Pulpitis (Reversible/Irreversible)

Pulpitis

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.

Presentation

Most Common Sites of Occurrence

• Primary and permanent teeth
• Sites of recent or defective restorations
• Sites of recent trauma

Signs

Reversible pulpitis

• Caries
• Exposed dentin

Irreversible pulpitis

• Deep caries

Symptoms

Reversible pulpitis

• Non-lingering pain to temperature or osmotic changes

Irreversible pulpitis

• Intense, lingering pain to temperature changes
• Spontaneous pain
• Diffuse or referred pain

Investigation

1. Obtain thorough dental history and inquire about recent restorations or trauma. 
2. Inquire about previous history of pain on the offending tooth.
3. Ask the patient about:
   1. Location of the offending tooth
   2. When did the pain start?
   3. How intense is the pain?
   4. What causes the pain and what relieves it?
   5. How long does the pain last?
   6. Pain description (e.g., dull, sharp, throbbing)
4. Perform an intraoral examination to check for exposed dentin, caries, a deep or defective restoration, or trauma. 
5. Perform a percussion test to rule out acute apical periodontitis.
6. 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.
7. 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.
8. 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.

Diagnosis

Based on clinical examination and testing, a diagnosis of reversible or irreversible pulpitis is determined. 

Reversible Pulpitis

• Pain from cold test does not linger more than 30 s
• No percussion sensitivity
• No spontaneous pain
• No heat sensitivity

Irreversible Pulpitis

• 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

Differential Diagnosis

Pain of non-odontogenic origin:

• Musculoskeletal pain
• Neurovascular pain
• Neuropathic pain
• Pain caused by a distant pathology (cardiovascular, cranial, throat, neck)
• Psychogenic pain

Treatment

Common Initial Treatments

Reversible pulpitis

1. Remove the irritant or repair tooth structure (caries, exposed dentin, defective restoration). 
2. Continue to monitor the patient’s symptoms.
3. Advise patient to return if symptoms persist or worsen.

Irreversible pulpitis

1. 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. 
2. 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.

Alternate Treatments

Perform extraction.

Advice

• 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]).

THE AUTHOR

	Dr. Dabuleanu is an endodontist based in North York, Ontario.

Correspondence to: Dr. Mary Dabuleanu, Dabuleanu Dental, 2 Finch Avenue West, North York ON  M2N 6L1. Email: info@dabuleanu-dental.com

The author has no declared financial interests.

This article has been peer reviewed.