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Is pulpitis painful?

P. L. Michaelson & G. R. Holland

Division of Endodontics, School of Dentistry, University of Michigan, Ann Arbor, MI, USA

Abstract Results Approximately 40% of the teeth included

gave no history of spontaneous or prolonged pain to
Michaelson PL, Holland GR. Is pulpitis painful? International
a thermal stimulus. No statistically signi¢cant di¡er-
Endodontic Journal, 35, 829^832, 2002.
ences in the incidence of ‘painless pulpitis’ were
Aim To determine whether in£amed dental pulps pro- related to either gender or tooth type. Patients aged
gress to necrosis without pain. >53 years experienced ‘painless pulpitis’ more often
Methodology Records of 2202 maxillary anterior than patients <33 years.
teeth endodontically treated at the University of Michi- Conclusions Many teeth appear to progress to pul-
gan were collected. Records of teeth presenting with pal necrosis without the patient experiencing pain
periapical radiolucencies but no response to vitality attributable to the pulp.
tests were examined further to determine, from the
Keywords: endodonticdiagnosis, pulpalpain, pulpitis.
history, whether the patient had experienced pain or
no pain from the involved tooth. Received 8 January 2002; accepted 7 June 2002

di¡erent canals at di¡erent times thus making inter-

pretation di⁄cult. Other studies looking at teeth after
The diagnosis of a diseased dental pulpal can be di⁄cult. extraction and determining pulpal necrosis histologi-
Conventional diagnostic testing, both thermal and elec- cally suggest that pulpal necrosis can occur without
tric, does not accurately correlate with morphological pain in 14% (Dummer et al. 1980) and 58% (Seltzer et al.
changes in the dental pulp (Seltzer et al. 1963a, Bhaskar 1963a) of cases.
& Rappaport 1973, Dummer et al. 1980). In particular, The present study extends these previous reports by
the correlation between pulpal in£ammation and clini- restricting the observations to single-rooted teeth that
cal symptoms and test results is uncertain. had not been traumatized and correlating the observa-
Seltzer et al. (1963a) showed that the only signi¢cant tions to gender, tooth type and age. The present study
correlation between clinical signs and pulpal pathology design was based on the belief that, with a single-rooted
was with a history of spontaneous pain. They also con- tooth, a periapical radiolucency establishes that the pulp
cluded that a tooth could progress to pulpal necrosis is necrotic whereas in multirooted teeth a periapical
without pain. This concept, that a tooth could have an radiolucency is sometimes associated with a vital re-
in£ammatory reaction without pain, was later termed sponse (Lin et al. 1984) and that traumatized teeth may
a‘painless pulpitis’ by Hasler & Mitchell (1970). The inci- have necrotic pulps as a result of severing apical vessels
dence of a tooth presenting with a periapical radiolu- rather than in£ammation (Stanley et al.1978). The teeth
cency without a history of pain has been reported to be included in the present study were deemed to have
26^60% (Seltzer et al.1963b, Barbakow et al.1981, Bender necrotic pulps as a result of pulpal in£ammation (Van
2000). These studies included teeth with multiple roots Hassel1971). The observations determined what propor-
that may have had di¡erent levels of in£ammation in tion of teeth had progressed to pulpal necrosis without
the patient experiencing pain.

Correspondence: Dr G. R. Holland, Division of Cardiology Restora- Method

tive Sciences and Endodontics, University of Michigan School of
Dentistry, 1011 North University, Ann Arbor, MI 48109, USA (Tel.: Approval for the present study was obtained from the
þ1 734 763 3703, fax: þ1 734 936 1597; e-mail: Health Sciences Internal Review Board at the University

ß 2002 Blackwell Science Ltd International Endodontic Journal, 35, 829^832, 2002 829
Is pulpitis painful? Michaelson & Holland

of Michigan. Patient records maintained in the Graduate Table 1 Incidence of ‘painless pulpitis’
Endodontic Clinic at the University of Michigan School Incidence %
of Dentistry for the years 1989^2000 were screened
Overall 193/497 38.83
(>10 000). Only maxillary incisors and canines were Male 98/237 41.35
selected for possible inclusion in the study as these teeth Female 81/226 35.84
have been shown to have one canal 100% of the time No statistical differences were noted with respect to gender (Chi-square
(Vertucci 1984). A total of 2202 maxillary anterior teeth P > 0.05).
had been treated during this period. Of these teeth, the
patient record was included in the study only if the diag-
nosis made was pulpal necrosis with chronic apical per- was 42.89 years (17.46). Thirty-four records failed to
iodontitis. The patient record was required to include a document the gender of the patient. In 29 of the cases/
report of the clinical examination and diagnostic test records, the age of the patient was not recorded. In
results su⁄cient to support a diagnosis of pulpal necro- both these groups, the rest of the data are complete,
sis. These clinical tests included thermal and/or electric and so they were included in the overall analysis, but
pulp testing (EPT) of a¡ected and control teeth in the were excluded from calculations regarding gender or
same patient. Radiographs were examined to con¢rm age.
that a periapical radiolucency was present. The record The overall incidence of ‘painless pulpitis’was 38.83%.
was then examined for an adequately recorded pain The incidence of ‘painless pulpitis’ for male and female
history, including current and previous pain to thermal patients was 41.35 and 35.84%, respectively; the di¡er-
stimuli, as well as spontaneous pain. The word ‘spon- ence was not statistically signi¢cantly di¡erent (Table 1).
taneous pain’, ‘history of spontaneous pain’, ‘thermal The incidence of ‘painless pulpitis’ was determined
sensitivity’, ‘cold sensitivity’, ‘hot sensitivity’ ‘history of with relation to tooth type. No statistical di¡erences
thermal sensitivity’, ‘history of cold sensitivity’, or ‘his- (P > 0.05) were noted in regard to tooth type (Table 2).
toryof hot sensitivity’were required to be verbatim docu- The incidence of ‘painless pulpitis’ varied with age.
mented on the record. For inclusion, radiographs were The ages ¢rst were determined to be normally dis-
required to be of diagnostic quality with the tooth in tributed. A Student’s t-test indicated that patients who
the centre of the ¢lm, 3 mm of periapical bone present experienced a ‘painless pulpitis’ had an average age of
apical to the root end, and of good contrast. 46.83 years (17.63 years) compared to the average age
Teeth with other endodontic diagnoses (normal pulp, of the patients reporting a ‘painful pulpitis’ which was
irreversible pulpitis, previous root-canal treatment, 40.27 years (16.87 years) (P < 0.01). In an attempt to
and surgery) were excluded from the study, as well as derive greater meaning from the age data, the ages were
charts with incomplete data or teeth that failed to also divided into three groups of approximately equal
demonstrate a periapical radiolucency. Multiple a¡ected size, one including all those more than one-half the SD
teeth, immature teeth and traumatized teeth were below the mean (33 years), one of those within one-
omitted. Patients on long-term analgesics, such as as- half of a SD above or below the mean (33^52 years) and
pirin or nonsteroidal anti-in£ammatory medications one containing those more than half a SD above the
for nondental reasons, or psychoactive drugs, such as mean (53 years). Patients 53 years of age had a
antidepressants, were eliminated from the study. Four greater incidence of ‘painless pulpitis’ than the 33-
hundred and ninety-seven records met the criteria for year-old group (Table 3, Chi-square P < 0.01). No other
inclusion. signi¢cant di¡erences were noted between the age
The data were tabulated using an Excel (Microsoft groups.
Corporation, Redmond, USA) worksheet and analysed
statistically using the Student’s t- and Chi-square test
to correlate a history of pain with the incidence of pulpal
Table 2 Incidence of ‘painless pulpitis’ by tooth type
necrosis as appropriate. P-values <0.05 were accepted
as signi¢cant. Tooth

Central Lateral Canine

Results Incidence 49/140 91/218 53/139

% 35 41.7 38.1
Of the 497 records that were included in the study, 226 No statistical differences were noted (Chi-square P > 0.05) between
were male and 237 female subjects. The average age any of the groups.

830 International Endodontic Journal, 35, 829^832, 2002 ß 2002 Blackwell Science Ltd
Michaelson & Holland Is pulpitis painful?

Table 3 Incidence of ‘painless pulpitis’ in relation to age small degrees of injury and in£ammation would be read-
Age (years) ily detected. More recently, it has been demonstrated that
33 34^52 53
a major role of pulpal nerves is in controlling blood £ow
(Tonder & Naess 1978) and participating in neurogenic
Incidence 54/168 61/168 72/132
in£ammation (Byers et al. 1992). Clinical experience
% 32.1 36.3 54.6
and anecdotal evidence suggest that pain is rarely
The 53-year-old age group showed statistically a greater incidence of
experienced from a healthy pulp in an intact tooth and
‘painless pulpitis’than the 33-year-old group (Chi-square P < 0.01). No
differences were noted between the middle-age group and either the unpredictably from a diseased pulp. Pulpal in£amma-
young or old groups. tion occurs even in early dental caries (Bra«nnstro«m &
Lind 1965) but, presumably, escapes sensory detection.
Our results support the theory that pulpal in£ammation
is not necessarily readily detectable by the patient,
The overall incidence of ‘painless pulpitis’, as determined although, clearly, it cannot speak to the degree of in-
in this study, is similar to the earlier reports by Seltzer £ammation that may be detectable.
et al. (1963b), Hasler & Mitchell (1970), and Bender There are insu⁄cient data to provide a plausible exp-
(2000) which were 40, 58, and 60%, respectively. Our lanation of ‘painless pulpitis’. Pulps may die quietly as
results, however, are in marked contrast to those of a result of rapidly spreading in£ammation, perhaps
Dummer et al. (1980) whose data suggested that only related to the virulence of the bacteria involved. On
14% of patients presenting with necrotic and periapical the other hand, pulps may adjust to slowly advancing
periodontitis report no previous symptoms consistent in£ammation, holding mediators below a level that
with pulpitis. They also di¡er, though less dramatically, would activate nociceptors. There may be e¡ects more
from the 26% incidence of ‘painless pulpitis’ reported centrally in the nervous system which gate-out in-
by Barbakow et al. (1981) from a study that included coming activity from the dental pulp. Local antialgesic
multirooted teeth. Detailed comparison of these various mediators such as endorphin or somatostatin, known
studies is di⁄cult because of substantial di¡erences in to be present in the pulp (Casasco et al. 1990), may
study design. Nonetheless, all available data agree that playa role. If the main role of pulpal nerves is in vascular
‘painless pulpitis’ is not an oxymoron. control the number and synchrony of action poten-
The absence of any di¡erence in the incidence of ‘pain- tials sent centrally may be insu⁄cient to converge and
less pulpitis’ between genders di¡ers from studies that summate.
have looked at postoperative pain (Torabinejad et al. This simple surveycon¢rms the phenomenon of pulpi-
1988). This could indicate that ‘painless pulpitis’ is more tis without pain and points out, once again, the severe
strongly related to the pathophysiological processes in limitations of the techniques currently available for
the injured pulp than to perception. The absence of any diagnosing the condition of the dental pulp.
di¡erence between tooth types is hardly surprising as
only three tooth types of basically similar morphology
were included.
The apparently higher incidence of ‘painless pulpitis’ The authors wish to thank and express their sincere gra-
with greater age could be attributed to several factors. titude to Jennifer Michaelson for her help in designing
The original pulpal lesion may have been less aggressive computer tabulation worksheets for the 2202 records
and progressed more slowly resulting in necrosis at a which were investigated as well as aiding in online litera-
later age. The pulps in older teeth are less heavily in- ture searches and retrievals, and Keith Sleeper for his
nervated than younger teeth (Johnsen & Johns 1978, help in data collection.
Johnsen et al. 1983). False negatives to vitality tests may
be more common in teeth with coronal tissue thickened
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ß 2002 Blackwell Science Ltd International Endodontic Journal, 35, 829^832, 2002 831
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832 International Endodontic Journal, 35, 829^832, 2002 ß 2002 Blackwell Science Ltd