Modernized classification of diseases and pathological processes of the pulp. Exacerbation of chronic pulpitis
Pulpitis- inflammatory disease of pulp tissue (Fig. 5.1). By origin, infectious, traumatic and drug-induced pulpitis are distinguished.
Rice. 5.1. Chronic hyperplastic pulpitis
5.1. CLASSIFICATION OF PULPITIS
There are several dozen systematizations of pulp diseases in the literature. This number can be explained by the variety of types of pulp damage, etiology, clinical manifestations and pathomorphological signs. Classifications of pulp diseases can be divided according to the following characteristics.
1. By etiological factor: infectious (microbial), chemical, toxic, physical (thermal, traumatic, etc.), hematogenous and lymphogenous, iatrogenic.
2. According to morphological characteristics: pulp hyperemia, exudative (serous, purulent), alterative (ulcerative, gangrenous, pulp necrosis), proliferative (hypertrophic, fibrous, granulating, granulomatous), dystrophic (pulp atrophy).
3. Topographic-anatomical:
a) partial, limited, local, superficial, coronal;
b) general, total, diffuse, diffuse, etc.
4. Clinical (pathophysiological): acute, chronic, aggravated, open, closed aseptic, complicated by periodontitis.
One of the first widespread classifications is the classification of E.M. Gofunga (1927). It is built taking into account the fact that in different clinical manifestations of pulpitis there is a single pathological process: inflammation of the pulp with a transition in the acute course from the serous stage to the purulent stage, in the chronic stage - to proliferation or necrosis.
Classification by E.M. Gofunga (1927)
1. Acute pulpitis: partial, general, purulent.
2. Chronic pulpitis: simple, hypertrophic, gangrenous.
Classification E.E. Platonova (1968)
2. Chronic pulpitis: fibrous, gangrenous, hypertrophic.
3. Exacerbation of chronic pulpitis. MMSI classification (1989)
1. Acute pulpitis: focal, diffuse.
2. Chronic pulpitis: fibrous, gangrenous, hypertrophic, exacerbation of chronic pulpitis.
3. Condition after partial or complete removal of the pulp.
International classification of dental diseases ICD-C-3, created on the basis of ICD-10
K04.0. Pulpitis.
K04.00. Initial (hyperemia).
K04.01. Spicy.
K04.02. Purulent (pulp abscess).
K04.03. Chronic.
K04.04. Chronic ulcerative.
K04.05. Chronic hyperplastic (paired polyp).
K04.08. Another specified pulpitis.
K04.09. Pulpitis, unspecified. K04.1. Pulp necrosis.
Pulp gangrene. K04.2. Pulp degeneration.
Denticles.
Pulp calcifications.
Pulp stones.
5.2. PATHOGENESIS OF PULPTIS
5.3. DIAGNOSIS OF PULPTIS
Pulp necrosis (pulp gangrene) (K04.1) (chronic gangrenous pulpitis)
Chronic hyperplastic (pulp) polyp (K04.05) _ (chronic hypertrophic pulpitis) _
5.4. DIFFERENTIAL DIAGNOSTICS OF PULPTIS
5.5. METHODS OF TREATMENT OF PULPTIS
When treating pulpitis, it is necessary to solve the following problems: eliminate the pain symptom, eliminate the source of inflammation, protect periodontal tissue from damage, restore the integrity, shape and function of the tooth.
All methods of treating pulpitis can be systematized (Scheme 5.1).
Scheme 5.1. Treatment methods for pulpitis
Table 5.1. Calcium-containing preparations for coating dental pulp
Table 5.2. Medicines for medicinal treatment and rinsing of root canals
CLINICAL SITUATION 1
Patient V., 24 years old, came to the clinic with complaints of severe spontaneous paroxysmal pain in tooth 36, prolonged pain from temperature stimuli, and pain in this tooth at night.
According to the patient, the tooth has been hurting for the 2nd day. Previously I noted the presence of a cavity in this tooth.
Upon examination: on the chewing surface of tooth 36 there is a deep carious cavity filled with softened dentin. Probing the bottom of the cavity is sharply painful at one point, the reaction to cold is prolonged, percussion of the tooth is painless.
Make a diagnosis. Carry out differential diagnosis. Make a treatment plan.
CLINICAL SITUATION 2
Patient K., 37 years old, came to the clinic with complaints of severe, prolonged pain in the teeth of the upper jaw on the left, radiating to the temple. Attacks occur both during the day and at night, the pain intensifies from temperature stimuli.
From the anamnesis: about a week ago appeared sharp pain in tooth 24. I didn’t see a doctor, I took analgesics that briefly relieved the pain. The attacks became longer, and pain appeared in the neighboring teeth, the pain began to radiate to the temple.
On examination: tooth 24 has a deep carious cavity on the posterior contact surface, filled with softened dentin. Probing the bottom of the cavity is sharply painful along the entire bottom, the reaction to temperature stimuli is prolonged, percussion is painful.
Make and justify the diagnosis. Define the stages of endodontic treatment. Name the dental drugs used at the stages of treatment.
GIVE ANSWER
1. The peripheral zone of the pulp is formed by cells:
1) pulpocytes;
2) odontoblasts;
3) osteoblasts;
4) fibroblasts;
5) cementoblasts.
2. Complete preservation of dental pulp is possible with:
1) acute focal pulpitis;
2) acute diffuse pulpitis;
3) acute periodontitis;
4) chronic gangrenous pulpitis;
5) chronic hypertrophic pulpitis.
3. To make a diagnosis of pulpitis, an additional research method is used:
1) clinical blood test;
2) serological blood test;
3) blood test for glucose levels;
4) electroodontodiagnostics;
5) bacterioscopy.
4. Electrical excitability of the pulp in purulent pulpitis (μA):
1)2-6;
2)10-12;
3)15-25;
4)25-40;
5) more than 100.
5. In acute pulpitis, probing the carious cavity is most painful in the area:
1) enamel-dentin junction;
2) neck of the tooth;
3) projections of one of the pulp processes;
4) enamels;
5) the entire bottom of the carious cavity.
6. The persistence of pain after the removal of the stimulus is typical for:
1) dentin caries;
2) pulp hyperemia;
3) acute pulpitis;
4) acute periodontitis;
5) chronic periodontitis.
7. Attacks of spontaneous pain occur when:
1) enamel caries;
2) dentin caries;
3) pulp hyperemia;
4) acute pulpitis;
5) chronic pulpitis.
8. Differential diagnosis of purulent pulpitis is carried out with:
1) dentin caries;
2) acute pulpitis;
3) chronic periodontitis;
4) chronic gangrenous pulpitis;
5) chronic hyperplastic pulpitis.
9. Chronic fibrous pulpitis is differentiated from:
1) dentin caries;
2) necrosis (gangrene) of the pulp;
3) enamel hypoplasia;
4) chronic periodontitis;
5) radicular cyst.
10. The vital pulp extirpation method involves removing the pulp:
1) under anesthesia;
2) without anesthesia;
3) after using arsenic preparations;
4) after using paraformaldehyde paste;
5) after using antibiotics.
11. Detection of root canal orifices is carried out using:
1) root needle;
2) boron;
3) probe;
4) example;
5) K-file.
12. To expand the mouths of root canals, use:
1) K-file;
2) H-file;
3) probe;
4)Gates-glidden;
5) root needle.
13. Immediately before filling, the root canal is treated:
1) hydrogen peroxide;
2) ethyl alcohol;
3) sodium hypochlorite;
4) distilled water;
5) camphor-phenol.
14. When the pulp is inflamed, the root canal is filled:
1) to the anatomical apex;
2) to the physiological apex;
3) beyond the opening of the tooth apex;
4) not reaching 2 mm to the hole in the apex of the tooth;
5) 2/3 of the length.
RIGHT ANSWERS
1 - 2; 2 - 1; 3 - 4; 4 - 4; 5 - 3; 6 - 3; 7 - 4; 8 - 2; 9 - 2; 10 - 1; 11 - 3; 12 - 4; 13 - 4; 14 - 2.
Many people are familiar with this situation when fear of dental treatment forces them to postpone visiting the dentist for an indefinite period of time. It may not bother you for some time, but suddenly such an unbearable toothache occurs that the sufferer immediately consults a doctor. A diagnosis of pulpitis is often made. Pulpitis is inflammation of the neurovascular bundle of the tooth. It has a certain classification.
- infectious;
- traumatic;
- retrograde;
- concremental.
Basically, pulpitis occurs with complicated caries, when the hard tissue of the teeth is very much destroyed. The infection located in the carious cavity contributes to inflammation of the pulp.
In addition, this disease is often occurs as a result of medical error, for example, if the filling was installed poorly or the pulp was opened carelessly during the treatment of caries. The tooth can also be injured due to an impact.
Very rarely, but the infection can penetrate through the vessels along with blood from the root.
A hard formation called a denticle may appear inside the tooth itself. It also promotes inflammation of the pulp.
Symptoms
Inflammation of the pulp is accompanied by unbearable pain, which sometimes subsides. The pain is especially severe at night and the body temperature may rise.
In the initial stage of inflammation, periodic aching pain occurs. The advanced stage is characterized by an increase in pain, which gradually becomes longer and more pulsating. For a chronic form of inflammation, pain is characteristic only during exacerbation. Pus forms, and if you press a little on the sore tooth, pain immediately occurs.
Classification
Modern dentistry has several dozen different classifications of pulpitis. This happens because There are many types of pulp damage, as well as the ways of their formation. Many people define the classification of pulpitis in their own way.
The following classifications are considered the most popular:
- Platonov's classification;
- classification according to ICD-10;
- Gofung classification.
Platonov's classification.
As a result of this classification, pulpitis is divided into the following types and forms:
- acute (focal and diffuse);
- chronic (fibrous, gangrenous and hypertrophic);
- chronic in the acute stage.
Acute pulpitis is characterized by intense throbbing pain that occurs in attacks. At first, the pain is short-lived, but the period of calm can last a long time. Then pulp inflammation begins to progress, the pain becomes stronger and longer, and the period of calm becomes shorter and shorter. A diseased tooth begins to ache from interaction with hot water.
Chronic pulpitis is sluggish, almost painless. External irritants do not greatly disturb the aching tooth. The color of the tooth changes, the pulp is significantly exposed, and you can even see the mouths of the root canals.
Exacerbation of chronic pulpitis has all the symptoms of acute pulpitis. The only difference is that the pain practically does not go away. Externally, the tooth looks the same as with chronic inflammation of the pulp.
Classification according to ICD-10.
The World Health Organization offers the following classification:
- pulp inflammation;
- diseases of the pulp and periapical tissues;
- pulp hyperemia;
- spicy;
- chronic;
- purulent, pulpal abscess;
- chronic ulcerative pulpitis;
- pulp recrosis;
- pulp polyp;
- other specified pulpitis;
- unspecified pulpitis;
- improper formation of hard tissue in the pulp;
- pulp degeneration.
This qualification has distinctive feature- V separate category identified changes in the dental pulp before the appearance of systematic pain.
Gofung classification.
The most popular classification of pulp inflammation among dentists. It perfectly reflects all stages of the disease.
Acute pulpitis.
Partial. If acute partial inflammation occurs, then changes in the pulp are completely reversible. If you immediately consult a doctor as soon as pain appears, then it is possible to cure a tooth and save your nerve.
General. Acute general inflammation of the pulp is characterized by diffuse inflammation that completely covers the pulp. By characteristic features acute general pulpitis almost impossible to distinguish from the beginning of purulent destruction Therefore, they resort to surgical treatment.
ABOUT general purulent. This stage is characterized by the development of irreversible pathology, which is why vital extirpation is considered a treatment method. The doctor should pay special attention to the prevention of periodontitis.
Chronic pulpitis.
Simple.
Hypertrophic. Both this and the first form can be successfully treated surgical method, preserving the root areas of the pulp.
Gangrenous. The most severe form of chronic inflammation. The treatment here is extirpative. This form is characterized by maximum saturation of the walls of the root canals with pathogenic microflora. Treatment is carried out in several stages. This promotes long-lasting action of antiseptics, which reduce the risk of complications after filling.
MMSI classification.
It is very similar to Gofung’s classification, only some points of exacerbation of chronic inflammation of the pulp are added and the peculiarities of the occurrence of inflammation in a previously treated tooth are taken into account.
- acute (serous, focal purulent, diffuse purulent);
- chronic (fibrous, gangrenous, hypertrophic);
- exacerbation of chronic pulpitis (fibrous, gangrenous);
- condition after pulp removal - partial or complete.
Exacerbation of fibrous pulpitis usually does not have such a destructive effect, as an exacerbation of gangrenous. In the latter option, the degree of periodontal complications is high.
The tooth begins to strongly resist filling the canals, and severe pain appears when it is filled with a temporary filling. This is due to the fact that anaerobic microflora thrives when isolated from the external environment.
It often happens that removing part of the pulp does not relieve inflammation. This happens due to the fact that the diagnosis is made incorrectly or the treatment technology is violated. In this case, complete removal of the tooth along with the roots helps.
Thus, we come to the conclusion that treatment of pulpitis is early stage promotes nerve preservation, which nourishes the tooth and ensures its vital functions. Therefore, at the very first signs of pulpitis, you should immediately consult a doctor.
Khidirbegishvili O.E.,
dentist, graduate of SSMI in 1978,
owner of the dental clinic “Dentstar”,
Tbilisi, Georgia
Modern endodontics has achieved enough high level developments in the field of etiology, clinic and treatment of pulp pathologies, however, oddly enough, a classification of diseases and pathological processes of the pulp has not yet been created that would fully meet the requirements of clinicians. The WHO classification is no exception, which considers the following pulp diseases:
K 04 Diseases of the pulp and periapical tissues ICD-10
K04.0 Pulpitis
K04.1 Pulp necrosis
Pulp gangrene
K04.2 Pulp degeneration
Denticles
Pulp calcifications
Pulp stones
K04.3 Incorrect formation of hard tissue in the pulp
Secondary or irregular dentin
Having, of course, many advantages, it is still not without certain disadvantages. First of all, in the WHO classification it is difficult to determine the main signs of some pathologies (etiology, clinical picture, diagnosis, treatment, etc.), allowing the doctor to easily diagnose them in the clinic as a nosological form and choose the appropriate treatment method. In fact, of all the pathologies proposed in the WHO classification, in my opinion, only pulpitis and pulp necrosis can be classified as pulp diseases, while the rest are not nosologies that can be diagnosed in the clinic, but only certain pathological processes. Dear Colleagues! It is necessary to understand that disease and pathological process are not identical concepts. In response to the damaging influence of a pathogenic factor, the body responds with a combination of pathological and protective-adaptive reactions. These short-term reactions may develop different levels organism: molecular, cellular, tissue, systemic, etc., gradually turning into pathological processes. Often, one or more pathological processes with various clinical manifestations (symptoms) lead to persistent disruption of the body’s functioning and the onset of disease.
In essence, a disease is the result of several pathological processes, but not in all cases the pathological processes lead to the onset of the disease. A clear example of this is pulp hyperemia, which refers to discircular reactive or pathological changes in the pulp. Hyperemia, as a rule, is a consequence of the impact of various irritants on the dental pulp, which increase blood flow in it, resulting in excess pressure on the nerve fibers, which, in turn, causes slight pain. In fact, hyperemia is a mild inflammatory reaction, which to one degree or another is characteristic of various forms caries, and is also detected during the preparation of a carious cavity, pathological abrasion, various diseases periodontal, etc. Since inflammatory reactions in the pulp develop long before its actual damage, with timely elimination, for example, of a carious process, hyperemia will disappear even without affecting the pulp medical pads. If the carious process is not treated, it transforms into acute or chronic inflammation of the pulp. Consequently, hyperemia is only one of the stages of the inflammatory-reparative process, which arose as a reaction to the action of a pathogenic factor, and not an independent nosology. In addition, using only ordinary clinical methods research, hyperemia is almost impossible to diagnose in conditions of mass admission of patients. On this basis, I believe, the tactics of German scientists are justified, who do not distinguish pulp hyperemia as a nosology in any classification, considering it problematic from both diagnostic and pathogenetic points of view. At the same time, is the tactics of WHO specialists logical, who for some reason consider hyperemia a nosology and classify it as inflammatory diseases of the pulp (pulpitis).
As for pulp degenerations and improper formation of hard tissues in the pulp, I believe that they also should not be identified either with diseases of the pulp in general or with inflammatory diseases pulp. Denticles and calcifications are often found in various pulp pathologies, but cause-and-effect relationships are difficult to establish. It is also important that calcifications and denticles are often observed with age-related changes in the pulp and their presence has virtually no effect on the choice of treatment method. They are often diagnosed on X-rays in patients who show virtually no complaints, although surgical intervention is performed only in case of exacerbation of the inflammatory process. American scientists claim that there is a positive relationship between pulp calcification and its pathology, especially with a long course of the pathological process. Based on many years practical activities, I want to note that it is not denticles and calcifications that are the cause of pathological processes in the pulp, but on the contrary, their formation is often associated with developed pathology. The opinion of some clinicians that pain in the tooth allegedly occurs due to compression of the nerve endings by denticles and calcifications, and not as a result of the direct progression of the inflammatory process in the pulp, was not justified. In this regard, the method of artificial movement of denticles, proposed by I. O. Novik, deserves attention in its own way. As a young specialist, I tried to put this method into practice, but after repeatedly sharply lowering the chair with the patient, the movement of loose denticles did not happen, but the patient’s loss of consciousness brought me a lot of trouble!
It is also difficult to agree with the concept of “improper formation of hard dental tissues” as a designation of a specific nosology, since Mother Nature does not do anything wrong. Replacement or irregular dentin is not the incorrect formation of hard tissues in the pulp, but the formed protective-adaptive layers of the carious process. It is not replacement dentin that is pathological, but its formation occurs in response to pathology. Modern science does not yet have accurate data on the mechanism of formation of replacement dentin and its pathological effect on the dental pulp. However, we can say with confidence that since its formation is associated with protective-adaptive processes and generally does not threaten the vital activity of the pulp, there is no point in diagnosing this pathology at all. It is also important that information about the presence of replacement dentin is more important when diagnosing progressive forms of caries and pulp atrophy, but not pulpitis. In addition, no specific nosological form of pulp disease has yet been identified, the diagnosis of which at least indirectly reflected inadequate formation of replacement dentin.
Based on all that has been said, I would like to offer to the attention of my colleagues a classification of pulp diseases that takes into account the disadvantages listed above:
1. Pulpitis
3. Intrapulpal granuloma
2. Pulp necrosis
4. Pulp ischemia
First of all, noteworthy is the fact that there are no malignant neoplasms in the list of pulp diseases, although there is data on the possibility of their metastasis into the dental pulp. The literature describes a case in which impaired sensitivity and the formation of a focus of bone tissue destruction in the area of the roots of the teeth turned out to be the first sign of leukemia.
Let us take a closer look at the clinical manifestations of the nosologies with which the classification was supplemented. Intrapulpal granuloma is one of the rare forms of pulp disease that occurs for unknown (idiopathic) reasons. There are other names for this nosology (internal granuloma, internal resorption, etc.), but I consider the most appropriate term used in the classification. Intrapulpal granuloma is characterized by the transformation of the pulp in one or another part of it into granulation tissue, which, as it grows, resorbs the hard tissues of the tooth from the side of the pulp cavity. Its favorite localization is areas near the mouth of the root canal and, less often, in the middle of the tooth root. In the process of progression, the pulp and root dentin, which are a single functional organ (dentin-pulp complex), are primarily resorbed. If the process does not stabilize, the pathology spreads to the tooth tissue surrounding the root (periodontium). It is important to note that the pathological process stops only after the death of the pulp, since viable cells are required for the resorption of hard tissues. This fact once again confirms that this pathology belongs specifically to diseases of the pulp, and not of periapical tissues (for example, periodontitis). Despite the fact that intrapulpal granuloma is characterized by a long course of the inflammatory process, as a result of which many clinicians classify it as pulpitis, this nosology differs significantly from the latter in the severity of the damage caused to the dental tissues. In addition, the identification of this nosology in the classification of pulp diseases is justified by the peculiarities of its diagnosis and the treatment methods used (see below).
As for the proposed nosology “pulp ischemia”, it is also one of the rarely diagnosed diseases. It is characterized by disruption of blood flow in the root part of the canal due to blockage of the apical vessels of the pulp, as a result of which ischemic processes occur in the pulp. In this case, the walls of the capillaries are damaged, and red blood cells flow into the tissues. Hemoglobin is converted into a homogeneous granular substance that replaces pulp tissue. Ultimately, all the cells disappear, and only homogeneous material remains. Due to impaired blood flow, cells cannot enter the tissue, so nerves, blood vessels and fibroblasts undergo degeneration in the absence of an inflammatory response. Even if bacteria are present, there is no blood flow to provide a response to them. In such cases, only a collagen “framework” remains of the pulp, and when it is extirpated, a non-bleeding, dense material shaped like a pulp is obtained. Clinically, this phenomenon is called "fibrous pulp".
It is important to note that pulp ischemia and intrapulpal granuloma, along with other pathologies, are considered by many clinicians in the classification reactive changes pulp. I believe that such tactics are quite problematic, since, unlike other pathologies considered in this classification, the proposed pulp diseases have pronounced etiological, clinical, morphological manifestations and, what is especially important, they are easily detected in the clinic using conventional diagnostic methods and sometimes special methods are used in their treatment. For example, intrapulpal granuloma is easily diagnosed radiographically, and in its treatment special tactics of canal obturation are used. The diagnosis of “pulp ischemia” is made on the basis of objective data from the exposed fibrous pulp, removed not from a carious tooth, in which its occurrence is often associated with infectious carious processes, but as a result of depulpation for orthopedic indications of an intact, but apparently previously injured tooth. Agree that in this case, given the reason surgical intervention and the objective state of the extirpated pulp, it is simply illogical to make a different diagnosis. It was the clinical manifestations considered that made it possible to classify these nosologies as pulp diseases.
If the proposed innovations are accepted, then it will be necessary to slightly change the classification of reactive changes in the pulp or pathological processes of the pulp, which in this case will look like this:
I. Alternative changes
1. Petrification.
2. Fibrinoid changes
3. Pulp hyalinosis
4. Pulp amyloidosis
5. Mucoid swelling
6. Hydropic and fatty degeneration of odontoblasts
II. Dyscirculatory changes
1. Pulp hyperemia
2. Intrapulpal hemorrhages
3. Thrombosis and embolism of pulp vessels
4. Pulp swelling
III. Adaptive processes
1. Pulp atrophy
2. Formation of denticles and pulp calcifications
3. Fibrosis (fibrosclerosis) of the pulp.
4. Formation of replacement dentin
IV. Functional pulp deficiency
In contrast to the existing classification of reactive changes in the pulp, the modernized one does not include the nosologies “pulp necrosis”, “intrapulpal granuloma” and “pulp ischemia”, since they are classified as pulp diseases. An important addition, in my opinion, is the consideration in the “adaptive processes” section of the patterns of formation of replacement dentin and pulp calcifications.
At the same time, I would like to touch in more detail on the fourth section of the classification “functional pulp deficiency”, proposed instead of the section “intrapulpar cysts”, which considered intrapulpal granuloma. Typically, functional pulp failure is a transient condition that develops under the influence of various exogenous and endogenous factors. Similar condition often occurs in pilots when climbing to a height, in divers when diving to depth, stress, hypertension, etc. This condition is primarily characterized by an attack of toothache (barodentalgia), especially in poorly treated teeth. Currently, the pathogenesis of the development of barodentalgia is well known and is caused by a violation of pressure regulation in gas-containing cavities of the body. In this case, hyperemia and lack of electrical excitability are observed in the pulp. dystrophic changes which can cause various pathologies. On this basis, I consider the tactics of V.I. Lukyanenko, who considers the functional failure of the pulp in the clinical and morphological classification of pulpitis, to be unfounded, since in the clinic, as a rule, it is not the functional failure of the pulp itself that is diagnosed, but various pathologies that can arise as a result of its effects. That is why, I believe, consideration of this pathological process in the proposed classification is justified.
The rest of the forms discussed in the classification are quite informatively covered in the scientific literature, so there is no point in examining them in detail in this publication. At the same time, it should be noted that all these pathological processes are practically not detected in the clinic, since they are diagnosed only by morphological research methods, which are not carried out in conditions of mass admission of patients, therefore this classification, unlike the classifications of pulp diseases, is pathoanatomical and has a purely scientific interest.
Dear Colleagues! In conclusion, I invite clinicians and all interested colleagues to take part in the discussion of a new version of the classification of diseases and pathological processes of the pulp and the possibility of its use in clinical practice. I will gratefully accept and take into account all the amendments and recommendations sent by you ( [email protected]).
Literature
1. Tronstad L.. Clinical endodontics - MEDpress-inform, 2006 - P. 37.
2. Cohen, S., R. C. Burn; Pathways of the pulp, Mosby, St. Louis 1984.- P. 322
3. Seltzer S. Bender J.R. The Dental Pulp. Considerations in Dental Procedures. – Philadelphia, P.A. USA: Zippincot, 1984.
4. Iordanishvili A.K., Kovalevsky A.M. Endodontics plus – St. Petersburg, 2001 – P.28, 28, 22
5. Helwig E., Klimek J., Attin T. Therapeutic dentistry. – Lvov: GalDent, 1999.-P. 228, 57
6. Khidirbegishvili O. E.. Modern cariesology. - Moscow: Medical book, 2006 - P. 134.
7. International classification of dental diseases ISD-DA, WHO, Geneva, 1995
8. Internet: Pathological anatomy pulp and periodontal disease – Wikipedia
9. Ivanov V. S., Urbanovich L. I. Inflammation of the tooth pulp. - Medicine, 1990.
A COMMON PART
DIAGNOSTICS
Diagnostics (end)
TREATMENT
Treatment (end)
INFORMATION SUPPORT FOR PATIENT MANAGEMENT PLAN
Justification of the patient management plan: assessment of the effectiveness of recommended diagnostic and therapeutic measures
DIAGNOSTICS
Diagnostics (end)
TREATMENT
Treatment (continued)
Treatment (end)
Ensuring Patient Safety
PATIENT SAFETY: WHAT NOT TO DO IN PULP DEGENERATION K04.2 (DENTICS, PULP CALCIFICATIONS, PULP STONES)
Patient safety: what not to do in case of pulp degeneration K04.2 (dentals, pulp calcifications, pulp stones) (end)
Brief information note
Pulpitis (K04.0 according to ICD-10) is an inflammation of the dental pulp (pulpitis from the Latin pulpitis): a complex vascular, lymphatic and local reaction to an irritant. The prevalence of pulpitis, according to various authors, is 30% or more. In the general structure of dental care, pulpitis occurs in all age groups. Untimely treatment of this disease leads to the development of apical periodontitis, radicular cyst and, as a consequence, to the extraction of the causative tooth.
Main symptoms. Pulp degeneration K04.2 (dentals, pulp calcifications, pulp stones) is usually asymptomatic. It is determined only by opening the pulp chamber or by an accidental X-ray examination.
Etiology. The etiological factor leading to such a response of the dental pulp is inflammation of the pulp with the influence of exotoxins of microorganisms during a long-term carious process, tooth abrasion, and chronic trauma. All this affects the function of odontoblasts. However, there is currently no definitive opinion on the etiology and pathogenesis of degenerative changes in the pulp. Pulp stones can also form in an intact tooth with a living, normal pulp. They can only be seen on a histological specimen. The denticles located in the pulp chamber and pulp calcifications in the root canal can be seen on an x-ray or computed tomography. The formation of degenerative changes in the pulp does not depend on age.
Level of evidence (source)
In the structure of dental care in terms of visits, patients with pulpitis occupy 14-20% or more, depending on the region of residence.
Classification of pulpitis: by etiology:
infectious pulpitis; non-infectious pulpitis, according to the flow:
acute pulpitis; chronic pulpitis; exacerbation of chronic pulpitis. In our country, clinical and morphological classifications proposed by E.E. Platonov and V.I. are widely used. Lukyanenko. They are, in general, very similar:
Platonov's classification:
1) acute pulpitis
Focal;
Diffuse.
2) chronic pulpitis
Fibrous;
Gangrenous;
Hypertrophic (proliferative);
3) exacerbation of chronic pulpitis.
- Lukyanenko classification:
1) Acute pulpitis
Serous-purulent;
Purulent-necrotic.
2) Chronic pulpitis
Fibrous;
Ulcerative-necrotic;
Hypertrophic;
3) Exacerbation of chronic pulpitis.
The official classification of pulp diseases is the WHO nomenclature (ICD-X).
K 04. Pulp diseases
By 04.0. Pulpitis
By 04.00 Initial (hyperemia)
K 04.01 Acute
K 04.02 Purulent (pulp abscess)
By 04.03 Chronic
K 04.04 Chronic ulcerative
By 04.05 Chronic hyperplastic (pulp polyp)
By 04.08 Other specified pulpitis
By 04.09 Pulpitis, unspecified
K 04.1 Pulp necrosis
Pulp gangrene
K 04.2 Pulp degeneration
Denticles
Pulp calcification
Pulp stones
K 04.3 Incorrect formation of hard tissue in the pulp
K 04. ZH Secondary or irregular dentin
Inflammation of the pulp in children occurs at any age, at different stages of the formation of both milk and permanent teeth. The most acceptable in the practice of pediatric dentistry is the classification of pulpitis proposed by E.E. Platonov (see above).
In addition, there is necrosis, or gangrene, of the pulp, as well as pulp degeneration caused by denticles and pulp petrification.
Each of these forms has its own clinical characteristics and can be diagnosed based on subjective and objective data.
In the vast majority of cases, pulpitis occurs as a complication of caries. The following factors can be identified as reasons causing the development of pulpitis:
infectious(streptococci, lactobacilli, less commonly staphylococci, some viruses);
chemical(effects of acids on pulp tissue, including iatrogenic ones, which occur when etching a formed cavity with acid-containing solutions and when filling materials are used incorrectly);
physical(trauma, exposure to electricity and radiation, thermal effects, including iatrogenic ones, that occur when the regime for preparing teeth for fillings, inlays and artificial crowns is violated).
The most common route of exposure of damaging factors to the dental pulp is descending or odontogenic and, first of all, due to the progression of carious lesions. With moderate and especially with deep caries, conditions are created for infection to penetrate into the pulp tissue. Sometimes the cause of infection can be tooth trauma (fracture) or rapidly progressing abrasion with exposure of the pulp horn. Less common is the ascending path of damage when infection occurs hematogenously or less commonly, lymphogenous. This may occur when infectious processes accompanied by bacteremia and viremia (typhoid, malaria, ARVI). In some cases, immune complexes circulating in the blood of patients with systemic diseases, which can settle in the microcirculatory bed of the dental pulp, can play a role in the occurrence of pulpitis.
For the development of diseases, it is necessary to have not only damaging factors, but also a state of local and general reactivity. One of the main places in the development of pulpitis is occupied by sensitization of both pulp tissue and the body as a whole. A possible condition for the development of sensitization is a slow-moving infectious process in the carious cavity. During its progression, information about antigens is constantly received in small doses, forming hypersensitivity of the pulp tissue and creating conditions for a subsequent hyperergic response.
An important role in the development of pulp inflammation is played by the contradiction inherent in its microvasculature between the volume of capillary blood flow and the potential for drainage through the venules. This discrepancy is due to the rather narrow apical foramen of the root and a wider tooth cavity, and its almost closed space with unyielding walls makes the pulp tissue extremely vulnerable even with minimal hemodynamic disorders and increased vascular permeability.
The trigger point in the development of acute pulpitis is the release of vasoactive substances as a result of exposure to pulp tissue, in particular, pathogenic microflora. In this case, primary damage occurs - characteristic local changes, which consist of hyperemia, edema, hemorrhages, inhibition of fibrinolytic and phagocytic activity. Against this background, tissue infection occurs. Cascade mechanisms mediating inflammation are consistently activated (activation of the kallikrein-kinin system, complement and blood coagulation, release of biological active substances from platelets, basophils and mast cells).
At the site of damage in the capillaries, a marginal standing of neutrophilic leukocytes appears. The swelling of the pulp tissue increases and spreads, the plethora becomes widespread, arteriovenous anastomoses open, and serous inflammation occurs. Along with this, the processes of disorganization of connective tissue increase, and dystrophic changes in odontoblasts occur. In cells, the activity of aerobic oxidation enzymes decreases and glycolysis increases, tissue acidosis occurs.
At this stage pain occurs. The reason for this is acidosis and swelling in the pulp. At first, the pain is periodic and pulsating in nature, and then becomes constant. This symptomatology is closely related to the gradual slowing of blood flow in the microvessels.
In the microvasculature, in all its parts, sludge and stasis of formed elements are formed, and blood clots form. At this point, in the damaged area, neutrophils begin to migrate into the tissue with their partial disintegration - focal purulent inflammation of the pulp (abscess) occurs. Next, necrobiotic processes are added to the dystrophic changes in the pulp tissue, the development of which is primarily associated with hemodynamic disorders. Secondary tissue damage occurs.
The process ends with the release of neutrophils into all parts of the dental pulp (leukocyte infiltration).
Often occurring inflammatory changes are combined, which gives a picture of mixed exudative inflammation (serous-purulent, purulent-necrotic).
The entire process from the beginning to diffuse purulent inflammation of the pulp takes from 3 to 5 days; its morphology and rapid development may indicate a hyperergic reaction.
The most likely ways of developing chronic pulpitis are:
a) the presence of an open tooth cavity;
b) chronicity of acute pulpitis.
In both cases, there is incomplete elimination of the damaging factor, which makes the course of this process chronic. Chronic pulpitis is characterized by the predominance of a productive tissue reaction, which can be expressed both in the processes of sclerosis and in the formation of granulation tissue with a cellular infiltrate of lymphocytes, macrophages and plasma cells.
The peculiar clinical picture of pulpitis in children is due to the anatomical and physiological features of the structure.
decay of teeth and bone tissue at different age periods, as well as the pronounced reactivity of the child’s body.
In baby teeth, the shape of the tooth cavity follows the shape of the tooth. The pulp horns are clearly defined and are much closer to the incisal edge or occlusal surface than in permanent teeth. On the contact surfaces of the first primary molars and upper primary incisors, the dentin layer is thin during all periods of formation, therefore, when carious cavities are localized in these areas, the pulp quickly becomes infected.
In both primary and permanent immature teeth, the dentin layer is thin, and the tooth cavity is large. The dentinal tubules in these teeth are wider, shorter and straighter than in permanent formed teeth, which causes infection of the pulp with relatively shallow carious defects, as well as inflammation of the pulp when toxic filling materials are used.
The pulp in milk and permanent immature teeth contains a large number of cellular elements and fewer fibers, including nerve fibers. A developed network of blood and lymphatic vessels leads to the rapid development and predominance of the exudative component of the inflammatory reaction. In this case, there is the possibility of a good outflow of exudate through the wide apical foramen and through the dentinal tubules of unformed milk or permanent teeth, as well as milk teeth in the stage of root resorption. All this, in turn, leads to the absence of pain during pulpitis in these teeth, as well as to the frequent presence of a pronounced reaction from the periapical and surrounding soft tissues. In children with reduced body reactivity, pain due to pulpitis is also absent or mild.
The periodontium in children contains a large number of cellular elements, blood and lymphatic vessels, and loose connective tissue. This contributes to its great reactivity in response to the entry of virulent microflora, toxins and metabolic products of the inflamed pulp.
Bone tissue has a small thickness of the compact plate, thin bone beams, large bone marrow spaces, which also affects the development of inflammation in the surrounding tissues.
Acute serous-purulent (focal) pulpitis. The leading clinical symptom of acute pulpitis is pain. The serous stage of pulp inflammation is characterized by attacks of intense, spontaneous pain. It is localized, that is, the patient can indicate the causative tooth. Pain can occur from all types of irritants, especially thermal ones. Attacks of pain at night are very common.
Upon examination, a deep carious cavity is determined; probing the bottom is sharply painful at one point. The tooth cavity is not opened. Percussion is painless. Electroodontometry indicators reach 20-30 μA. There are no radiological changes. The duration of this stage does not exceed 2 days.
Acute purulent-necrotic (diffuse) pulpitis. The purulent stage of acute pulpitis is characterized by prolonged attacks of tearing, shooting pain with short “light” intervals. The pain is not localized, but radiates along the branches of the trigeminal nerve. Thus, with acute inflammation of the pulp of the teeth of the lower jaw, pain radiates to the back of the head, ear, submandibular region, temple, and teeth of the upper jaw. In case of inflammation of the pulp of the teeth of the upper jaw - in the temple, superciliary, zygomatic area, in the teeth of the lower jaw. With pulpitis of the anterior teeth, pain may radiate to the opposite jaw. Characterized by persistent pain at night, as well as prolonged pain from irritants.
Upon examination, a deep carious cavity is determined, probing the entire bottom is painful, percussion may be slightly painful (the symptom is not constant). Electroodontometry indicators reach 30-50 μA. There are no radiological changes.
Acute pulpitis is more often diagnosed in strong, practically healthy children. As is known, acute inflammation is an active reaction of pulp tissue to irritants that enter the dental pulp when the barrier function of dentin is disrupted and against the background of the mobilization of the body's defenses. A strong organism is more capable of such a reaction.
Features of the clinical course of pulpitis in children are:
Its frequent occurrence in teeth with a shallow carious cavity, without communication with the tooth cavity;
Rapid spread of inflammation deep into the pulp;
Chronic forms of pulpitis, which are asymptomatic, are more common;
In chronic gangrenous pulpitis, a fistula may be present, and changes in bone tissue are determined by x-ray;
The same form of pulpitis can have a different clinical picture in teeth with different degrees of root formation;
In acute and exacerbation of chronic forms of pulpitis in children, the development of a clinical picture of acute periodontitis or periostitis is possible: a feeling of an “overgrown” tooth, its painful percussion, hyperemia, swelling and painful palpation of the oral mucosa in the area of the “causal” tooth, swelling of the surrounding soft tissues, inflammation of regional lymph nodes;
In children early age a pronounced general reaction of the body is possible: increased body temperature, headache, general malaise; in the study of peripheral blood - an increase in the number of leukocytes and ESR.
The appearance of a clinic of acute periostitis with pulpitis is a formidable symptom, indicating a high activity of the inflammatory process associated with the virulence of the infection and the weak resistance of the child’s body.
Acute partial pulpitis occurs very rarely, mainly in permanent formed teeth in older children. The clinical picture of this form of pulpitis in children is similar to that in adults: short-term painful attacks are replaced by a long pain-free period.
The diagnosis of acute partial pulpitis can be made when a tooth cavity is accidentally opened during preparation of a carious cavity or when a crown is broken off exposing the pulp, if the patient seeks dental care in the first 1-2 hours after the injury. With this form of pulpitis, as a rule, it is possible to keep the pulp viable due to its high ability to regenerate.
Acute diffuse pulpitis has a varied clinical picture, depending on the age of the child, the reactivity of his body, as well as on the group affiliation and stage of tooth development. As a rule, this form of pulpitis is determined in children in formed milk or permanent teeth.
In children 3-4 years old, acute general pulpitis occurs very rapidly, with severe intoxication, an increase in body temperature to 38-39 C, within 24-48 hours from the onset of pain, hyperemia of the mucous membrane of the alveolar part, collateral swelling of the soft tissues, enlargement and soreness appear. regional lymph nodes. Percussion of the tooth is painful.
This course of acute general pulpitis is differentiated from exacerbation of chronic periodontitis, chronic gangrenous pulpitis in the acute stage and periostitis of the jaw. Taking into account a number of similar symptoms in these diseases, as well as the inability of the child to express his complaints and sensations, it is necessary to conduct an X-ray examination and assess the condition of the pulp after its exposure .
In older children, in permanent teeth with formed roots, the symptoms of acute general pulpitis are well expressed and similar to those in adults.
Chronic fibrous pulpitis. Chronic fibrous pulpitis is characterized by attacks of pain when exposed to various irritants, especially thermal ones, primarily cold. A characteristic feature of pain in chronic fibrous pulpitis is that it does not occur immediately in response to an irritant, but only goes away some time after its action has ceased. This is apparently explained by the fact that nerve fibers undergo changes in chronic fibrous pulpitis. The pain is localized. Sometimes it occurs when moving from a cold to a warm room.
Upon examination, a deep carious cavity is discovered; the pulp horn is usually not opened or is found under a layer of softened dentin after its removal. On probing, the pulp horn is painful and bleeds. Electrical odontometry indicators are 20-25 µA. Percussion of the tooth is painless. X-ray examination reveals widening of the periodontal fissure in 30% of cases.
As indicated, in children, chronic forms of pulpitis predominate over acute ones. Firstly, these forms of pulpitis often develop as primarily chronic, rather than as an outcome of acute ones. Secondly, acute pulpitis becomes chronic very quickly - from 24 to 72 hours, depending on the age and reactivity of the child’s body. Thirdly, the absence of pain, which often occurs, does not contribute to timely seeking dental care.
In children with multi-rooted teeth, it can be detected different condition pulps in different canals. For example, in one channel there is pulp necrosis, in others there is inflammation. In this case, different diagnoses are made in accordance with the condition of the root pulp (for example: - chronic granulating periodontitis of the distal canal of the tooth, chronic gangrenous pulpitis in the mesial canals).
Considering that the diagnosis of pulpitis in children is quite complicated, pulpitis develops in teeth at different stages of their formation, mainly with a shallow carious cavity, without communication with the tooth cavity, and the clinical picture of pulpitis often does not correspond to the condition of the periapical tissues, X-ray examination of teeth with carious cavities is necessary for correct diagnosis and selection of an adequate treatment method.
Among chronic forms, it is more common than others chronic fibrous pulpitis, detected during preventive examinations or sanitation of the oral cavity. In milk and permanent unformed teeth it occurs asymptomatically or with slight pain. The history sometimes indicates a history of pain in the past. Upon examination, a carious cavity is visible, filled with food debris and softened dentin. After removing them with an excavator, in 50% of cases a point connection between the carious cavity and the tooth cavity is found. The pulp is red in color, probing it from painless to painful, depending on the degree of changes in it caused by the time of the pathological process and the stage of tooth development, as well as on the individual threshold of pain sensitivity of the child.
In the case when the tooth cavity is not opened, probing the bottom of the carious cavity will be sensitive or painful at one point, depending on the above factors. At the same time, at the bottom of the carious cavity in the area of the projection of the pulp horn, the tooth cavity can sometimes “shine through”.
Chronic fibrous pulpitis is differentiated from deep caries and chronic gangrenous pulpitis. Difficulties in carrying out differential diagnosis arise in the absence of communication between the carious cavity and the dental cavity in young children. An X-ray examination will help clarify the diagnosis. With chronic fibrous pulpitis, a deep carious cavity will be visible on the x-ray, separated from the tooth cavity by a thin layer of dentin. Sometimes the connection between the carious cavity and the tooth cavity is determined. In 20-50% of cases, widening of the periodontal fissure and osteoporosis in the area of bifurcation of the roots of primary molars are detected. In children over five years of age, pathological root resorption may occur.
As noted earlier, in order to clarify the diagnosis, it is possible to apply a therapeutic and diagnostic dressing - a thickly mixed zinc oxide eugenol paste - to the bottom of the carious cavity.
Chronic ulcerative-necrotic (gangrenous) pulpitis. Chronic ulcerative pulpitis manifests itself in the form of localized aching pain from food and thermal irritants, mainly from hot, which does not stop after their elimination, but goes away from cold (this is explained by the formation of gases during gangrenous breakdown of tissue). There is a history of severe pain in the causative tooth.
Upon examination, a deep carious cavity is discovered in the tooth with dull gray enamel. The tooth cavity is opened, the surface of the pulp is covered with gray plaque. With chronic ulcerative pulpitis, probing may be painful in the coronal part of the pulp. During the transition to the gangrenous stage, the coronal part of the pulp dies, and pain during probing remains only in the area of the root canal orifices. Electroodontometry indicators rise to 60-90 µA.
X-rays can detect destructive changes in the form of bone resorption in the area of the root apex.
Chronic gangrenous pulpitis in children and adolescents is in second place in terms of frequency of occurrence. More often it is the outcome of acute diffuse or chronic fibrous pulpitis. There are usually no complaints. Sometimes there is pain or a feeling of fullness after eating hot food. The history usually indicates the presence of pain several months ago. Upon examination, a carious cavity is visible, filled with softened pigmented dentin and food debris. The size of the cavity can vary. The tooth color may be darker, gray. Sometimes a fistula, hyperemia and swelling of the transitional fold may occur on the gum according to the projection of the root apex, regional lymph nodes are enlarged and painful on palpation.
In the process of removing softened dentin with an excavator, as a rule, the tooth cavity is opened. The pulp is gray in color, has an unpleasant odor, and is painless upon probing. Having opened the tooth cavity, it is necessary to carefully examine the mouths of the root canals. If the root pulp is red, the diagnosis of “chronic gangrenous pulpitis” is beyond doubt. In the case when the root pulp is gray, it is necessary to carry out a differential diagnosis with chronic periodontitis. With gangrenous pulpitis, probing the root pulp causes pain.
In the absence of communication between the carious cavity and the dental cavity, it is necessary to carry out a differential diagnosis with deep caries. On an x-ray with deep caries, a thick layer of replacement dentin will be visible, which ensures the absence of pain when preparing a carious cavity.
In any case, it must be remembered that the diagnosis of “chronic gangrenous pulpitis” in children is made after opening the tooth cavity based on the condition of the coronal and root pulp.
In chronic gangrenous pulpitis, in 80% of cases the following radiological changes are detected: widening of the periodontal fissure and osteoporosis of bone tissue, especially pronounced in the area of root bifurcation.
In case of chronic gangrenous pulpitis in permanent unformed teeth, a clear zone of tooth growth is projected on the radiograph; the stage of root formation corresponds to the age of the child.
This form of pulpitis is also differentiated from chronic fibrous pulpitis, moderate caries, and in case of exacerbation of the process - with acute general pulpitis, acute periodontitis and chronic periodontitis in the acute stage.
Chronic hypertrophic (proliferative) pulpitis. The course of chronic hyperplastic pulpitis is calm, usually without exacerbations. Patients complain of tissue growth in the tooth, bleeding during eating, and moderate pain from pressure from solid food. There is a history of pain in the causative tooth for a long time.
Upon examination, severe destruction of the tooth crown is determined; a dense, tumor-like growth protrudes from the carious cavity. Probing is slightly painful. Electroodontometry indicators are at the level of 40-50 μA. As a rule, there are no radiological changes.
Chronic hypertrophic pulpitis in children is quite rare. Patients complain of bleeding and pain when eating. As a rule, the tooth previously hurt. This form of pulpitis always occurs when the coronal part of the tooth is significantly destroyed and when there is extensive communication between the carious cavity and the tooth cavity. The pulp responds to constant mechanical irritation by proliferation. The size of the overgrown pulp can be different; it looks like a pedunculated polyp, red in color, and bleeds upon probing. The hypertrophied pulp is sensitive when probed superficially and painful when probed deeply.
There will be no radiological signs of periodontal damage in chronic hypertrophic pulpitis.
Clinical picture during exacerbation of chronic pulpitis. Exacerbation of chronic pulpitis usually occurs under the influence of both general (hypothermia, infection) and local (mechanical, thermal, etc.) causes. Most often, chronic fibrous and chronic ulcerative pulpitis are aggravated. Exacerbation of chronic pulpitis in children can be caused by increased virulence of microorganisms located in the pulp, deterioration of conditions for the outflow of exudate, as well as weakening of the child’s body’s defenses.
The severity of clinical phenomena during exacerbation of chronic pulpitis depends on whether the tooth cavity is open or closed, that is, whether there is a possibility of outflow of exudate. To aggravate chronic pulpitis, there is a constant aching, paroxysmal pain in the tooth of a spontaneous nature, which intensifies when biting on the tooth. Characterized by swelling of the surrounding soft tissues, enlargement and painful palpation of regional lymph nodes.
In the anamnesis, the tooth had previously been ill with signs of one of the forms of chronic pulpitis. The survey reveals the presence of pain in the past. A carious cavity can be of varying depth; its connection with the tooth cavity is not always the case.
The tooth cavity is often open, and probing is painful. Electroodontometry indicators are reduced and correspond to either chronic fibrous or chronic ulcerative pulpitis.
An x-ray may reveal either a widening of the periodontal fissure or a loss of bone tissue in the area of the apex of the root of a given tooth. In children, destructive changes in bone tissue are found in the area of the bifurcation of primary molars, an unclear pattern of bone beams, and osteoporosis of the compact end plate of the tooth socket.
The outcome of exacerbation of chronic fibrous pulpitis is usually chronic ulcerative pulpitis, and exacerbation of chronic ulcerative pulpitis leads, as a rule, to pulp necrosis.
In addition to X-ray examination, thermal diagnostics, electroodontodiagnostics, and rheodentography are used to diagnose pulpitis. (see section 2).
In the differential diagnosis of acute forms of pulpitis with acute and aggravated forms chronic periodontitis The doctor must take into account that with periodontitis, the pain is aching and constant, intensifies when touching the tooth, swelling may be observed along the transitional fold of the oral mucosa, and symptoms of general intoxication of the body often occur. Painless probing and electroodontometry readings over 100 μA indicate pulp necrosis. X-ray changes in the periapical tissues are observed only during exacerbation of chronic periodontitis and correspond to the clinical form of the disease.
For trigeminal neuralgia central genesis is characterized by the presence of “trigger” zones, touching which provokes attacks of burning short-term pain and its absence at night.
At sinusitis And purulent otitis The general condition of the body suffers; with sinusitis, nasal breathing is difficult, a feeling of heaviness when tilting the head, serous or purulent discharge from the nasal passage are characteristic. For otitis media, the appearance of pain when pressing in the area of the tragus of the ear is specific. At alveolar pain Differential diagnosis is difficult only in the presence of adjacent teeth with carious cavities.
Differential diagnosis of various forms of chronic pulpitis is based, first of all, on the difference in the patient’s complaints. Thus, chronic fibrous pulpitis is characterized by the presence of aching pain from all types of irritants, which does not go away after removal of the irritant (unlike deep caries) for a long time (more than 20 minutes). For ulcerative pulpitis, pain from hot heat is typical, and with hypertrophic pulpitis there is mild pain, but significant bleeding from mechanical irritation.
For fibrous pulpitis at the bottom of the carious cavity under layers of softened dentin, the pulp horn can be visible; probing at this point is extremely painful.
For ulcerative pulpitis an opened gray pulp horn is found, superficial probing of which can be painless; pulp sensitivity appears in the deeper layers.
For hyperplastic pulpitis characterized by the proliferation of granulation tissue, protruding from the tooth cavity with significant destruction of the tooth crown.
Differential diagnosis of hyperplastic pulpitis from the growth of the gingival papilla is quite simple: by tracing along the outer edge of the carious cavity
probe, you can push back the overgrown papilla. Differential diagnosis with papillitis is quite simple: it is necessary to determine the “leg” of the growth by passing a probe around the neck of the tooth. It is much more difficult to carry out a differential diagnosis with chronic granulating periodontitis. With periodontitis, the tooth may be mobile, the gums may be hyperemic or cyanotic, and upon palpation of the projection area of the root apexes, destruction of bone tissue or a fistulous tract may be detected.
To prove the assumption that the source of the proliferation of granulation tissue is periodontitis due to perforation of the bottom of the carious cavity, an x-ray examination is necessary.
Changes in the dental pulp under various pathological conditions. For caries in the spot stage in the pulp tissues, minimal local (corresponding to the projection of the process zone) changes are noted in the form of slight congestion of the capillaries of the subodontoblastic layer, activation of synthetic processes in odotoblasts and initial signs of tertiary dentin deposition. These changes do not always occur, and they can be considered as a biological reaction of the pulp in response to changes in the structure and permeability of tooth enamel.
Superficial caries may be characterized by the appearance of focal vacuolar degeneration of odontoblasts, congestion and swelling in the subodontal layer may be observed, the appearance of a small number of lymphocytes and plasma cells in the perivascular areas, and accumulation of macrophages in these areas is possible. The tertiary dentin layer becomes more visible.
For average caries more significant vacuolar degeneration of odontoblasts is revealed, Toms fibers undergo granular degeneration with foci of fatty inclusions. The process ends with the loss of calcareous stones in the processes of odontoblasts. Individual dentinal tubules contain bacterial accumulations.
A long course of pathology can lead to compensatory hypertrophy of odontoblasts with symptoms of their hyperfunction, leading to the formation of a fairly pronounced band of replacement dentin. Depletion of synthesis and compensation processes is replaced by atrophy of odontoblasts. Tertiary dentin production stops. The focal swelling of the tissues observed initially, giving the impression of a local depletion of the pulp in cells, is subsequently replaced by the phenomena of collagenization in this area with the appearance of an infiltrate of lymphocytes, plasma cells and macrophages.
Deep caries characterized by processes of complete atrophy of odontoblasts in the focus of the projection of the pathological process and the phenomena of their vacuolar degeneration along the periphery. There are no Toms fibers in the dentinal tubules in the affected area; the tubules themselves are filled with colonies of bacteria. The formation of tertiary dentin can be completely stopped. In the coronal part of the pulp, processes of sclerosis with symptoms of hyalinosis may predominate, often with the continuation of the process into the root part. Petrification occurs, and congestion of the capillaries with symptoms of exudation may occur. In addition to lymphocytes, plasma cells and macrophages, a small number of neutrophilic and, to a lesser extent, eosinophilic leukocytes are observed.
With acid necrosis of enamel and dentin a stereotypical reaction may occur in the form of compensatory hypertrophy of odontoblasts with increased production of replacement dentin, which is subsequently, as a rule, replaced by atrophy of specialized cells. At
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In cases of significant deep lesions of tooth tissue, coagulation necrosis of pulp tissue is observed in 7.5%.
Wedge-shaped defects and erosions also lead to compensatory restructuring of odontoblasts with hyperplasia of intracranial structures and an increase in the volume of the cells themselves. This process is accompanied by the synthesis of tertiary dentin. Depletion of compensatory capabilities leads to atrophy of odontoblasts and the appearance of eosinophilic granularity in their cytoplasm. The cells themselves take on a cubic or flattened shape, and the number of their rows is reduced to one. Pulp tissue is often subject to sclerosis with symptoms of hyalinosis, spreading to all its parts.
With increased abrasion In teeth, after the phenomena of hypertrophy, odontoblast atrophy occurs. By this point, a fairly wide band of tertiary dentin has usually already formed, significantly reducing the size of the tooth cavity. In the pulp tissue, against the background of sclerosis and hyalinosis, petrificates from calcium salts appear. With a rapidly progressing process, the compensatory reactions of the pulp in the form of the formation of replacement dentin turn out to be untenable, and therefore the opening of its horn is often observed.
Development periodontitis also leads to reactive restructuring of pulp tissue, which can occur in three ways:
fragmentation of dendritic cell processes, separation of them and fibroblasts. Subtotal denervation of the processes and apical sections of odontoblasts with activation of the lysosomal apparatus in them and an increase in lipid droplets in the cytoplasm. Reduction of part of the capillaries. Accumulation of plasma cells in the pulp tissue;
disruption of intercellular contacts of odontoblasts, death of some of them. Denervation and local damage to the myelin sheaths of nerve fibers, accumulation of a small number of neutrophilic leukocytes in the tissue. The appearance of moderate fibrosis;
death of all cellular elements of the pulp with complete disintegration of odontoblast processes in the dentinal tubules. Destruction of the axial cylinders of nerve fibers and pronounced fibrosis of the pulp tissue. Destruction of the vascular wall of the hemocirculatory bed with the release and disintegration of red blood cells. Migration of a moderate number of neutrophils into the tissue.
Generalized periodontitis is often accompanied by processes of disturbance of mineral metabolism in the dental pulp tissue itself, which is expressed in the appearance of petrificates.
For periodontal disease In the tooth cavity, the formation of all types of denticles is observed: highly and lowly organized, lying freely and near the wall.
In patients suffering from cardiovascular pathology, in particular, hypertension, the main changes in the pulp are caused by the state of tissue hypoxia. It may be associated both with heart failure itself and with the presence of microangiopathy in these patients. Hyalinosis of arterioles, reduction of capillaries and atrophic processes develop in the pulp. Odontoblasts undergo fatty and vacuolar degeneration. Sclerosis and petrification are pronounced in the root part of the pulp.
In patients with chronic lung pathology and severe respiratory failure, reactive changes in the pulp are similar to those in cardiovascular pathology. The exception is the absence of arteriolar hyalinosis.
Sick rheumatism may have changes in the pulp in the form of sclerosis and infiltration of lymphocytes, plasma cells and macrophages. Immune complexes circulating in the blood in some cases cause the development of productive endovasculitis with endothelial proliferation, and immune complexes fixed in tissues can cause local disorganization of connective tissue and chemotaxis of neutrophils to areas of their accumulation. In this case, odontoblasts undergo both the processes of dystrophy and atrophy.
In patients with renal failure Vacuolar degeneration of odontoblasts is often observed, followed by processes of cell atrophy.
For endocrine diseases the nature of the changes largely depends on the type of pathology. Against the background of stereotypical processes of dystrophy and atrophy of odontoblasts in diabetes mellitus, hyalinosis and the formation of false aneurysms in the hemomicrocirculatory bed can be observed, and in odontoblasts - the phenomenon of fatty degeneration. Hyperparathyroidism often leads to metastatic calcification of the pulp along the vessels in the form of small petrification.
Vitamin deficiencies also affect the condition of the pulp. With vitamin C deficiency, degeneration of the peripheral layer and plethora with diapedetic hemorrhages in the central departments, false microcysts filled with serous contents are revealed. With vitamin deficiency A and D, there is a sharp disturbance in the formation of dentin, while denticles are found in the pulp, odontoblasts are in a state of dystrophy and atrophy.
U cancer patients changes in the pulp are associated, first of all, with the emerging cancer intoxication and cachexia and are expressed in the development of dystrophic and atrophic processes in odontoblasts. In rare cases, with hemoblastoses (leukemia), the pulp tissue may be subject to specific infiltration by leukemic cells, and against the background of progressive hemorrhagic syndrome, these patients may experience minor hemorrhages in the coronal part of the pulp.
For acute serous-purulent (focal) pulpitis macroscopically, the pulp tissue appears edematous, congested and has a dull appearance. Microscopically, pronounced congestion of the capillaries with elements of erythrocyte sludge, leukostasis and blood clots, swelling of the endothelium of all parts of the vascular bed is determined. There is an overflow of lymphatic capillaries with lymph and its stasis. The ground substance is in a state of edema and basophilic degeneration. Vacuolar degeneration of odontoblasts and pyknosis of their nuclei are observed.
The fibrous structure of the pulp is preserved, but there are areas of collagen fragmentation and partial swelling. The pulp tissue is infiltrated to varying degrees by neutrophils and macrophages. There are areas of destruction of leukocytes with the formation of acute microabscesses containing colonies of bacteria in the center. A distinct thickening of the nerve fibers is observed. The progression of the process leads to its transition to the next stage.
In acute purulent-necrotic (diffuse) pulpitis macroscopically, against the background of hyperemia, edema and dullness of the tissue, areas of decay appear in greater or lesser quantities, having a greenish-brown color.
Microscopically, diffuse changes in the microcirculatory bed with thrombosis are detected. Phenomena of fibrinoid necrosis of the walls of microvessels and arterioles are observed. The venules show signs of inflammation, with blood clots containing colonies of bacteria and disintegrating white blood cells. All structural elements of the pulp are densely infiltrated with neutrophils with signs of their decay.
In almost all departments, collimation necrosis of tissue and cellular structures is observed, odontoblasts are in a state of necrosis and necrobiosis. In the pulp, basophilic fragments of decaying cell nuclei and bacterial colonies are detected. There may be confluent acute microabscesses. There are fields of hemorrhages with signs of hemolysis and the formation of a brown pigment - hemosiderin.
In cases where putrefactive processes are added, wet gangrene develops and gas bubbles appear. The breakdown of hemoglobin, together with the processes of decay, leads to the formation of iron sulfide in the tissues, which gives the pulp a black color. Nerve fibers undergo vacuolization, fragmentation and lysis. Around abscesses they are clearly thickened. This form of pulpitis ends with complete necrosis of all pulp tissue. The spread of the pathological process beyond the root apex may be the beginning of the development of apical periodontitis caused by odontogenic infection.
For chronic fibrous pulpitis the tooth cavity remains closed. The pulp is a fibrous cord of grayish-white color and dense consistency.
Microscopically, a pronounced proliferation of coarse fibrous connective tissue in all parts of the pulp is revealed, and hyalinosis is noted. The capillary hemo- and lymphatic bed is subject to significant reduction. The cellular composition is small, but at the same time quite polymorphic and is represented by fibroblasts, macrophages, they take a cubic shape in all parts of the pulp. In addition, vacuolar degeneration and a decrease in the number of nerve fibers are observed in individual cells.
When the process worsens, the connective tissue undergoes fibrinoid changes: swelling of collagen fibers and congestion of capillaries appears, and neutrophilic leukocytes are present in the mobile cellular composition. Progression of the process can lead to the development of acute abscesses, phlegmon or gangrene of the pulp.
For chronic ulcerative-necrotic (gangrenous) pulpitis the roof of the tooth cavity is destroyed. The pulp surface facing the lumen resembles a chronic ulcerative defect. The pulp in the defect area is represented by granulation tissue and looks full-blooded and loose; in other parts there is moderately pronounced plethora and swelling of the tissue, and pockets of compaction.
Microscopically, in the coronal part of the pulp (in the area of the open cavity of the tooth), a strip of fibrinoid necrosis is detected, densely infiltrated with neutrophilic leukocytes with signs of their decay and colonies of bacteria. Below is a layer of granulation tissue with an abundance of capillary-type vessels that have a vertical course and, to a lesser extent, form arcades. Fibrin thrombi are detected in a number of vessels.
The tissue between the capillaries contains a rich infiltrate of neutrophils, macrophages, plasma cells and lymphocytes. Below there is connective tissue of varying degrees of maturity: first, loose fibrous (in the form of a narrow strip), then rough, similar to scar. In the root part of the pulp, there is vascular congestion, sclerosis and the phenomena of moderate severe chronic inflammation with a predominantly mononuclear infiltrate (macrophages, lymphocytes, plasmacytes). Odontoblasts in all parts of the preserved pulp with signs of vacuolar degeneration. Nerve fibers in the area adjacent to the granulation tissue have distinct thickenings, and their demyelination is also observed in the coronal part and, to a lesser extent, in the root part. Exacerbation of the pathological process can lead to pulp necrosis.
For chronic hypertrophic pulpitis the macroscopic picture is quite characteristic. From the area of the defect in the bottom of the carious cavity, a polypoid growth of pinkish-gray soft elastic tissue is observed. The underlying sections are moderately plethoric, somewhat edematous, and somewhat compacted in the root part.
Histological examination reveals well-developed granulation tissue in the area of polypoid growth. Granulations can come from a sufficient depth of the pulp tissue, including from the root. The surface is covered with a thin layer of necrotic tissue, which can sometimes undergo epithelialization due to the grafting of stratified epithelial cells onto it from the surrounding mucous membrane of the oral cavity.
Often this form of pulpitis is accompanied by dentin resorption from the tooth cavity. Here, giant multinucleated cells such as foreign body cells and osteoclasts appear. They are located in the lacunae of resorbable dentin. Along with this, one can observe the process of dentin formation, as well as tissues very similar in structure to bone (osteodentin), as well as preserved odontoblasts with the phenomena of vacuolar degeneration. The nerve fibers of the pulp are often thickened and have distinct swellings. With exacerbation of this form of pulpitis, pulp gangrene usually develops.
Clinicians identify the so-called traumatic pulpitis. The cause of acute non-infectious pulpitis is most often acute mechanical or thermal injury to the hard tissues of the tooth.
Mechanical damage is possible:
1) upon impact (with or without chipping of part of the hard tissues of the tooth);
2) in case of improper preparation of carious cavities (opening of the pulp horn with medium or deep caries due to ignorance of the topography of the tooth cavity, individual characteristics or other reasons);
3) in case of violation of the tooth preparation regime for fixed dentures.
Thermal burn of the pulp occurs due to non-compliance with the rules of working with rotating cutting instruments when grinding hard tooth tissues. Acute pulpitis may occur when using potent drugs for the treatment of deep caries, overdrying of exposed dentin under glass ionomer cements and dentinal primers.
Clinical manifestations of acute traumatic pulpitis are identical to acute infectious pulpitis (history of trauma). Treatment of acute traumatic pulpitis is possible both with preservation of the tooth pulp and with its extirpation. Indications for treatment with a conservative (biological) method are similar to those for acute infectious pulpitis (in the presence of a carious cavity). In case of chipping of hard tooth tissues with exposure of the pulp or when opening a tooth cavity during preparation for an artificial crown, vital amputation or vital extirpation is indicated (in accordance with the indications for these treatment methods). Treatment of acute traumatic pulpitis without exposing the pulp is carried out according to the treatment plan for acute traumatic periodontitis, which is most often combined with it.
The causes of chronic inflammation or necrosis of the dental pulp can be:
1) overheating of significant layers of dentin when working with a bur without cooling;
2) excessive pressure on the bottom of the carious cavity;
3) treatment of the carious cavity with a strong antiseptic;
4) applying medications that irritate the pulp to the bottom of the carious cavity;
5) the use of toxic filling materials in the absence or insufficient isolation of the dental pulp from them; lack of adequate treatment for deep caries;
6) carrying out a conservative method of treating pulpitis. In case of chronic non-infectious pulpitis soon after
When filling a tooth, patients experience pain in response to a cold, and in some cases, a hot stimulus. The pain does not go away after removing the irritant. Often these manifestations of pulpitis turn out to be transient.
With pulp necrosis, the patient does not have any complaints after filling the tooth. A history of pain may be noted primarily from thermal stimuli. The color of the tooth crown can be changed, especially with pulp necrosis, to a grayish-dull color. The electrical excitability of the pulp is reduced (with pulp necrosis up to 100 μA). Comparative percussion of the tooth can be positive. Typically, pulp necrosis is discovered accidentally on an x-ray or during an exacerbation of chronic apical periodontitis.
Treatment of chronic non-infectious pulpitis involves complete extirpation of the dental pulp and filling of canals (a description of materials for filling canals is given in section 4 "Dental materials science". Note editors).
If periapical lesions occur, treat the appropriate form of periodontitis in compliance with strict asepsis rules.
Treatment of pulpitis. Modern methods Treatments for pulpitis can be classified as follows:
1) conservative (or biological, vital)- with preservation of viable pulp:
a) with preservation of the entire pulp (conservative);
b) with preservation of the root pulp (vital amputation, vital extirpation);
2) radical (surgical, devital) - without maintaining pulp viability:
a) devital amputation;
b) devital extirpation.
Amputation(Latin amputato - cutting off) - surgical removal of any organ, limb or part thereof.
Extirpation(Latin extirpatio - uprooting) - removal of an organ.
Premedication is of great importance in the treatment of pulpitis, since in most cases patients turn to the dentist in the stages of acute or aggravated chronic pulpitis, which, with attacks of severe pain, disrupt their normal lifestyle.
Premedication(lat. prae - in front medicatio - prescribing or prescribing a medicine, treatment) - the use of medicines in preparing a patient for anesthesia or local anesthesia in order to increase their effectiveness and prevent complications.
Premedication has two main goals: reducing emotional stress and pain sensitivity, which increases the effectiveness of anesthesia and prevents the development of complications. It is usually combined with local or general anesthesia. Some types of premedication are performed by an anesthesiologist, but more often they are performed by a dentist.
As a rule, premedication is preceded by psychotherapy, central electroanalgesia and electrotranquilizer, acupuncture; use of sedatives and other psychotropic drugs. For premedication on an outpatient basis, sedatives of plant origin can be used: tincture of valerian, motherwort, peony, 30 drops at night and one hour before treatment. In patients with mental disorders, benzodiazepine tranquilizers (diazepam 0.005, 1 tablet at night and an hour before treatment), and other psychotropic drugs are used. Premedication also includes medications that the patient takes for concomitant chronic somatic diseases to prevent their exacerbation.
Patients with borderline mental disorders may be offered general anesthesia: inhalation, endotracheal, intravenous anesthesia.
Most dental interventions are accompanied by pain of greater or lesser intensity. Pain sensitivity within a tooth is very diverse. In enamel it is absent, in dentin it is very low, in pulp it is several times higher than the usual sensitivity of soft tissues. The nerve elements of the pulp occupy 20.5% of its volume. In conditions of acute inflammation, its sensitivity increases and spontaneous pain occurs. Therefore, the need for anesthesia in the treatment of pulp diseases reaches 100%.
In the treatment of dental pulp diseases, methods of local anesthesia are of particular importance, among which the most commonly used are devitalization or the use of local anesthetics (lidocaine, mepivacaine, articaine, etc.).
The choice of drug depends on the nature and duration of the intervention, as well as the individual characteristics of the patient. For endodontic interventions, short-acting (prilocaine, articaine - duration of analgesia 30-40 minutes) and medium-acting (lidocaine, trimecaine, mepivacaine - duration of analgesia up to 60 minutes) anesthetics are used. The concentration of the vasoconstrictor added to the anesthetic solution is important, which allows you to increase the duration local anesthesia and its effectiveness, reduces toxicity. The optimal concentration is considered to be 1:200,000, however, a dilution of 1:100,000 is also used.
When treating pulpitis while maintaining the vitality of the dental pulp, when prolonged ischemia of the pulp tissue is undesirable, preference should be given to mepivacaine, which does not have a vasodilator effect and is used without a vasoconstrictor. When choosing an anesthetic, you should also take into account general contraindications to the use of a vasoconstrictor and the allergic status of the patient. According to the method of drug administration, infiltration and conduction anesthesia are used in the treatment of pulp diseases.
With infiltration anesthesia, submucosal, subperiosteal, intraosseous, intraseptal, intraligamentary, and intrapulpal administration of the drug is possible. The most widespread are submucosal and intra-pulse-pair techniques. There are significant prospects for intraligamentary anesthesia, in which the drug solution is injected directly into the periodontal area of the tooth being anesthetized, which allows the use of a minimal amount.
Before intraligamentary anesthesia, antiseptic treatment of the gingival sulcus and tooth surface is carried out with a 0.05% solution of chlorhexidine bigluconate, and removal of dental plaque. The needle is inserted into the periodontal groove at an angle of 30 degrees to the central axis of the tooth with the needle beveled to the root surface, penetrating to a depth of 1-3 mm into the periodontal space until a sensation of tissue resistance appears, then an anesthetic solution is injected in an amount of up to 0.6 ml over 10- 15 sec. It is not recommended to inject anesthetic into the area of root bifurcation and from the vestibular surface.
Also, the injection should not be carried out on both sides of the alveolar septum (vestibular and oral) between the mesial surface of one tooth and the distal surface of the other. When anesthetizing molars, it is necessary to carry out two injections at the mesial and distal edges of this tooth. Intraligamentary anesthesia occurs in 15-45 seconds, maintaining a duration of up to 30-45 minutes. Its effectiveness reaches 90-96%.
Pain relief may also be necessary after treatment of pulpitis when so-called post-filling pain appears for several days. For this purpose, non-narcotic analgesics are used (paracetamol, nurofen, solpadeine, salpo-flex). Additionally, for example, laser therapy on the area of projection of the root apex, cold and other physiotherapeutic procedures may be prescribed.
When choosing a treatment method for pulpitis in children, it is necessary to solve the following problems:
1) elimination of odontogenic infection;
2) prevention of periodontal diseases;
3) providing conditions for the full development of milk (including their physiological resorption) and permanent teeth.
The solution to these problems should be carried out taking into account the fact that the course and outcome of pulpitis in children are in close relationship with the general condition of the child’s body, the nature of the development of the carious process, age, group affiliation of the tooth, the stage of its development and the form of pulpitis. It is also necessary to remember the treatment conditions: maximum simplicity; minimal time costs; painlessness of the procedures.
To eliminate the inflammatory process in the dental pulp and ensure further development of the tooth, various medications are used. It is necessary to take into account
their antibacterial effect, diffusion ability, effect on the dental pulp. Range medicines, used in the treatment of pulpitis in children, is quite wide: these are enzyme preparations (trypsin, chymopsin, etc.), broad-spectrum antibiotics, sulfonamides, phyto- and apiproducts, glycosaminoglycans (honsuride, heparin), vitamin preparations, odontotropic agents (calcium hydroxide , zinc oxide eugenol paste), disinfectants and mummifying agents (phenol, formalin, resorcinol, etc.).
Indications for one or another method of treating pulpitis in children are presented in Table. 8.1.
Table 8.1Choosing a treatment method for pulpitis in children
|
Group affiliation of the tooth and stage of its development |
Biological method |
Vital amputation |
Devital amputation |
High amputation |
Extirpation |
|
53,52, 51,61,62,63, 73,72,71,81,82,83 unformed |
Chronic fibrous pulpitis |
Chronic gangrenous, acute general |
|||
|
53, 52, 51, 61, 62, 63, 73, 72, 71, 81, 82, 83 formed |
All forms of pulpitis |
||||
|
55, 54, 64, 65, 75, 74, 84,85 unformed |
Chronic fibrous [asymptomatic] with carious cavity class 1 |
Chronic fibrous (asymptomatic), planar form of caries |
All forms of pulpitis |
||
|
55, 54, 64, 65, 75, 74, 84,85 formed |
Chronic fibrous and acute focal pulpitis in teeth with the beginning of root resorption |
All forms of pulpitis |
|||
|
15, 14, 13, 12, 11,21, 22, 23, 24, 25, 35, 34, 33 32, 31, 41, 42, 43, 44,45 unformed teeth |
Chronic fibrous (asymptomatic) with carious cavity class 1, acute focal, acute general (up to 24 hours), accidental opening. |
Acute general, chronic fibrous, crown fracture (< 48 ч) |
Chronic gangrenous, crown fracture (> 48 h) |
||
|
15, 14, 13, 12, 11,21, 22, 23, 24, 25, 35, 34, 33 32, 31, 41, 42, 43, 44,45 formed |
Accidental autopsy |
All forms of pulpitis |
|||
|
17, 16, 26, 27, 37,36, 46, 47 unformed teeth |
Accidental autopsy |
All forms of pulpitis |
With accompanying inflammation |
||
|
17, 16, 26, 27, 37,36, 46,47 formed teeth |
Accidental autopsy |
All forms of pulpitis |
Conservative treatment method is a medicinal effect on the source of inflammation in the pulp while maintaining its integrity and functional ability. The effectiveness of treatment with a conservative method depends on a number of objective conditions, the most important of which are the following:
the disease has been developing for no more than 1-2 days;
patient age under 30 years;
route of infection. The method is not indicated for hematogenous contact lymphogenous infection and through the periodontal pocket, as well as for localization of the carious cavity according to Black class II III IV and V;
electrical odontometry at the level of 20-30 μA;
the patient does not have concomitant diseases that reduce the overall resistance of the body;
the possibility of creating aseptic conditions during the treatment of pulpitis (absolute isolation of the tooth using a rubber dam).
In general, biological methods of treating pulpitis are aimed at preserving the vital activity of the entire pulp or only its root part. The basis for their use was, on the one hand, data on the morphology and biology of the pulp, proving its high activity and ability to resist various pathogenic factors (microbes, toxins, injuries, etc.); on the other hand, the emergence of drugs with a pronounced antimicrobial and anti-inflammatory effect, such as broad-spectrum antibiotics, corticosteroid hormones, calcium hydroxide preparations, nitrofuran series, etc.
Indications for the use of these gentle methods in adult patients the following: acute serous pulpitis, traumatic pulpitis (accidentally opened pulp horn), chronic fibrous pulpitis.
In children, indications for the biological method of treating pulpitis are:
accidental opening of a tooth cavity during the treatment of caries;
acute focal pulpitis in permanent teeth (unformed and formed);
acute diffuse pulpitis in single-root permanent immature teeth;
asymptomatic course of chronic fibrous pulpitis in primary and permanent multi-rooted teeth in the presence of good conditions for fixing the filling (class I carious cavity);
fracture of part of the crown of a permanent unformed tooth in the first 6 hours, with the possibility of protecting the medications applied along the fracture line with an orthodontic crown.
In this case, contraindications to this method of treatment are:
multiple caries;
root resorption of more than 1/3 of the length, since during this period involutive changes occur in the pulp and the use of agents that stimulate its biological activity is pointless;
subcompensated or decompensated course of somatic pathology;
history of antibacterial or hormonal therapy.
Method of conservative treatment includes the following sequential stages:
a) preparing the tooth for preparation - rinsing the mouth and treating the carious cavity with disinfectant solutions;
b) anesthesia (see above) and careful isolation of the tooth with a cofferdam;
c) preparation of a carious cavity - mechanical removal of overhanging edges of enamel - necrotomy. The latter is carried out first with a sharp excavator, then with a carbide bur using gentle jerky movements. The rotation speed of the bur should not exceed 10,000 rpm with mandatory cooling. First, the walls of the carious cavity are prepared, then they move to the bottom, which avoids unnecessary trauma, as well as invasion of microorganisms into the pulp through thinned dentin. In this case, two goals are achieved: the source of infection is eliminated and access is created to the pulp for exposure to drugs. Finally, the edges of the enamel are ground off;
d) irrigation of the carious cavity with antiseptics. In this case, a thin cannula (an injection needle with a blunt end) is inserted into the carious cavity and an antiseptic is irrigated from a syringe: heated to 36°C. Irrigation is usually carried out with various disinfectant solutions containing:
preparations of the nitrofuran series (solutions of furazolidone 1:15000, furacillin 1:5000, furazolin 1:10000), which have antimicrobial and antiexudative effects;
enzyme preparation lysozyme;
iodine preparation (1% iodinol solution);
e) application to the bottom of the carious cavity of a medicinal paste that has a pathogenetic effect that stops the inflammatory process in the pulp.
Exposure to the inflamed pulp with drugs is the main therapeutic agent. In this case, the drug must meet the following requirements: have a pronounced antibacterial and anti-inflammatory effect, stimulate pulp regeneration, do not cause irritation, do not contain an allergic component, and there must be no microbial resistance to it.
Depending on the method of exposure, they are divided into: indirect and direct pulp coating. Indirect is called exposure through the layer of peripulpar dentin; direct - exposure through an opened tooth cavity (if the pulp horn is accidentally opened).
Rice. 8.1. Micrograph of the distal part of the coronal pulp. Duration of observation 5 months:
a - the mesial part of the tooth cavity is filled with calcite, b - the formed dentinal bridge covers the distal part of the coronal pulp (from materials by T.F. Strelyukhina)
Most clinicians in Russia and abroad, when treating traumatic and chronic fibrous pulpitis using a conservative method for direct and indirect pulp coverage, prefer pastes based on calcium hydroxide. The widespread use of these drugs is explained by their antimicrobial, anti-inflammatory and odontotropic effects (Fig. 8.1). Calcium hydroxide, most widely used in dentistry and included in many pastes, has a certain antibacterial and anti-inflammatory effect, but it does not apply to all layers of the pulp. Therefore, some patients require more intensive anti-inflammatory therapy. However, no antibacterial agents or glucocorticoids should be left under the permanent filling.
Used as domestic drugs: Calmecin, Calcidont, Biodent, and foreign Life, Kaltsikur,Kα-lasept etc. Pastes containing calcium hydroxide are applied to the exposed pulp horn - with direct coating, then an insulating lining and filling are applied according to indications.
Depending on the form of pulpitis, treatment with a conservative method is carried out in one or two visits. In one visit it is possible to complete the treatment of traumatic and chronic fibrous pulpitis.
Acute serous pulpitis is treated over several visits. Wherein on the first visit, After preparing the carious cavity and irrigating it with antiseptic solutions, antimicrobial and anti-inflammatory drugs are applied to the bottom of the cavity. Among the antimicrobial agents used are broad-spectrum antibiotics (bicillin colimycin), sulfonamide drugs (albucid norsulfazole; metronidazole), and drugs of the nitrofuran series. Anti-inflammatory drugs include both steroidal and non-steroidal drugs. Various drug compositions are widely used: antibiotics with sulfonamides, antibiotics with glucocorticoids, dimexide with crystalline lysozyme, etc. After applying the medicinal paste, the cavity is closed with a temporary filling, without pressure, for 2-4 days.
On the second visit if the patient has no complaints, the bandage is removed and a therapeutic pad containing calcium hydroxide is applied, then an insulating pad and a filling as indicated. If the pain persists, but with a positive dynamics of the clinical picture, the temporary filling is removed, the cavity is irrigated with antiseptics, then another medicinal composition is applied to its bottom and again closed with a temporary filling for 2-4 days. The persistence of pain during this time indicates the ineffectiveness of treatment and requires a change in medical tactics.
Therapeutic compositions used in the treatment of pulpitis using a conservative method:
Rp. Furazolidoni 0.1
Sol. Luroniti 5% q.s. ut fiat pasta
M.D.S. For application to the bottom of a carious cavity.
Rp. Colimycini 10"000 ED
Hydrocortisoni 0.01 Boli albi 0.5
Olei Persicosae q.s. ut fiat pasta
M.D.S. Medicinal paste according to V.S. Ivanov, E.E. Leibur.
Rp. Laevomycetini 0.01
Haemopsini 0.002
Norsulfazoli 0.2
Sol. Natrii Chloridi isotonic 2.0
Boli albi q.s. ut fiat pasta
M.D.S. Medicinal paste according to N.N. Kirilenko.
Conservative treatment of pulpitis in children, depending on the specific clinical picture, is also carried out in one, two or three visits.
In case of chronic fibrous pulpitis in baby teeth with the beginning of root resorption, treatment is carried out in one visit. A carious cavity is formed, a paste with calcium hydroxide is applied to its bottom, then a permanent filling is applied.
In case of accidental exposure of the pulp and fracture of the crown, treatment is carried out in two visits. First, the pulp is covered with a preparation based on calcium hydroxide and a temporary bandage is applied for 5-7 days. Next, if there are no complaints, a permanent filling is placed, selected taking into account the stage of tooth development.
In case of acute pulpitis, on the first visit, under anesthesia, the carious cavity is opened, demineralized dentin is removed layer by layer and the carious cavity is washed with solutions of enzymes and antiseptics heated to 37 °C. The pulp is then covered with a paste containing various antibacterial and anti-inflammatory agents for 1-3 days. For focal pulpitis, indirect pulp capping can be used. In this case, the patient is scheduled for a follow-up appointment in 10-14 days. If there is no pain, on the second visit the bandage is removed, the final formation of the carious cavity is carried out and the pulp is covered with a paste based on calcium hydroxide, then with a temporary filling. After 7 days, if there are no complaints, a permanent filling is placed, selected taking into account the stage of tooth development.
In case of acute diffuse pulpitis, antibacterial, anti-inflammatory and restorative agents are prescribed internally.
When treating with a biological method, dynamic observation is necessary - x-ray control must be carried out after 3 weeks, then after 3 months, then every six months until the change of a baby tooth or the end of the formation of the roots of a permanent tooth. The criterion for a favorable outcome will be the formation of a dentinal “bridge” and further development of the roots. If the outcome is unfavorable, pulp necrosis occurs and chronic periodontitis develops.
In widespread practice, conservative treatment of pulpitis in children is used extremely rarely due to the large number of complications. This is due to a number of reasons:
lack of clinical tests that accurately determine the form of pulpitis and the extent of the inflammatory process and, as a consequence, errors in diagnosis (the discrepancy between clinical and pathological diagnoses is up to 90% (Roginsky V.V., 1998));
the need for strict adherence to aseptic and antiseptic conditions;
non-compliance with the conditions of use (indications and contraindications) and the technology of the method;
inadequate selection of antibacterial and anti-inflammatory drugs.
Vital amputation method is aimed at preserving the viability of the root pulp, as it serves as a reliable barrier to the penetration of microorganisms into the periapical tissue. The root pulp contains a small amount of cellular elements and is built like coarse fibrous connective tissue. It is capable of metaplasia and the construction of dentin-, cement- and osteo-like tissue. This determines the resistance of the root pulp (especially its apical part - the growth zone) to adverse influences.
The main goal of the method - preserving the periodontium in an intact state - is based on the significant resistance of the root pulp to various influences (microbes, toxins, drugs), which, in turn, is determined by the peculiarities of the histological structure, in particular, the poverty of the root pulp in cellular elements, a large number collagen fibers (Falin L.I., 1965; Gavrilov E.I., 1969). The possibility of transforming the root pulp into osteoid tissue after removal of the coronal pulp has long been known (Ryvkind A.V., 1925; Gutner Ya.I., 1936, etc.).
The method is used for acute serous pulpitis in permanent teeth (unformed and formed), chronic fibrous pulpitis (including in milk teeth with just begun root resorption or unformed permanent teeth), traumatic pulpitis (accidentally exposed pulp horn) due to the breaking off of a part crowns with exposure of the pulp during the first 48 hours after injury, with a planar form of medium and deep caries of primary teeth.
Vital amputation is used under the following conditions:
in multi-rooted teeth (with a clearly defined boundary between the root and coronal pulp);
with EDI values not exceeding 25-40 μA;
in patients with good body reactivity, young and without concomitant chronic somatic diseases, or in healthy, without concomitant pathology, teenage children with still unformed roots of permanent teeth.
Contraindications to the use of the method in children are multiple caries, subcompensated or decompensated somatic pathology.
After two-stage anesthesia according to the method of V.I. Lukyanenko, under aseptic conditions (using a rubber dam), the carious cavity is prepared with exposure to the chewing surface in class II and V according to Black. The roof of the tooth cavity is removed with a sterile bur, then the coronal pulp is removed with a sharp excavator or a sterile spherical bur. After this, platforms are made at the mouths of the canals with a small reverse-conical sterile bur with simultaneous deep amputation of the pulp. Bleeding is stopped with hemostatic agents. After this, pastes containing calcium hydroxide (calcicur or calmecin) are applied to the mouths of the root canals, then a dentin bandage is applied. It is recommended to apply a permanent filling after 3-4 weeks, if no complications have arisen. The application of a permanent filling in children is carried out taking into account the stage of tooth development after 5-7 days, in the absence of complaints.
Based on histological studies by T.A. Belova (1970), E.E. Leibur (1973) found that pulp regeneration processes with this method proceed according to the general laws of wound regeneration. As a result of these processes, a so-called “dentinal bridge” is formed at the mouths of the canals, which has the appearance of imperfect osteoid tissue. In this case, the root pulp is preserved in the form of a sclerosed connective tissue cord.
The immediate complication may be residual pulpitis, and the long-term complication may be periodontitis, sometimes detected only by x-ray.
The effectiveness of treatment is monitored after 3 months, then after six months to a year using the X-ray method. If the outcome is favorable, a year after the method, a layer of replacement dentin 1-2 mm thick, located across the root canal at its mouth, will be clearly visible on the x-ray. The formation of the roots of previously unformed teeth will occur somewhat faster than in a symmetrical tooth. If there are radiological signs of pulp death, the tooth must be treated even in the absence of complaints and clinical signs of periodontal inflammation.
The vital amputation method has not found wide application in the treatment of pulpitis in baby teeth, because its implementation is associated with the need for injection anesthesia and a long stay in the dental chair, which is a strong stress factor for the child. In young children, this method is mainly used when conservative treatment is ineffective, when the next day the child complains of pain in the tooth.
For chronic gangrenous pulpitis in single-root permanent immature teeth or when part of the crown is broken off with exposure of the pulp in single-root permanent immature teeth 48 hours after injury, use high pulp amputation method. This method involves removing the entire coronal and auricular part of the root pulp while preserving its apical section and the growth zone of the tooth, which ensures further formation of the tooth root.
It is necessary to conduct a thorough examination, since depending on the characteristics of the clinical picture of the disease, the method of performing high amputation will have its own characteristics:
The high amputation method includes several stages:
1) anesthesia - application anesthesia for a weak pain reaction, infiltration or conduction anesthesia for a strong pain reaction of the root pulp;
2) preparation of a carious cavity (with frequent replacement of the bur to avoid infection of deeper tissues) or a traumatic defect with exposure to the palatal (lingual) surface to achieve good access to the tooth cavity and the mouth of the root canal;
3) treatment of the carious cavity with an antiseptic solution;
4) with a sharp spherical or wheel-shaped bur, inserted 3-5 mm into the canal, the aperture part of the root pulp is cut off in one movement. This avoids the formation of a laceration;
5) stopping bleeding with the help of hemostatic agents applied to the wound surface without pressure for 15-30 minutes;
6) the part of the pulp remaining in the root canal is treated with drugs in order to stop inflammation and ensure further formation of the tooth root.
With absence clinical signs exacerbation of chronic gangrenous pulpitis and with pronounced sensitivity of the root pulp, it can be assumed that the remaining part of the pulp in the canal is slightly damaged by the inflammatory process. In this case, the wound surface is covered with a paste with calcium hydroxide: the paste is applied to the mouth of the canal using a trowel, then carefully moved deep into the canal with a cotton swab on the root needle to the pulp stump. As a result, the paste should fill the entire root canal from the mouth to the wound surface of the pulp (without putting pressure on it!). Next, use a dry cotton swab to isolate the paste and place a temporary filling. After 5-6 days, if there is no pain, the bandage is removed and a permanent filling is placed from the material indicated for restoring unformed permanent teeth.
If there are clinical signs of exacerbation of the inflammatory process in the root pulp, a paste consisting of various antibacterial and anti-inflammatory agents, enzymes and glucocorticoids is applied to the amputation wound under a bandage for 1-2 days. According to indications, the bandage is reapplied for another 1-2 days. If there are no complaints, treatment is completed by filling the part of the canal from the mouth to the pulp stump with a formalin-containing paste prepared ex tempore: formalin and glycerin 1 drop each, a thymol crystal and zinc oxide. This paste does not stain the tooth, deeply disinfects and mummifies the root pulp, while its apical part and growth zone remain viable.
The effectiveness of treatment of pulpitis using the high amputation method is monitored using radiography after 3 weeks, then after 3 months, after six months, and later - at least once a year until the root formation is complete.
In the absence of pathological changes on the radiograph and clinical well-being, treatment is considered complete.
In cases where there is osteoporosis in the bone tissue surrounding the formed apex of the tooth, widening of the periodontal fissure, or in the middle part of the root canal remains wide (dentin formation in the mummification zone does not occur), repeated treatment with the extirpation method is indicated.
Vital extirpation. The method provides, in contrast to the classical method of vital amputation, the preservation of the viability of only the apical part of the root pulp, approximately 2-3 mm, as well as the preservation of the pulp in numerous branches from the macrocanal in the area of the apical foramen (in the area of the deltoid branches). The indications are the same as for vital amputation, but with fully formed roots.
After two-stage anesthesia, under aseptic conditions, the carious cavity is prepared and the coronal pulp is amputated, as described above for vital amputation. Next, the root pulp is extirpated while simultaneously expanding the root canal with an endodontic instrument. After this, the bleeding is stopped, the canal is washed with solutions of weak antiseptics from a syringe, dried with sterile turundas and filled with root filling material containing calcium hydroxide (calcite, sealopex, etc.).
Subsequently, part of the preserved pulp metaplasizes into dentin-like tissue, forming a so-called “biological filling”.
Method of pulp extirpation under anesthesia provides complete removal coronal and root pulp under anesthesia with or without diathermocoagulation and subsequent filling of the root canal.
The method is indicated for all irreversible forms of pulpitis (acute purulent, chronic ulcerative, hyperplastic), pulp gangrene or exacerbation of chronic pulpitis, in teeth with well-passable root canals. For reversible forms of pulpitis (acute serous, chronic fibrous), as well as for traumatic pulpitis, the method is used if there are contraindications to preserving the viability of the pulp.
Indications for this method in children are:
all forms of pulpitis in primary single-rooted teeth;
all forms of pulpitis in permanent teeth with complete root formation;
The method has not been widely used due to children’s fear of injections and the laboriousness of treatment, which tires the child. If vital extirpation is used, it is carried out in the same way as in adults.
Extirpation under anesthesia cannot be used if there are contraindications to anesthesia: in patients who have suffered a myocardial infarction or stroke in the first 6 months from the onset of the disease; in patients with angina pectoris and hypertension of II-III degree; in weakened patients with severe general somatic diseases; in pregnant women in the first and last trimesters of pregnancy; in patients with mental disorders; with an allergic reaction to anesthetics.
Methodology. After the onset of anesthesia and evaluation of radiographs, preparation of the carious cavity begins, following all stages. At the formation stage, it is necessary to bring the carious cavity to the occlusal surface in the area of projection of the root canal mouths to create direct access to them. If the carious cavity is located in the cervical region, it is prepared and filled independently, and access to the root canals is created through a trepanation hole in the occlusal surface. This is also done if there is no carious cavity (traumatic pulpitis, retrograde pulpitis, etc.).
P 
When performing trephination of a tooth crown, a good knowledge of the anatomy of the dental cavity is required. Significant difficulties at the stage of creating access to the root canals can occur if the tooth is covered with an artificial crown, as well as with micro-stomy or difficulty opening the mouth. After all stages of preparation of the carious cavity are completed, it is treated with medication. Further manipulations should be carried out under conditions of maximum dryness of the surgical field to prevent the penetration of microorganisms into the tooth cavity. Absolute dryness surgical field is achieved by using a cofferdam (Fig. 8.2).
Rice. 8.2. Set of tools for installing a cofferdam (rubber curtain): 1 - punching pliers (punch); 2 - forceps for applying staples; 3 - polymer frame for tensioning the rubber curtain; 4 - brackets for holding the curtain on the teeth; 5 - rubber curtain
The next stage - opening the tooth cavity is carried out with a sterile cylindrical bur; special attention should be paid to opening all the horns of the pulp of a given tooth and creating a good overview of the bottom of the tooth cavity. Then, the coronal pulp is amputated using an excavator or a ball-shaped bur. After medicinal treatment with solutions of weak antiseptics, expansion of the root canal mouths is carried out using a spherical bur. For this purpose, you can use a special drill (Detailed information about cutting instruments is provided in section 3 "Dental office". Note editors).
The principle of mechanical root canal preparation is an apical movement from the occlusal surface, a “step back”, or a combination of both. They make it possible to expand the root canal with the least complications (pushing putrid masses of necrotic pulp beyond the root apex, breaking off an instrument in a narrow, curved canal). First, approximately 1/3 of the root canal is expanded by 2-3 sizes using a drill, drills (manual or machine), then it is determined working length, that is, this is the distance from the occlusal surface of the tooth to the apical foramen.
Determination of the working length is carried out using an x-ray, an apex locator or a table. When determining the length of the front teeth, the cutting edge is used; for chewing teeth, the buccal cusps of the teeth are used.
The working length is the distance that is 1 mm shorter than the radiographic apex. The working length is determined by a measuring ruler and recorded in the medical history. To more accurately determine the apical foramen, an apex locator device has been developed. The device is based on the principle of recording a sharp increase in electrical conductivity at the boundary between the soft and hard tissue of the tooth. The end point of the measurement is when the apical constriction is reached.
The treatment is completed by leveling the middle part of the root canal with drills.
To prevent bleeding in young patients with anatomically wide root canals, diathermocoagulation can be used before pulp extirpation. In this case, a tissue heating temperature of 60-80 ° C is achieved, which leads to protein coagulation occurring directly at the point of contact and around it for half the diameter of the electrode.
Rice. 8.3. Scheme of the structure of the apex of the tooth root (according to Borovsky E.V., Zhokhova N.S., 1997): 1 - physiological apex, 2 - anatomical apex, 3 - radiological apex
Further, it is possible to use a pulp extractor to remove pulp. It is better to use it only in relatively wide canals (for example, in the incisors of the upper jaw, in molars in the palatal and distal canals). In narrow and curved canals, a pulp extractor may not be used, since the drill and rasp simultaneously cut off the pulp while passing and expanding the canal. But after mechanical expansion, when the canal becomes accessible to the pulp extractor, they need to check whether there are any pulp fragments left, possibly crushed to the apical foramen (Fig. 8.3).
After studying the preliminary x-ray, a drill (or depth gauge) is selected, depending on the expected width and length of the canal. With the marker mounted, it is inserted into the canal until resistance is felt in the apical part, and the coronal reference point is selected. A new x-ray is then obtained.
During treatment pulp necrosis it is also necessary to remove infected dentin from the walls of the root canal and carry out additional antiseptic treatment using turundas soaked in antiseptics or filling the canal with pastes specially designed for this for a period of 2 to 5 days. Drugs used for this purpose must meet the following requirements:
1) have a bactericidal effect on microorganisms located in the root canal;
2) have the ability for deep diffusion into the dentinal tubules;
3) do not irritate periodontal tissue;
4) do not have a sensitizing effect;
5) be chemically resistant and retain their activity during long-term storage.
We have divided the drugs currently used in dentistry depending on their purpose. The first group includes preparations for treating root canals before filling. This is a 2.5-3% sodium hypochlorite solution (Parkan); 0.01-0.05% chlorhexidine solution, 3% hydrogen peroxide solution (Camphorophenol, Crezofen) used for treatment of root canals for gangrenous pulpitis. Eugenol can be used for infected root canals and for reactive periodontal inflammation that complicates pulpitis.
The second group includes preparations for expanding root canals (contain EDTA). This Aargal Ultra, Channel Plus, Verifix, RS-prep.
Preparations for temporary filling of root canals for pulp necrosis and periodontitis constitute the third group. This - Septomixin forte, containing antibiotics and dexamethasone, Grinazol, which is based on metronidazole, Rocle- a mixture of phenol, formaldehyde, dexamethasone, Periocur- a combination of sulfonamides, herbal extracts with antiseptic and anti-inflammatory effects, Timoform - combination of thymol and paraformaldehyde, Abscess Remedy Paste - a mixture of paraformaldehyde and cresol (PD). Currently, preference is given to drugs that do not contain phenol or formaldehyde, since they are more capable of causing periodontal irritation, allergic and neurotoxic reactions in patients.
And finally, means for drying root canals make up the fourth group of means. It is most advisable to use paper points according to the size of the root canal. You can also use a drying liquid, such as Siko, Hydrol, Anhydron.
The treatment ends with filling the root canal. Preference is given to root fillings with calcium hydroxide material in combination with gutta-percha.
Devital extirpation method provides for the complete removal of the coronal and root pulp after preliminary devitalization, followed by filling the root canal.
Indications to carry out this method consist of indications for pulp extirpation (irreversible forms of pulpitis, as well as reversible forms of pulpitis in the presence of contraindications to pulp preservation or failure of conservative treatment; well-passable canals) and devitalization (in the presence of contraindications to local anesthesia). An indirect indication may be the patient's fear of anesthetic injections and the lack of time for the patient or doctor to perform extirpation under anesthesia.
Indications for devital pulp extirpation in children are:
all forms of pulpitis in formed permanent teeth and single-rooted milk teeth;
breaking off part of the tooth crown with exposure of the pulp in formed single-rooted teeth.
Contraindication to devitalization are:
the ability to maintain the viability of the entire pulp or its root part;
the presence of periapical inflammation during ulcerative necrotic pulpitis or its exacerbation;
combination of pulp and periodontal inflammation;
a carious cavity extending under the gingival margin without the possibility of sealing it with a temporary filling;
absence of a carious cavity in traumatic pulpitis;
the presence of allergic reactions to the components of devitalizing pastes.
To devitalize the pulp, pastes containing arsenic anhydride or paraformaldehyde are used. Arsenic anhydride blocks the thiol groups of oxidative enzymes (oxidases), disrupting tissue respiration, which leads to necrotic decay of all cellular elements of the pulp. Paraformaldehyde, which is part of the devitalizing paste, coagulates pulp proteins, causing its dehydration and partial mummification.
Devital extirpation is carried out in two visits. On the first visit, after partial preparation of the carious cavity (exposure of the pulp horn), a devitalizing paste is applied and hermetically sealed with a temporary filling. It is possible to additionally introduce a small amount of anesthetic into the carious cavity on a cotton swab (in the absence of allergic reactions to it).
On the second visit, the final preparation of the carious cavity and endodontic treatment of the tooth cavity are carried out in the same way as during extirpation under anesthesia, also subject to all aseptic rules (application of a rubber dam, medicinal treatment of the root canal). The treatment ends with filling the root canal, applying a lining and a permanent filling.
In the treatment of permanent teeth in children, devital extirpation (see table 8.1.) carried out in the same way as in adults.
There are some peculiarities in the treatment of baby teeth. The pulp is removed with two or three pulp extractors, which helps to more reliably capture and remove it. Next, the bleeding is stopped, antiseptic treatment is performed, the canal is dried and sealed with an oil-based paste. The use of phosphate cement and pins for obturation of the roots of primary teeth is contraindicated, since they do not dissolve and prevent the eruption of permanent teeth. A permanent filling can be applied either at this visit or at the next visit - after the paste has hardened.
If there is a wide apical foramen after extirpation, severe bleeding sometimes occurs. In this case, a turunda with Platonov’s liquid or camphoraphenol is left in the canal for 1-2 days. On the next visit, using dry turundas, clotted blood is removed from the canal and it is sealed.
Sometimes, due to the close proximity of the primordia of the permanent incisors, the roots of the primary incisors are bent towards the vestibular side and during extirpation it is not possible to completely remove the pulp. In this case, resorcinol-formalin paste is used to fill the canal, which protects the apical part of the pulp from necrosis.
The method of devital extirpation in primary single-rooted teeth actually does not produce periodontal complications, but sometimes causes difficulty in the eruption of permanent teeth, since the paste filling the canal is absorbed much more slowly than the tooth tissue. In this case, baby teeth should be removed by a doctor at the appropriate age.
Prescriptions of pastes for pulp necrosis
Rp. Acidi arsenicosi anhydrici
Cocaini hydrochloridi aa 2.0
Phenoli puri liquefacti q.s. ut fiat pasta
D.S. For a dental office.
Rp. Acidi arsenicosi anhydrici
Cocaini hydrochloridi aa 1.0
Trioxymethyleni 4.0
D.S. Long-acting paste.
Rp.: Paraformaldehydi 2.0
Cocaini hydrochloride 1.0
Phenoli puri liquefacti q.s. ut fiat pasta.
D.S. For the dental office, arsenic-free devitalizer (according to T.M. Mikulina, 1974).
Preparations from foreign companies are widely used: KAystinerv, Depulpin.
For the treatment of pulpitis in children, more often than any other method is used. method of devital amputation.
Indications for it are:
all forms of pulpitis in primary molars, regardless of the stage of their development;
all forms of pulpitis in immature permanent molars.
Contraindications are:
the presence of inflammatory changes in the tissues surrounding the tooth (hyperemia and swelling of the transitional fold, pain on percussion) and regional lymph nodes, the presence of a fistula;
chronic gangrenous pulpitis with significant pulp necrosis.
The devital amputation method is carried out in three or two visits, depending on the form of pulpitis and the characteristics of its clinical course. The general scheme for treating pulpitis with this method is as follows:
a) first visit. Application of a devitalizing paste to an opened or “transparent” tooth cavity in order to necrotize the pulp. Next, an anesthetic is applied under the bandage. Arsenic paste is often used to necrotize the pulp in children. Its dose and duration of stay in the tooth do not differ from those in adults. In this case, there is no need to carry out local anesthesia, which children are very afraid of. During the period of active resorption of the roots of primary molars, when the pulp is insensitive, a mixture of phenol and formalin (2 drops of phenol, 1 drop of formalin), which is prepared immediately before application to the tooth, can be used as a necrotizing agent. The tampon is immediately closed with a temporary filling for a period of 5 days;
b) second visit:
1) the temporary filling and bandage are removed;
2) the final formation of the carious cavity is carried out, the tooth cavity is opened taking into account the topography of the root canals and the coronal pulp is removed;
3) the tooth is isolated from saliva;
4) using a tampon with hydrogen peroxide, the bleeding is stopped and antiseptic treatment of the tooth cavity is carried out;
5) the tooth cavity is dried with a stream of air;
6) a tampon with a resorcinol-formalin mixture is inserted into the tooth cavity, which is hermetically sealed with a temporary filling and remains in the tooth for at least 5 days. The swab should cover all root canal orifices. Before introducing it into the tooth cavity, it should be slightly squeezed. The resorcinol-formalin mixture diffuses along the dentinal tubules to a depth of 3-4 mm, disinfecting and mummifying the necrotic root pulp. The growth zone of the tooth is usually preserved and continues to function, which is confirmed by the further formation of tooth roots.
For complete polymerization of the resorcinol-formalin mixture, a number of conditions must be met:
a) the mixture is prepared immediately before use, and resorcinol should not be pink, and formaldehyde should not have a white precipitate;
b) the mixture is introduced into the dry cavity of the tooth and hermetically sealed;
c) its complete polymerization lasts from 3 to 5 days. c) third visit:
1) the tooth is isolated from saliva;
2) the temporary filling and tampon with a resorcinol-formalin mixture are removed. If the tampon turns pink and is difficult to remove from the tooth cavity, we can assume that the resorcinol-formalin method was carried out correctly. If the tampon is easily removed, it must be re-applied in compliance with the requirements listed above;
3) resorcinol-formalin paste is applied to the mouths of the root canals, then an insulating lining is applied and a permanent filling is applied.
In case of chronic gangrenous pulpitis, there is no need to use a devitalizing paste, however, the tooth should be carefully examined to determine the depth of pulp necrosis.
In case of chronic hypertrophic pulpitis, before applying arsenic paste under topical anesthesia, the pulp growth is removed with a sharp excavator.
The effectiveness of treatment of pulpitis using the method of devital amputation is monitored after 3 months, then every six months until the change of baby teeth or the end of the formation of the roots of permanent teeth.
Despite many criticisms leveled at the resorcinol-formalin method, it remains the most widely used method in the treatment of pulpitis in children. There are several reasons for this. Firstly, the method is very simple and painless, allowing you to spare the child’s psyche as much as possible. Secondly, the method is reliable - with careful and correct application, complications practically do not occur, which is confirmed by analysis of long-term (several decades) results.
None of the methods used in our country and abroad as an alternative to resorcinol-formalin has such a number of positive treatment results. The most studied are formocresol and kresacin. When using formocresol, damage to the periapical and soft tissues is observed, since it freely penetrates through the apical foramen of the tooth. There is debate about its possible local and systemic adverse effects, as well as its mutagenic and carcinogenic effects. Caused by kresacin side effects are less intense, it penetrates less through the apical foramen, however, the number of successfully performed pulpotomies with its use is significantly less than with formocresol.
Analysis of unsuccessful treatment of pulpitis in children using the method of devital amputation allowed us to identify typical mistakes made when using it:
1) failure to comply with the necessary conditions for polymerization of the resorcinol-formalin mixture;
2) incomplete opening of the tooth cavity;
3) reducing the number of visits;
4) perforation of the bottom of the tooth cavity;
5) diagnostic errors - application of the method in teeth with severe inflammatory phenomena in the periapical tissues or in chronic gangrenous pulpitis with significant pulp necrosis.
Combined method of treating pulpitis. In difficult-to-pass root canals of multi-rooted teeth, if it is impossible to completely extirpate the pulp (curvature of more than 25°, deep bifurcation of the roots, breakage of the instrument in the root canals, obliteration), the deep amputation method is performed, and in passable ones, the extirpation method is used. In practice, this method is used much less frequently than the extirpation method, since currently there is an arsenal of drugs and instruments that allow chemical and mechanical expansion of curved, obliterated root canals.
A combined treatment method under anesthesia using electrophoresis with potassium iodide can be performed in one visit. Under infiltration or conduction anesthesia, depending on the group of the tooth, the carious cavity is prepared, providing direct access to the mouths of the root canals. Then the coronal pulp is amputated and the root pulp is extirpated from well-passable canals and from the passable part of poorly passable canals.
Well-passable ones are filled using the generally accepted method, and in the area of each of the impassable root canals, electrophoresis is performed for 20 minutes with potassium iodide, followed by applying one of the mummifying pastes to the mouth or filling the passable part of the root canals.
Electrophoresis technique: The apparatus "Potok-1" is used. After removing the putrid masses, washing and drying the carious cavity and the mouths of the root canals (or the passable part thereof), a cotton swab and turunda moistened with a solution of the medicinal substance are introduced into the tooth cavity, into the mouth of the root canal. As a rule, 5% or 10% alcohol solutions of iodine are used.
Mixing a 10% alcohol solution of iodine with a solution of potassium iodide is justified by the additional introduction of free iodine ions and increased dissociation of molecular iodine into ions. Alcohol solution iodine (5%) contains about 2% potassium iodide, so it is not necessary to add additional iodide to it. Then the electrode, together with a tampon (turunda), is filled with sticky wax melted in an alcohol lamp. The dentition must be isolated from oral fluid to avoid electrical leakage.
The dental electrode is connected to the corresponding pole of the device (the same charge of the drug ion). The second electrode is usually placed on the forearm just above the hand. The current is supplied by slowly rotating the potentiometer knob to the right, bringing the current strength to 3 mA. Disconnection is carried out in the reverse order. Then the passable part of the canal is sealed with mummifying paste. An insulating lining and seal are applied.
In recent years, dentists in many countries have begun to use a new method of treating complicated caries - depophoresis of a suspension of copper-calcium hydroxide. Indications for the use of this method are pulp necrosis, obliteration, complex anatomical structure of root canals, denticles and all forms of periodontitis.
To carry out depophoresis, “Comfort” or “Original II” devices are used. The root canal is expanded mechanically and with medication. In this case, the apical part is not formed
crashes and the contents are not deleted from it. The negative electrode is inserted into the root, and the positive electrode is fixed in the vestibule of the oral cavity, behind the cheek. The session lasts 2-5 minutes. A total of 3 sessions are required, during which a total dose of electricity of 15 mA min is accumulated. It is recommended to leave the cavity open for the time between sessions. The next session is carried out in 3-10 days. After the last procedure, the entrance to the canal is filled with Atamacyte cement and a permanent filling is placed.
Prevention. To prevent damage to the pulp, it is necessary to strictly adhere to the preparation regime for the hard tissues of the tooth (changing the speed of rotation of the cutting instrument in accordance with the stage of manipulation, avoiding excessive pressure on the bottom of the carious cavity, constant cooling of the hard tissues of the tooth). It should be taken into account that when working with a larger bur, the tissue heats up more than when working with a small one. Prolonged contact of a rotating dental bur with dentin also leads to overheating. Excessively intense polishing of a filling can have the same effect. Prolonged pulp ischemia during inadequate anesthesia can aggravate the effects of the above unfavorable factors. Toxic effects on the dental pulp can be prevented by following the rules for medicinal treatment of deep cavities, refusing medications if the patient is sensitized to them, and following the rules for applying a lining and filling.
Errors and complications in the treatment of pulpitis. The doctor may make mistakes in diagnosis due to insufficiently carefully collected life history data or illness; without the use of paraclinical examination methods. The result may be the wrong choice of medical tactics.
When choosing a method of anesthesia, it is necessary to take into account the emotional and somatic state of the patient, the duration and aggressiveness of the effect on the dental pulp, and the features of various methods of injection anesthesia. Errors and complications when performing injection anesthesia are described in textbooks on surgical dentistry. It should be noted that performing only injection anesthesia without premedication in anxious patients burdened with somatic diseases may be insufficient and leads to general complications (emotional lability, noticeable pulse irregularities and changes in blood pressure, the occurrence of emergency conditions, negative trace memory of a visit to the doctor ).
An excessively long period of action of injection anesthesia, compared to the duration of treatment, can lead to persistent ischemia of the pulp and the development of necrotic processes in it. When performing the vital amputation method, the formation of hematomas of the pulp stump is also possible. As a result, complete extirpation of the pulp is required. Prolonged anesthesia can also lead to injury to the soft tissues of the oral cavity during eating and speaking (erosions, ulcers of the tongue, cheeks). Treatment of such complications is carried out with the use of antiseptics and drugs that accelerate epithelization. Prevention comes down to choosing an adequate method of pain relief and limiting chewing for 2-2.5 hours after treatment.
Errors and complications at the stages of treatment of pulpitis and ways to eliminate them are presented in Tables 8.2-8.4.
Table 8.2Errors and complications at the stages of treatment of pulpitis using the conservative method
|
Complications |
|||
|
1) opening of the carious cavity |
Insufficient opening of the carious cavity overhanging edges of enamel are not removed |
lack of sufficient review, further spread of inflammation in the dental pulp, relapse of caries |
complete preparation of a carious cavity, pulp extirpation, treatment of caries |
|
2) necrotomy |
Insufficient removal of necrotic dentin Excessive necrotomy |
further spread of inflammation mechanical or thermal trauma of the pulp, further spread of inflammation |
pulp extirpation |
|
3) preventive expansion |
not performed if indicated |
caries relapse |
caries treatment |
|
4) formation of a carious cavity |
without taking into account the topography of the tooth cavity, long-term use of a bur without cooling |
mechanical trauma to the pulp thermal trauma of the pulp, further spread of inflammation |
pulp extirpation |
|
5) grinding the edges of the enamel |
not carried out |
violation of the marginal seal of the filling, relapse of caries |
caries treatment |
|
6) drug treatment |
violation of asepsis rules use of potent drugs |
further spread of inflammation further spread of inflammation |
pulp extirpation |
|
7) application of a therapeutic pad |
lack of healing lining wrong choice of medications |
further spread of inflammation; increased inflammation |
|
|
8) applying an insulating lining |
absence or reduction of the boundaries of the insulating lining; the insulating lining protrudes to the surface |
further spread of inflammation dental caries |
pulp extirpation treatment of caries |
|
9) placing a filling |
uneven compaction of the filling material ("air bubbles") articulatory interference |
violation of the aesthetic properties of the filling destruction of filling traumatic periodontitis |
filling replacement replacement of fillings treatment of periodontitis |
|
10) final finishing and polishing of the filling |
operation without cooling |
overheating of hard tissues and dental pulp, further spread of inflammation |
pulp extirpation |
Table 8.3Errors and complications at the stages of surgical treatment of pulpitis
|
Complications |
|||
|
1) opening of carious |
insufficient disclosure carious cavity overhanging edges not removed |
lack of sufficient review, further distribution inflammation caries relapse |
pulp extirpation treatment of secondary caries |
|
2) necrotomy |
insufficient removal necrotic dentin excessive necrotomy |
chipping of the tooth wall, relapse of caries, change in enamel color perforation of the carious wall |
treatment of secondary caries, filling replacement closing the perforation holes with amalgam, foil, medicinal lining materials and then glass ionomer insulation cements |
|
4) Formation carious cavity |
did not remove the carious cavity in projection of root orifices |
the mouths of all have not been found available channels, further spread of inflammation |
pulp extirpation, treatment periodontitis |
|
5) sanding the edges |
grinding not carried out |
violation of marginal seal fillings, caries recurrence |
caries treatment |
|
6) medicinal treatment |
violation of asepsis rules, use of potent |
further distribution inflammation |
pulp extirpation |
|
7) opening of the tooth cavity |
incomplete removal of cavity roof |
pulp necrosis in the horn area, change in tooth crown color |
tooth crown whitening, production of artificial tooth crowns; |
|
over-preparation walls of the tooth cavity |
perforation of the walls and bottom of the cavity tooth, acute traumatic periodontitis |
closing the perforation holes with amalgam, foil, therapeutic lining materials with their subsequent insulation with glass ionomers cements |
|
|
8) coronal amputation |
incomplete coronal amputation |
tooth color change |
tooth crown whitening, artificial prosthetics crown |
|
9) medicinal treatment |
violation of asepsis rules, use of potent |
further distribution inflammation |
pulp extirpation |
|
10) wellhead treatment root canals |
no platform has been created for medicinal composition perforation of the bottom of the tooth cavity |
further distribution inflammation acute traumatic periodontitis |
pulp extirpation closing the perforation holes with amalgam, foil, therapeutic lining materials, followed by their insulation with glass ionomers cements |
|
11)medicinal treatment |
violation of asepsis rules, use of potent funds, poor hemostasis |
further distribution inflammation, hematoma formation pulp stumps, further spread of inflammation |
pulp extirpation |
|
12) application of therapeutic linings on root canal orifices |
medical contact not created pads with pulp stump excessive pad pressure on the pulp stump |
further distribution inflammation |
|
|
13) application of insulation lining |
lack of insulating linings |
toxic effect of constant filling material for pulp stump |
|
|
14) placing a filling |
see previous table. pp.9,10 |
||
Table 8.4Errors and complications at the stages of surgical treatment of pulpitis using extirpation methods
|
Complications |
|||
|
1) Opening of carious |
insufficient disclosure carious cavity |
lack of sufficient review |
periodontitis treatment |
|
overhanging ones not removed |
spread of inflammation to periodontal caries recurrence |
filling replacement |
|
|
2) necrotomy |
insufficient removal necrotic |
relapse of caries, change in enamel color |
treatment of secondary caries |
|
excessive necrotomy |
thinning of tooth walls, their chipping perforation of the cavity wall |
repositioning the filling closing the perforation hole amalgam foil; treatment traumatic periodontitis |
|
|
3) preventive expansion (not performed) |
|||
|
4) formation of caries |
caries has not been removed cavity in the projection of the orifices root canals |
the mouths of all root roots were not found |
pulp extirpation |
|
further distribution inflammation in the pulp and periodontium |
periodontitis treatment |
||
|
5) processing of enamel edges |
no processing carried out enamel edges |
violation of the marginal seal seal |
treatment of secondary caries |
|
6) drug treatment |
violation of asepsis rules |
spread of inflammation to the periodontium |
periodontitis treatment |
|
7) opening of the tooth cavity |
incomplete removal of the roof of the tooth cavity excessive preparation of the walls of the tooth cavity |
necrosis of the pulp in the area of the horns, discoloration of the tooth crown, difficult access to the root canals, breakage of the endodontic instrument perforation of the carious cavity wall, acute traumatic periodontitis |
tooth crown whitening; prosthetics with an artificial crown; [full opening of the tooth cavity; removal of the working part of the tool; electrophoresis of iodine in order to cause corrosion of the metal and removal of the working part of the instrument; closing the perforation hole with amalgam or foil, calcium-containing materials, followed by insulation with glass ionomer cement |
|
8) amputation of coronal pulp |
incomplete amputation of coronal pulp |
change in tooth crown color |
tooth crown whitening; artificial crown prosthetics |
|
9) drug treatment |
contact of potent drugs with the oral mucosa (alcohol, ether) |
chemical burn of the oral mucosa |
antiseptic wound treatment; agents that accelerate epithelialization |
|
10) opening of the root canal orifices |
the mouths of the root canals are not opened |
poor access to the root canal, breakage of the endodontic instrument |
removal of the working part of the tool; electrophoresis of iodine to cause metal corrosion and removal of the working part of the instrument |
|
skipping the root canal orifice perforation of the bottom of the tooth cavity |
chronic or acute residual pulpitis) pulp necrosis, transition of inflammation to the periodontium; acute traumatic periodontitis |
extirpation of pulp from this canal; periodontitis treatment closing the perforation hole with amalgam, foil, calcium-containing materials, followed by insulation with glass ionomer cement |
|
|
11) pulp extirpation |
choosing a smaller size pulp extractor than needed choosing a large size pulp extractor insertion of the pulp extractor in the center of the root canal, guiding the pulp extractor by the apical foramen |
incomplete removal of the pulp, necrosis of its remains, periodontitis pulp extractor breakage pushing of pulp into periodontium, pulp necrosis, periodontitis traumatic periodontitis |
periodontitis treatment removal of the working part of the instrument, iodine electrophoresis in order to cause corrosion of the metal and removal of the fragment, the canal is treated as impassable with periodontitis (impregnating methods), treatment of periodontitis, treatment of traumatic periodontitis |
|
12) drug treatment of the canal |
violation of aseptic rules, use of potent drugs, incomplete cessation of bleeding, hematoma formation |
chronic periodontal inflammation damage to periodontal tissues, traumatic periodontitis, leaky obturation of the root canal, periodontitis |
periodontitis treatment treatment of periodontitis treatment of traumatic periodontitis re-filling of the root canal, treatment of periodontitis |
|
13) expansion of the root canal |
violation of the method of using the instrument trauma to periodontal tissues obstruction of the apical third of the canal with dentin chips due to non-compliance with the rule of returning to the main drill or premature use of a large instrument formation of a ledge periapical expansion; change in the shape of the canal in the apical third) due to the premature use of a large instrument, which during further work leads to separation of the root apex; perforation of the walls of the root canal; creation of a canal shape that is inconvenient for filling |
tool breakage traumatic periodontitis incomplete root canal filling, periodontitis traumatic periodontitis traumatic periodontitis in early dates chronic infectious periodontitis in late stages poor canal obturation, chronic periodontitis in the long term |
debris removal; iodine electrophoresis for metal corrosion and removal of debris treatment of traumatic periodontitis treatment of periodontitis treatment of periodontitis tooth canal filling, periodontitis treatment, tooth extraction periodontitis treatment, canal re-filling |
|
14) root canal filling |
selection of channel filler small size selection of large channel filler violation of the filling technique |
exit of the filling material beyond the root apex, traumatic periodontitis, sinusitis, neuritis, fracture of the canal filler excessive canal filling |
treatment of traumatic periodontitis, surgery corresponding disease, removal of the working part of the instrument, iodine electrophoresis for metal corrosion and removal of debris, treatment of traumatic periodontitis |
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15) lining |
no lining |
change in the properties of permanent filling material change in tooth color |
applying a new filling, tooth whitening, artificial crown prosthetics |
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16) placing a filling |
uneven compaction of the filling material (“air bubbles”) articulatory interference absence of a contact point |
violation of the aesthetic properties of the filling, destruction of the filling chronic or acute traumatic periodontitis, inflammation of the interdental papilla (papillitis), localized periodontitis |
replacing a filling replacing a filling, periodontitis treatment treatment of papillitis, treatment of localized periodontitis, filling replacement |