Exacerbation of chronic pulpitis. Causes, differential diagnosis, treatment of chronic pulpitis

Probably, there is no such person who never had a toothache. And when, as they say, the process has gone, all the sensations center around one single aching tooth. If you postpone the visit to the dentist for later, the patient has every chance to know all the "delights" of chronic pulpitis.

What is the essence of the process?

Pulpitis, if available, is an inflammatory process that develops in the vascular-neural bundle within the root canal channels and their crown part. If the patient turned to the doctor with complaints of severe pain (ie, there is an acute pulpitis), 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 is formed, necrosis or transformation of the neurovascular bundle is observed, up to such a state that all the carious cavity is filled with its tissues, which led to 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.

Causes of development

Any pathology has prerequisites and circumstances that gave impetus to the development of the pathogenic process. No exception and pulpitis. Chronic forms of this disease are provoked by pathogenic microorganisms and products of their vital activity. As a rule, the beginning of all the beginnings is the presence in the patient of deep caries or poor-quality treatment of this widespread ailment. The latter term means non-observance of the technique of treating a diseased tooth, insufficient cleaning of the carious cavity, an inadequately placed seal, and so on.

Less common causes of chronic pulpitis, which trigger the development of the pathological process, can be a trauma to the tooth, blockage of the channels of the neurovascular bundle with salt stoppers ("concrements"). 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 root of the tooth.

Types of chronic process

Dentists distinguish 3 varieties of chronic pulpitis: hypertrophic, fibrous, gangrenous.

In the hypertrophic process in the carious plane, there is a proliferation of pulp tissues in the form of a polyp. As a rule, the patient sees a bleeding build-up, which is traumatized when chewing food. The pains can be moderate and are caused in most cases by external irritating factors.

The fibrous form occurs more often and is characterized by periodically arising aching pain sensations which within 1-2 days cease by themselves, but the carious cavity practically constantly bleeds.

Gangrenous form is characterized by complete decomposition of the nerve tissue of the tooth and a large destruction of the crown part of the tooth. This form of pulpitis is always accompanied by an unpleasant odor from the mouth. Pain sensations, as a rule, are mild, arising periodically. Typical complaints of the patient in this case look like this: "the tooth was very sick, and then stopped itself".

It is worth noting that most often (≈ 70% of cases) doctors diagnosed with chronic fibrotic pulpitis, much less often - gangrenous. The hypertrophic form in adult patients practically does not occur. This diagnosis is sometimes put children's dentists.

Diagnosis of chronic pulpitis

In order to diagnose, 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 aching tooth, thermometry, EOD and radiography.

At visual inspection the doctor receives about 50% of the information on a condition of a causal tooth. Thermometric studies on the response to cold and hot stimuli provide an opportunity to understand what kind of disease and what kind of disease the patient turned to the doctor. For example, the reaction to the cold says that the "nerve" is not dead.

Electroodontodiagnosis (EOD) is one of the most reliable methods of diagnosing pulpitis. The technique is based on the fact that diseased and healthy pulp tissues have different electrical excitability. A healthy nerve will respond with minor pain sensations to the effect of current intensity of 2-6 μA, fibrous pulpitis with pain of the same intensity will respond to 35-50 μA, gangrenous will require exposure in 60-90 μA.

Radiography involves evaluating the state of the tooth from x-ray images.

Differential diagnosis of chronic pulpitis involves a comprehensive assessment of all the above methods and a comparative analysis of the information obtained in the diagnosis process.

Symptomatic of chronic pulpitis

In general, the disease at this stage is asymptomatic. How can you understand that a person has chronic pulpitis? Complaints are mostly reduced to the presence of aching pains with different intervals of silence between them.

In fibrotic form, as a rule, there are pain sensations as a result of the action of irritating factors (hot, cold, sweet). The pains do not last long even after the effect of stimuli is eliminated. A characteristic symptom is the development of prolonged painful sensations when the external temperature changes from cold to warm (for example, moving from street to room). Although in some cases the course of fibrous pulpitis is possible without obvious signs. This happens if the stimuli do not have direct access to the carious 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 puffiness, the pulp "does not burst out," and, as a result, there are no pains.

With gangrenous pulpitis there is always an unpleasant smell from the sick tooth and from the mouth. Characteristic pain from the effects of hot, which do not stop long enough even after the stimulus is eliminated. Often there are feelings of raspiraniya in the tooth. In addition, the tooth color changes almost always: it becomes grayish.

Hypertrophic pulpitis is accompanied by aching pain while chewing food and bleeding. This is due to the germination of pulp into a carious cavity like "wild meat". It is this factor that most often frightens the patient and makes him turn to the doctor.

Stages of treatment of chronic process

As with this disease soft tissues in the tooth can not be saved, the main kind of therapy is the removal of pulp from all the canal channels. Modern dentistry in the overwhelming majority of cases prefers the technique of vital extirpation (live extraction) of the nerve, when only anesthetic agents are used without medication to kill the pulp.

However, sometimes the individual characteristics of the patient's jaw, lack of time and lack of good anesthetics prevent the nerve from being removed immediately on the first visit. Then the treatment of chronic pulpitis is applied in stages, when a special paste is put in the carious cavity, which is intended to prepare the pulp for removal, which is what happens during the second visit.

After treatment

Quite often after the treatment of chronic pulpitis is over, people complain of pain. These sensations are called post-pilling (as they are called dentists). As a rule, discomfort appears for several reasons and fits into the conventionally permissible norm. The emergence of pain after pulpitis treatment is possible in view of the fact that the tissues around the diseased tooth can be slightly traumatized or with rough, sharp separation of the "nerve" in the process of its removal. Also, pain can appear if during the treatment the canals of the tooth were treated with powerful antiseptic agents, which in small amounts could go beyond the root.

Another reason for post-pilling pain is the output of a thin instrument that dentists use during the treatment to work inside the canals, beyond the apical foramen of the root.

Causes of complications after therapy

Sometimes after a seemingly successful "communication" with the dentist, severe pain begins, and the initially treated exacerbation of chronic pulpitis is complicated. The reasons for this phenomenon can be several. These are poorly performed work on filling the tooth canals, breaking off the dental instrument when it is in the dental canal or perforating (creating a hole) in the root wall.

In the event that the canals are poorly filled or the penetration of the filling material beyond the apex of the root was allowed, the symptoms of periodontitis in the acute stage will appear for a period of time (from several days to a year). Fracture of the tool may not immediately manifest itself, but the infection in the unwashed and unsealed channel will still declare itself by flux, the periodic appearance on the gingiva of fistula (at best) or the formation of cysts with purulent contents.

Exacerbation of the chronic process: signs

If a sick tooth with manifestations of acute pulpitis in time is not cured, the disease will go into a chronic form and will remind you of itself with an enviable permanence throughout life. How does the exacerbation of chronic pulpitis manifest ? Symptoms are unpleasant: pain from the effects of various stimuli (warm, cold, sweet, transition from cold to heat), quite a negative sensation in palpation and percussion (mild tapping of the 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 ways of the passage of the trigeminal nerve is characteristic. It is for this reason that patients say that pain is given in the field of the temple or under the eye, nose or chin.

The aggravation and reasons for its development

Exacerbation of chronic pulpitis can be felt for several months. Pain sensations are not as intense as in acute form. The most frequent causes of worsening may be such phenomena as worsening of outflow of exudate, trauma to the tooth, intensification of activity of pathogenic bacteria. In addition, the reduction of general immunity, the inflammatory process in the lymph nodes and the general intoxication of the body may contribute to relapse.

Exacerbation of the chronic form of pulpitis can be accompanied by the phenomena of focal periodontitis. In such cases, patients come to the dentist with complaints of persistent pain. Pathological changes are recorded on the X-ray.

Temporary teeth in small patients

Not only in adult patients, chronic pulpitis is diagnosed. 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 can not chew food properly. The causative tooth reacts to temperature stimuli. With gangrenous form of pain appear in response to irritation warm, hot or when going from a 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 polyp of the pulp bleeds during mechanical exposure.

The peculiarity of the course of the disease at this age is a low intensity of pain, which can be explained by the structural change in the pulp and its dense communication with the periodontium. In this case, optimal conditions are created for the free drainage of exudate, as a consequence, there are no severe pains.

Constant teeth in children

Constant teeth in children are also susceptible to pulpal diseases. Forms of chronic pulpitis in children are exactly the same as in adult patients. The chronic process in the acute stage in small patients is usually characterized by a prolonged sluggish course with periods of acute pain. Often, the growing discomfort suddenly goes away, and the child does not bother with a sufficiently long period of time. But in most cases, patients complain of paroxysmal or tearing sharp pains that give off in the direction of the branches of the trigeminal nerve. Low electroexcitability (120-160 μA) indicates changes in nerve elements in the pulp, which are of a dystrophic and destructive nature.

Let's generalize all of the above

To the great regret of patients, by itself neither the acute phase of the disease nor the subsequent exacerbation of chronic pulpitis will pass. Treatment with a dentist will sooner or later. And it is better that this happens as soon as possible in order to save the patient from unnecessary suffering and costly and painful interventions, and the doctor from a long and tedious work that requires considerable experience and patience.