Pulpitis of Temporary Teeth: Diagnosis and Treatment

Maintaining the health and integrity of the dental arch during the temporary bite in children is extremely important for the formation of proper occlusion, ensuring effective chewing functions, speech development, socialization, and preventing psychological consequences of tooth loss.

Let us recall the beloved words that a child is not a small adult, and all physiological and psychological processes in a child's body occur quite differently. Learn how to successfully conduct a pediatric appointment in the course “Daily Manipulations of a Pediatric Dentist: From Communication to Restoration”.

Pulpitis is a condition that arises as a result of inflammation in the loose fibrous connective tissue of the pulp, which is the body's response to damaging factors.

The pulp is represented by loose fibrous connective tissue, nerve fibers, blood vessels, and lymphatic vessels. The cellular components of the pulp consist of odontoblasts, fibroblasts, undifferentiated cells, and immune system cells. The pulp responds to changes in the environment just like any other loose connective tissue. However, the absence of collateral circulation, the presence of odontoblasts, and its location in an inflexible closed space of the dentin chamber make its inflammatory response unique compared to any other organ in the human body.

Anatomical features of the structure of temporary teeth

• Compared to permanent teeth, there is a smaller thickness of dentin between the pulp chamber and enamel, especially in the lower second temporary molar.
• Very thin, highly protruding pulp horns in molars, especially mesially.
• Relatively larger volume of the pulp chamber compared to the corresponding permanent tooth.
• The openings of the root canals are not pronounced and are difficult to find.
• Root canals are long; in molars, root canals are often ribbon-like and discontinuous.
• The root canals of temporary molars diverge significantly.

Classification of Pulpitis

According to the International Classification of Diseases (WHO, ICD 10), pulpitis falls under the category:

Diseases of the pulp and periapical tissues (K04)

K04.0 Pulpitis

Pulpitis:

• unspecified
• acute
• chronic (hyperplastic/ulcerative)
• irreversible
• reversible

K04.1 Pulp Necrosis

Pulp Gangrene

K04.2 Pulp Degeneration

Dentinicles

Pulpal:

• calcifications
• stones

K04.3 Abnormal Formation of Hard Tissues in the Pulp

Formation of secondary or irregular dentin

Features of Pulpitis in Children:

1. Inflammation of the pulp develops in teeth with a small carious cavity.
2. Rapid, sometimes lightning-fast spread of the process.
3. The acute process quickly transitions to a chronic one, which is why chronic pulpitis or its exacerbation is more common in children.
4. The symptoms of pulpitis depend on the stage of tooth formation.
5. Frequent inflammation of the surrounding tooth tissues.
6. Pronounced general reaction of the body (increased temperature, drowsiness, headache, leukocytosis, and increased ESR in the blood).

Characteristics of acute and chronic forms of pulpitis:

Acute Pulpitis

• Inflammation is localized in the area of the pulp horn projection
• The stage lasts up to two days
• Complaints of pain that occurs from all types of irritants, not passing after the cause is eliminated within 10-20 minutes, pain-free intervals – several hours
• Spontaneous evening pain may occur
• Radiation of pain is absent
• Deep carious cavity
• The tooth cavity is not opened
• Cold test is sharply positive
• Percussion is painless

Reversible Pulpitis

• Complaints of pain, occurring more often from thermal and mechanical irritants, lasts for a short time after removal
• Unpleasant sensations persist after eating
• Caries cavity of medium depth
• Probing the cavity is painful at one point or throughout the entire bottom
• Cold test is positive
• Percussion is negative

Irreversible Pulpitis

• Involvement of the entire coronal and root pulp
• In the first days – prolonged spontaneous pain with long intervals without pain, with progression the pain periods become longer than the "light" intervals
• Pain manifests mainly from heat, cold soothes the pain
• Radiation of pain along the trigeminal nerve
• Deep carious cavity
• Communication with the tooth cavity is absent
• Probing is painful throughout the bottom
• When opening the tooth cavity, a drop of pus may be released
• Percussion is painful

Hyperplastic pulpitis

• The tooth cavity is open
• Bleeding granulation tissue protrudes from the tooth cavity, sometimes resembling a polyp
• Pain and bleeding may occur when consuming hard food
• Radiographically, there may be widening of the periodontal space

Ulcerative pulpitis

• A feeling of discomfort, heaviness in the tooth, which during exacerbation is replaced by sharp pain attacks
• The tooth cavity can be either closed or open
• Pain may occur from hot food or when food gets stuck
• Deep probing is painful
• The pulp is a necrotic mass with an unpleasant odor
• Percussion may be weakly positive
• Radiographically, there is widening of the periodontal space, sometimes with resorption of bone tissue

Etiology

The most common cause of pulp diseases is infection by microorganisms from the affected tooth. However, there are several other factors that can affect the health of the pulp. They can be classified as:

• Bacterial: through direct invasion into the pulp tissues or indirectly through toxins from microorganisms. The coronary (descending) pathway of infection through the crown and the radicular (ascending) pathway through the root are also distinguished.
• Mechanical: occlusal disorders, trauma, abrasion, erosion, preparation of hard tooth tissues, orthodontic treatment, surgical interventions in the area of the alveolar processes.
• Thermal: friction during tooth preparation, exothermic reactions of dental materials, thermal conductivity of materials in deep fillings, laser burns.
• Electrical: galvanism.
• Chemical: etching agents, cements, disinfectants.

Diagnosis

Currently, despite the availability of a large number of diagnostic tests for pulp condition, the correlation between the results of clinical diagnosis and the histopathological status of the pulp is minimal. Technologically advanced tests and tools are available to determine the viability of the pulp, such as laser Doppler flowmetry and pulse oximetry. However, when providing dental care to young children and patients with special medical needs, the interpretation of results may be uninformative due to potential lack of cooperation.

Main steps in diagnosis:

1. Thorough comprehensive medical history collection
2. Characterization of pain and pulp sensitivity tests
3. Detailed extraoral and intraoral examination methods
4. Analysis of radiographs

Data collection, according to the aforementioned algorithm, will provide the doctor with important information about the condition of the pulp of a specific tooth or teeth. In addition, the source of discomfort (such as trauma or caries, the presence of large, deep, or unsuccessful restorations) also plays a crucial role in diagnosing the pulp and, consequently, in the treatment prognosis.

Medical History Collection

Children with systemic diseases may require different treatment than completely healthy ones. For severely ill children, the method of choice is the removal of the infected tooth after antibiotic premedication, rather than pulp therapy. It is also important to warn about the possibility of developing acute infection due to unsuccessful pulp therapy in children with conditions that make them susceptible to bacterial endocarditis, as well as in patients with nephritis, leukemia, oncological diseases, neutropenia, or any other condition that causes suppression of granulocytes and polymorphonuclear leukocytes. Sometimes, pulp therapy for a chronically ill child's tooth may be justified, but only after careful consideration of the overall prognosis of the child's condition, the prognosis of endodontic therapy, and the relative value of preserving the affected tooth.

Characteristics of Pain

Usually, pain always accompanies pulpitis, but pulp diseases can develop without any history of pain. If possible, a distinction should be made between pain in response to stimuli and spontaneous pain.

Immediate pain in response to stimuli, which ceases after the removal of the causal factor, is usually reversible and indicates minor inflammatory changes in the coronal pulp. Stimuli include thermal, chemical, and mechanical irritants and in many cases are a result of deep caries, poor-quality restorations, tenderness around a temporary tooth approaching physiological change, or the eruption of a permanent tooth.

Spontaneous pain is a constant and pulsating pain that occurs without stimulation or persists for a long time after the removal of the causal factor.

The history of spontaneous toothache is usually associated with extensive irreversible degenerative changes spreading into the root canals.

Pain that occurs during eating or immediately after does not always indicate pulp inflammation. The pain may be caused by food accumulation in the carious cavity, pressure, or chemical irritation of the vital pulp, which is protected only by a thin layer of intact dentin.

Severe pain at night usually indicates extensive pulp degeneration. Spontaneous tooth pain lasting more than a few seconds, occurring regardless of the time of day, usually means that the pulp disease is irreversible and any pulp therapy will be ineffective.

How to effectively manage the behavior of children experiencing acute pain during an appointment? Learn all the secrets of successful pediatric behavior management in the course “Acute” Issues in Pediatric Dentistry”.

Pulp Sensitivity Tests

Sensitivity tests, sometimes referred to as pulp vitality tests, such as thermal and electric pulp testing (EPT), are valuable diagnostic methods in endodontics. However, such sensitivity and percussion tests are not indicated for primary teeth due to ambiguous and difficult-to-interpret results.

Young patients may be more anxious, and the results may be less reliable due to the subjective nature of the test. To avoid a negative experience, when performing percussion and palpation tests on young children, the fingertip should be used carefully in conjunction with the "tell-show-do" technique. The clinician should start the test with the contralateral unaffected tooth to familiarize the patient with the normal response to stimuli.

Extraoral and intraoral examination methods

Clinical examination will help identify signs of pulp pathology. Redness, swelling, fluctuation, deep caries, inadequate or missing restorations, and fistulous tracts indicate pulp involvement. Sensitivity to percussion is quite informative for differential diagnosis, but it can be unreliable due to psychological aspects of child development. Tooth mobility may be present within normal limits due to physiological resorption, while many teeth with pulp involvement show no mobility.

X-ray analysis

Interpreting X-rays of primary teeth is always complicated by the presence of a permanent tooth and its surrounding follicle. Misinterpretation of the follicle can easily lead to erroneous diagnosis of periapical pathology.

The placement of a permanent tooth can obscure the visibility of the furcation and the apices of the temporary tooth roots, which can lead to misdiagnosis. This should be added to the normal physiological process of resorption.

The proximity of carious lesions to the pulp cannot always be accurately determined on an X-ray. What often appears to be an intact barrier of secondary dentin protecting the pulp may actually be perforated by a mass of unevenly calcified and carious tissues. The pulp beneath these tissues may be generally inflamed.

As with permanent teeth, periapical changes can also be detected at the apices of temporary teeth. In temporary molars, pathological changes are most often visible in the area of bifurcation or trifurcation.

Pathological resorption of bone and root is a sign of a progressing pulp pathological process that has spread to the periapical tissues and usually can only be treated by extraction. Mild chronic irritation of the pulp, such as in caries, can stimulate the deposition of tertiary reactive dentin. In acute or rapid onset cases, when the disease reaches the pulp, calcified masses may form away from the site of the pathogenic factor. Such calcified masses always indicate progressive degeneration of the pulp, spreading to the root canals. Temporary teeth with such calcified masses are candidates for pulpectomy or extraction. Internal resorption of temporary teeth is always associated with extensive inflammation. Due to the thinness of the roots of molars, if internal resorption is visible radiographically, there is usually perforation, and the tooth needs to be extracted.

Diagnosis and Treatment Method Selection

The most important and simultaneously the most challenging aspect of pulp therapy is determining the health of the pulp or the stage of its inflammation, so that an appropriate decision can be made regarding the most effective treatment method. For primary teeth, pulp treatment methods can be divided into two categories.

1. Vital pulp therapy with a diagnosis of normal pulp or reversible pulpitis

• Indirect pulp therapy method
• Direct pulp therapy method
• Vital pulpotomy
• Vital pulpectomy

        2. Devital therapy of the pulp with a diagnosis of irreversible pulpitis or pulp necrosis

When the infection cannot be stopped by any of the listed methods, changes in the periapical tissues are observed, and the tooth is not amenable to restoration, extraction is the method of choice.

There are cases when a definitive diagnosis can only be made through direct assessment of the condition of the pulp tissue, and accordingly, a treatment decision is made. It is necessary to evaluate the quality (color) and volume of bleeding upon direct exposure of the pulp. Profuse bleeding or purulent exudate indicates irreversible pulpitis or pulp necrosis. Based on these observations, the treatment plan may be confirmed or altered. For example, if pulpotomy is planned, the nature of the bleeding from the amputation site should be as follows: red blood color and hemostasis achieved in less than 5 minutes with light pressure using a cotton swab. If bleeding persists, a more radical treatment (pulpectomy) should be performed. Excessive bleeding is a sign that inflammation has reached the root pulp. Conversely, if a pulp polyp is present (hyperplastic pulpitis) and bleeding usually stops after amputation of the coronal pulp, a pulpotomy can be performed instead of a more radical procedure.

Direct pulp capping of carious primary teeth is not recommended due to questionable prognosis. However, how should deep caries in primary teeth be treated? What are the indications for indirect pulp capping? What materials should be used? Get the keys to clinical success after completing the lesson “Pulp Capping of Primary Teeth”!