Reversible pulpitis: pulpal inflammation which should resolve once the etiology is removed (defective restorations or caries).
Irreversible pulpitis: pulpal inflammation which will not resolve once the etiology is removed.
Most Common Sites of Occurrence
- Primary and permanent teeth
- Sites of recent or defective restorations
- Sites of recent trauma
- Exposed dentin
- Deep caries
- Non-lingering pain to temperature or osmotic changes
- Intense, lingering pain to temperature changes
- Spontaneous pain
- Diffuse or referred pain
- Obtain thorough dental history and inquire about recent restorations or trauma.
- Inquire about previous history of pain on the offending tooth.
- Ask the patient about:
- Location of the offending tooth
- When did the pain start?
- How intense is the pain?
- What causes the pain and what relieves it?
- How long does the pain last?
- Pain description (e.g., dull, sharp, throbbing)
- Perform an intraoral examination to check for exposed dentin, caries, a deep or defective restoration, or trauma.
- Perform a percussion test to rule out acute apical periodontitis.
- Perform a cold test using a refrigerant spray (e.g., Endo-Ice®) or an ice stick. Test the healthy control teeth first in order to better localize the offending tooth.
- Perform a hot test using hot water in a syringe (e.g., Monojet®) and rubber dam isolation, a heated gutta percha stick or heat source (e.g., System B™ Heat Source) to reproduce pain to hot. Healthy control teeth should be tested first. Delayed and prolonged pain triggered by heat may indicate irreversible pulpitis.
- Use radiographs to identify teeth with large restorations or caries that are not clinically visible. Keep in mind that teeth with reversible or irreversible pulpitis will not show periapical lesions radiographically, but may show thickening of the periodontal ligament (PDL), loss of lamina dura, and/or condensing osteitis. Irreversible pulpitis may show widened PDL space.
Based on clinical examination and testing, a diagnosis of reversible or irreversible pulpitis is determined.
- Pain from cold test does not linger more than 30 s
- No percussion sensitivity
- No spontaneous pain
- No heat sensitivity
- Pain from cold test lingers more than 30 s
- May get pain from heat test
- May have spontaneous pain
- May be percussion sensitive
- Radiographically or clinically visible deep caries
Pain of non-odontogenic origin:
- Musculoskeletal pain
- Neurovascular pain
- Neuropathic pain
- Pain caused by a distant pathology (cardiovascular, cranial, throat, neck)
- Psychogenic pain
Common Initial Treatments
- Remove the irritant or repair tooth structure (caries, exposed dentin, defective restoration).
- Continue to monitor the patient’s symptoms.
- Advise patient to return if symptoms persist or worsen.
- Pulpectomy of the offending tooth: complete removal of the pulp. If it is determined that the case in question is too complex, promptly refer to an endodontist.
- If treatment is undertaken and the appointed treatment time permits, root canal treatment can be completed in one visit.
Antibiotics are not recommended for irreversible pulpitis as they will not alleviate the patient’s pain and should not be given in lieu of performing an immediate pulpectomy.
- The patient may take an anti-inflammatory such as ibuprofen (600 mg q. 6 h. to a maximum of 2400 mg/day).
- This may be supplemented with scheduled dosing of acetaminophen (e.g., Extra Strength TYLENOL® [500 mg q. 4–6 h. to a maximum of 3000 mg/day]).
- American Association of Endodontists. Guidelines and Position Statements. Case difficulty and assessment form and guidelines [edited 2010; accessed 2013 Jun 5]. Available: http://www.aae.org/guidelines/
- American Association of Endodontists. Endodontics: Colleagues for Excellence Newsletter; Spring/Summer 2005. Endodontic case difficulty assessment and referral [accessed 2013 Jun 5]. Available: http://www.aae.org/colleagues/
- Hargeaves KM, Cohen S. Pathways of the pulp. 10th ed. St. Louis (Mo.): Mosby Elsevier; 2011.
- American Association of Endodontists. Guide to clinical endndontics. 5th ed. 2013 [accessed 2013 Sep 6]. Available: www.nxtbook.com/nxtbooks/aae/guidetoclinicalendodontics5/#/0
- Ruddle CJ. Endodontic diagnosis. Dent Today. 2002;21(10):90-2, 94, 96-101.
- American Association of Endodontists. Tooth Pain. 2013. [accessed 2013 Sep 6]. Available: www.aae.org/patients/symptoms/tooth-pain.aspx