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Modern methods of treatment of pulpitis

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Consider modern methods of treatment of pulpitis, as well as the main stages from which the procedure is composed.

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:

At the cut, it can be seen that the carious cavity has come close to the pulp chamber of the tooth.

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.

Attempts to regularly drink toothache with pain pills can end very badly ...

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:

One of the possible complications of pulpitis is phlegmon

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.

Photograph of pulp extracted from a tooth

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 most cases, the treatment of pulpitis involves the complete removal of the pulp from the tooth.

Photo pulp close-up

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.

A piece of remote pulp on the instrument

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”.

The photograph shows the so-called arsenic in the tooth - a temporary filling 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.

If the source of infection remains in the root canals, this can create major problems in the future and with a high probability will result in the need for over-treatment of the tooth.

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):

Pink tooth after treatment of pulpitis using resorcin-formaldehyde method.

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.

With the help of modern anesthesia methods, the treatment of pulpitis today can be 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.

In the treatment of pulpitis, a high-quality cleaning of the dental canals from pulp residues and infections is very important.

Dental files - used when cleaning dental canals.

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:

This is how the tooth looks at the beginning of the treatment procedure - a devitalizing material is visible in the mouth of the root canal.

And it looks like the same tooth after treatment.

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.

Today, they are increasingly refusing to use arsenic-containing substances to kill pulp in favor of alternative options.

 

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.

Indications for depophoresis of copper-calcium hydroxide

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.

In the treatment of pulpitis, doctors often make various mistakes that can lead to channel over-treatment and other problems.

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.

An x-ray shows an example of the perforation of the tooth 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.

Break off the tool in the channel

Another shot showing a broken instrument clearly visible, stuck in the dental canal and going beyond the bounds of the tooth 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.

Not completely sealed canal

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.

Overly sealed canal with the withdrawal of filling material beyond 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.

Waiting room in a modern dental clinic.

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

 

 

To write "Modern methods of treatment of pulpitis" 10 comments
  1. Natalia:

    For about 40 years I have worked as a dentist and I can say about the resorcin-formalin method, that this method has proven itself over the decades of its use in dentistry. The only minus is tooth staining, but the teeth cured by this method cost decades to the end of a patient's life. Another thing is that this method is cheap, but now everyone wants to get as much money from the patient as possible, so expensive imported drugs are being introduced.

    Reply
    • Rabis:

      The method, of course, is cheap, but it stains the tooth and, moreover, the tooth becomes fragile. This may further adversely affect the ability to perceive the chewing load, and if you need to remove, then the removal will be difficult. The tooth will constantly crumble, which means you will need to cut it out of the jaw. And then suturing, etc.

      Reply
    • Yuri:

      Yeah, my friend, while studying at the institute, treated his teeth this way, they got painted. And after standing for more than 5 years, they began to inflame! Until now, the mother of doctors from urban dentistry.There were such painted teeth ...

      Reply
  2. Vitali:

    When nerves are removed from the canals, the tooth becomes dead, gradually becoming more fragile and collapsing. I understand that sooner or later it will collapse and will have to be removed? So is it not easier to immediately remove such a tooth without treatment of pulpitis and insert an artificial one?

    Reply
    • Svyatoslav Gennadievich:

      Hello! A quotation from one film not yet made: “If we die anyway, isn’t it easier right away ...”

      First, you are right, the tooth becomes more fragile than alive (with pulp), but this does not mean that it crumbles during life. Secondly, a dead tooth that has 4 full-fledged walls (that is, the filling is in the middle of a tooth) can completely collapse without correction for 10-20 years, and this is not the option to say: “Isn't it easier to immediately remove such a tooth ?

      Moreover, research has proven that while it is difficult to build something better than your teeth in terms of anatomy and functionality, it’s more expensive than that. You can not even imagine how many people rightly cling to each tooth, try to treat, even if it is enough for only a couple of years.Thirdly, about those teeth that have not entirely reliable walls, or there are not so many of these walls: the tooth is restored on a pin, or (which is more reliable and reliable, but more expensive) they put a stump tab in the tooth canal, and then a crown. . With proper manipulation, it prolongs the life of a dead tooth to 15-20 years or more. Of course, no one argues with the fact that the audit of dental work is supposed to produce 1 time in 1-3 years.

      More than once they even told me more abruptly: “Wouldn't it be easier for all teeth to be removed and inserted implants, dentures?”. In order to talk like that, you need to have at least 400-800 thousand rubles and more, because the whole mouth of high-quality implants is expensive, or prepare for cheaper counterparts, where problems can wait at every turn. So what you are saying may lead to rash financial expenses (at best), or to frustration with the loss of your teeth.

      Reply
  3. Rabis:

    Even if you cured pulpitis according to the protocol, then there is no guarantee that the tooth will not hurt when you catch a cold, freeze, etc. As a rule, there is pain in the treated tooth, which indicates that it is very difficult to maintain sterility in the canals during treatment.Yes, the endometazon paste and gutta-percha pins will reach the tops of the roots, but this, alas, is not a guarantee of a complete cure from the residual pulpitis. Absorbers, files, protepers, etc. - everything is sterile only when not unpacked. Everything has relative sterility. It is often simply impossible to observe this sterility, based on the rules of asepsis and antisepsis. The dentist's office is not a large operating room, where the air is constantly sterilized, where the patient is covered with sterile sheets, where only sterile instruments are served, where doctors and sisters in sterile lab coats, shoe covers, masks, etc. There is a lot of infection in the oral cavity. Therefore, the effectiveness of treatment of pulpitis is not always high, and the complaints of patients after dental treatment to the teeth or doctors are sometimes unfounded. It is best to treat caries and not to bring to pulpitis, periodontitis, and not to eat a lot of sweet. It would be nice if experts and judges who take part in the “flights” analysis understood this.

    Reply
    • Kseniya:

      I went to a private clinic to treat pulpitis. Only for the rehabilitation and sealing of channels, the price was told to me - to lay out my entire salary for the month (I have an average salary, not the smallest). And this is a temporary seal, albeit a polymer one.Permanent betting - to pay separately ... For the money I paid, I did an operation on the thyroid gland in the state clinic + 5 days of in-patient care and tests. So, taking such money, sterility could provide the maximum, and not slip the contract at the box office - "in case of complications I have no complaints." And I treat my teeth on time, I try. My fault is not in the fact that I had a burn of pulp out of the blue, although the caries was not very deep (I treated in an inexpensive private clinic initially).

      Reply
  4. Anonymous:

    The tin

    Reply
  5. Veronica:

    How to understand from all the complex prices of dentistry, how much will it cost to cure pulpitis? All stages of me, as a simple inhabitant, are of little interest, to be honest. It's important for me:

    a) To the maximum, keep the tooth alive (and not as it used to be, 10 years ago - depulping the teeth in the treatment of any caries and then grind and set the crown).

    b) To the cost of all work is not bent. With the salary of a state employee in the minimum wage, how can one set such prices for treatment? And now, even according to the compulsory medical insurance, everything is paid, and there the materials of the past generation and the doctors are no

    Reply
    • Hello, Veronica! The cost of treatment can be calculated only after examining your image and face-to-face examination. To do it yourself (in advance, without visiting the doctor) will be quite problematic.

      After studying the history and X-ray examination, it will be possible to judge - either save the tooth pulp (nerve) or delete it. This greatly affects the cost of treatment. Also, the cost is significantly influenced by the number of tooth channels. And without diagnostic procedures, the range of likely prices for treatment will be very wide - from about 2,000 rubles to 10,000 rubles.

      Reply
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