Topic 37.

Exacerbation of chronic pulpitis: pathomorphology, clinical picture,

diagnosis, differential diagnosis.

1. A 29-year-old woman complains of acute paroxysmal pain in the upper jaw on

the left, aggravated by cold pain, radiating to the ear and temple. A year ago, tooth
26 had a severe pain and did not go to the doctor. Three days ago, the pain
reappeared. Objectively: tooth 26 has a deep carious cavity, communicating with
the tooth cavity. Probing the opened point is sharply painful. What is the most
likely diagnosis?
Exacerbation of chronic pulpitis
Acute serous periodontitis
Acute localized pulpitis
Acute diffuse pulpitis
Exacerbation of chronic periodontitis

Solution algorithm:
1. Pay attention to complaints - acute paroxysmal pain in the upper jaw on the left,
aggravated by cold, radiating to the ear and temple (acute pain is characteristic of
acute processes and exacerbations, increased pain from irritants with irradiation is
characteristic of pulpitis).
2. Pay attention to the history - a year ago, tooth 26 had a severe pain and did not
go to the doctor. Three days ago, the pain reappeared. (Repetition of painful
sensations of the same nature indicates an exacerbation of the process).
3. Pay attention to the data of an objective examination - in tooth 26 there is a
deep carious cavity, connected to the tooth cavity. Probing the opened point is
sharply painful... (It is typical for pulpitis, since there is a communication between
the carious cavity and the tooth cavity and the pulp reacts to probing).

2. The patient complains of paroxysmal pain in the left upper jaw tooth, aggravated
at night and from the action of various stimuli, radiating to the left temple and eye.
Similar pains were three months ago, no treatment was carried out. Objectively:
there is a deep carious cavity in 25, communicates with the tooth cavity. Probing at
the point of communication is sharply painful, vertical percussion is slightly
painful, horizontal percussion is painless. The mucous membrane in the projection
of the root apex 25 is unchanged, palpation is painless. Thermal diagnostics is
sharply painful, the pain attack is prolonged. EOD - 60 μA. X-ray diagnostics -
slight widening of the periodontal gap at the root apex 25 What is the most
probable diagnosis?
Exacerbation of chronic pulpitis
Exacerbation of chronic periodontitis
Acute purulent pulpitis
Acute purulent periodontitis
Acute general pulpitis

Solution algorithm:
1. Pay attention to complaints - paroxysmal pain in the tooth of the upper jaw on
the left, aggravated at night and from the action of various stimuli, radiates to the
left temple and eye. (Paroxysmal pain is characteristic of acute processes and
exacerbations, increased pain from irritants with irradiation is characteristic of
pulpitis).
2. Pay attention to the history - there were similar attacks three months ago, no
treatment was carried out. (Repetition of painful sensations of the same nature
indicates an exacerbation of the process).
3. Pay attention to the data of an objective examination - in 25 a deep carious
cavity communicates with the tooth cavity. Probing at the point of communication
is sharply painful, vertical percussion is slightly painful, horizontal percussion is
painless. The mucous membrane in the projection of the root apex 25 is
unchanged, palpation is painless. (It is characteristic of pulpitis, since there are
messages of the carious cavity with the cavity of the tooth and at the same time the
pulp reacts to probing, a slightly painful vertical percussion indicates focal
inflammation).
4. Pay attention to the data of the additional examination - the thermodiagnostics is
sharply painful, the pain attack is prolonged. EOD - 60 μA. X-ray diagnostics - a
slight expansion of the periodontal gap at the root apex 25 (the pulp reacts to a
thermal stimulus with sharp pain, which indicates its vitality, as well as EDI, and a
slight expansion of the periodontal gap at the root apex indicates an exacerbation
of a chronic focal pathological process).

3. A 40-year-old woman complains of short-term sudden pain, as well as pain from

hot and cold food at 46. Such attacks were half a year ago, no treatment was
carried out. On the chewing surface 46 there is a carious cavity with a large
amount of softened dentin. Probing the bottom is painful at one point. The reaction
to thermal stimuli is painful and does not disappear after their elimination. EOD -
25 μA. What is the most likely diagnosis?
Exacerbation of chronic pulpitis
Acute purulent pulpitis
Acute diffuse pulpitis
Acute localized pulpitis
Chronic fibrous pulpitis

Solution algorithm:
1. Pay attention to complaints - short-term sudden pain, as well as pain from hot
and cold food at 46. (Sudden pain from hot and cold food is characteristic of acute
processes and exacerbations in the pulp).
2. Pay attention to the history - similar attacks were half a year ago, no treatment
was carried out. (Repetition of painful sensations of the same nature indicates an
exacerbation of the process).
3. Pay attention to the data of an objective examination - a carious cavity with a
large amount of softened dentin. Probing the bottom is painful at one point.
(Typical for pulpitis, as the pulp reacts to probing in the area of the nearest horn).
4. Pay attention to the data of additional examination - the reaction to thermal
stimuli is painful and does not disappear after their elimination, EOD - 25 μA.
(The pulp reacts to a thermal stimulus with sharp pain, which indicates its vitality,
like the EDI).