Toothache is often deemed as one of the most agonising experiences anyone could ever have, and while there can be many reasons why you’re experiencing dental pain, pulpitis is one of the most common ones.

Pulpitis is no ordinary dental villain – it is the inflammation of the dental pulp; the innermost part of your tooth housing nerves and blood vessels. Pulpitis presents itself in a variety of symptoms varying according to the severity of inflammation; it could be sharp pain triggered by something hot or cold, unprovoked pain or in some cases, it may even be silent. 

What is pulpitis?

Dental pulp is the vital, soft tissue found in the centre of a tooth. It resides within the pulp chamber and extends down into each root canal, comprising a delicate network of nerves, blood vessels, and connective tissue. This pulp plays a pivotal role in maintaining the health and vitality of the tooth by providing nourishment, sensation, and a defence mechanism against external irritants.¹

Any infection or irritation to the pulp may lead to an inflammatory reaction inside the pulp known as Pulpitis. The symptoms and their treatment vary according to the type of pulpitis that you’re experiencing.

Type of pulpitis

According to the American Association of Endodontists, Pulpitis is categorised into two types depending on the extent of the inflammation inside the pulp:²

Reversible pulpitis

Reversible pulpitis is the early stage of pulpitis and can be reversed if it is treated timely. Patients experience sharp pain on stimulus (cold or sweet) which goes away within a couple of seconds following the removal of the stimulus.

The pulp returns to its normal status once the cause is removed.

Irreversible pulpitis

Irreversible Pulpitis is a later stage in which the inflammation has progressed to the extent that it cannot be reversed. The pulp will not return to its normal status indicating the need for a root canal treatment. It can be further divided into two types:

• Symptomatic irreversible pulpitis: In this type of pulpitis, one experiences sudden pain, often without any stimulus, which lingers for 30 seconds or longer. Postural changes, like lying down or bending over, can often intensify the pain
• Asymptomatic irreversible pulpitis: Such cases present with no symptoms of pain. This occurrence is often observed in teeth with extensive carious lesions that have already reached the nerve. Despite the absence of pain, the condition is deemed irreversible due to permanent damage and exposure to the pulp caused by bacterial invasion²

What causes pulpitis?

Dental pulp is encased in a protective shell of enamel and dentin that guards it from the outside environment of the oral cavity and therefore, protects it from all kinds of irritants. However, any breach in the structure of enamel or dentin that exposes the tooth pulp will result in an inflammatory reaction inside the pulp chamber.

Understanding the causes is essential for preventing and addressing this dental condition. The various causes of Pulpitis include:¹

Dental decay

In its early stages, caries or cavities do not have a significant impact on the dental pulp since the decay is limited to the surface level of enamel. However, if left untreated, the caries progress, eventually reaching the tooth's pulp and resulting in an inflammatory reaction. 

Dental procedures

Multiple dental procedures on the same tooth, especially those involving drilling or extensive work, may contribute to pulpitis over time.

Moreover, certain dental products or materials used in dental procedures contain irritants or produce heat which may contribute to inflammation of the pulp. 

Cracked or fractured tooth 

Cracks or fractures in the tooth can expose the pulp to bacteria, leading to inflammation.

Tooth wear 

Tooth wear resulting from vigorous tooth brushing with abrasive toothpaste, teeth grinding (bruxism)and an improper bite, known as malocclusion, may also result in exposure to pulp and eventually lead to inflammation.³

Signs & symptoms

The symptoms of pulpitis vary according to the extent of inflammation inside the pulp.²

Symptoms of reversible pulpitis

• Sharp pain on stimulus (cold or sweet)
• Pain does not linger, and goes away within seconds after the removal of the stimulus
• Sensitivity 

Symptoms of irreversible pulpitis

• Spontaneous/ intermittent pain without stimulus
• Lingering pain (lasting over 30 seconds or longer after removing the stimulus)
• Potential exacerbation of pain with postural shifts like lying down or bending over
• Pain not relieved from conventional over-the-counter painkillers

Diagnosis

Diagnosing pulpitis typically involves a comprehensive examination by a dental professional. Here's an overview of the diagnostic process:

Medical & dental history 

Your dentist will ask questions about the pain you are experiencing and about any past dental treatments.²

• What is the onset of pain; is it spontaneous or upon stimulus?
• How long does the pain last?
• Where does it hurt?
• Is the pain limited to one area?
• Is the pain continuous or intermittent?
• What is the character of pain; is it dull aching, sharp or throbbing?
• Is the pain relieved with the help of painkillers?
• Did you get any recent dental treatment done?

Clinical examination

Following a detailed history, your dentist will proceed with a physical examination of your face and intra-oral area. This includes looking for any cavities, fillings and crowns, signs of tooth wear, swelling or redness around teeth and examination of your overall gum health.²

Clinical tests

A crucial component of the diagnostic procedure for pulp-related conditions involves conducting pulp sensibility tests. These tests play a vital role in reproducing reported symptoms, aiding in the diagnosis of both the affected tooth and the overall state of the disease.⁴

Percussion and palpation

The dentist may use percussion (tapping) and palpation (gentle pressure) to assess the tooth's response to stimuli. Pain of tapping indicates that the inflammation has reached the surrounding bone of the tooth.

Electric pulp testing

This test involves the use of a low electrical current to assess the vitality of the dental pulp. If your pulp is alive, you will feel the stimulation; however, if the pulp tissue is dead (necrosed), there will be no sensation. 

Thermal testing

Hot and cold stimuli are applied to the tooth to evaluate the response of the dental pulp.

• In cases of reversible pulpitis, exposure to thermal stimuli, typically cold, results in an immediate sharp pain that diminishes either upon removal of the stimulus or within a brief span of seconds
• Irreversible pulpitis manifests as a sharp pain induced by temperature changes, often cold, followed by a lingering, dull ache that can persist for up to an hour in certain instances⁴

Radiographs

For a much better understanding of your condition, your dentist might take a few radiographs of your teeth. These radiographs provide a detailed view of the tooth's internal structures, allowing the dentist to assess the extent of decay, infections, or other issues. 

Treatment 

In the case of reversible pulpitis, your dentist will aim to eliminate the causative factor. This usually is done by removing the decayed tooth structure and replacing it with a filling. The tooth is then evaluated over the months to see if the pulp has restored to its normal status.²

In the case of irreversible pulpitis, more extensive intervention is required to eliminate the infected pulp tissue. Treatment options include:

• Root canal treatment: Typically performed by an endodontist, this procedure involves removing the infected pulp, cleaning the root canal, and then filling and sealing the tooth. Subsequently, a crown is placed on the tooth during a follow-up appointment
• Tooth extraction: When there is extensive loss of tooth structure due to decay or fracture and the tooth can’t be restored by root canal treatment, then your dentist might advise a tooth extraction followed by replacement options, such as a dental implant or bridge^2,5

Prevention

Given that cavities and decay are the primary culprits behind pulp inflammation, steering clear of sugary and acidic foods to protect tooth enamel becomes essential. Maintaining a good oral hygiene routine by regularly brushing, flossing, and using mouthwash proves effective in preventing decay.

Additionally, scheduling routine checkups with your dentist is crucial. Detecting cavities early allows for timely intervention before reaching the pulp and causing painful issues.

Summary 

Dental pulp, the vital tissue within a tooth, plays a crucial role in maintaining tooth health but is susceptible to inflammation due to factors like decay and trauma. Pulpitis is classified into two types: Reversible, manageable with timely intervention, and Irreversible, demanding more extensive treatments such as root canals or tooth extraction. Understanding the causes, symptoms, and preventive measures is key to managing and avoiding the discomfort associated with pulpitis, underscoring the significance of proactive dental care.