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Diagnosis and managing pulpitis: reversible or irreversible?

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Adriano Piattelli Tonino Traini

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editorial commentary
DIAGNOSIS AND MANAGING PULPITIS:
REVERSIBLE OR IRREVERSIBLE?
Adriano Piattelli, MD, DDS*
Tonino Traini, DDS, PhD*
C aries, tooth fracture, and operative procedures
can produce pulp inflammation and necrosis.1 The
inflammatory processes that occur in pulp tissue are
extremely complex and release a wide assortment of
chemical mediators (ie, prostaglandin E2 and F2 alpha,
6-ketoprostaglandin F1 alpha, bradykinin, substance P,
neurokinin A, interleukin-1 beta, alphathrombin, super-
oxide dismutase, nitric oxide, interleukin-6).2-9 The devel-
opment and spread of pulp inflammation follow several
changes in the tissue such as vasodilatation, increased
vascular permeability, and leukocyte extravasation.
Pulp is a tissue placed inside a low compliance
environment, entirely dependent upon the arterioles enter-
ing the apical foramens for the blood supply. When
edema accumulates in a soft tissue, swelling can occur
to accommodate the increased extravasated fluids. Since
the pulp is unable to swell, the inflammation produces
a marked increase in pressure inside the tissue. When
interstitial tissue pressure exceeds intravascular pressure,
fluid is forced back into the venules or lymphatics to
remove the excess of fluids. Pulpitis is defined as the
inflammation of pulp tissues that is accompanied by the
sudden onset of pain. Acute pulpitis may be either
⫻
100⫻
Dentin
Pulp
Figure 1. Image at 100⫻ ⫻ magnification under a bright
field light microscope of reversible pulpitis. Black arrows
indicate a disruption of the odontoblastic layer.
A Vol. 19, No. 2
reversible or irreversible, referring to the capacity of the
pulp tissues to regenerate following injury. It is, there-
fore, important to distinguish between reversible pulpi-
tis and irreversible pulpitis, as this will indicate the
appropriate treatment.
Reversible Pulpitis
This mild inflammation of the tooth pulp is caused by
caries encroaching on the pulp. Clinical features are
characterized by hypersensitivity to thermal (ie, hot or
cold) or sweet stimulus, which rapidly disappears when
the stimulus is removed, a localized increase in intra-
pulpal pressure threshold, and lowering in stimulation
threshold for A-delta nerve fibers. The etiology of reversible
pulpitis is due to bacterial, chemical, or physical irrita-
tion. Histologically, it is characterized by an inflamma-
tory cell’s disruption of the odontoblastic layer with the
presence of dilated blood vessels (Figures 1 and 2).
Irreversible Pulpitis
Usually progressing from reversible pulpitis as a severe
inflammation of the pulp, irreversible pulpitis is charac-
terized in hypersensitivity to thermal stimulus (ie, hot or
Pulp
Dentin
Figure 2. Image at 50⫻ ⫻ under a confocal scanning laser
microscope. Inflammatory cells can be seen inside the pulp
tissue near the disrupted odontoblastic layer.
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editorial commentary continued
Figure 3. Image at 50⫻ ⫻ magnification under bright field
light microscope of irreversible pulpitis. A localized area of
necrosis is evident.
cold), which produces pain that lasts for a few seconds
after the stimulus is removed. Pain is severe, persistent,
and poorly localized and may radiate to the ear, tem-
ple, eye, or neck. Histologically, it is characterized by
dilated blood vessels and inflammatory cells infiltrated
within the localized area of necrosis (Figures 3 and 4).
Clinical Symptoms and Diagnosis
Before making a diagnosis, it is necessary to determine
whether dental pain is of nonodontogenic or odonto-
genic origin. Among the nonodontogenic pathological
conditions, referred pain presents more difficulties in
differential diagnosis, while majority of the nonodonto-
genic diseases (eg, temporomandibular joint syndrome,
pericoronitis, mouth ulcers, sinusitis, sialolithiasis) do
not present difficulties in differential diagnosis.10
Clinically, it is possible to determine the degree of
pulp pathology by asking the patient about the history
of pain of the involved tooth. This history adds a useful
dimension in the diagnosis for the clinician as to whether
the pulpitis is reversible or irreversible.10,11 Irreversible pul-
pitis produces pain that occurs spontaneously or lingers
for a few seconds after the stimulus is removed. A patient
may have difficulty locating the precise tooth that is the
source of the pain, even confusing the maxillary and
mandibular arches (but not the left and right sides), since
the pulp has no proprioceptive fibers. The pain may then
cease for several days after removal of the stimulus as
a result of pulpal necrosis. When bacteria or their metabo-
lites exit through the apical foramen, they cause inflam-
mation in the adjacent periodontal tissues. The tooth then
becomes exquisitely sensitive to pressure and percussion.
B Vol. 19, No. 2
Figure 4. Image at 100⫻ ⫻ magnification under bright field
light microscope. Several inflammatory cells can be seen
inside the residual pulp tissue.
As a periapical (ie, dentoalveolar) abscess forms, the
tooth is elevated from its socket and feels "high" when
biting down.
Conversely, reversible pulpitis is characterized by
hypersensitivity to thermal or chemical stimuli, which
rapidly disappears when the stimulus is removed.
Diagnosis depends upon the ability to obtain an exhaus-
tive dental history and to reproduce the symptoms with
endodontic tests. Nevertheless, it is likely that the prob-
lem is not endodontically related. Attempting treatment
on a tooth without a firm diagnosis may result in error.
There are several tests that can be used for endodon-
tic diagnosis. These include thermal, cavity, and elec-
tric tests. The cavity test is generally used last since it is
an invasive test. The electric pulp test, which is of great
value in determining whether a pulp is vital or necrotic,
cannot be used in teeth with a crown or in some teeth
with large fillings. Thermal tests are helpful in determin-
ing the presence of pulp vitality; a cold test is useful for
diagnosing reversible or irreversible pulpitis, while a heat
test is essential for diagnosing irreversible pulpitis.
Percussion indicates the condition of the periodontal
ligament and supporting structures, while palpation doc-
uments periapical involvement.
In any case of suspected necrosis, a cavity test remains
the gold standard in order to definitively prove a lack of
vitality of the coronal pulp. Since pulp pathosis occurs coro-
noapically, there is always a possibility of having vital tis-
sue in the apical third of a tooth when the chamber is found
to be nonvital. In multi-rooted teeth, caution must be exer-
cised, as it is also feasible to have necrosis in one root
and vital tissue in the canal of an adjacent root.
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editorial commentary continued
Figure 5. Radiograph after root canal filling showing a
radiolucent area.
Treatment
In reversible pulpitis, pulp vitality can be maintained
if the tooth is treated, usually by caries removal, and
then restored. Generally, no treatment is necessary,
other than the healing period for the pulp. Irreversible
pulpitis and its sequelae require endodontic therapy,
nevertheless, preoperative administration of ibuprofen
one hour before local anesthesia injection is an effec-
tive method for achieving a deep anesthesia during
endodontic treatment of patients with irreversible pul-
pitis.12 Moreover, anti-inflammatory treatment improves
the postoperative pain.13 After root canal treatment,
adequate healing is evidenced clinically by resolution
of symptoms and radiographically by bone filling in the
radiolucent area at the root apex (Figures 5 and 6).
If systemic signs of infection surface in the patient,
an antibiotic (eg, penicillin VK 500 mg q 6 h; for
patients allergic to penicillin, clindamycin 150 mg
or 300 mg q 6 h, or metronidazole 500 mg q 8 h)
is effective. If symptoms persist or worsen, medical
consultation is advisable, and the tooth may need to
be extracted.
Conclusion
In the presence of severe, or mild to moderate
pain with a previous history of pain, the pulp is
in the irreversible pulpitis category. In this case,
treatment dictates endodontic therapy. For mild
pain elicited only when a stimulus is applied to the
tooth and not after removal of the stimulus, the pulp
is characterized as reversible pulpitis; no treatment
is needed.
C Vol. 19, No. 2
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Figure 6. Radiograph after four months; the radiolucent
area is almost completely filled by newly formed bone.
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*Department of Applied Sciences of Oral and Dental Diseases,
School of Dentistry, G. D’Annunzio University, Chieti, Italy. He
may be reached at apiattelli@unich.it.
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