Permanent tooth - pain or infection
Permanent tooth with pain or infection
Clinically, it is useful to divide this process into three stages, pulpitis with reversible symptoms, pulpitis with irreversible symptoms, and dental abscess/periradicular periodontitis. However, these do not refer to discrete, well separated stages of pathology, but are on a continuum of unmanaged pulpal disease from mild inflammation through to pulpal necrosis. Clinicians must use their clinical judgement to decide the extent of the pulpal pathology and then determine the appropriate management strategy.
Pulpitis – reversible symptoms
Description: Pain is provoked by a stimulus (e.g. cold, sweet) and relieved when it is removed. The pain is intermittent and does not tend to affect the child’s sleep. The pulp is vital.
Aim: To remove pain and avoid the disease progressing to pulpitis with irreversible symptoms.
If a dentine bridge is visible radiographically, aim to carry out selective caries removal, taking care to avoid the pulp, and place a restoration. If the lesion is shallow, complete caries removal might be necessary to provide sufficient depth for the restoration.
- It may be necessary to provide a temporary dressing and review the tooth before placing a permanent restoration later.
If no dentine bridge is visible, consider carrying out selective caries removal or pulpotomy.
Pulpitis – irreversible symptoms
Description: Pain can occur spontaneously but if provoked by a stimulus, is typically not relieved when the stimulus is removed. The pain may last for several hours, may be difficult for the child to localise and may keep the child awake at night. The pain may be dull and throbbing, worsened by heat and may be alleviated by cold. There are no signs and symptoms of infection such as sinuses or abscesses or periradicular pathology and the pulp is still vital, although inflamed. Usually, the tooth is not tender to percussion.
Aim: To relieve pain.
Either carry out pulpotomy or pulpectomy/root canal therapy or extract the tooth (see Extraction).
- Pulpotomy (either partial or full coronal) is the treatment of choice where the clinician assessed that the pulp is not totally irreversibly inflamed, and is also useful in immature permanent teeth to allow continued dentine and root development.
- By carrying out a pulpotomy, a pulpectomy is still possible if clinically necessary in the future.
To relieve symptoms, and to allow time for long term treatment planning, consider pulpotomy or pulpectomy with dressing of the root canals, before deciding on extraction of a permanent tooth.
- In some cases, local measures to bring infection under control may be appropriate.
Several factors need to be considered when making the decision to carry out a pulpotomy or a pulpectomy or to extract in the young permanent dentition, including the long-term prognosis of the tooth (see First permanent molars of poor prognosis), occlusal development and whether avoiding extraction may reduce the risk of treatment-induced anxiety. Therefore, a comprehensive assessment should be undertaken prior to undertaking one of these treatment options.
Dental abscess/periradicular periodontitis
Description: When acute, pain is likely to be spontaneous, will keep the child awake at night and can be easily localised by the child. The tooth may show increased mobility and may be tender to percussion. There may be clinical evidence of a sinus, abscess or swelling or radiographically evidence of periradicular pathology. When chronic, the child may not report pain but other signs and symptoms may be present. The infected, necrotic remnants of the dental pulp will continue to cause problems unless managed by pulp therapy.
Aim: To remove the source of infection and avoid or relieve pain.
Either carry out pulpectomy/root canal therapy or extract the tooth (see Extraction).
- To relieve symptoms, and to allow time for long term treatment planning, consider pulpectomy and dressing of the root canals, before deciding on extraction of a permanent tooth.
- In some cases, local measures to bring infection under control may be appropriate.
Several factors need to be considered when making the decision to carry out a pulpectomy or to extract in the young permanent dentition, including the long-term prognosis of the tooth (see First permanent molars of poor prognosis), occlusal development and whether avoiding extraction may reduce the risk of treatment-induced anxiety. Therefore, a comprehensive assessment should be undertaken prior to undertaking one of these treatment options.