Modern methods of treatment of pulpitis

Strangely enough, but today there is still a common misconception among the people that as long as the tooth does not hurt, it is not necessary to treat it. However, it should not be forgotten that caries is often asymptomatic or with mild symptoms until the tooth collapses so deeply that the microbial infection comes close to the pulp chamber of the tooth and then penetrates into it (that is, the so-called dental “nerve”) .

The photo below shows a section of a tooth with a carious cavity through which the infection penetrated into the pulp chamber:

When a sharp, throbbing pain in a tooth occurs, this is already a clear signal for immediate treatment, indicating in most cases the development of pulpitis. But it is very strange that even in this case, some people consciously decide to endure the pains in the hope that they will pass, that everything will somehow resolve itself, and try to postpone the treatment of pulpitis for an indefinite time.

In some cases, this happens for quite simple reasons: not all people know what pulpitis is and even more so about how it is treated (and even more so they are not tormented by fears of possible complications, otherwise they would immediately run to the clinic). Following the phrase “aware is armed”, each person should have at least a general idea of ​​pulpitis and its treatment, although in order to keep his teeth in critical situations.

 

Why do I need to treat pulpitis?

Imagine a person to whom a career, a constant lack of time or another reason gives a seemingly reasonable reason not to rush to the treatment of pulpitis, despite the regular and severe pain in the tooth. Such funds come to the rescue Ketanov, Nurofen, Ketorolak, Baralgin, Nise and others related to pain medication.

It is important to understand that even if the pain has subsided, then a huge number of bacteria continue to be in the pulp chamber of the tooth and do their destructive work. Irreversible changes gradually take place inside the tooth, leading sooner or later to the death of the “nerve” with the formation of pus in the root canals.

When pus goes beyond the root towards the gum, a "flux" occurs.In fact, this can be expressed not only in the slight swelling of the cheeks, sometimes the face can literally inflate with a strong symmetry violation. In severe cases, we can talk not only about the preservation of the tooth, but can also develop life-threatening purulent inflammation of the person - phlegmon. And this is only part of the possible problems, in reality, the options for serious complications are much more, including damage to the bones of the jaw, blood poisoning, etc.

The photo shows cellulitis - a terrible complication of pulpitis:

To prevent the complications of pulpitis it is very important to start its treatment in time. In some clinical cases, the entire neurovascular bundle can be saved during treatment without resorting to removing it from the canal, but more often, amputation (partial extraction) or extirpation (complete removal) of the pulp is performed.

The meaning of the pulp removal procedure is to completely rid the tooth of the source of infection and avoid the spread of bacteria through the roots into the gums. This is the only way to save the tooth and surrounding tissue from additional problems.

On a note

Many years ago there was a popular method of treatment of pulpitis with the resorcin-formalin method, which is still relevant in some institutions.Quite often, people with pink and red teeth turn to dentists, because sooner or later they begin to disturb. To cure a tooth in the advanced stage (in aggravation) after such treatment can be difficult or already impossible. The sooner the resorcin-formalin paste is replaced and the canal is flushed from the “infection”, the easier it is to save the tooth from inevitable removal.

 

Classical methods and approaches to the treatment of pulpitis

All known methods of treatment of pulpitis can be divided into two large groups:

• treatment with full preservation of live pulp in the tooth;
• and treatment with pulp removal.

The latter group is still divided into partial (amputation) and complete (extirpation) pulp extraction.

The photo below shows the pulp removed from the tooth:

In order to assess the possibility of applying one or another method and approach to the treatment of pulpitis, it is necessary to first understand the condition of the “nerve” in the dental canal. The biological method of treatment most sparing to the pulp can be applied only if it does not have inflammation or it is in the very initial stage.

It is interesting

Biological method of treatment of pulpitis,in addition to adhering to strict indications for it and the rules of asepsis and antisepsis (sterility during operation), has more than 10 basic requirements, ranging from the young patient's age and the absence of acute infectious diseases, to the use of effective air-water cooling, a large number of sterile burs etc. That is why in most dentists this method is not used for the treatment of pulpitis, since high risks of failure (repeated pulpic pain) provoke doctors to use methods aimed at complete removal pulp from channelsto prevent conflicts.

Surgical treatment of pulpitis, as noted above, includes methods for the partial or complete removal of pulp from a tooth:

• if partial removal of the “nerve” (amputation treatment of pulpitis) is performed immediately under anesthesia, then this is a vital amputation;
• if at the first stage of treatment of pulpitis a devitalizing paste is put (in order to preliminarily “kill the nerve”), then the method is called devital amputation.

Similarly, extirpation, that is, the complete removal of the pulp, is divided into vital and devital.

On a note

Vital amputation, as one of the most difficult for the implementation of the methods of treatment of pulpitis, also has a whole set of indications and strict requirements for compliance with the necessary conditions during the procedure. These include: healthy periodontal (complex of tissues surrounding the tooth), age limit up to 45 years old, adherence to perfect sterility during work and others.

Amputation of the pulp requires hard work, followed by the formulation of drugs (powerful anti-inflammatory drugs). Most dentists (except for children), who for many years successfully practiced the removal of the entire “nerve” (extirpation), are already not aware of the risk of not observing the maximum sterility of the working field, when the patient has millions of microbes in his mouth, are not ready to take on the difficult and lengthy work on partial removal of the pulp.

Vital and devital extirpation have long been entered into practical dentistry, as the most effective and reliable methods of treating pulpitis. The essential difference between them is that the vital extirpation, or the complete extraction of pulp from the canals, is carried out immediately and under effective anesthesia.And the devital extirpation can be carried out without anesthesia (although in practice it is more often also performed with it), but with a preliminary presentation during the first visit to a special paste to kill the “nerve”.

A special place in the Russian dentistry is occupied by the method of devital amputation, which in Soviet times in many dental institutions was the only possible way to cure pulpitis and save the tooth in the conditions of a shortage of imported drugs, lack of time, the dentist’s lack of knowledge of the technique of searching and processing channels, etc. This technique is amazing in its simplicity and false effectiveness.

Removing only the part of the neurovascular bundle that is inside the crown of the tooth with partial or complete preservation of the root pulp creates conditions for the further development of the infection. Despite the use of various potent solutions and pastes for root pulp, which could turn it into a kind of “mummy” (dry antiseptic cord), the presence of voids in the treated canal with the remnants of killed and weakened microflora created all the conditions for the appearance of sluggish root or rootthe inflammation stretched on years with gradual dissolution of a bone tissue.

Unexplained facts

Most often, mummifying resorcin-formalin paste, which has long been banned in many countries of the world because of its irritating, toxic and even possible carcinogenic effect (that is, its ability to provoke the formation of cancer cells). Russia in this regard is one of the few countries that has not yet taken into account the results of research by world-renowned scientists.

In this photo you can observe how the tooth looks after the treatment of pulpitis using the resorcin-formalin method (devital amputation):

The combined method of treatment of pulpitis is the use of, as a rule, two methods, for example, extracting the entire root pulp from the available channels (devital extraction) and partial removal of the “nerve” (devital amputation) from channels with complex anatomy, for example, highly curved, or breaking off the tool and the impossibility of its extraction.Unlike devital amputation, with the combined method, the prognosis is more favorable, but only if most of the channels are still passed along the entire length and sealed with reliable filling materials.

It is also useful to read about the problems that sometimes arise when removing the dental "nerve".

 

Important nuances of the treatment procedure

Modern dentistry and the dental market are aimed at implementing programs to improve the method of treatment of pulpitis by means of vital extirpation - that is, the complete removal of the pulp without first killing it. Every year there are new tools and devices aimed at preventing errors during treatment and the convenience of a dentist.

Thanks to modern anesthetics and devices for their controlled administration, it is no longer necessary to put the paste for devitalization on the exposed “nerve” - the so-called “arsenic”. Since anesthesia is effective, even intracanal treatment of difficult to “freeze” lower large molars, associated with the extraction of pulp from the canal system, can now be safely carried out in one visit.

Removal of the pulp is carried out under local anesthesia, for which the articaine-type drugs are used more often: Ubystezin, Alfacain, Septonest, Ultracain, etc. After reaching a stable tooth freeze, the dentist first performs a pulp amputation (with boron or an excavator), and then extirpate, removing from the canal of the neurovascular bundle all at once or in parts. After that, the most crucial stage of the treatment of pulpitis begins, when with the help of small “needles” (for example and files) the doctor goes through the channels along the entire length, expands them and processes them with medication with antiseptic solutions.

It is not by chance that many leading dentists adhere to the following principle in their work: it doesn’t play a significant role, which will fill the canal, it’s important how well prepared it is. Just this “quality” includes a long and painstaking work of washing out all the “dirt” from the canals: live and dead microbes, sawdust from the infected inner walls of the canal, blood impurities, nerve residues from all canals, etc.

The canals of the tooth can be compared to a tree, which has numerous large and small branches.With the help of “needles” (pulpoextractors, files, etc.), the nerve can be removed only from the main canals (maximum 4-5), but thin branches, leaving the main walls of the thickness of the tooth, are difficult to clean mechanically. That is why drug treatment with modern antiseptics allows not only to make the canal sterile, but also to dissolve nerve residues in the hard-to-reach area. It takes time and a sufficient amount of antiseptic solution.

It is interesting

Sodium hypochlorite solution is still among the most effective antiseptics used during the treatment of pulpitis. Can be used and 3% and 5% solutions. Successful channel processing is accurate and safe blasting from a special syringe. Professionalism, instrumental control of work, lack of haste, etc. allows you to avoid serious errors in the form of removing the solution beyond the root, where it can have a strong irritant effect.

Canal treatment ends with their filling up to apex - physiological narrowing or maximum narrowing point.

Popular fill materials are pasta mixes (Endometazon, AN Plus, etc.) and gutta-percha pins.The high rating of use remains with the method of volumetric sealing of all branches of the channel of the hot gutta-percha of the Termafil system. As a rule, according to the protocol, cure pulpitis is obtained in 2-3 visits.

Photo pulpit tooth at the beginning of treatment and after its completion:

Removal of the pulp with its preliminary killing has the same principles and stages of treatment for pulpitis, but only on the second visit. And on the first visit, with or without anesthesia, a small slice of paste (arsenic or boneless) is placed on the exposed horn of the pulp.

Arsenic paste is placed for 24 hours (treatment of single-root teeth) and for 48 hours (treatment of pulpitis multi-rooted teeth). Due to the fact that this type of treatment is difficult to control, and often the patient may appear later than the prescribed period, there are frequent cases of emergency care with the toxic effect of arsenic on the tooth root. Constant complaints from patients and a study of the effect of the paste on the tissues surrounding the root led the doctors to conclude that the use of arsenic containing substances in the treatment of pulpitis is better to refuse in favor of alternative pastes that do not contain arsenic.

 

New techniques and devices for the successful treatment of pulpitis

If pediatric dentists actively continue to apply for the treatment of pulpitis dairy and permanent teeth with unformed roots of the vital and devital amputation, then for the adult population the most acceptable methods of complete removal of the pulp. To create maximum sterility in the canals, the dental market releases new devices and preparations every year, and new methods of treatment for pulpitis are being developed, allowing the tooth to be kept for life.

Strengthened disinfection of channels can be accomplished with the help of ultrasonic and laser devices and instruments. Also depophoresis of copper-calcium hydroxide is considered an effective treatment.

It is interesting

Copper-calcium hydroxide not only has a bactericidal effect, but also destroys spores and fungi in the canals. Due to the destructive effect on proteins, even small branches of the canal are cleared of any form of life.

Physiotherapy for pulpitis, as well as for periodontitis, is a methodwhich is most often used for the treatment of post-filling pains, which often arise on the background of adaptation to the filling material. As part of physiotherapeutic procedures, for example, a DiaDENS device, a darsonvalization apparatus, Amplipuls and others can be used. In general, it should be noted that physiotherapy in the treatment of pulpitis is rarely used.

 

Common mistakes in the treatment of pulpitis and how it may threaten

Modern methods of treatment of pulpitis allow you to avoid most of the mistakes that dentists of the last century made during the processing and filling of dental canals. Despite this, for a number of reasons (for example, haste, lack of professionalism, poor equipment of the clinic) such errors appear as a violation of the integrity of the channel, breakdown of the instrument in it, incomplete filling, excessive filling.

Violation of the integrity of the canal is perhaps one of the most problematic complications during the treatment of pulpitis: it creates a false hole or perforation at a certain level of the root: at the beginning, end, and in its middle. At the same time, a tool for passing or expanding a channel accidentally ends up outside the root in the surrounding tissues.This complication complicates the normal processing and filling of the real channel, as well as in the future provokes the presence of a source of inflammation in the place of the "wound" at the root.

It is interesting

During perforation, the patient often notices himself, as if the doctor punctured the gum, went away from the tooth, “touched the flesh”. It manifests itself as a sudden pain somewhere in the depths. At the same time, blood often appears in the spittoon when spitting.

Breaking the instrument in the channel: if not working properly with small endodontic instruments, it is possible that the end of the “needle” is jammed and then broken off, which does not allow the pulpitis to be properly treated. Part of the channel is not processed and not sealed. If the microbes continue to multiply in the root voids, then this leads to the appearance of periodontitis pains indicating the inflammation of the root.

Not completely sealed canal: normally, it should be sealed to a physiological constriction, that is, not reaching a visually detectable radiological apex of the tooth root by about 1-2 mm. Regardless of the material chosen, this requirement must satisfy the pulpitis treatment protocol.Otherwise, there will be inflammation of the root.

Overly sealed canal: when removing a large amount of filling material beyond the root, the dentist risks giving the patient in addition to severe pain in the tooth after the treatment of pulpitis, also big problems in the future. The fact is that the standards of treatment of pulpitis provide for a clear filling of the canal according to its working length, measured with a ruler, using a special device, X-ray, etc. When material enters the root tip, it is perceived as a foreign body, which entails a response and provokes inflammation of the tissues surrounding the root.

Very rarely, even cases of removal of a filling material in the maxillary sinus with the development of antritis and in the mandibular canal with numb jaw for a long time are recorded. All this is serious enough.

And now let's talk about the prices for the treatment of pulpitis ...

 

How much does it cost to cure pulpitis

The cost of treatment of pulpitis is determined in part by the geographical location of the dental institution. For example, treatment in some small town may differ markedly in price for the same services, but in St. Petersburg or Moscow.To better understand what, in fact, you are paying money, it is useful to know a little about the pricing policy of clinics.

Most dentists include anesthesia, the passage of canals, the use of mechanical and drug treatment, material for “root filling”, filling material at the end of treatment, as well as some other stages and materials used in the cost of treatment of pulpitis of the tooth. Low-budget organizations almost do not include advertising, high service, comfort level, etc. in the price for pulpitis treatment.

From the observations of the dentist

Some advanced patients not from a good life during the treatment of pulpitis act like the real Ostap Benders. The most difficult treatment of canals, which requires a lot of time, high level of equipment, professionalism of the doctor, quality control in the form of pictures, they spend in a good clinic at a decent level. In this case, the person asks the dentist to treat pulpitis without applying a seal in order to then install it free of charge or for a minimal fee in a budget institution (clinic or hospital).Unfortunately, this event can be doomed to failure, as the low quality of the budgetary seal often affects the possibility of microbes from the oral cavity entering a well-sealed system of channels in a couple of years or earlier. The result is repeated costly retreatment of the tooth.

A number of dentists carry out the treatment of pulpitis at one time with immediate payment for it. Studies have shown that the clinic’s commercial desire to quickly receive the full amount for the complicated work done is fraught with future patient complications, since most dental institutions work with a set of materials that, when not solidified, can either not be combined or stick badly during the filling process. tooth immediately after treatment. There is also a risk of micro-cuts ("falling through") of the filling, when the material placed in the channels starts to harden, and the filling in the formed voids will naturally descend with the formation of cracks along its edges.

 

The best way to avoid costly treatment is to prevent pulpitis. It consists of timely treatment of caries at any stage of the process, professional oral hygiene from plaque and stone, as well as from the formation of a proper food culture with the restriction of sweets in all types, proper and regular brushing of the teeth, the use of dental floss and rinses.

 

An interesting video showing what can be expected at the clinic during the treatment of pulpitis.

 

Removing a broken instrument from a tooth channel