The histological state of the pulp cannot be assessed clinically.
Nevertheless, the signs and symptoms associated with progressive pulpal and periapical disease can give a reasonable indication of the likely state of an inflamed pulp, that is whether it is reversibly or irreversibly damaged.
Irritation of the pulp causes inflammation, and the level of response will depend on the severity of the irritant. If it is mild, the inflammatory process may resolve in a similar fashion to that of other connective tissues; a layer of reparative dentine may be formed as protection from further injury. However, if the irritation is more severe, with extensive cellular destruction, further inflammatory changes involving the rest of the pulp will take place, which could eventually lead to total pulp necrosis.
There are features of pulpitis which can make the borderline between reversible and irreversible pulpitis difficult to determine clinically. In general, if the responses to several tests are exaggerated, then an irreversible state is possible.
The essential feature of a reversible pulpitis is that pain ceases as soon as the stimulus is removed, whether it is caused by hot or cold fluids, or sweet food. The teeth are not tender to percussion, except when occlusal trauma is a factor. Initially, one of the following treatment may be all that is necessary:
Check the occlusion and remove nonworking facets.
Place a sedative dressing in a cavity after removal of deep caries.
Apply a fluoride varnish or a dentine bonding resin to sensitive dentine and prescribe a desensitizing toothpaste.
Should the symptoms persist and the level of pain increase in duration and intensity, then the pulpitis is likely to be irreversible. The patient may be unable to decide which tooth is causing the problem, since the pain is often referred to teeth in both the upper and lower jaw on the same side. In the early stages, the tooth may exhibit a prolonged reaction to both hot and cold fluids, but is not necessarily tender to percussion. When testing for sensitivity to percussion it is not necessary to tap the tooth with the handle of dental instrument. Gentle finger pressure will be more than sufficient to elicit a response, and much kinder to your patient.
Only when the inflammation has spread throughout the pulp and has involved the periodontal ligament, will the tooth become tender to bite on. In these circumstances, the application of heat will cause prolonged pain which may be relieved by cold. Both hot and cold can precipitate a severe bout of pain, but as a rule heat tends to be more significant. Pain from an irreversibly damaged pulp can be spontaneous and may last from a few seconds to several hours. A characteristic feature of an irreversible pulpitis is when a patient is woken at night by toothache. Even so, if untreated a symptomatic pulpitis may become symptomless and pulp tests may give equivocal results. In time, total pulp necrosis may ensue, without the development of further symptoms and the first indication of an irreversibly damaged pulp may be seen as a periapical rarefaction on a radiograph, or the patient may present with an acute periapical abscess. To summarize, therefore, in reversible pulpitis:
The pain is of very short duration and does not linger after the stimulus has been removed.
The tooth is not tender to percussion. The pain may be difficult to localize. The tooth may give an exaggerated response
to vitality tests. The radiographs present with a normal
appearance, and there is no apparent widening of the periodontal ligaments.
Nevertheless, the signs and symptoms associated with progressive pulpal and periapical disease can give a reasonable indication of the likely state of an inflamed pulp, that is whether it is reversibly or irreversibly damaged.
Irritation of the pulp causes inflammation, and the level of response will depend on the severity of the irritant. If it is mild, the inflammatory process may resolve in a similar fashion to that of other connective tissues; a layer of reparative dentine may be formed as protection from further injury. However, if the irritation is more severe, with extensive cellular destruction, further inflammatory changes involving the rest of the pulp will take place, which could eventually lead to total pulp necrosis.
There are features of pulpitis which can make the borderline between reversible and irreversible pulpitis difficult to determine clinically. In general, if the responses to several tests are exaggerated, then an irreversible state is possible.
The essential feature of a reversible pulpitis is that pain ceases as soon as the stimulus is removed, whether it is caused by hot or cold fluids, or sweet food. The teeth are not tender to percussion, except when occlusal trauma is a factor. Initially, one of the following treatment may be all that is necessary:
Check the occlusion and remove nonworking facets.
Place a sedative dressing in a cavity after removal of deep caries.
Apply a fluoride varnish or a dentine bonding resin to sensitive dentine and prescribe a desensitizing toothpaste.
Should the symptoms persist and the level of pain increase in duration and intensity, then the pulpitis is likely to be irreversible. The patient may be unable to decide which tooth is causing the problem, since the pain is often referred to teeth in both the upper and lower jaw on the same side. In the early stages, the tooth may exhibit a prolonged reaction to both hot and cold fluids, but is not necessarily tender to percussion. When testing for sensitivity to percussion it is not necessary to tap the tooth with the handle of dental instrument. Gentle finger pressure will be more than sufficient to elicit a response, and much kinder to your patient.
Only when the inflammation has spread throughout the pulp and has involved the periodontal ligament, will the tooth become tender to bite on. In these circumstances, the application of heat will cause prolonged pain which may be relieved by cold. Both hot and cold can precipitate a severe bout of pain, but as a rule heat tends to be more significant. Pain from an irreversibly damaged pulp can be spontaneous and may last from a few seconds to several hours. A characteristic feature of an irreversible pulpitis is when a patient is woken at night by toothache. Even so, if untreated a symptomatic pulpitis may become symptomless and pulp tests may give equivocal results. In time, total pulp necrosis may ensue, without the development of further symptoms and the first indication of an irreversibly damaged pulp may be seen as a periapical rarefaction on a radiograph, or the patient may present with an acute periapical abscess. To summarize, therefore, in reversible pulpitis:
The pain is of very short duration and does not linger after the stimulus has been removed.
The tooth is not tender to percussion. The pain may be difficult to localize. The tooth may give an exaggerated response
to vitality tests. The radiographs present with a normal
appearance, and there is no apparent widening of the periodontal ligaments.