Chronic Pulpitis

Differential diagnosis with deep caries

Making an accurate diagnosis in chronic pulpitis is objectively difficult due to the similarity of its symptoms with deep caries. The clinician's main goal in borderline conditions is to preserve pulp vitality.

If a decision is made to treat deep caries, the process includes the following steps:

• Conservative preparation of the carious cavity (standardized according to G.V. Black's classes depending on localization) followed by restoration.
• Medication treatment of the prepared cavity with the mandatory use of warm antiseptic solutions.
• Placement of special therapeutic liners containing calcium hydroxide.
• Application of sealants containing fluoride.
• Use of low-toxicity materials for restoration (e.g., fluoride-releasing glass ionomer cements).

Characteristics of pain syndrome

When investigating complaints of toothache, the clinician must detail its nature, duration, time of onset, and localization (whether it is strictly localized or radiating).

Differential diagnosis based on the nature of pain:

• Caries: pain is short-lived and occurs exclusively in response to chemical, thermal, or mechanical stimuli.
• Pulpitis: pain is acute, paroxysmal, often occurs at night and spontaneously (without external factors). Pain may radiate along the branches of the trigeminal nerve (n. trigeminus).
• Periodontitis: pain is constant, with a characteristic sharp intensification of discomfort when biting on the affected tooth.

Patient examination algorithm

A comprehensive approach is used to establish a diagnosis. A neat appearance and a friendly attitude from the clinician are basic prerequisites for gaining the patient's trust. Proper questioning and attentive listening allow for an optimal action plan.

Eliciting complaints provides initial data for a preliminary diagnosis. Options may vary:

• No complaints: the patient came for a routine check-up.
• Complaints of a cavity, aesthetic defect, change in tooth color or shape: occur in asymptomatic caries, chronic periodontitis, or non-carious lesions.
• Complaints of pain: require detailed analysis.

Examination methods are divided into two groups:

1. Basic methods:
2. Interview: collecting complaints, history of present illness (anamnesis morbi), life history (anamnesis vitae), as well as information about past and comorbid conditions.
3. Examination: includes external facial inspection, palpation, probing of the carious cavity, and tooth percussion.
4. Additional methods:
5. Thermal testing (response to thermal stimuli).
6. Radiographic (imaging) method.
7. Electric pulp testing (EPT) — a key method for assessing pulp status.
8. Laboratory tests (cytological, histological, bacteriological methods).

Differentiation from neurological pathologies

Acute manifestations of pulpitis or exacerbations of its chronic forms must be distinguished from cranial nerve disorders in the maxillofacial region.

• Trigeminal neuralgia: pain is strictly paroxysmal in nature. The condition requires differential diagnosis not only with pulpitis, but also with acute periodontitis, alveolitis, and maxillary sinusitis.
• Neuropathy: unlike neuralgia, when the nerve trunk itself is damaged, the pain is constant in nature and often accompanied by functional deficits.

Compliance issues in the treatment process

The success of chronic pulpitis therapy largely depends on the doctor-patient relationship. Compliance issues can arise at various stages:

• At the decision-making stage: the patient may refuse consultations and additional examinations (e.g., X-rays or EPT), impose their own opinion on the doctor, or search for a "better specialist".
• During treatment: problems are triggered by attempts at self-medication, failure to strictly follow medical prescriptions, or complete abandonment of therapy.

Class and exam questions

What else to study on this topic

• Classification of carious cavities according to G.V. Black and defect localization
• Variants of dental patient complaints in asymptomatic disease courses
• Additional diagnostic methods for facial nerve injuries (EMG, masticatory muscle electromyography)
• Anatomical and physiological characteristics and lesions of the facial nerve
• Principles of pharmacotherapy for maxillofacial neurological pain

Other topics in the "Additional Topics" section

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