pink. EOM data - up to 25-80 microns. Usually EDI is not performed, since the clinical picture of the disease is pronounced. The x-ray shows a defect in the tooth tissue in the crown area that does not communicate with the carious cavity; there are no pathological changes in the periodontium.
Clinical example. Patient Kh., 29 years old, complains of acute spontaneous attacks of pain, radiating to the ear on the left, pain at night. The duration of the attack is about 25-30 minutes, the period without pain lasts 1-2 hours. During the day, taking cold food or getting solid food into a carious cavity causes an attack of acute pain, radiating into the ear, lasting 5-7 minutes. He cannot accurately indicate the causative tooth.
Anamnesis. The patient has a carious cavity that is sensitive to the effects of cold food. Previously, the pain was short-term, and the patient did not go to the doctor. Acute pain appeared for the first time, lasted for 3 days and increased in intensity and duration of painful attacks. The patient's general condition is satisfactory, body temperature is 36.6° C. He denies concomitant diseases and has not suffered from viral hepatitis. He also denies allergies. Previously, I treated tooth 46 for caries under anesthesia and tolerated it well. Hygiene skills are good.
External inspection. The general condition of the patient is satisfactory. The face is symmetrical, the skin is of normal color, the lymph nodes are not palpable, the opening of the mouth is free.
Examination of the oral cavity. The mucous membrane of the mouth and lips is pale pink. The bite is orthognathic. The frenulum of the lips and tongue is without any features. The level of oral hygiene is satisfactory. Dental formula:
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
The carious cavity in the 36th tooth of class 1, deep, is made of softened dentin, probing the bottom of the carious cavity is painful along the bottom, percussion of the tooth is painless, the color of the tooth is A3. The thermotest causes an attack of radiating pain in the 36th tooth, lasting about 4 minutes. The EOM data for this tooth is 25 µA. X-ray 36 reveals a defect in the crown of the tooth that does not communicate with the tooth cavity. The tooth has 2 roots, the apices deviate posteriorly; root canals are identified in them; there are no pathological changes in the area of the apical periodontium.
Differential diagnosis is carried out with deep caries, acute partial pulpitis, exacerbation of chronic pulpitis, acute and exacerbation of chronic periodontitis, trigeminal neuralgia, alveolitis.
Diagnosis: Acute diffuse pulpitis of the 36th tooth.
The patient is given information about the results of the examination, diagnosis, treatment plan and possible complications associated with anesthesia, preparation, passage, expansion and filling of root canals. Written consent for treatment was obtained from the patient.
