Probably there is no such person who never had a toothache. And when, as they say, the process began, all sensations center around a single, sick tooth. If you postpone the visit to the dentist until later, then the patient has every chance to know all the "charms" of chronic pulpitis.
What is the essence of the process?
Pulpitis, if one is available, is an inflammatory process that develops in the neurovascular bundle inside the root canals of the teeth and their crown. If the patient turned to the doctor with complaints of severe pain (i.e., acute pulpitis occurs), in some cases the inflammatory process can be stopped and the tooth can be saved.
In a state of chronic pulpitis, the pulp gradually degenerates, fibrous tissue forms, necrosis or transformation of the neurovascular bundle is observed up to a state where the entire carious cavity is filled with its tissues, which led to the pathology.
Most often, with chronic pulpitis, acute pain does not happen, and patients come to the doctor in order to save the tooth from removal. However, the chronic form of pulpitis is almost always an irreversible disease.
Reasons for development
Any pathology has the prerequisites and circumstances that gave impetus to the development of the disease process. Pulpitis is no exception. Chronic forms of this disease are provoked by pathogenic microorganisms and their metabolic products. As a rule, the beginning of all beginnings is the presence of deep caries in the patient or poor-quality treatment of this widespread ailment. The latter concept implies non-compliance with the technique for treating a diseased tooth, insufficient cleansing of the carious cavity, poorly placed filling, etc.
Less common causes of chronic pulpitis, provoking the development of the pathological process, may consist in tooth injury, blockage of the channels of the neurovascular bundle with salt plugs (“calculi”). Also, chronic pulpitis can appear as a complication in maxillofacial and general diseases (sinusitis, influenza, periodontitis, osteomyelitis, periostitis, etc.) During the course of such diseases, pathogenic microorganisms can penetrate through the apex of the tooth root.
Varieties of the chronic process
Dentists distinguish 3 types of chronic pulpitis: hypertrophic, fibrous, gangrenous.
With the hypertrophic process in the carious plane, the growth of pulp tissue in the form of a polyp is observed. As a rule, the patient sees a bleeding outgrowth that is injured when chewing food. Pain can be mild and is caused in most cases by external irritants.
The fibrous form occurs most often and is characterized by periodically occurring aching pain that stops within 1-2 days by itself, but the carious cavity almost constantly bleeds.
The gangrenous form is characterized by complete decomposition of the nerve tissue of the tooth and a large destruction of its crown part. This form of pulpitis is always accompanied by bad breath. Pain, as a rule, is moderate, arising periodically. Typical complaints of the patient in this case are: "the tooth was very sick, and then it stopped by itself."
It should be noted that most often (≈ 70% of cases), doctors diagnose chronic fibrous pulpitis, much less often - gangrenous. The hypertrophic form in adult patients practically does not occur. Such a diagnosis is sometimes made by pediatric dentists.
Diagnosis of chronic pulpitis
In order to make a diagnosis, the doctor, in addition to listening to the patient’s complaints, will need to carry out a certain set of measures, consisting of a visual examination of the diseased tooth, thermometry, EDI and radiography.
At a visual examination, the doctor receives about 50% of the information about the condition of the causative tooth. Thermometric studies on the reaction to cold and hot stimuli provide an opportunity to understand what disease and its type the patient turned to the doctor. For example, a reaction to the cold suggests that the "nerve" has not died.
Electroodontodiagnosis (EDI) is one of the most reliable ways to diagnose pulpitis. The technique is based on the fact that diseased and healthy pulp tissues have different electrical excitability. A healthy nerve will respond with a slight pain to the effect of a current of 2-6 μA, fibrous pulpitis with pains of the same intensity will respond to 35-50 μA, gangrenous will require an impact of 60-90 μA.
Radiography involves evaluating a tooth’s condition from x-rays.
Differential diagnosis of chronic pulpitis involves a comprehensive assessment of all the above methods and a comparative analysis of the information obtained in the process of diagnosis.
Symptoms of chronic pulpitis
Basically, the disease at this stage is asymptomatic. How can we understand that a person has chronic pulpitis? Complaints mainly boil down to the presence of aching pain with different intervals of lull intervals between them.
With the fibrous form, as a rule, pain is present as a result of exposure to irritating factors (hot, cold, sweet). The pains do not go away for a long time even after the influence of irritants is eliminated. A characteristic symptom is the development of prolonged pain when the external temperature changes from cold to warm (for example, the transition from the street to the room). Although in some cases, the occurrence of fibrous pulpitis is possible without obvious signs. This happens if the stimuli do not have direct access to the cavity (for example, it is localized under the gum or has a through communication with the pulp chamber). In the latter case, there is no swelling, the pulp is not bursting, and, as a result, there is no pain.
With gangrenous pulpitis, there is always an unpleasant odor from a diseased tooth and from the mouth. Pain from exposure to hot is characteristic, which does not stop long enough even after the irritant is eliminated. Often there are sensations of fullness in the tooth. In addition, the color of a tooth almost always changes: it becomes grayish.
Hypertrophic pulpitis is accompanied by aching pain when chewing food and bleeding. This is due to the germination of the pulp into the cavity in the type of "wild meat". It is this factor that most often scares the patient and makes him consult a doctor.
Stages of treatment of a chronic process
Since with this disease the soft tissues in the tooth cannot be preserved, the main type of therapy is the removal of pulp from all channels of the tooth. In the vast majority of cases, modern dentistry prefers the technique of vital extirpation (live extraction) of the nerve, when only anesthetics are used without the use of medications to kill the pulp.
However, sometimes the individual characteristics of the jaw of the patient, lack of time and lack of good anesthetics do not allow you to remove the nerve immediately on the first visit. Then the treatment of chronic pulpitis is applied in stages, when a special paste is placed in the carious cavity, with the aim of preparing the pulp for removal, which happens on the second visit.
After treatment
Quite often after the treatment of chronic pulpitis is completed, people complain of pain. These sensations are called post-filling (as dentists call them). As a rule, discomfort appears for several reasons and fits into a conditionally acceptable norm. The occurrence of pain after treatment of pulpitis is possible due to the fact that the tissues around the diseased tooth may be slightly injured or with a rough, sharp separation of the "nerve" in the process of its removal. Also, pain can occur if during the treatment the tooth canals were treated with powerful antiseptic agents that could go beyond the root in small volumes.
Another reason for post-filling pain is the exit of a thin instrument, which dentists use during treatment to work inside the canals, beyond the apical root opening.
Causes of complications after therapy
Sometimes after seemingly successful “communication” with the dentist severe pain begins, and the initially treated exacerbation of chronic pulpitis is complicated. There may be several reasons for this. These are poorly performed work on filling the tooth canals, breaking off the dental instrument when it is in the tooth canal or perforation (creating a hole) in the root wall.
If the channels were poorly sealed or penetration of the filling material outside the apex of the root was allowed, symptoms of periodontitis in the acute stage will appear over a period of time (from several days to a year). The breaking of the instrument may not immediately manifest itself, but the infection in the incomplete and unsealed canal will nevertheless declare itself to be a flux, the periodic appearance of fistulas on the gum (at best) or the formation of cysts with purulent contents.
Exacerbation of the chronic process: symptoms
If a sick tooth with manifestations of acute pulpitis cannot be cured in time, the disease will go into a chronic form and will remind of itself with enviable constancy throughout life. How is exacerbation of chronic pulpitis manifested? Symptoms are unpleasant: pain from exposure to various stimuli (warm, cold, sweet, transition from cold to warm), quite negative sensations during palpation and percussion (lightly tapping the foot of a dental instrument on the causative tooth). Most often, patients describe pain as paroxysmal. At the stage of exacerbation of the chronic process, the spread of pain along the pathways of the trigeminal nerve is characteristic. It is for this reason that patients say that pain is given in the temple area or under the eyes, in the nose or chin.
Aggravation and causes of its development
Exacerbation of chronic pulpitis can be felt for several months. Pain is not as intense as in acute form. The most common causes of exacerbation may be phenomena such as a worsening of the outflow of exudate, tooth injury, increased activity of pathogenic bacteria. In addition, weakening of general immunity, the inflammatory process in the lymph nodes and general intoxication of the body can contribute to relapse.
An exacerbation of the chronic form of pulpitis may be accompanied by focal periodontitis. In such cases, patients come to the dentist complaining of persistent pain. Pathological changes are recorded on an x-ray.
Temporary teeth in small patients
Not only adult patients are diagnosed with chronic pulpitis. In children, and not only with permanent, but also with temporary teeth, this disease is also possible. All forms of chronic inflammation are characterized by pronounced symptoms.
A child cannot chew food normally. The causative tooth reacts to temperature stimuli. With the gangrenous form, pain appears in response to irritation warm, hot, or when moving from cold to a warm room. Proliferative pulpitis (and its hypertrophic form in particular) is characterized by the appearance of pain when food particles enter the carious cavity. In addition, the pulp polyp bleeds when exposed to mechanical stress.
The peculiarity of the course of the disease at this age is the low intensity of pain, which can be explained by a structural change in the pulp and its tight connection with the periodontium. In this case, optimal conditions are created for the free removal of exudate, as a result, there are no severe pains.
Permanent teeth in children
Permanent teeth in children are also susceptible to pulp diseases. The forms of chronic pulpitis in children are exactly the same as in adult patients. The chronic process in the acute stage in young patients is usually characterized by a prolonged sluggish course with periods of acute pain. Often the growing discomfort suddenly disappears, and the child is not bothered by anything for a sufficiently long period of time. But in most cases, patients complain of paroxysmal or tearing sharp pains, giving in the direction of the branches of the trigeminal nerve. Low electroexcitation (120-160 μA) indicates changes in the nerve elements of the pulp, which are dystrophic and destructive in nature.
Summarize all of the above
To the great regret of the patients, neither the acute phase of the disease, nor the subsequent exacerbation of chronic pulpitis will pass by itself. A dentist will need treatment sooner or later. And it is better for this to happen as soon as possible in order to save the patient from unnecessary suffering and expensive and painful activities, and the doctor from long and tiring work that requires considerable experience and patience.