Pulpitis is reversible and irreversible. It’s the inflammation of the innermost tissue of the tooth that contains nerves and blood vessels.
Whenever the nerves inside the pulp get triggered, primarily due to a cavity, you experience a toothache.
Treating reversible pulpitis is comparatively easier than treating irreversible pulpitis. The pulpal inflammation can be reversed in the case of reversible pulpitis by removing caries, providing a pulpal barrier, and doing a dental filling.
However, irreversible pulpitis demands the complete removal of caries and pulpal tissues, adequate debridement of root canals, and filling of the canals with a sealing material followed by a dental filling and a dental crown.
The process is trickier and tougher for irreversible conditions and comes with a lot of aftermath, too.
Let’s delve into more detail about the treatment options for the discussed condition.
What is Pulpitis?
Definition and symptoms of pulpitis
Your tooth comprises three primary dental tissues: enamel, dentine, and pulp. The dental pulp is highly vascularized with numerous blood vessels and nerves. It’s a tissue that keeps your tooth alive.
Whenever the pulp gets irritated, it gives you a wide range of symptoms, which include:
- sensitivity,
- dull tooth pain and discomfort,
- sharp throbbing and lingering pain
- severe pain
- sometimes no pain
Inflammation of the pulp is called pulpitis. Whenever the pulp gets irritated, the blood flow inside the pulp chamber increases. This raises the blood pressure within the pulp, giving you intense pain.
The pain pathway is also triggered as the pain-causing receptors are activated on the nerves and the blood vessels, and the signals reach the brain. The severity of the pain depends on the stage of pulpitis.
There are three major stages of pulpitis:
1) Reversible Pulpitis:
The inflammation is reversible.
Hence, the pulp can stay alive once the cavity is removed and filled with dental material. In this condition, one responds excessively to cold and hot foods, and the response typically lasts for one to two seconds.
2) Irreversible Pulpitis:
The inflammation is irreversible, and the pulp is near to die. It cannot be reversed; however, a root canal treatment can be performed on the tooth to keep it functional in the oral cavity. The hot food usually causes the pain, and it typically lasts for hours and minutes. Some cases require tooth extraction as well.
3) Necrotic Pulp:
The later stage of irreversible pulpitis is pulp necrosis. The pulp tissue is now dead, and it doesn’t respond to hot and cold foods but is always painful on percussion. A root canal therapy or extraction is needed
Causes of Pulpitis
There are a lot of reasons why the pulpal status changes from alive to dead. Here are a few:
1) Dental Cavity:
A carious lesion in a tooth that reaches close to the pulp can cause inflammation of the dental pulp. Many times, the deep pits and fissures on the chewing surface of the tooth and the proximal tooth surfaces between two teeth are the major sites for caries initiation. Regular visits to a dentist twice a year can save you from having this condition.
2) Dental Procedures:
Drilling of the tooth for caries without water coolant and excessive drilling near the pulp can cause the pulp to undergo necrosis.
3) Cracked Tooth:
A crack in a tooth or a tooth fracture extending to the pulp can cause pulpitis.
4) Trauma:
An injury to the tooth can lead to the pulp being exposed. The pulpal response will depend on the severity of trauma to the tooth.
5) Worn Tooth Enamel:
Aggressive brushing and conditions like GERD and certain eating habits can expose the pulp tissues by removing the protective tooth, later called enamel.
Pulpitis Treatment Options
Nonsurgical Treatments:
Medications for pain relief:
Dental pain is primarily treated with over-the-counter painkillers or the nonsteroidal antiinflammatory drugs prescribed by a dentist.
This is the immediate pain reliever and does the symptomatic treatment of your tooth. Examples of NSAIDs include ibuprofen, acetaminophen, naproxen, celecoxib, and aspirin. These inhibit the production of inflammation-causing agents called prostaglandin that activate the pain-causing receptors, which give the brain a signal for pain.
Specific NSAIDS like aspirin and ibuprofen are available in doses like 200mg 325 msg in the market. However, higher doses are prescribed by a dental practitioner to manage pain. Although NSAIDs are effective in relieving pain, however, they can be accompanied by side effects. Major side effects include kidney and gut problems.
Other analgesic types that are commonly prescribed are opioid analgesics, which include oxycodone, hydrocodone, and codeine. These are often prescribed in combination with acetaminophen, and they are great at altering pain perception received by the brain.
Adverse effects associated with opioids include sedation, nausea, vomiting, and breathing difficulty. The worst part about opioids is they are associated with withdrawal symptoms if withdrawn after prolonged use.
Antibiotics for infection control:
Irreversible pulpitis can lead to the formation of periapical abscess, sinus tract, fistula, or the infection spreading throughout the oral cavity and body. If signs of infection like fever are accompanied by irreversible pulpitis, your dentist will prescribe antibiotics for infection control; oral dose of amoxicillin 500 mg every 8 hours is prescribed. Alternatively, patients allergic to penicillin are given cephalosporin, azithromycin, or doxycycline.
Surgical Treatments:
Root canal therapy:
Root canal treatment, also called endodontic procedure, removes the infectious pulp from the center of the tooth to save the tooth that might need an extraction in the future. The tooth consists of two structures called the crown and the root. The tooth canal extends from the crown to the end of the root.
A root canal is needed when the pulps show the signs and symptoms of irreversible pulpitis and necrosis. Almost 15 million root canal procedures are performed in us every year. The clinical diagnosis is confirmed after taking an X-ray of the tooth, which reveals the extended tooth damage till the pulp surpasses enamel and the dentine.
A root canal procedure is performed to eliminate bacteria that have reached the pulp.
There are specific steps in this procedure. Here are these:
1) A dentist or a dental assistant will inject an anesthetic agent on the affected side to numb the area and keep you safe from dental pain during the procedure.
2) If you feel anxious at the dental office, you may also be given some sedative agents to make you feel drowsy and to help you relieve your anxious state. Nitrous oxide sedations are usually provided at dental offices.
3) Next, your dental provider will place a rubber dam sheet over your infected tooth to achieve a clean, clear, and dry workspace to access the tooth.
4) Next, if your tooth is carious, your dentist will remove the caries before accessing the pulp chamber to remove the infected pulp.
5) Next, he’ll use dental instruments called files to remove the nerves and vessels from the narrow canals. This goes simultaneously with continuous cleaning and disinfection with a disinfectant.
6) Next, the empty pulp canals are filled with a rubber-based material called gutta-percha.
7) Your tooth will then be sealed with a permanent dental filling material.
8) Lastly, your dentist will place a dental crown on the treated tooth to make it functional in the oral cavity.
Pulpotomy:
A root canal therapy or Pulpectomy is the complete removal of the pulp from both the root and the crown, while pulpotomy is the partial removal of the pulp tissue from the crown portion of the tooth.
In pulpotomy, the pulp tissues inside the canal are left intact. This procedure is majorly performed on baby teeth when they show the signs and symptoms of irreversible pulpitis. The process is as follows:
1) A dentist or a dental assistant will inject an anesthetic agent on the affected side to numb the area and keep your child free from dental pain during the procedure.
2) If your child feels anxious at the dental office, he may also be given some sedative agents to make him feel drowsy which will help him relieve his anxiety. Nitrous oxide sedations are usually provided at dental offices.
3) Next, the dental provider will place a rubber dam sheet over your infected tooth to achieve a clean, clear, and dry workspace to access the tooth.
4) Next, if the tooth is carious, the dentist will remove the caries before accessing the pulp chamber to remove the infected pulp.
5) The roof of the pulp is drilled until it bleeds. The pulp tissue is removed from the crown portion of the tooth and is dried with cotton pellets and swabs. If the bleeding stops, the remaining pulp is considered healthy. Then, the pulp inside the root is treated with either medication, which includes formocresol, ferric sulfate, and mineral trioxide.
6) The pulp chamber is then sealed with zinc oxide.
7) Later, it’s sealed with a stainless steel crown.
Tooth extraction:
A tooth extraction is a procedure in which the tooth is completely pulled out of the socket if the tooth is unsalvageable with a root canal treatment.
The steps for the procedure include:
1) Local anesthesia is provided at the affected side to numb the area.
2) Nitrous oxide sedation or oral or IV sedation is provided to make you feel relaxed during the treatment.
3) Special dental instruments are used first to loose the tooth and then to pull it out of the tooth socket.
4) Once the tooth is removed, it’s cleaned, disinfected, and sewed with sutures.
5) You’ll be provided some post-operative instructions, like keeping the extraction site clean and taking the painkillers and antibiotics if needed.
Pros and Cons of Each Treatment Option
Nonsurgical treatments
Pros:
~ Instant relief from pain
~ Can help delay the treatment until the appointment date.
~ Over-the-counter medications are readily available for pain relief and require no prescription.
~ Escapes the anxiety that will be experienced at the dental chair.
~ Saves a lot of money.
Cons:
~ Can worsen the tooth condition. You might have facial swelling or a tooth abscess.
~ Delaying the treatment can further destroy the tooth structure, leading the tooth to extraction.
Surgical treatments
Pros:
~ It saves the tooth from further damage. The earlier the treatment, the better the prognosis.
~ Lesser chances of having facial swelling and tooth abscess.
Cons:
~ Long wait for the appointment day.
~ Needs insurance coverage or a good amount of money to pay at the dental office,
Potential Outcomes and Recovery
- Recovery process after nonsurgical treatments
- The recovery process after surgical treatments
- Long-term outcomes and considerations
Aftermath of Root Canal Treatment
One of the biggest and the major outcomes of root canal therapy found in a clinical practice is the root fracture. Root fracture happens due to a lot of reasons, and here are they:
Structural weakness: Teeth that have undergone root canal treatment are structurally weaker than healthy teeth due to the removal of the nerve and blood supply, which can cause the tooth to become brittle and more prone to fracture.
Over-preparation: Over-preparation of the root canal during treatment can weaken the tooth structure and increase the fracture risk. This can occur if too much of the tooth structure is removed during the canal preparation.
Vertical root fracture: Vertical root fractures (VRFs) can occur during or after endodontic treatment. These fractures are usually caused by excessive lateral pressure during root canal preparation or instrumentation.
Tooth Filling: A poorly fitting or inadequate tooth filling and dental crown can also cause root fractures. If the restoration is not strong enough or does not provide adequate support, it can cause the tooth to fracture.
External trauma: External trauma, such as a blow to the face or an accident, can also cause root fracture, even if the tooth has undergone endodontic treatment.
It is important to note that root fractures can sometimes occur without an apparent cause or explanation. Regular dental checkups and follow-up appointments after endodontic treatment can help identify potential issues and prevent complications.
Preventing Pulpitis and Maintaining Dental Health
Maintaining good oral hygiene:
Here are a few tips to keep your oral hygiene to prevent pulpitis:
1) Brush your teeth twice a day with a fluoride toothpaste.
2) Use a dental floss to clean between the teeth.
3) Drink fluoridated water daily to receive an adequate amount of fluoride to keep your teeth healthy.
4) Don’t smoke. Smoking is terrible for your gums and teeth.
5) Eat a healthy and balanced diet while limiting the intake of sugary and processed foods.
Regular dental checkups and cleanings:
Routine dental checkups are important to know whether you are at high risk for caries or not.
If you’re declared someone prone to caries, your dentist or dental hygienist might advise you to go for fluoride treatment or be asked to see your medical practitioner to correct your systemic condition. Moreover, dental scaling and polishing twice a year can help remove plaque deposits from your oral cavity.
What is Elective Root Canal Therapy?
A root canal treatment of healthy teeth to hold a dental crown or bridge is called elective root canal therapy. The root canal treatment is performed, followed by a post-placement inside the tooth to hold the crown.
