Chronic Pulpitis: Clinical Features,

Diagnostic Methods

E.L. Kolb
1
 Microbes from caries
Dentin and pulpal reactions

Dentin reactions
 Microbes from caries
Dentin and pulpal reactions
 Pulpal reactions

0.5

0.25
Minimal

Maximal

reactionary dentin
formation by odontoblasts reparative dentin (bridge)
formation by recruited blast cells

Dahl & Ørstavik 2008 based on Murray PE et al. Am J Dent. 2002 Feb;15(1):41-6.
 International Classification ICD-10
K 04 Diseases of pulp and periapical tissues
K04.0 Pulpitis
K04.00 Initial (hyperaemia)
K04.01 Acute
K04.02 Suppurative [pulpal abscess]
K04.03 Chronic
K04.04 Chronic, ulcerative
K04.05 Chronic, hyperplastic [pulpal polyp]
K04.08 Other specified pulpitis
K04.09 Pulpitis, unspecified
K04.1 Necrosis of pulp
Pulpal gangrene
 International Classification ICD-10

K04.2 Pulp degeneration

Denticles
Pulpal calcification
Pulpal stones
K04.3 Abnormal hard tissue formation of pulp
K04.3X Secondary or irregular dentin
Excludes: pulpal calcifications (K04.2)
pulpal stones (K04.2)
 IRREVERSIBLE PULPITIS
It is a persistent inflammatory condition of the
pulp, symptomatic or asymptomatic, caused by
noxious stimuli
It has both acute and chronic stages in pulp
 IRREVERSIBLE PULPITIS
Chronic Pulpitis
It is an inflammatory response of pulpal
connective tissue to an irritant. Here pain is
absent because of diminished exudative
inflammatory activity and corresponding
decrease in intrapulpal pressure to a point below
threshold limits of pain receptors
Chronic pulpitis can be
of three types:
•Ulcerative/open form
•Hyperplastic form
•Closed form
 IRREVERSIBLE PULPITIS
Proliferation
PATHOGENESIS
Hyperplastic form Fibrous form

Microbes from
caries

Necrosis

Ulcerative form Pulp necrosis

 Chronic Pulpitis
Signs and Symptoms
•Pain is absent because of low activity of
exudative forces
•Here proliferative granulomatous forces
dominate
•Symptoms develop only when there is
interference with drainage of exudates
 Chronic Pulpitis
Diagnosis
•Pain
it is usually absent
hyperplastic form shows a fleshy, reddish pulpal mass
which fills most of the pulp chamber or cavity. It is less
sensitive than normal pulp but bleeds easily when probed
•Radiographic changes show
chronic apical periodontitis in long standing cases
in young patients, low grade long standing irritation
stimulates periapical bone deposition, i.e. condensing
osteitis. Radiograph shows areas of dense bone around
apices of involved teeth
Chronic Pulpitis
Diagnosis
•Vitality tests
the tooth may respond feebly or
not at all to thermal test, unless one
uses extreme cold
more than normal current is
required to elicit the response by
electric pulp tester
 RESPONSE TO THE TEMPERATURE TEST
5. Pain reaction occurs chronic forms of pulpitis
slowly and increases from
any temperature stimuli;
the patient feels pain for
some time
pulp necrosis, chronic
apical periodontitis,
6. No reaction complete obliteration of
the pulp cavity in
advanced age
 ELECTROEXCITABILITY TOOTH TEST
Threshold values of
№ Tooth disease
amperage (mcA)
1. Intact tooth 2 -6
2. Caries tooth 2 -10
3. Hyperemia of the pulp 12 -18
4. Acute pulpitis 20 -30
5. Acute purulent pulpitis 30 -60
6. Chronic pulpitis 40 -60
7. Chronic ulcerative pulpitis 60 -90
8. Chronic hyperplastic pulpitis 50 -70
9. Necrosis of the pulp (dry) 60 -80
10. Necrosis of the pulp (wet) 100
11. Chronic apical periodontitis > 100
 IRREVERSIBLE PULPITIS
Chronic Pulpitis
Closed form of chronic pulpitis (fibrous)
may occur from operative procedures,
excessive orthodontic forces, trauma or
periodontal lesions
carious lesion may be absent
the tooth can be changed in color
 IRREVERSIBLE PULPITIS
Chronic Pulpitis
Complaints:
 Of the aching pain in the tooth by the actions of all
kinds of stimuli (especially temperature), passing
slowly after their elimination
 Of the aching pain in the tooth when a sharp
change in temperature takes place
 May be asymptomatic
 IRREVERSIBLE PULPITIS
Chronic Pulpitis

Clinical picture:
 On examination, a deep carious cavity made by
softened dentin is revealed
 Probing of the bottom of the cavity can be painful at
only one point
 The pulp chamber is usually closed
 Bleeding pulp
 The tooth is painless on percussion
 The alveolar process in the tooth root apex
projection is painless on palpation
 Pulp electroexcitability is reduced to 40-60 mA
IRREVERSIBLE PULPITIS
Chronic Pulpitis
IRREVERSIBLE PULPITIS
Chronic Pulpitis
IRREVERSIBLE PULPITIS
Chronic Pulpitis
Ulcerative form
is a chronic inflammation of cariously exposed pulp
characterized by formation of an abscess at the point
of exposure
abscess is surrounded by granulomatous tissue
this condition is also known as pulpal granuloma
 IRREVERSIBLE PULPITIS
Chronic Ulcerative Pulpitis
 On examination a deep carious cavity made by softened dentin is
revealed
 The pulp chamber is usually open
 At the place of opening, pulp has an ulcer which may bleed on
probing; its surface may be covered with a layer of necrotic tissue
with an unpleasant odor
 The pulp ulcer may be painful on probing
 Weakly expressed reaction to hot and cold stimuli
 The tooth is painless on percussion
 The alveolar process in the tooth root apex projection is painless on
palpation
 Pulp electroexcitability is reduced to 60-90 mA
Hyperplastic form is overgrowth of
granulomatous tissue into the carious
cavity
Hyperplastic form of chronic pulpitis is
seen in the teeth of children and
adolescents whose pulp tissue has high
resistance, and a large carious lesion
permits free proliferation of hyperplastic
tissue
Since it contains few nerve fibers, it is
painless but bleeds easily due to a rich
network of blood vessels
 PULP NECROSIS, or death, is a condition
following untreated pulpitis
Necrosis may be partial or total, depending on the extent of
pulp tissue involvement
Pulp necrosis is of two types:

•Coagulation necrosis: In coagulation

necrosis, protoplasm of all cells becomes
fixed and opaque; cell mass is
recognizable histologically; intracellular
details are lost
•Liquefaction necrosis: In liquefaction
necrosis, the entire cell outline is lost
 PULP NECROSIS
Necrosis is caused by injuries to pulp by
bacteria, trauma, and chemical irritation

•Discoloration of the tooth—first indication of pulp death

•The patient’s history
•The tooth may be asymptomatic
 PULP NECROSIS
Diagnosis
•Pain: It is absent in complete necrosis
•The patient’s history reveals a past trauma or past history of
severe pain which may have lasted for some time followed by
complete and sudden cessation of pain
•Radiographic changes show a large cavity, restoration, or normal
appearance unless there is concomitant apical periodontitis or
condensing osteitis
•Vitality test: The tooth does not respond to vitality tests. But
multirooted teeth may show mixed response because only one
canal may have necrotic tissue. Sometimes teeth with liquefaction
necrosis may show positive response to electric test when electric
current is conducted through moisture present in the root canal
•Visual examination: The tooth shows color change as a dull or
opaque appearance due to lack of normal translucency
Unfortunately, the beginning of the necrotic process
may not be easily diagnosed clinically, as pain
symptoms can be absent.
Calcifications
In calcific degeneration, part of the pulp
tissue is replaced by calcific material

Mainly three types of calcifications are

seen in the pulp:

•Dystrophic calcifications
•Diffuse calcifications
•Denticles/pulp stones
Dystrophic Calcifications
•They occur by deposition of calcium salts in dead or
degenerated tissue. Local alcalinity of destroyed tissues
attracts the salts
•They occur in minute areas of young pulp affected by
minor circulatory disturbances, in a blood clot or around a
single degenerated cell
•They can also begin in the connective tissue walls of
blood vessels and nerves, and follow their course

Diffuse Calcifications
•They are generally observed in root canals
•The deposits become long, thin and fibrillar on fusing
 Calcifications
Atrophic changes in pulp with age
Denticles/Pulp Stones
They are usually seen in the pulp chamber

Classification of pulp stones

According to location
•Free
•Embedded
•Attached

According to structure
•True
•False
Denticles/Pulp Stones
Denticles/Pulp Stones
Denticles/Pulp Stones
True denticle: It is composed of dentin
formed from detached odontoblasts or
fragments of Hertwig's enamel root
sheath, which stimulates the
undifferentiated cells to assume
dentinoblastic activity
False denticle: Here degenerated tissue
structures act as nidus for deposition of
concentric layers of calcified tissues
 Make a diagnosis
Following the placement of a full gold crown on the
maxillary right second molar, the patient complained of
sensitivity to both hot and cold liquids; now the
discomfort is spontaneous. Upon application of Endo-
Ice® on this tooth, the patient experienced pain and
upon removal of the stimulus, the discomfort lingered for
12 seconds. Responses to both percussion and
palpation were normal; radiographically, there was no
evidence of osseous changes
 Make a diagnosis
Following the placement of a full gold crown on the
maxillary right second molar, the patient complained of
sensitivity to both hot and cold liquids; now the
discomfort is spontaneous. Upon application of Endo-
Ice® on this tooth, the patient experienced pain and
upon removal of the stimulus, the discomfort lingered for
12 seconds. Responses to both percussion and
palpation were normal; radiographically, there was no
evidence of osseous changes

Diagnosis:
Symptomatic irreversible
pulpitis
normal apical tissues
 Make a diagnosis
The maxillary left first molar has occlusal-
mesial caries and the patient has been
complaining of sensitivity to sweets and to
cold liquids. There is no discomfort to biting
or percussion. The tooth is hyper-
responsive to Endo-Ice® with no lingering
pain
 Make a diagnosis
The maxillary left first molar has occlusal-
mesial caries and the patient has been
complaining of sensitivity to sweets and to
cold liquids. There is no discomfort to biting
or on percussion. The tooth is hyper-
responsive to Endo-Ice® with no lingering
pain
Diagnosis: reversible
pulpitis; normal apical
tissues
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