What are the Differences between Reversible and Irreversible Pulpitis – Differential Diagnosis of Pulpitis

Pulpitis is the inflammation of the dental pulp which can be a result of untreated caries , trauma, multiple restorations etc with the primary symptom being pain. Pulpitis is defined in multiple stages, the most distinctive ones being Reversible Pulptis and Irreversible Pulptitis, based on the diagnosis the treatment plan can be decided. Treatment options for pulpitis include, Restoration (Composite, GIC, Cention, Amalgam etc) with a base, Root Canal Therapy or Extraction of tooth in severe cases where the tooth is unrestorable.

Pulpitis most commonly is the result of caries progressing deep into the dentin close to the pulp or involving the pulp. The inflammation of the dental pulp initially starts as a reversible condition when the lymphatic and blood supply is disrupted due to caries (infection), trauma etc. If this is left untreated, the inflammation of the pulp progresses as a swelling inside the pulp chamber which compromises the circulation leading to necrosis of pulp.

When the pulp is infected, it is termed as irreversible pulpitis and it proceeds to become apical periodontitis, periapical abscess, cellulitis and osteomyelitis of the jaw if left untreated.

How to Differentiate (Differential Diagnosos) between Reversible and Irreversible pulpitis:

Reversible Pulpitis Definition: It is the general category which histologically may represent a range of responses varying from dentin hypersensitivity without concomitant inflammatory response to an early phase of inflammation.

Irreversible Pulpitis Definition: It is a persistent inflammatory condition of the pulp, symptomatic or asymptomatic, caused by a noxious stimulus.

Pain Type:

Reversible Pulpitis: Sharp and Fleeting pain which dissipates or decreases after the stimulus is removed (biting or chewing, hot or cold foods)

Irreversible Pulpitis: Intense, Continuous and prolonged pain due to pressure or secondary irritants – No external stimulus is needed for pain. The dead or injured pulp tissue acts as a secondary stimulant

When does it Pain – Night or Postural:

• Reversible Pulpitis: No (Only on stimulus)
• Irreversible Pulpitis: Yes (at night and increases on sleeping or bending down)

Stimulus:

• Reversible Pulpitis: External stimulus is required – heat, cold, sweet or sour
• Irreversible Pulpitis: No external stimulus required to incite pain, dead or injured pulp tissue acts as secondary stimulant

Referred Pain:

• Reversible Pulpitis: Not found, pain is localized to just the tooth
• Irreversible Pulptitis: Commonly found, radiating to ear, side of head etc

Pain Localization:

• Reversible Pulpitis: Is seen when Cold stimulus is applied or PDL stimulation
• Irreversible Pulpitis: Only when Heat stimulus is applied or PDL stimulation

Histopathology or History:

• Reversible Pulpitis: Any recent trauma, Cervical abrasion, erosion, History or past/recent Dental treatment
• Irreversible Pulpitis: History of Deep dental caries, trauma, Heavy or Extensive restorations

Pulp Testing:

• Electronic Pulp Test: Normal response in Reversible pulpitis, Normal to Elevated in Irreversible pulpitis
• Cold Test: Exaggerated response in Reversible pulpitis, Pain is relieved by Cold stimulus in Irreversible pulpitis
• Heat Test: Normal to Exaggerated response to heat in Reversible Pulpitis, Acute pain on heat in Irreversible pulpitis

Radiograph:

• Reversible Pulpitis: Seen with Restoration without pulp protection, Caries, Cracks on tooth extending to Dentin
• Irreversible Pulpitis: Deep Caries, defective restorations with caries under restoration, PDL enlargement

Color Change:

• Reversible Pulpitis: No color change to tooth
• Irreversible Pulpitis: Color Change is seen on the affected tooth

Treatment Options:

• Reversible Pulpitis: Caries excavation, replace the defective restoration, Interim restoration with ZOE dressing, Occlusal adjustment in case of Trauma from Occlusion
• Irreversible Pulpitis: Pulpectomy (single root), Pulpotomy (multiple roots), occlusal adjustments in TFO.

Diagnosis of Pulpitis is important to get to a proper treatment plan, based on whether it is reversible or irreversible pulpitis we can decide if the treatment is as simple as removal of caries and restoring the tooth or Root canal Treatment or Extraction of tooth in case of extensive infection.