Pulpagia - the symptom

1. Hyperreactive
2. Acute
a. Incipient
b. Moderate
c. advanced
3. Chronic

HYPERREACTIVE PULPAGIA
Dentinal sensitivity
 Pulp condition is reversible
 Characterized as short, SHARP shock
 Always in response to stimuli (never spontaneous)
o Eg heat/cold, sweet/sour, acid, touch
 Not pathologic.
 May develop post-perio surgery or from gingival recession
 Causes:
o Stimuli > fluid flow in dentinal tubules stretching/compressing nerve endings that pass
alongside odontoblastic processes
o Plaque build-up from failure of brushing area d/t nerve response to
toothbrushing/scratching worsens condition
o Marginal microleakage around restorations > bacterial invasion and irritation >
hypersensitivity
o Acidic soft drinks > remove smear layer

Examination
 Apply irritant that triggers reaction
 Radiograph: normal
 EPT: normal
 Percussion: Normal

Treatment
 Insulating cement base under amalgam fillings >> prevents shock >> irritation dentin protects
pulp from thermal shock
 Use of bonding agent during restoration > protects exposed tubules, serves as insulation in
place of cement base
 Post-perio surgery > seal dentinal tubules w/ potassium oxalate/strontium
chloride/fluorides/dentin bonding agents
 TOOTHPASTE containing 5% potassium nitrate
o MOA: "numbs" nerve endings. (interferes with pulpal nerve conduction)
 Note: doesn't block the tubules. Also doesn't stop fluid flow within tubules.
 Root surface of hypersensitive teeth: dentin adhesive application

ACUTE PULPAGIA

(i) INCIPIENT
 Pulp condition is reversible. Inflammation absent.
  Characterized by mild discomfort (eg. Post-cavity/crown prep). May be gone the next day.
 Marginal increase of leukocytes and fluid pressure against nerves accompanying odontoblasts.
 Causes:
o Fluid pressure (disappears when pressure lowers)
o Caries entering dentin
o Constant trauma from 'high' filling

Examination
 Radiography (the only way to make out interproximal incipient carious lesion)
o If constant trauma >> PDM thickening at apex
 Stimulus: cold (best)
 Percussion: mild response
 EPT: normal

Treatment
 If d/t cavity prep: TIME
 If d/t initial caries: caries removal + CaOH dressing + ZOE temp filling until sensation returns to
normal > permanent restoration
 If d/t trauma: relieve high spot on filling of opposing tooth
 STAY AWAY FROM RCT

(ii) MODERATE
 Pulp condition reversible/irreversible. Inflammation PRESENT.
o Reversible: mild, short duration
o Irreversible: moderately severe, continuous indicating possible infected pulp. MOST
moderate pulpagias are irreversible
 Described as "nagging" or "boring". Pain is extended, diffuse, hard to locate (referred)
 Triggers
o Spontaneous
o Cold, hot
 Causes
o Reversible: pulp reacting to acidic output of bacteria > inflammation and swelling
o Irreversible: infected pulp

Examination
 Radiograph
o Normally large interproximal caries or deep filling reaching pulp
o Thickening of PDL at apex (maybe)
 Thermal testing w/ cold first
o If pain increases then disappears, look for rebound of pain before testing on other teeth
 Then, see if other teeth respond with same intensity
 EPT: more sensitive than other teeth
 Percussion: more sensitive than other teeth
 LA: pain elimination confirms tooth. LAST RESORT!

Treatment
 Mild: remove caries > CaOH dressing > temp filling > permanent filling
 Irreversible: pulpotomy. Change of survival less than 50:50.

(iii) ADVANCED
  Pulp condition totally irreversible
 Pain as hell
 Relief: cold water (temp relief)
o d/t contraction of gas and excess fluid in response to cold

Examination
 Radiograph: IRRELEVANT
 EPT: IRRELEVANT
 Thermal testing: Heat - explosive response!
 LA: block injection gives relief

Treatment
Only one solution…Pulp removal
i. Pulpectomy: make sure everything is removed
ii. Root canal
iii. Extraction

Tooth may have risen in socket SO make sure to relieve occlusion

Iv) CHRONIC PULPAGIA

 Mild, consistent discomfort w/ diffuse and ambiguous pain which may refer to other teeth
 Triggers
o Biting on open cavity (pain)
o Airplane flight (barodontalgia during flight ascent d/t low cabin pressure)
o Heat (discomfort)
 Pulp appearance
o Mostly necrotic, just enough vital remnants to extend sensation

Examination
 IO exam: Huge carious lesion/fractured filling
 Radiograph:
o huge interproximal cavity or recurrent caries
o Thickened apical PDL w/ external root resorption
o Condensing osteitis: (more bone production in surrounding cancellous bone)
 Disappears after endodontic treatment
 EPT: very high value
 Percussion: one tooth more sensitive
o Biting on cotton roll or hot water rinse may be more indicative

Treatment
Basically only can:
 Treat endodontically
 Extract

v) PULP NECROSIS
 Quiet killer. Slowly and silently kills pulp.
 D/t
o Caries
o Trauma cutting of apical blood supply
Examination
 *Thermal testing: no response
 EPT: no response (unless multirooted and other roots vital)
 Partial necrosis
 Radiograph: not reliable.
o Root resorption/PA lesions
o Diff diagnosis: osteofibrosis (PA radiolucency)

Treatment
 RCT: cleaning, shaping, disinfecting, obturating
 Extraction

Pulpitis - the cause

1. Reversible
2. Irreversible

Reversible
 Stimuli-based (non-spontaneous)
 Sharp sensitivity, relieved when stimulus removed
 Causes
o Exposed dentin (dentinal sensitivity) [no inflammation, not pulpitis]
o Caries
o Deep restorations
 Negative percussion
 EPT responds early
 No periapical changes
Treat: remove stimuli, pulp cap

Irreversible
Symptomatic
 Spontaneous
 Sharp lingering pain (30s or more after removing stimulus) on thermal stimulus esp heat
 Referred pain
 Triggers
o Lying down
o Bending over
 Causes
o Deep caries
o Extensive restorations
o Fractures exposing pulp
 Maybe negative percussion
 EPT delayed OR early OR mixed

Asymptomatic
 No symptoms
 Normal thermal testing

TREAT: Pulpotomy or pulpectomy, RCT

Symptomatic Apical Periodontitis
 Inflammation of apical periodontium
 Positive percussion
 Maybe radiographic changes
Treat: RCT

Asymptomatic Apical Periodontitis

 Inflammation and destruction of apical periodontium
 Asymptomatic
 Apical radiolucency
Treat: RCT

Acute PA abscess
 Sudden onset
 Spontaneous pain
 Tender to pressure
 Pus and swelling
 No radiolucency
Treat: RCT, drainage (antibiotics)

Chronic PA abscess
 Gradual onset
 Little to no discomfort
 SINUS TRACT
 Radiolucency
 Thermal no response
 EPT no response
Treat: RCT

Apical periodontitis > apical abscess > granuloma > apical cyst
Note: acute apical periodontitis doesn't show anything on radiograph, chronic apical periodontitis
will show radiolucency

Abscess not-so-well-defined margin

Granuloma <1.5cm, corticated margin
Cyst >1.5cm, corticated margin

Pulpotomy: coronal pulp removal

Pulpectomy: whole pulp removal (basically RCT without shaping/cleaning, obturation)-