Pulpitis can occur when
A tooth requires multiple invasive procedures
Trauma disrupts the lymphatic and blood supply to the pulp
Pulpitis is designated as
Reversible: Pulpitis begins as limited inflammation, and the tooth can be saved by a simple filling.
Irreversible: Swelling inside the rigid encasement of the dentin compromises circulation, making the pulp necrotic, which predisposes to infection.
Infectious sequelae of pulpitis include apical periodontitis Periodontitis Periodontitis is a chronic inflammatory oral disease that progressively destroys the tooth-supporting apparatus. It usually manifests as a worsening of gingivitis and then, if untreated, with... read more , periapical abscess, cellulitis Cellulitis Cellulitis is acute bacterial infection of the skin and subcutaneous tissue most often caused by streptococci or staphylococci. Symptoms and signs are pain, warmth, rapidly spreading erythema... read more , and (rarely) osteomyelitis Osteomyelitis Osteomyelitis is inflammation and destruction of bone caused by bacteria, mycobacteria, or fungi. Common symptoms are localized bone pain and tenderness with constitutional symptoms (in acute... read more of the jaw. Spread from maxillary teeth may cause purulent sinusitis Sinusitis Sinusitis is inflammation of the paranasal sinuses due to viral, bacterial, or fungal infections or allergic reactions. Symptoms include nasal obstruction and congestion, purulent rhinorrhea... read more , meningitis Overview of Meningitis Meningitis is inflammation of the meninges and subarachnoid space. It may result from infections, other disorders, or reactions to drugs. Severity and acuity vary. Findings typically include... read more , brain abscess Brain Abscess A brain abscess is an intracerebral collection of pus. Symptoms may include headache, lethargy, fever, and focal neurologic deficits. Diagnosis is by contrast-enhanced MRI or CT. Treatment is... read more , orbital cellulitis Preseptal and Orbital Cellulitis Preseptal cellulitis (periorbital cellulitis) is infection of the eyelid and surrounding skin anterior to the orbital septum. Orbital cellulitis is infection of the orbital tissues posterior... read more , and cavernous sinus thrombosis Cavernous Sinus Thrombosis Cavernous sinus thrombosis is a very rare, typically septic thrombosis of the cavernous sinus, usually caused by nasal furuncles or bacterial sinusitis. Symptoms and signs include pain, proptosis... read more .
Spread from mandibular teeth may cause Ludwig angina Submandibular Space Infection Submandibular space infection is acute cellulitis of the soft tissues below the mouth. Symptoms include pain, dysphagia, and potentially fatal airway obstruction. Diagnosis usually is clinical... read more , parapharyngeal abscess Parapharyngeal Abscess A parapharyngeal abscess is a deep neck abscess. Symptoms include fever, sore throat, odynophagia, and swelling in the neck down to the hyoid bone. Diagnosis is by CT. Treatment is antibiotics... read more , mediastinitis Mediastinitis Mediastinitis is inflammation of the mediastinum. Acute mediastinitis usually results from esophageal perforation or median sternotomy. Symptoms include severe chest pain, dyspnea, and fever... read more , pericarditis Pericarditis Pericarditis is inflammation of the pericardium, often with fluid accumulation in the pericardial space. Pericarditis may be caused by many disorders (eg, infection, myocardial infarction, trauma... read more , empyema, and jugular thrombophlebitis.
Symptoms and Signs of Pulpitis
In reversible pulpitis, pain occurs when a stimulus (usually cold or sweet) is applied to the tooth. When the stimulus is removed, the pain ceases within 1 to 2 seconds.
In irreversible pulpitis, pain occurs spontaneously or lingers minutes after the stimulus (usually heat, less frequently cold) is removed. A patient may have difficulty locating the tooth from which the pain originates, even confusing the maxillary and mandibular arches (but not the left and right sides of the mouth). The pain may then cease for several days because of pulpal necrosis. When pulpal necrosis is complete, the pulp no longer responds to hot or cold but often responds to percussion. As infection develops and extends through the apical foramen, the tooth becomes exquisitely sensitive to pressure and percussion. A periapical (dentoalveolar) abscess elevates the tooth from its socket, and the tooth feels “high” when the patient bites down.
Diagnosis of Pulpitis
Sometimes dental x-rays
Diagnosis is based on the history and physical examination, which makes use of provoking stimuli (application of heat, cold, and/or percussion). Dentists may also use an electric pulp tester, which indicates whether the pulp is alive but not whether it is healthy. If the patient feels the small electrical charge delivered to the tooth, the pulp is alive.
X-rays help determine whether inflammation has extended beyond the tooth apex and help exclude other conditions.
Treatment of Pulpitis
Drilling and filling for reversible pulpitis
Root canal and crown or extraction for irreversible pulpitis
Antibiotics (eg, amoxicillin or clindamycin) for infection that cannot be resolved with local measures
In reversible pulpitis, pulp vitality can be maintained if the tooth is treated, usually by caries removal, and then restored.
In irreversible pulpitis, the pulpitis and its sequelae require endodontic (root canal) therapy or tooth extraction. In endodontic therapy, an opening is made in the tooth and the pulp is removed. The root canal system is thoroughly debrided, shaped, and then filled with gutta-percha. After root canal therapy, adequate healing is manifested clinically by resolution of symptoms and radiographically by bone filling in the radiolucent area at the root apex over a period of months. If patients have systemic signs of infection (eg, fever), an oral antibiotic is prescribed (amoxicillin 500 mg every 8 hours; alternatives for patients allergic to penicillin include cephalexin or another first- or second-generation cephalosporin, azithromycin, clarithromycin, or doxycycline) (1 Treatment reference Pulpitis is inflammation of the dental pulp resulting from untreated caries, trauma, or multiple restorations. Its principal symptom is pain. Diagnosis is based on clinical findings, and results... read more ). If symptoms persist or worsen, root canal therapy is usually repeated in case a root canal was missed, but alternative diagnoses (eg, temporomandibular disorder, occult tooth fracture, neurologic disorder) should be considered.
Very rarely, subcutaneous or mediastinal emphysema develops after compressed air or a high-speed air turbine dental drill has been used during root canal therapy or extraction. These devices can force air into the tissues around the tooth socket that dissects along fascial planes. Acute onset of jaw and cervical swelling with characteristic crepitus of the swollen skin on palpation is diagnostic. Treatment usually is not required, although prophylactic antibiotics are sometimes given.
1. Wilson WW, Gewitz M, Lockhart PB, et al: Prevention of viridans group streptococcal infective endocarditis: A scientific statement from the American Heart Association. Circulation 18;143(20):e963-e978, 2021. doi: 10.1161/CIR.0000000000000969
Pulpitis is inflammation of the dental pulp due to deep cavities, trauma, or extensive dental repair.
Sometimes infection develops (eg, periapical abscess, cellulitis, osteomyelitis).
Pulpitis may be reversible or irreversible.
In reversible pulpitis, the pulp is not necrotic, a cold or sweet stimulus causes pain that typically lasts 1 or 2 seconds, and repair requires only drilling and filling.
In irreversible pulpitis, the pulp is becoming necrotic, the stimulus (often heat) causes pain that typically lasts minutes, and root canal or extraction is needed.
Pulpal necrosis is a later stage of irreversible pulpitis; the pulp does not respond to hot or cold but often responds to percussion, and root canal or extraction is needed.