How to manage a tooth with pulpitis or infection?

Management of a Hot Tooth (Pulpitis or Infection)

The definitive management of a hot tooth (pulpitis) requires immediate pulp therapy to preserve pulp vitality or root canal therapy, depending on the maturity of the tooth and severity of inflammation. 1

Initial Assessment

• Assess for signs of respiratory distress, including dyspnea or stridor, as maxillofacial infections can lead to airway compromise due to soft-tissue edema 2, 1
• Perform thorough examination of the oral cavity after cleansing with water or saline to accurately assess the extent of infection 1
• Evaluate for signs of spreading infection that may require immediate intervention, including facial swelling, trismus, or systemic symptoms 2, 1

Diagnostic Approach

• Perform clinical investigation searching for signs of pulp necrosis such as color changes, fistula, swelling, abscess, or pain 3
• Consider radiographic examination (periapical or orthopantomogram) to identify enlarged pulp chambers and periapical bone loss 3
• Distinguish between reversible and irreversible pulpitis based on clinical presentation - irreversible pulpitis typically presents with spontaneous, lingering pain that may worsen with thermal stimuli 4

Treatment Algorithm

For Reversible Pulpitis:

• Remove the irritant (caries, fractured restoration) 4
• Place appropriate restorative material to seal the tooth 3
• Monitor for signs of pulpal necrosis 3

For Irreversible Pulpitis:

• Provide appropriate pulp therapy immediately to preserve pulp vitality in immature teeth 3
• For mature teeth, root canal therapy is usually the treatment of choice 3
• Antibiotics are NOT indicated for irreversible pulpitis without signs of systemic infection 5, 6
• Provide analgesics for pain management 5

For Dental Abscess/Infection:

• Establish drainage if possible 2
• Consider antibiotics only if there are signs of spreading infection or systemic involvement 2, 5
• For severe infections with risk of airway compromise, consider hospital admission 2, 1

Supportive Measures

• Recommend warm saline rinses to promote drainage and reduce inflammation 2, 1
• Advise patients to avoid painful stimuli including smoking, alcohol, and spicy or hot foods 3, 2
• Consider alcohol-free antimicrobial mouth rinses such as 0.2% chlorhexidine to reduce bacterial load 2, 1
• Maintain good oral hygiene with gentle brushing using a soft toothbrush and mild fluoride-containing toothpaste 3, 1

Follow-up Care

• Instruct patients on warning signs that should prompt immediate return for care, including increasing swelling or difficulty breathing/swallowing 2, 1
• Schedule follow-up to monitor for signs of pulpal necrosis in cases of reversible pulpitis 3, 4
• For teeth that have undergone endodontic treatment, monitor for healing and absence of periapical pathology 3

Common Pitfalls to Avoid

• Failure to recognize potential airway compromise is the most dangerous pitfall in managing dental infections 2, 1
• Inappropriate prescription of antibiotics for irreversible pulpitis without systemic infection contributes to antibiotic resistance 5, 6
• Underestimating the severity of dental infections can lead to delayed treatment of potentially life-threatening conditions 2
• Inadequate pain management may lead to unnecessary antibiotic prescriptions 5, 6