Differential Diagnosis of Pulpitis

Basic principles of patient examination

Diagnostic search begins with establishing a trusting rapport — a neat appearance and the doctor's friendliness play a key role in this.

Main examination methods include:

• Interview: detailed clarification of complaints, history of the present illness (anamnesis morbi), and personal history of the patient (anamnesis vitae). Special attention is paid to the characteristics of pain: time of onset, duration, localization, and presence of irradiation.
• Inspection: external evaluation of the maxillofacial region, palpation, percussion, and probing.

Based on these data, a preliminary diagnosis is formulated. To establish a final diagnosis, a detailed study of the lesion focus (status localis), additional tests, and differential diagnosis with diseases having similar semiotics are required.

Differentiating pulpitis from caries

The main differential diagnostic criterion is the nature of the pain syndrome.

In asymptomatic caries, complaints may be limited only to the presence of a carious cavity, an aesthetic defect, or tooth discoloration. If pain is present, in caries it is always short-lived and occurs strictly in response to chemical, mechanical, or thermal stimuli.

In pulpitis, the clinical picture is radically different: the pain is acute, paroxysmal, often occurs at night, and is spontaneous, meaning it appears without apparent external causes.

Differentiating pulpitis from acute periodontitis

This is the most complex stage of diagnostics, since in diffuse pulpitis the inflammatory process can extend beyond the pulp to the periodontal tissues, causing tenderness upon percussion.

Key criteria for differentiation:

1. Nature of pain: in periodontitis, the pain is constant, aching, and sharply intensifies when biting down (patients often come to the appointment with an open mouth). In pulpitis, the pain is paroxysmal, with possible irradiation along the branches of the trigeminal nerve (n. trigeminus).
2. Probing: in pulpitis, touching the bottom of the carious cavity causes a sharp attack of pain.
3. Local symptoms: when periodontitis transitions to the purulent stage, edema and hyperemia of the mucous membrane in the projection of the tooth, thickening of the periosteum, painful palpation, increased tooth mobility (up to degree II), and regional lymphadenitis are observed.
4. General condition: purulent periodontitis is accompanied by general weakness, fatigue, and an increase in body temperature to subfebrile values.

Role of thermal testing and EPT

Additional instrumental methods are used to verify the diagnosis.

Thermal testing is a physical method for assessing the reaction of tooth tissues to heat and cold (using water, a heated instrument, or gutta-percha):

• Quickly passing pain is characteristic of caries.
• Prolonged pain sensations indicate pulpitis.
• Lack of reaction is a sign of pulp necrosis.

Electric pulp testing (EPT) is the only non-invasive method that provides insight into qualitative disorders in the pulp. The device generates a direct current (in the range of 2–200 µA), determining the excitation threshold of pain and tactile receptors. In pulpitis, the excitability threshold changes due to direct damage to nerve endings and secondary atrophic processes. In periodontitis, EPT indicators confirm the complete death of the pulp.

Laboratory and radiation diagnostics

As auxiliary methods, the following are used:

• X-ray examination: in acute periodontitis, destructive bone changes are not yet determined, but widening of the periodontal ligament space due to inflammatory edema may be observed.
• Clinical blood test: in purulent periodontitis, minor leukocytosis (up to 10–11 × 10⁹/L) and an increase in ESR are possible, whereas in pulpitis, the blood picture does not change significantly.
• In complex clinical situations, cytological, histological, and bacteriological research methods may be involved.

Class and exam questions

What else to study on this topic

• Methodology for performing electric pulp testing (EPT) and interpretation of numerical values.
• Clinical picture and stages of development of acute periodontitis.
• Indices for assessing the intensity and prevalence of caries (DMF index).
• Causes of patient non-compliance at the stages of decision-making and treatment.
• Radiological signs of caries complications and interpretation of images.

Other topics in the "Additional Topics" section

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.