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Oral & Dental Health

Pulpitis

Inflammation of the dental pulp (the soft tissue containing nerves and blood vessels inside the tooth), usually caused by caries, trauma, or restorative procedures.

Also known as: Inflamed Tooth Pulp

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Referral and warning signs

When to refer

Refer ALL cases of suspected irreversible pulpitis or pulp necrosis to dental personnel (Dentist/Dental Officer at HC4/RR) for definitive treatment (root canal or extraction).

Red flags

  • Spontaneous, severe, lingering toothache.
  • Pain waking patient at night.
  • Signs of associated swelling/abscess formation.
  • Fever.

Signs and symptoms

  • Reversible Pulpitis: Sharp pain provoked by stimuli (cold, sweet), subsides quickly after stimulus removal. No spontaneous pain.
  • Irreversible Pulpitis:
  • - Spontaneous, unprovoked toothache.
  • - Severe, throbbing, or dull aching pain.
  • - Pain lingers long after stimulus removal (esp. heat, sometimes relieved by cold).
  • - Pain often worse when lying down / at night.
  • - May be difficult to localize pain initially.
  • - Tooth may become tender to percussion (tapping) as inflammation progresses to periapical tissues.
  • Pulp Necrosis: May become asymptomatic after period of severe pain, OR develop into periapical abscess.
  • Tooth may appear normal or have deep cavity/filling/fracture.

Risk factors

  • Deep dental caries approaching the pulp.
  • Trauma to the tooth (fracture, concussion).
  • Extensive dental restorations (fillings, crowns).
  • Cracked tooth syndrome.
  • Thermal injury (from dental procedures).
  • Chemical irritation.

Diagnosis

Clinical assessment

Based on history of pain (type, duration, triggers, spontaneous?). Clinical examination for caries, restorations, fractures. Pulp vitality testing (thermal test - cold/heat; electric pulp test - EPT) helps differentiate reversible from irreversible.

Investigations

  • Dental examination.
  • Pulp vitality testing (Thermal, EPT).
  • Percussion test.
  • Dental X-rays (Periapical): Assess proximity of caries/restoration to pulp, check for periapical changes (widened PDL, radiolucency suggest irreversible/necrosis).

Diagnostic criteria

Clinical symptoms and signs supported by vitality testing and radiographic findings indicating pulp inflammation.

Differential diagnosis

  • Dentin hypersensitivity (pain sharp, brief, stimulus-provoked).
  • Periapical abscess (swelling, severe tenderness to percussion, often non-vital tooth).
  • Periodontal abscess (swelling on gum, associated pocket, usually vital tooth).
  • Cracked tooth syndrome (pain on biting/release).
  • Sinusitis (maxillary tooth pain, nasal symptoms).
  • Atypical facial pain / Trigeminal neuralgia.

Management

Pharmacological treatment

  • Pain Relief: Paracetamol 1g Q8H (Adult); 10-15mg/kg/dose Q8H (Child). OR Ibuprofen 400mg Q8H (Adult); 7-13mg/kg/dose Q8H (Child). (LOC: HC2)

Dental Treatment (Referral Required)

  • Reversible Pulpitis: Remove irritant (e.g., excavate caries, place sedative dressing/filling).
  • Irreversible Pulpitis / Pulp Necrosis:
  • - Root Canal Therapy (Endodontics): Removal of inflamed/necrotic pulp, cleaning/shaping/filling of root canals. Saves the tooth. (LOC: RR)
  • - Pulpotomy: Partial removal of coronal pulp (often in primary teeth or as emergency pain relief). (LOC: HC4/RR)
  • - Extraction: Removal of the affected tooth if not restorable or patient choice. (LOC: HC4+)

Monitoring

Follow up after dental treatment to ensure symptom resolution and healing.

Complications

  • Progression to pulp necrosis.
  • Development of periapical abscess.
  • Cellulitis.
  • Severe pain.

Prevention

  • Prevention and early treatment of dental caries.
  • Prompt management of tooth trauma.
  • Use of protective bases under deep fillings.

Patient education

  • Explanation of inflamed tooth nerve.
  • Difference between reversible/irreversible.
  • Need for definitive dental treatment (root canal/extraction) for irreversible cases.
  • Analgesia for temporary relief.
  • Risks of delaying treatment (abscess, tooth loss).

Uganda-specific notes

Pulpitis is a common reason for seeking emergency dental care. Provide analgesia and refer promptly for definitive treatment. Root canal therapy access is limited, extraction is common.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 23, Section 23.2.3

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