Diagnosis of pulpitis

Clinical presentation and patient complaints

The initial stages of acute pulpitis are characterized by acute, paroxysmal pain that occurs spontaneously and significantly intensifies at night. The pain syndrome is often triggered by temperature and mechanical stimuli entering the carious cavity.

When the inflammation progresses to the purulent stage, the symptoms change and sharply intensify:

• The pain becomes constant, aching, and extremely intense.
• Sharp pain appears when biting down on the causative tooth. Due to the inability to close the jaws, patients often sit during the appointment with their mouths slightly open.
• Symptoms of general intoxication join in: against the background of stress, lack of sleep, and inability to eat, pronounced weakness develops.
• Body temperature may rise to subfebrile values.

In some cases of purulent inflammation, slight soft tissue swelling of the face on the affected side is visually determined, and regional lymph nodes enlarge and become painful (lymphadenitis).

Rules and stages of instrumental examination

Since pain in pulpitis can radiate along the branches of the trigeminal nerve, the patient cannot always precisely point to the troublesome tooth. Therefore, the physician must perform a systematic examination of the entire oral cavity according to the scheme: from the maxillary molars on the right from left to right, then on the mandibular arch from left to right.

A dental mirror and a sharp explorer are used for the examination, as well as the transillumination method (translucency of tissues using light guides).

Features of the local status in pulpitis:

1. Mucous membrane: prior to pus formation, only slight gingival edema may be observed. In the purulent stage, the mucobuccal fold and gingiva in the projection of the tooth are hyperemic and edematous, and the periosteum thickens.
2. Probing: reveals a carious cavity with softened dentin. Touching the bottom of the cavity with the explorer causes pronounced pain.
3. Percussion: is painful. When the inflammation extends beyond the pulp into the periodontal tissues, tapping pain becomes sharp.
4. Tooth mobility: in severe cases (purulent process) can reach degree II.

Laboratory and hardware diagnostics

Additional diagnostic methods help confirm the diagnosis and assess the degree of involvement of surrounding tissues:

• X-ray examination: foci of destruction in the bone tissue are absent. The only possible radiological sign is the widening of the periodontal ligament space resulting from inflammatory edema.
• Electric pulp testing (EPT): makes it possible to assess tissue vitality. At the stage of purulent melting, EPT values will indicate the death of the pulp.
• Blood test: no specific changes. In severe courses, slight leukocytosis (up to 10–11 × 10⁹/L) and a moderate increase in the erythrocyte sedimentation rate (ESR) are possible.

Differential diagnosis

Acute diffuse pulpitis (and exacerbation of chronic pulpitis) is most often differentiated from acute or exacerbated chronic periodontitis. Difficulties arise because in pulpitis, the inflammatory infiltrate can penetrate into the periodontium, causing a similar reaction to percussion.

Class and exam questions

What else to study on this topic

• Differential diagnosis with trigeminal neuralgia and sinusitis
• Distinctive criteria for deep and medium caries
• Methodology for transillumination of hard dental tissues
• Assessment of regional lymph node status in odontogenic infection
• Modern Methods of Carious Cavity Preparation

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