Introduction

Pulpitis refers to the inflammation of the dental pulp, which is the soft tissue inside your tooth containing nerves, blood vessels, and connective tissue. Inflammation of the tooth pulp is caused by harmful stimuli including bacterial infection resulting from tooth decay, trauma, or other factors such as bacterial infiltration of the tooth structure. When the stimulus is removed, it usually advances from a reversible to an irreversible stage. Based on past and present clinical signs and symptoms, the number of neighbouring caries, responses to pulp tests and percussion, and the radiographic presentation of the periapical tissues at the root apex are important factors to consider in diagnosing the condition. Even though inflammatory changes in teeth exhibiting these symptoms are often restricted to the coronal pulp adjacent to carious lesions, pre-operative spontaneous or elicited severe pain and carious pulp exposure are widely regarded as indicators of irreversible pulpitis.

Causes of pulpitis

The pulp of your tooth is shielded by its strong enamel. Pulpitis may result from injury to the enamel. Damage to teeth can result from:

• Cavities: Acid made by the bacteria in your mouth can erode your enamel and cause holes to form
• Small cracks may occur as a result of trauma to your teeth or from chewing on hard foods
• Dental procedures: Pulpitis might result from dental procedures. During a dental operation, an incorrectly sealed tooth may allow the filling to leak and result in pulpitis
• Enamel wear: Vigorous brushing or teeth grinding can wear down the enamel, increasing the nerve's susceptibility to irritation

Types of pulpitis

Two varieties of pulpitis exist. Dentists categorise them according to the severity of the infection:

• Reversible pulpitis: If your dentist repairs the tooth and places a filling on it, pulpitis in this early stage can be reversed
• Irreversible pulpitis: The tooth is incapable of healing at this point due to the severity of the inflammation. Eventually, the pulp tissue will decompose resulting in pulp necrosis

Irreversible pulpitis caused by caries is frequently histologically characterised by bacterial colonisation of necrotic tissue, the development of micro-abscesses, and an incapacity to heal. Conversely, the pulp tissue that surrounds it develops an immunological defence response to stop the infection from spreading and is mostly free of necrosis or inflammation. Therefore, the healthy non-infected pulp tissue would remain healthy if it was isolated and the infected pulp is removed (prior to necrosis spreading). On the other hand, the pulp has the ability to mend and rebuild tissue when it is only slightly inflamed. Although it is possible to distinguish between reversible and irreversible pulpitis histologically, pulp tissue repair cannot be objectively evaluated from a clinical perspective. Compared to cases of irreversible pulpitis, studies found a stronger association between the histologic results and the clinical diagnosis of normal pulp/reversible pulpitis, raising another concern about the choice of treatment. Therefore, to accurately diagnose pulp status and determine a related clinical strategy that would improve the prognosis for treating a tooth with inflamed pulp, a biologically based pulp examination is required.

Diagnosis

A dentist's primary method of diagnosing pulpitis is to measure the tooth's sensitivity. Sensitivity test types consist of:

• Electric pulp testing: This test checks whether the infection has advanced to pulp necrosis or whether your pulp is still viable. Your dentist applies a brief electrical pulse to the tooth using an apparatus. Your pulp will be stimulated if it is living. The electrical pulse won't be felt if the pulp tissue is dead
• Heat or cold test: A hot or cold material will be applied to your teeth by your dentist. Pressure sensitivity persists for more than a few seconds in irreversible pulpitis. You won't experience any sensitivity if the pulp tissue is dead
• Tapping teeth (Percussion test): This involves tapping the teeth lightly. Tapping-induced pain is indicative of irreversible pulpitis

Treatment

Treatment and prevention strategies for pulpitis aim to alleviate symptoms, preserve the tooth, and prevent further damage. Your dentist will attempt to treat the underlying cause of reversible pulpitis. This usually entails cleaning out the decay and sealing the tooth with a standard filling. This procedure is known as pulpotomy. This involves removing the infected portion of the pulp while leaving the healthy portion intact.

Vital pulp therapy (VPT), which generally consists of direct pulp capping (DPC), partial pulpotomy (PP), and complete pulpotomy (FP) operations, is an alternative to non-surgical pulp repair for teeth with pulp inflammation. VPT has long been regarded as the gold standard for treating permanent immature teeth with reversible or irreversible pulpitis and baby teeth with pulp inflammation. Hydraulic calcium silicate cements (HCSCs) effectively seal the pulp wound interface and permit pulp healing. Examples of these cements include mineral trioxide aggregate (MTA), calcium-enriched mixture cement (CEM), and Biodentine.^,

In case of irreversible pulpitis, it is necessary to undergo more aggressive treatment to eliminate the pulp tissue. Options for treatment include:

Pain management

• Over-the-counter pain relievers like ibuprofen or acetaminophen can help alleviate pain and discomfort. Your dentist might prescribe stronger pain medications if needed.

Antibiotics

If there's an active infection, your dentist may prescribe antibiotics to eliminate bacteria and prevent further spread of infection.

Root canal therapy (RCT)

For irreversible pulpitis, root canal therapy is often necessary. Pulpectomy, sometimes referred to as nonsurgical root canal therapy (NSRCT), is the conventional treatment option for permanent adult teeth with incurable pulpitis. The main procedures and objectives of NSRCT are well-established, and they involve:

1. Cavity preparation in the tooth's pulp chamber
2. Extraction of the pulp tissue 
3. Full pulp space filling to create a healing environment and stop future bacterial infiltration Endodontic cavity and coronal tooth structure restoration

Although widely acknowledged, this very complex therapeutic approach — which frequently necessitates multiple sessions and a diverse toolkit — may not be feasible for patients if they are unable to pay for NSRCT or do not have access to qualified healthcare providers who can administer it.

Extraction

If the tooth is severely damaged or infected and cannot be saved with RCT, extraction may be necessary, especially when patients lack access to qualified healthcare practitioners who can do root canal treatment or when they are unable to pay for it.Under such circumstances, function and quality of life may be compromised by the extraction of teeth that have been identified with irreversible pulpitis. Based on radiographic and clinical criteria, 92–98% of teeth with irreversible pulpitis are projected to stay healthy several years after treatment with NSRCT. On the other hand, high prevalence values of inadequate root fillings (56 to 86%) and apical periodontitis (34 to 68%) have been reported in cross-sectional studies of root-filled teeth in general populations from many countries. These findings suggest that often neither the accepted process goals nor the expected outcomes.

Prevention

Good oral hygiene

Brushing your teeth at least twice a day with fluoride toothpaste and flossing daily to remove plaque and food particles from between teeth and along the gumline can help maintain good oral hygiene.

Regular dental check-ups

It is a good practice to visit your dentist regularly for check-ups and professional cleanings. Early detection of cavities and other dental issues can prevent them from progressing to pulpitis.

Healthy diet

Limit sugary and acidic foods and beverages, as they can contribute to tooth decay. Eating a balanced diet rich in fruits, vegetables, and dairy products helps to promote overall oral health.

Protective measures

Wear a mouthguard if you engage in contact sports to prevent dental trauma. Also avoid using your teeth to open bottles or bite down on hard objects, as this can cause damage.

Address dental issues promptly

If you experience tooth pain, sensitivity, or any other dental problems, don't ignore them. Seek prompt dental care to prevent complications like pulpitis.

Fluoride treatment

Your dentist may recommend fluoride treatments to strengthen tooth enamel and make it more resistant to decay.

Summary

 Pulpitis is a painful condition characterised by inflammation of tooth pulp. It occurs due to cavities, trauma or poorly performed dental procedures. Pulpitis can be diagnosed at dental clinics by performing simple tests to check the health of the teeth. Treatment of pulpitis depends on the type, reversible or irreversible, and includes antibiotics to alleviate pain, root canal therapy, vital pulp therapy, or extraction. Regular dental care, a proactive approach to oral hygiene, and maintaining a healthy diet are essential for preventing pulpitis and preserving your teeth. Additionally, when diagnosing reversible pulpitis in adult permanent teeth or even when there are indications of irreversible pulpitis, vital pulp therapy can be effectively used. Choosing the right materials, including bioactive cement, and providing accurate diagnoses of pulp inflammation are essential to improving the efficacy of the vital therapy.