Pulpitis Causes And Symptoms

Introduction 

Pulpitis, also known as inflammation of the pulp tissue, commonly occurs as a result of tooth decay that has penetrated all layers of the tooth (enamel and dentin). The clinical picture of pulpitis has a large variety of manifestations, however, in practically every case the patient usually presents with tooth pain which may be dull or throbbing. Pulpitis can also be caused by chemical irritation, thermal injury, bacterial penetration or as a result of illness caused by dental procedures.¹

The treatment and management of pulpitis, although usually root canal therapy, depends on the cause and symptoms of each case. Pulpitis may be diagnosed by the intensity of pain with different irritating moments, the spread of pain over the tooth and the connection of the pain to a body posture.² The treatment tactics depend on the correctness of the diagnosis. It should be stressed that pulpitis is a reversible state, the earlier you give a visit to the dentist, the fewer the consequences will be.

What is pulpitis?

The pulp is what is known as the living part of the tooth. It is the innermost tissue located in the centre of a tooth, which is soft and consists of blood vessels and nerves. When the dental pulp becomes inflamed, this condition is known as pulpitis. Because the dental pulp is encased by hard tissue and tooth enamel, it is difficult to expand while inflamed. As a result, the increased pressure caused by the inflammatory response often activates the nerves in the pulp. This manifests as a persistent, severe toothache that is often provoked by stimuli such as hot and cold food or drink.³

Pulpitis in its early stages is reversible. This means that the pulp can return to a healthy state if the stimuli that caused the inflammation are removed and the tooth is adequately treated. Reversible pulpitis is characterised by short, sharp painful episodes and can be treated by removing the dental decay as well as the restoration of the tooth with a filling, inlay or crown. However, if the condition worsens and becomes irreversible, the pulp will begin to die over time and the pain from the tooth may begin to subside.⁴

Irreversible pulpitis, the most common form of the condition, is characterised by toothache of a more spontaneous and unpredictable nature. The symptoms can be both mild and severe, with the pain being aggravated when lying down or consuming hot food or drink.

This would require root canal therapy where the damaged or dead pulp is removed and the remaining space is filled and sealed. However, if the tooth is particularly difficult to operate on, or the nearby tissues are severely infected, the treatment may be completed over several visits once the infection is brought under control.⁴

The significance of understanding the causes and symptoms of pulpitis

It is important to understand the causes and symptoms of pulpitis for several reasons. First, identifying the underlying cause of pulpitis allows dentists to start treating the condition in the early stages before irreparable damage is done to the dental pulp.⁴ This helps patients avoid the pain and discomfort associated with more advanced stages of the condition.

Secondly, recognising the symptoms of pulpitis can prevent the incorrect diagnosis and treatment of other dental conditions with similar symptoms.² Finally, an increased understanding of pulpitis can also lead to further research and improved treatment methods for the condition, ultimately benefiting both dental professionals and patients.

Our understanding of the causes and symptoms of pulpitis can only serve to benefit patients seeking medical care for the condition, both in the present and in the future. This justifies the almost certain necessity of continued work and research into dental pulp inflammation and its related conditions.

Causes of pulpitis

Tooth decay

Dental decay is the most common cause of pulpitis. It occurs when the enamel and dentin layers of the tooth are damaged by acid and bacteria in plaque. The bacteria release toxins and acids that cause an infection in the pulp, resulting in inflammation and pulpitis. Dental decay is usually due to poor oral hygiene, consumption of sugary foods and drinks and infrequent professional dental care. However, there are also other potential causes, including enamel defects, tooth root exposure due to gum recession and decreased saliva flow.

As the decay progresses through the tooth structure, it can lead to different types of cavities at various stages of severity. These are classified according to the tooth layers that are affected - enamel, dentin and pulp. In the initial stages, the decay is limited to the enamel and usually no symptoms are experienced.

However, as the decay advances and reaches the dentin and then the pulp, the tooth becomes increasingly sensitive. Toothache and persistent pain are common symptoms at this stage. Moreover, bacterial infection of the pulp can cause the formation of an abscess, leading to more severe pain and swelling.

When left untreated, severe tooth decay can lead to irreversible pulpitis. This means that the inflammation is so substantially progressed that the pulp is no longer capable of healing. At this point, the main symptom will be intense pain, and it is also possible for the pain to spread to the jaw, face or head.⁵

Periodontal disease

Unlike dental decay which mainly affects the enamel, gum disease leads to an inflammation of the tissues surrounding and supporting the teeth. Gum disease is caused by the bacteria found in plaque, a sticky colourless film that constantly forms on the teeth.⁶ If the plaque is not removed through regular brushing and flossing, the harmful bacteria can spread, causing the gums to become inflamed.

As the disease progresses, the gums may pull away from the teeth, creating pockets that can become infected. The immune system - the body's defence against infection - starts to release substances that attack and destroy the bone and connective tissue that hold the teeth in place. As a result, gum disease loosens the tooth from its socket and eventually the tooth falls out or is removed.

Studies investigating the inflammatory processes of pulpitis have found that chemical substances produced in the diseased pulp can diffuse through the tiny tunnels present in the hard tissues of the teeth and trigger immune responses in the surrounding tissues as well.⁷

By eliminating the bacteria causing the gum disease and avoiding potential infection of the pulp tissue, the progression from gum disease to pulpitis can be stopped. Early detection of gum disease involves regular dental examinations and professional cleaning.

By maintaining good oral hygiene, the risks of gum disease and pulpitis can be significantly reduced; good oral hygiene involves brushing your teeth and tongue twice a day, using fluoride toothpaste, flossing once a day, having a mouthwash and not smoking or chewing tobacco. Patients should also have regular dental check-ups to allow any gum disease to be detected early.

Mechanical injury

Trauma or tooth wear - this occurs in habits such as bruxism (teeth grinding) or nail biting and is thus more common in children. It could also be as a result of injuries caused by dental procedures.

Barodontalgia - this is also known as aerodontalgia and is used to describe toothache that occurs at low atmospheric pressures at high altitudes. This effect is commonly detected at an altitude of 5000-10000 feet, meaning that an asymptomatic tooth on the ground may only cause pain reaching these altitudes. The use of a liner or base in deep cavities prevents barodontalgia.

Cracked teeth - when a tooth is cracked or fractured, bacteria in the mouth can enter the crack and cause inflammation of the pulp. In some cases, the crack can be restored with a simple filling or a crown. However, if the crack has extended into the pulp, root canal treatment or even extraction of the tooth may be necessary.⁸

Thermal injury

This could be due to heat from cavity preparation, frictional heat during polishing of a restoration, deep restorations without liner or base and heat from cement setting.

Symptoms of pulpitis

Toothache is the most common symptom of reversible pulpitis, which occurs when anything - whether it's food or just the pressure of your teeth - unnerves the pulp inside the tooth. The pain that you feel can range from just a little bit of discomfort to being unbearable. It can keep you up at night, and bug you throughout the day.⁹

Temperature sensitivity

Often, when we have very hot or very cold food or drink, we may feel a mild discomfort caused by exposed dentine. This will often be a sign that the tooth nerve is inflamed and not healthy. The blood vessels in the pulp control the body's response to anything that may harm the tooth, including hot or cold temperatures, and will cause a toothache.

Swelling/ inflammation

In this stage, pulpitis is known as irreversible. It can be aggravated by further inflammation and infection from deep decay or damage to the tooth filling. Such symptoms may also include waking in the night with a painful throbbing that may spread to the entire side of the face. This pain is often made worse by cold foods and drinks.

Discoloured tooth

The tooth may appear pinkish or reddish which is a sign that the pulp inside the tooth is bleeding. In some cases the affected tooth may appear grey or dark yellow, which is a sign of a dying tooth.

Diagnosis for pulpitis

Proposals for a new pulp diagnosis by van der Sluis et al. 2013 and Asgary et al. 2015:

• Mild pulpitis - high and prolonged response to cold, warm, and sweet stimuli lasting 20s and dropping; it may be sensitive to percussion
• Moderate pulpitis - strong, high and prolonged response to cold stimuli that can last up to minutes, unstimulated dull pain that may respond to pain medication; it may be sensitive to percussion
• Severe pulpitis - severe unstimulated pain, strong reaction to warm and cold, pain is usually sharp or dull throbbing, pain is exacerbated by lying down; affected tooth is very sensitive to percussion and touch⁹

Summary

The key to avoiding pulpitis and other dental diseases is to maintain a good oral environment. This means it is essential to establish a habit of cleaning the teeth effectively but without damaging the enamel surface. Also, a balanced and tooth-friendly diet can contribute to preventing pulpitis. By eating less sugar and acid and having more protective food, for instance, milk and cheese, tooth decay and subsequent pulpitis can be avoided.

Finally, if anyone is experiencing any form of dental pain, be aware that some symptoms from pulpitis may come in short periods and then disappear. Nevertheless, pain that comes and goes is always a sign of an ongoing issue inside the tooth. Seek dental advice at once and never try to alleviate pain by placing heat on the affected tooth, for it can easily develop into an abscess.

With the technologies and knowledge that modern dentistry possesses, no patient should endure severe toothache unnecessarily. By cooperating with dental professionals and by adhering to the preventive advice, many patients can expect a pain-free outcome and the affected teeth can normally be preserved for function and aesthetics in the oral cavity.