Are You Still Well Verse with the Various Pulpal Injury, Its Signs & Symptoms?
On Part 1, we gave you a guide on your diagnosis technique to properly identify the pulpal condition and, of course, our treatment options. Click Here: PART I
On this Part 2, we will delve more into differential diagnosis between Reversible and Irreversible Pulpitis, the Histopathology and corresponding treatments we can implement to save the tooth.
Reversible VS Irreversible Pulpitis
I. Reversible Pulpitis
It is a mild to moderate inflammatory condition of the pulp caused by a noxious stimuli on which the pulp is still capable of healing itself to revert back to its normal state upon the removal of the causative factor. For example, discomfort is experienced by the patient when a stimulus such as cold or sweets is applied on the tooth and the irritation goes away within a couple of seconds following the removal of the stimulus.
Reversible pulpitis may range from hyperemia to mild to moderate inflammatory stated and limited only to the area of the involved dentinal tubules, such as the area where the dentinal caries is found. Microscopically, one may see the following:
- Dilated Blood Vessel.
- Extravasation of Edema Fluids.
- Disruption of the Odontoblast Layer.
- Reparative Dentin.
- Acute & Chronic Inflammatory Cells.
- Symptomatic Reversible Pulpitis is characterized by sharp pain lasting only for a moment.
- It is more often triggered by cold food, beverages and/or air.
- It does not occur spontaneously and does not continue when the cause has been removed.
- Diagnosis should be based on the symptoms.
- If it becomes chronic, patient will experience sudden intermittent pain. Each paroxysm may be of short duration, but, these paroxysms may continue for weeks or even months.
- A tooth with Reversible Pulpitis reacts normally to percussion, palpation, and mobility, and, the periapical tissue is also normal on radiographic examination.
E. Differential Diagnosis with Irreversible Pulpitis
The pain is generally transitory, lasting a matter of seconds. Whereas in Irreversible Pulpitis, the pain may last several minutes or even longer.
- Prevention is always better than cure.
i. Periodic dental professional care to prevent the development of caries.
ii. Early restoration like sealant if a cavity has developed.
iii. Desensitization of the exposed tooth neck in case of recession.
- When reversible pulpitis is present, remove the noxious stimuli causing it.
- Once the symptoms have subsided, the tooth should be tested for vitality, to make sure that pulpal necrosis has not occurred.
- When pain persists despite proper treatment, the pulpal inflammation should be regarded as irreversible wherein the treatment is pulp extirpation.
Prognosis of Reversible Pulpitis is very favorable and most of the time, removal of the causative stimulus will do the deed.
II. Irrevirsible Pulpitis
A. Classification and Definition
1. Symptomatic Irreversible Pulpitis - is based on subjective and objective findings that the vital inflamed pulp is incapable of healing and that root canal treatment is indicated.
2. Asymptomatic Irreversible Pulpitis - is a clinical diagnosis based on subjective and objective findings indicating that the vital inflamed pulp is incapable of healing and that root canal treatment is indicated.
- Microscopically, one sees the area of the abscess with microorganisms present. If the case is in the late carious state, lymphocytes, plasma cells, and macrophages are also present.
- No microorganisms are found at the center of the abscess because of the phagocytic activity of the polymorphonuclear leukocytes.
1. Symptomatic Irreversible Pulpitis
- Sharp pain felt upon thermal stimulus.
- Lingering pain often 30 seconds or longer after stimulus removal.
- Presence of spontaneous or unprovoked pain.
- Sometimes the pain may be accentuated by postural changes such as lying down or bending over and over-the-counter analgesics are typically ineffective.
- Can create referred pain to adjacent teeth, to the temple or sinuses when an upper posterior tooth is involved, or to the ear when a lower posterior tooth is affected.
- May be challenging to diagnose because the inflammation has not yet reached the periapical tissues, thus, resulting to no pain or discomfort during percussion test. So, in such cases, dental history and thermal testing are the primary tools for assessing the pulpal status.
2. Asymptomatic Irreversible Pulpitis
- No clinical symptoms.
- Usually respond normally to thermal testing even with probable existence of trauma or deep caries that can be seen upon further inspection and removal of the old restorative filling or carious tooth structure.
- Upon close inspection, it generally discloses an existence of deep cavity extending up to the pulp.
- The surface of the pulp is eroded.
- An odor of decomposition is frequently present in the affected area.
- Probing into the area is not painful to the patient until the deeper areas of the pulp are reached.
- A radiographic examination may show pulp exposure.
E. Differential Diagnosis with Irreversible Pulpitis
- Signs and Symptoms can provide differentiation between the two states.
- In later stage of irreversible pulpits, the symptoms may simulate those of an acute alveolar abscess. Abscess has following symptoms which helps in differentiating it from Pulpitis:
i. Tenderness on Percussion
ii. Tenderness on Palpation
v. Lack of Response to Pulp Vitality Test
- Complete Removal of Pulp | Pulpectomy.
- In Posterior Teeth – Removal of Coronal Pulp | Pulpotomy should be performed as an emergency procedure.
The prognosis of the tooth is favorable if the pulp is removed and if the tooth undergoes proper Endodontic Therapy and Restoration.
Special Considerations: When Irreversible Pulpitis is present, the teeth that are most difficult to anesthetize are mandibular molars, followed by mandibular premolars; the maxillary molars and premolars; and, the mandibular anterior teeth. The one with the least problem is the maxillary anterior teeth.
In some teeth, when irreversible pulpitis exists on the apical portion of the canals with necrotic tissue chamber and does not respond to pulp testing, a supplemental injection through the pulp chamber can be entered to lessen severe pain.
Differential diagnosis is as much as an important part in arriving to our definitive diagnosis especially when it comes to addressing if the tooth maybe in need of a more radical treatment like RCT. Thus, being well verse on the signs and symptoms of the different types of pulpal injuries and using the right method and tools to elicit them will greatly affect whether the prognosis and success of our dental treatment will be indeed highly favorable or not.
Dr. Bryan Anduiza - Main Writer
Dr. M. Jean Villanueva - Writer | Editor