Chronic pulpitis

Dr.Mohammad salah qrea

Definition

• Inflammation of the pulp tissue over an extended period of time which causes irreversible changes in the quality of pulp tissue.

Signs & Symptoms

• Dull pain but bearable

• Persistent for as long as an hour

• May be symptom less in some cases

• Pain triggered by hot and cold

Diagnosis

• Patient usually had a previous history of acute pain in the same tooth

• Ep test above normal ( 60-80 mhz)

• No signs of a continuity from cavity into pulp chamber

• Floor of cavity usually is formed of hardened dentine

Radiographic examination:• Not significant in exact

diagnosis but still important since they may show other pathologies.

• Radiographs may show : - recurrent caries under old

restorations. - pulp chamber

enlargement due to internal resorption.

- calcification in cases of long term low grade irritation.

Electric pulp testing

• Delivers a high frequency current to desired tooth.

• To determine the presence or absence of sensory nerves (pulp vitality).

• Stimulated nerves are of the myelinated A- delta fiber group.

How to perform EPT ?

• Clean, dry & isolate tooth.• Scrub facial surface with a dry cotton roll

and isolate with the same roll.• Make sure tooth is dry by air syringe.• Attach the clip of the device to patients lip or

let him hold it( closes the electrical circuit).

• Apply toothpaste or conducting medium to the electrode & touch tooth.

• A control test must be performed on a non affected tooth to make sure patient has a normal threshold of stimulation.

Differential diagnosis

• Acute pulpitis (pain is spontaneous and more intense)

• Deep situated carious lesion ( pulp is stimulated in the same way but stimulus subsides immediately)

Differential diagnosis

• Pulp necrosis ( same symptoms but pain is only triggered on hot irritant, also a continuity between cavity and pulp exists )

Pathologic progress

• recession of a case of acute pulpitis or abscess

• slow progressing carious lesions

• badly treated caries or recurrent caries

• trauma

Prognosis of untreated teeth:• Inflamed tissue will change into

granulation tissue due to persistent irritation.

• Later on fibrous tissue will form.• From this point several

pathologies may arise -necrosis -internal resorption -calcification of pulp chamber -pulpal stonesIt is important to keep in mind that a

chronic form may turn to the acute form in cases of decreased immunity.

Histopathology

The effects of inflammation on the dental pulp.

1. obliteration of bv.2. Increase in chamber

pressure.3. Increase in neutrophils

later on replaced by lymphocytes and fibroblasts.

Histopathology• Dilated

capillaries and neutrophils suggest acute inflammation.

• Lymphocytes and fibroblasts suggest chronic inflammation.

Treatment options

• RCT is treatment of choice.• In case there is insufficient

time, premature apex or primary tooth :

-Pulpotomy -Partial pulpectomy

• Extraction is less commonly used but is significant in patients of low socio-economic status.

Complications & follow up

• The most common is a transformation of a chronic pulpitis into the acute form either simultaneously or post operatively

• Most common causes of post operative flare ups include incomplete pulp tissue removal, and lack of isolation during procedure.

Intra operative tips:• In some cases of pulpitis

profound anesthesia is difficult to achieve. Recent studies recommend the administration of oral ibuprofen before procedure.

• Isolation is more important than your fancy cavity preparation.

• Always make sure all pulp tissue is removed from chamber at least.

• If bleeding persists after removal of pulp chamber it may indicate that the inflammation has reached to the radicular pulp, therefore proceed with a partial pulpectomy or complete RCT.

Don’t wait on tooth pain!!!

THANK YOU!!