The pain is characteristic of pulpitis. Inflammation of the tooth pulp

Do you or your child have a toothache that doesn’t look much different from other teeth? Perhaps these are signs of pulpitis.

What is pulpitis?

Pulpitis – inflammatory disease dental pulp, which is the neurovascular bundle of the tooth (or nerve, as it is also called), as well as connective tissue cells. The pulp is located under the dentin, which in turn is covered with tooth enamel. The pulp is responsible for nourishing the teeth from the inside.

Pulpitis is often a complication of another dental disease - and therefore, the main cause of pulpitis, like caries, is, for example, streptococcus. Thus, prevention of pulpitis implies protecting teeth from infection - proper care of teeth and oral cavity.

According to statistics, up to 20% of patients complaining of toothache have pulpitis. Particularly frequent guests of the dentist are children, who usually have pulpitis of the baby tooth.

Now let's briefly look at the mechanism of development of pulpitis, which will be convenient to do using the following image:

As you can see, dear readers that at the beginning of tooth damage, plaque appears on it, which is food debris (which over time begins to rot) and various microflora, most often pathogenic.

If you do not brush your teeth, infectious microorganisms, in the course of their vital activity, produce acid, which, together with decaying food particles, begin to eat tooth enamel, which is the surface or protective layer of the tooth. Damage to tooth enamel is called caries. The more time passes without proper oral care, the faster they go away. pathological processes for tooth destruction.

The third stage in the development of pulpitis is when the infection gets under the tooth enamel and the infection affects the dentin. Dentin is the hard and basic part of the tooth; in fact, it is bone. This is the last step of the infection before it reaches the pulp - the soft tissue of the tooth that lies directly under the dentin. Pass in the pulp blood vessels and nerve endings. This is precisely what causes the appearance of severe pain during pulpitis.

The fourth stage is actually pulpitis, in which the infection reaches the pulp, causing its inflammation.

The onset of pulpitis is accompanied by toothache, often pulsating in nature, hypersensitivity tooth to temperature changes, as well as a painful reaction of the tooth to cold or hot food/drink. Toothache due to pulpitis can spread to several nearby standing teeth, and on the entire jaw, over time even turning into a headache.

It is also worth noting that the course of pulpitis can be asymptomatic.

But still, you can independently determine the presence of pulpitis by the presence of gray enamel, frequent bleeding, dark holes or overgrown tissue in the hole from caries of a particular tooth, as well as increased sensitivity of the tooth when chewing.

The consequence of pulpitis in many cases is tooth loss, however, if this inflammatory process is not given due attention, it can spread to the jaw tissue, and then to sepsis, which is a rather dangerous complication.

Pulpitis - ICD

ICD-10: K04.0;
ICD-9: 522.0.

Symptoms of pulpitis

Toothache with pulpitis is the main symptom of this disease. By nature, the pain with pulpitis is usually pulsating in nature, often the tooth hurts so much that the patient feels as if half of his head hurts. Increased pain usually occurs at night, as well as when the affected tooth is exposed to cold or hot air or food, temperature changes, or chewing food. When tapped, the tooth is insensitive or insensitive.

Other signs of pulpitis include:

• Gray enamel of the affected tooth;
• Open tooth cavity;
• Bleeding from a tooth;
• Increased irritability.

Nonspecific symptoms include:

Complications of pulpitis

If pulpitis is not treated, it can lead to the following complications;

• Periodontitis;
• Tooth loss;

The cause of inflammation of the dental pulp is always an infection, mainly of nature - lactobacilli. As we have already said, the infection, in the process of its life activity, produces acid, which, together with food debris, destroys the integrity of tooth enamel, after which dentin, and then begins to affect the pulp itself. However, this is the entry of infection into the tooth through the crown, i.e. visible part of the tooth, but there is also another route of infection - through the apical foramen of the tooth, which is the anastomosis of the tooth root, through which blood vessels and nerve endings are connected to the tooth.

Let's consider how the integrity of the dental “chamber” is violated and infection gets into it:

• Violation of the integrity of the tooth due to incorrect actions of the doctor (poor quality filling, grinding of the tooth, surgical intervention in the jaw);
• Sinusitis, which may affect the upper teeth;
• Fracture of the crown or root of a tooth; children especially often break their front teeth;
• Increased tooth wear, which is often facilitated by the presence of diseases such as or;
• Incorrectly selected and installed braces;

Other causes of pulpitis include:

• Failure to comply with personal hygiene rules for oral care;
• Overheating of the pulp during dental treatment;
• Incorrect methods of dental treatment, including caries;
• Toxic effect of filling material on the tooth;
• Use of low-quality materials in dental treatment;
• Presence of infection in the blood.

Classification of pulpitis

The classification of pulpitis distinguishes the following types of this disease:

Acute pulpitis. It is characterized by an acute course of inflammation with severe radiating pain, worsening at night or when the tooth comes into contact with hot or cold. The acute form of pulpitis is divided into the following subtypes:

• Serous - is the initial stage of pulp inflammation, without the formation of purulent exudate;
• Focal purulent - is the second stage of pulp inflammation, in which purulent exudate is formed in the dental cavity, and the pain sometimes goes away when the tooth comes into contact with a cold substance;
• Diffuse purulent.

Chronic pulpitis. Usually it is a continuation of the development of acute pulpitis. Characterized by mild pain with frequent exacerbations. Sometimes it occurs with minimal symptoms, but pathological processes continue to destroy the tooth. The chronic form of pulpitis is divided into the following subtypes:

• Fibrous – is the initial stage of chronic pulpitis, which is characterized by the proliferation of connective tissue of the pulp, while the inflammation is almost asymptomatic;
• Hypertrophic (proliferative) – is a continuation of fibrous pulpitis, in which the pulp tissue grows through the carious cavity of the tooth, a fibrous polyp is formed;
• Gangrenous - characterized by the disintegration of pulp tissue.

There is also retrograde pulpitis, which is characterized by infection entering the pulp tissue through the apical foramen of the tooth.

Diagnosis of pulpitis

Diagnosis of pulpitis includes following methods examinations:

• Taking anamnesis;
• Visual examination of teeth;
• Questioning the patient about the nature of the pain, which is necessary for differential diagnosis pulpitis;
• teeth.

How to treat pulpitis? Treatment of pulpitis can be carried out by two main methods, which largely depend on the type of inflammation, so it is very important to turn to a doctor who will not only be able to accurately diagnose the disease, but also carry out the necessary therapeutic manipulations.

1. Treatment of serous pulpitis, i.e. without the presence of purulent exudate, usually involves applying a bandage or pad containing an antibacterial or alkaline agent to the pulp. These manipulations help destroy the infection, neutralize the acid produced by the infection (which actually destroys the teeth) and the formation of secondary dentin.

2. One of the popular methods of treating pulpitis of primary teeth is surgical removal of the pulp tissue (partially).

3. Treatment of purulent and chronic pulpitis is aimed at removing the “nerve”, sanitizing the roots of the tooth and removing the infection, after which filling is done, first of the roots of the tooth, then of the entire tooth.

The treatment of pulpitis by filling a tooth is divided into 2 methods - devital and vital extirpation(amputation).

3.1. Devital extirpation implies complete removal pulp ( neurovascular bundle) tooth, which usually happens in 2 visits to the dentist. To do this, local anesthesia is administered, after which the dental cavity is cleaned, into which a devitalizing paste is then placed for a week, usually a mixture of anesthetic and paraformaldehyde (previously arsenic was used for these purposes). After a week, the mixture is removed from the tooth, the tooth is cleaned of dead pulp particles and the tooth is filled.

3.2. Vital pulp amputation (pulpotomy) represents the preservation of the pulp in the area of ​​​​the roots of the tooth, while its upper part, along with the parts of the tooth affected by infection (caries), is removed. After this, the bleeding stops, the tooth cavity is sanitized antibacterial agents. Afterwards, a temporary filling is placed for approximately 6 months.

After this time, the temporary filling is replaced with a permanent one. The tooth can additionally be fluoridated to further strengthen the tooth enamel. This method has the advantage that the natural structure and nutrition of the tooth is preserved.

If you use the devital method of treating pulpitis, the tooth actually becomes “dead”, because he does not receive the necessary nutrition. Therefore, in case of repeated tooth infection, the disease will be more difficult to identify, since there may not be obvious clinical manifestations.

Traditional treatment of pulpitis, of course, does not replace the basic doctor’s procedures aimed at eliminating the inflammatory process in the pulp and filling the tooth, but it can help relieve painful sensations and destroy the infection, as well as relieve inflammation.

Important! Before using folk remedies, consult your doctor.

Baking soda, hydrogen peroxide and lemon. Make a mixture of half a teaspoon, 15-20 drops of hydrogen peroxide and 5 drops. Soak a cotton swab in this product and apply it to the affected area. The product will help relieve pain and disinfect the inflamed pulp.

Propolis. Take some, roll it into a ball and place it in the carious hole of the tooth. Place a cotton swab on top for 20 minutes.

Propolis and calamus root. Mix 1 teaspoon of propolis tincture with 1 tbsp. spoon and 2 tbsp. spoons warm boiled water. Rinse the affected tooth with this mixture and the pain will soon subside. The course of treatment is 30 days.

Horseradish tincture. Apply a cotton swab dipped in grated horseradish tincture to the affected tooth. This will help relieve pain and eliminate infection.

Onion peel. 3 tbsp. Pour a glass of boiling water over spoons of onion peel. Let the product sit for about 30-40 minutes, after which you can start rinsing your mouth with the prepared infusion.

Prevention of pulpitis

Prevention of pulpitis- This is, first of all, proper oral care and timely treatment of caries. To do this you need:

• If a hole or black plaque appears in a tooth, contact your dentist in a timely manner;
• It is advisable to visit the dentist once every six months for preventive examination teeth;
• Observe ;
• Regularly;
• Do not leave chronic diseases to chance.

Dentists often have to deal with patients who come for an appointment with advanced caries that has turned into pulpitis. Many people put off visiting the doctor until the last minute, while the tooth affected by caries continues to decay. They cite lack of time, money, or are simply afraid of treatment. But the disease does not disappear anywhere, and as a result, pulpitis develops. Some patients are so irresponsible about their health that even after the development of pulpitis they continue to delay visiting the clinic, trying to get rid of tooth pain on their own.

Important! Pulpitis – serious illness, requiring speedy treatment. However, even this is not the limit of destruction of a diseased tooth. Untreated pulpitis causes the risk of periodontitis, which requires more serious treatment. If measures are not taken in time, tooth extraction may be necessary, which leads to displacement of the dentition and malocclusion. After this, the patient can no longer chew food well enough, and this is fraught with the development of gastrointestinal diseases.

Many patients have encountered the phenomenon of periostotitis (flux) at least once in their lives. This disease is a complication of pulpitis. If a person suffers pain without consulting a doctor, the nerve located in the dental canal dies, and pus accumulates near the root, which swells the gums and cheek. The pus, unable to come out, collects in the tooth cavity, beginning to put pressure on the nerve endings, thereby intensifying the already mild pulpal pain.
Let's figure out what pulpitis is, how to recognize it, what the treatment for this disease is, what types and forms of the disease exist, and what complications it can cause untimely application to the dentist.

Attention! Even before the advent of such a branch of medicine as dentistry, people knew that exposure to the deep tissues of the tooth causes terrible pain. This was widely used during the Inquisition. For torture, the inquisitors used a mechanical device similar to a drill. With its help, they crushed and drilled the victim's teeth, getting to sensitive soft tissues. Such an impact caused the person unbearable pain, causing loss of consciousness. When a person lost consciousness, he was returned to consciousness and continued to be tortured, repeating the execution over and over again. After a few days of such torture, the unfortunate man died from painful shock.

Pulpitis is a dental disease characterized by inflammation of the nerve bundle (pulp), which is affected by external or internal factors. The pulp is a soft tissue riddled with nerves and blood vessels. That is why it is so sensitive, and its inflammation or mechanical damage causes severe pain.

The pulp of a tooth is loose, fibrous connective tissue, which fills the tooth cavity. It consists of the cellular part, the main substance, fiber, blood vessels, and nerves.

This is due to the fact that the inflamed pulp swells, increases in size and puts pressure on the nerve endings.

Attention! In the acute course of the disease, the pulp is covered from above by carious tissue, and in the case of chronic pulpitis, it is open and visible in the opening of the cavity. The chronic form of the disease is not accompanied by as much pain as the acute form. Painful sensations are aching in nature, intensifying when a chemical or thermal irritant hits the pulp.

When a person eats, food particles fall into the open cavity. If they are not removed from there, they clog the hole, begin to decompose and irritate the pulp, causing pain. The most difficult thing to remove from the cavity is the remains of solid food (pieces of vegetables, nuts or seeds).

How does pulpitis develop?

The main reason causing disease, is advanced caries. The carious cavity expands and deepens, allowing bacteria to freely enter the soft tissues of the tooth. Penetration of infection can be direct or indirect. When the pulp is open, microorganisms have direct access to it. When the pulp is covered, bacteria enter through the dentinal tubules.

This figure shows all the stages of development of pulpitis, which show how, as a result of damage to the outer and middle shells of the tooth, inflammation and destruction of its nervous system occurs.

Doctors distinguish two ways for infection to enter the pulp: through the crown of the tooth and through the apex of the root. The first method is a complication of deep caries. With the second method of infection, it is customary to talk about retrograde pulpitis. For some infectious diseases of the body inflammatory process may affect maxillofacial region. In this case, infection and inflammation of the pulp may begin. If foci of inflammation are located close to the teeth, there is a risk of developing pulpitis. Such foci are often maxillary sinuses. For example, if a person develops sinusitis, the infection can spread to the tooth. Patients suffering from sinusitis often consult a doctor with complaints of toothache. When a periodontal pocket - the space between the tooth root and the gum - becomes infected, the infection can rush to the root apex, causing pulpitis.
Very often the disease appears due to improper treatment or doctor errors. If the doctor does not follow the technology for preparing and filling a tooth damaged by caries, this can lead to the development of pulpitis. To the most common mistakes committed by doctors can include:

• overheating of tooth tissues during preparation;
• accidental damage to the pulp chamber with the installation of a permanent filling;
• violation of the technique of grinding a tooth for a crown.

As a result of improper treatment, the patient begins to experience pain, and the dentist has to redo his work.

Important! Exist different shapes pulpitis, the rarest of them are traumatic and concremental pulpitis. Traumatic pulpitis occurs as a result of a fall or blow. The most vulnerable are the front teeth, which are easily injured in this way. Traumatic pulpitis is non-infectious, but its symptoms are completely similar to the usual form of the disease that develops as a result of inflammation of the pulp. Concrete pulpitis develops under the influence of salt deposits (denticles and petrification) that accumulate on the teeth. These deposits put pressure on the soft tissue and irritate the nerve endings, causing inflammation.

Acute and chronic forms of the disease

Pulpitis, like any disease, has three stages: acute, chronic, and an exacerbation stage. As a rule, acute pulpitis appears first, which, if left untreated, becomes chronic. The chronic form of the disease is accompanied by periodic exacerbations. Sometimes the disease does not have acute stage, and a chronic, sluggish form immediately develops. Some patients have no exacerbations chronic illness, and it gradually, unnoticed by a person, turns into periodontitis. These processes are associated with individual characteristics the body of every person.
The pathogenesis of the disease has a direct connection with its cause. The main reasons: infection, injury, as well as the irritating effect of the material from which the filling is made. However, all inflammatory processes, regardless of their etymology, have many similarities. Thus, pulpitis triggers a number of structural changes in the tooth: the pulp swells, blood circulation is disrupted, cells cease to receive sufficient oxygen, the process of removing toxins becomes difficult and necrotic areas form in the tooth.

Acute pulpitis is an inflammatory process that affects the pulp chamber, crown and root canals of the tooth. It is diagnosed after an instrumental examination of the oral cavity, dental radiography, electroodontodiagnostics, and is treated surgically - through amputation of the dental pulp.

Acute pulpitis is of two types: focal and diffuse. In one and the other case, pain appears both with and without exposure to the diseased tooth. The irritant that provokes the resumption of pain can be anything. Usually these are sour, sweet, spicy or cold foods. Attacks of pain are interspersed with short periods of calm, and the pain intensifies at night.

Attention! In the focal form of the disease, the pain has a specific localization, and the patient clearly knows where exactly it hurts. In the diffuse form, the pain does not have a clear localization, so it can radiate to the ear, eye, temple, cheekbone, jaw, head or occipital region. This phenomenon occurs due to irritation trigeminal nerve. If this happens, the doctor conducts additional diagnostics to find the location of the pain.

Chronic forms of pulpitis include fibrous, hypertrophic, gangrenous. The name of these diseases characterizes the processes occurring in the diseased tooth. If left untreated, there is a risk of developing irreversible changes in the dental tissues. In the fibrous form, the tissue of the inflamed nerve bundle degenerates into fibrous tissue. If the disease takes hypertrophic form, the pulp tissue begins to grow, filling the entire carious cavity. This phenomenon is popularly called “wild meat”. At gangrenous form the crown and partly the root tissue of the tooth dies.
Chronic pulpitis, as a rule, is accompanied by regularly recurring, mild, aching pain. There is no strong sensitivity to irritants, especially hot ones. Painful sensations often recur at intervals of several months. The duration of pain attacks will vary for each patient. Exacerbation of chronic pulpitis can be caused by infectious diseases, stress, hypothermia, weakened immunity. During an exacerbation, the patient again experiences severe pain.

How does pulpitis develop in different groups of teeth?

Every tooth can be susceptible to pulpitis, but some are more vulnerable. The “sixes” or first molars are at risk. They are located in an unprotected area, and their fissures (natural depressions) are deep and closed. The Sixes are first permanent teeth, erupting in children as early as six years of age. Therefore, caries often affects them first. Parents often do not pay attention to the appearance of stains on these teeth in their child. As long as the tooth does not hurt, the child does not complain, so it is very easy to skip the initial stage of caries. But if children's teeth are not treated, caries can quickly turn into pulpitis.
If the disease affects the front teeth, it is usually the central and lateral incisors.

The development of pulpitis begins with the penetration of carious infection into the deep layers of the tooth, a color change in the tooth and carious destruction of enamel and dentin appear. Pain occurs as a result of inflammation of the pulp tissue.

Fangs are the most resistant to caries due to their structure. The lower anterior teeth are less susceptible to caries and, as a result, pulpitis. A large amount of saliva accumulates in this area, which serves as a natural protective factor against microorganisms and acids that destroy teeth. It contains minerals (calcium, phosphorus) that are necessary to restore enamel.
However, another problem awaits the lower teeth: most often it is on these teeth that tartar is deposited. The reason for this is the same saliva containing minerals that easily turn into dental plaque.

Why is pulpitis dangerous?

The disease is dangerous due to the development of complications. The main reason for this is delay in treatment and the use of a large number of painkillers. Attempts to wait out the pain or treat the tooth with painkillers lead to the loss of precious time and trigger the development of complications. The most likely complication is periodontitis - inflammation of the tissues adjacent to the root. Periodontitis is classified into acute and chronic forms. Acute periodontitis is characterized by severe throbbing pain, increased temperature, swelling of the tissues adjacent to the tooth and a feeling of fullness. When performing treatment, the doctor opens the tooth, releasing a large amount of unpleasant-smelling pus.
Another sign chronic periodontitis- the appearance of fistulas on the gums - channels for the removal of pus. Pus accumulates and periodically comes out through this hole, bringing temporary relief to the person.

Dental periodontitis is a disease that occurs when the apex of the tooth root becomes inflamed. It develops in the absence of timely treatment of tooth pulpitis or as a result of poor-quality root canal filling.

Chronic periodontitis, in which cysts develop, is very dangerous and difficult to treat. The tissue around the root grows and forms granulomas (sacs filled with pus). When a tooth is removed, these cysts are clearly visible. They hang from the roots and are red or bluish in color. Patients who saw them remember this unpleasant sight for a long time.
The above complications are not the most dangerous. Pulpitis and periodontitis lead to tooth loss, but this is far from the worst thing that can happen to a patient. With absence adequate treatment the risk of developing even more serious diseases increases, which lead not only to tooth loss, but also to serious health problems, and in advanced cases, even death. This includes complications such as periostitis, abscess, cellulitis, osteomyelitis and sepsis.
Periostitis is a disease in which the inflammatory process affects the periosteum. Pus penetrates underneath and causes inflammation. The patient has a high temperature, general weakness, the gums swell, changing the shape of the face. Experiencing severe suffering, the patient often regrets that he did not see a doctor in time and did not cure the pulpitis.
Osteomyelitis – dangerous disease, which is the dissolution of the jaw bone. If osteomyelitis is not treated for a long time, then jawbone becomes very fragile and may break. Such cases occur when a patient with advanced osteomyelitis finally goes to the dentist. During medical procedures, a fracture or breakage of part of the jaw bone may occur.
Abscess and phlegmon are purulent inflammations that are serious complications of pulpitis. Abscess is local purulent inflammation, and phlegmon is spilled. They develop when the infection becomes life-threatening. important vessels and nerves and can result in the death of the patient.
Sepsis is infection of the blood by toxic breakdown products of infected tissues. Infected blood spreads throughout the body. The result may be death.
From all of the above, it is clear what serious problems can be caused by seemingly harmless caries that turns into pulpitis. To protect yourself from these severe illness, it is necessary to treat caries and pulpitis in a timely manner, without waiting for complications to develop. The earlier treatment is started, the fewer problems can be avoided.

How to recognize pulpitis by symptoms?

To avoid serious health problems, it is important to recognize pulpitis promptly and consult a doctor. The disease has a pronounced severe symptoms, which allow you to diagnose it yourself without much difficulty.
The main symptom of pulpitis, which distinguishes it from caries, is acute spontaneous pain.

Acute pulpitis is pain that is provoked by various irritants (sour, sweet, spicy or cold foods). The attacks of pain either subside, then resume again, and in the evening the pain intensifies many times over.

With caries, pain occurs only upon contact with an irritant. Symptoms acute periodontitis are unbearable pain, which does not even allow you to touch the tooth, an increase in temperature and poor health of the patient.
Chronic pulpitis is more difficult to diagnose. If the carious cavity is open and soft tissue is visible in it, this indicates hypertrophic pulpitis. And if food entering the cavity causes prolonged aching pain, we can talk about gangrenous or fibrous pulpitis.

Important! The symptoms of chronic periodontitis are similar to the symptoms of chronic pulpitis, only with periodontitis, fistulas form on the gums, the gum itself swells, and pus periodically oozes from under it.

Knowing the signs of the disease, you can diagnose yourself preliminary diagnosis. Accurate diagnosis Only a doctor can determine it after a comprehensive examination.

Treatment methods and preventive measures

After making a diagnosis, the dentist decides how exactly the treatment will be carried out. Pulpitis can be treated in three ways: preserving the nerve, partially removing it, and completely removing the pulp. Of these three methods, doctors most often use the last one. Preservation of the pulp is often accompanied by complications, and partial removal is used in cases where, due to the complex structure of the dental canal, it is impossible to treat it completely.
High-quality treatment involves careful treatment of the root canals and filling them. During the treatment process, the doctor treats the canals with special needle-like instruments (files), then rinses them with a disinfectant, and then seals them. For filling, special hardening materials are used. Treatment is carried out under local anesthesia.
In most cases, pulpitis cannot be cured in one visit to the doctor. The patient may need to visit the dentist 2-4 times. This occurs when the doctor places a temporary filling in the root canal that contains arsenic, an antiseptic, or medicinal product. The patient wears this filling for several days.
If the treatment is carried out correctly, the patient should not have any pain. Sometimes there are post-filling pains that appear when chewing or pressing on the tooth, but they go away within a few days.
The main way to prevent pulpitis is timely treatment of caries. It is best to maintain oral hygiene to protect yourself from caries. Basic measures to prevent dental problems:

• brushing your teeth in the morning and evening, as well as every time after meals;
• cleaning the interdental spaces with dental floss;
• limiting sweet foods;
• undergoing a preventive examination at the dentist twice a year;
• removal of tartar;
• remineralization and fluoridation of tooth enamel.

The pulp is the inner part of the tooth, which contains the neurovascular bundle. Normally, it is protected from external environment hard dental tissues. If the enamel and dentin are affected by infection and caries or are injured, the pulp chamber loses its integrity and its contents become inflamed. This is how tooth pulpitis develops, the symptoms and treatment of which everyone should know, because this disease is very common.

Causes of tooth pulpitis

The pulp of a tooth can become inflamed under various circumstances. Most often this is a consequence of the progression of caries, which penetrates deep into the tooth. But there may be other reasons:

• Fractures and chips of teeth with damage to pulp tissue.
• Careless rendering dental services with tooth decay or incomplete removal of dead tissue.
• A complication of other dental diseases, in which the infection spreads not from the crown, but from the root, which provokes the development of retrograde pulpitis.
• A rare non-infectious form of pulpitis, calculiform, occurs in older people due to the accumulation of deposits in the root canals, causing the pulp to be compressed.

First, a protective defense develops in infected soft tissues. immune reaction- inflammation. More blood flows to the infected tooth so that the contents in it immune cells could destroy pathogenic microorganisms. The inflammatory process is expressed by pain and increased local temperature.

Further progression of the disease leads to tissue death and decay, therefore, in advanced stages of the disease, it is no longer possible to cure inflammation of the pulp - it must be completely or partially removed from the tooth.

Symptoms of acute tooth pulpitis

Acute pulpitis is accompanied by inflammation of tissues in a closed dental cavity and is accompanied by the following symptoms:

• Acute severe pain that occurs at any time of the day, especially when exposed to irritants - food, drinks. After eliminating the irritant, the feeling of discomfort does not subside for a long time - this symptom distinguishes pulpitis from caries. When tapping on a tooth, the patient may not feel increased pain - this distinguishes this disease from periodontitis.
• Headaches and painful sensations in the ear near a sore tooth.
• Inflammation can cause nearby lymph nodes to swell.
• A violent inflammatory process can cause an increase in not only local, but also general body temperature. The temperature during pulpitis can reach 38 °C.
• Due to the destruction of the inner part of the tooth, a dark gray spot is visible under the enamel.

Forms of acute dental pulpitis and their manifestations

The initial stage of acute pulpitis, which occurs in the absence of suppuration, is called serous. If acute pulpitis develops into purulent form, a person notices a peculiarity in the manifestation of pain: it intensifies when exposed to heat due to the activation of local blood circulation and subsides under the influence of cold. Purulent-inflammatory phenomena may be accompanied by foul breath.

Acute pulpitis is divided into focal and diffuse. The difference between these two types of disease can be determined by the nature of the pain: with focal pulpitis, the patient can feel exactly which tooth is sick; with diffuse pulpitis, the pain spreads along the jaw along the trigeminal nerve.

Acute pulpitis of three molars

Signs of chronic tooth pulpitis

The chronic form of pulpitis is most often diagnosed in patients as a complication acute form. It happens that acute pulpitis does not precede chronic pulpitis, then the disease may develop slowly and asymptomatically.

Chronic pulpitis develops in three successively changing forms, which differ in the characteristics of the processes occurring inside the pulp chamber:

Form of chronic pulpitis	Features of the course, how a tooth hurts with this form of pulpitis
Fibrous	The pulp chamber may be closed or have an opening. It is asymptomatic or accompanied by aching toothache from eating hot or cold food.
Hypertrophic	More often develops in childhood. The tooth hurts due to the filling of the inner chamber with tissue, which is popularly called wild meat. The tissue becomes irritated when chewing food.
Gangrenous	If the pulp chamber is closed, the tooth hurts severely and the temperature may rise. If the cavity is open, symptoms may be mild. The process of necrosis of inflamed tissues can be expressed by an unpleasant putrid odor from the mouth.

Hypertrophic pulpitis

Gangrenous pulpitis

Signs of pulpitis under a filling

If the patient visited the dentist for treatment of caries, he may feel discomfort some time after filling. This happens if an infection gets under the filling material and destroys the tooth, which happens when enamel and dentin affected by caries are not completely removed.

Such pulpitis can be recognized by the same symptoms that are characteristic of the acute or chronic form of the disease - depending on the path of its development.

With pulpitis, the enamel surrounding the filling may take on a characteristic gray tint.

Signs of complications

If pulpitis was treated incorrectly or not treated at all, it provokes various complications. Such diseases can be dangerous not only for health, but also for life, so you need to be able to recognize their symptoms in time:

How to determine pulpitis

At home, the patient cannot accurately determine the diagnosis. Having identified symptoms similar to manifestations of pulpitis, you need to go to dentistry, where not only the correct diagnosis will be carried out, but also effective medical care will be provided.

When a patient visits the dentist, the doctor can diagnose pulpitis by examining the patient with a mirror and palpating the tooth with instruments. In this way, the condition of the tooth is determined: whether it has holes in the pulp chamber, whether it can bleed, whether it is firmly held in the alveolus of the jaw.

To clarify the diagnosis, you may need x-rays and EDI, which allows you to assess the viability of the nerve in the diseased tooth.

Without additional hardware methods, it may not even be possible to determine some forms of pulpitis experienced dentists. Difficulties may arise if the disease is caused not by caries, but by inflammation of the root apex - then the tooth looks healthy in appearance. It can be difficult to detect a diseased tooth when diffuse pulpitis causes pain that spreads throughout the entire dentition.

Treatment of tooth pulpitis

The method of treating pulpitis depends on the degree of damage, providing effective assistance only possible in dentistry. If symptoms of dental pulpitis occur, the first thing you should do is make an appointment with a doctor, and not self-medicate. If your tooth hurts badly, you should ask your doctor what painkillers you can take by calling him. Selecting analgesics, and even more so antibiotics, on your own is very dangerous to your health.

Treatment of pulpitis in dentistry can be carried out in several ways:

• Conservative or biological method. It is used only for the treatment of young patients in the initial stages of inflammation of the dental pulp. It consists of applying a special medicinal disinfectant to the living pulp. After the inflammation is eliminated, a filling is placed.
• Surgical methods. Used when various degrees tooth damage. The pulp can be removed partially (by amputation) or completely (by extirpation). The nerve is removed on the day of the visit under anesthesia (vital method) or a certain time after killing the nerve (devital method). The hole in the tooth after the intervention is closed with filling material.

Advanced stages of pulpitis or complications that threaten the patient’s health may be an indication for removal of the affected tooth. If inflammation of the tooth pulp leads to Negative consequences, a longer and complex treatment, allowing to prevent or eliminate general infection of the body.

The appearance of a carious cavity in a tooth and an increase in its sensitivity can be harbingers of pulpitis. Therefore, the condition of the oral cavity, healthy and filled teeth must be carefully monitored. The initial stages of the disease are treated faster and with less discomfort than advanced purulent or gangrenous pulpitis, which can cause general intoxication of the body.

Pulpitis is an inflammation that occurs in the neurovascular bundle of the tooth, which is often defined as a nerve. Pulpitis, the symptoms of which consist of severe pain (intermittent or continuous), is essentially a consequence of previously neglected caries by the patient. It is after this that the diseased tooth is destroyed so badly that the infection freely enters the very root of the tooth, affecting the nerve.

general description

In addition to the complication that follows caries, pulpitis also often occurs due to the incorrectness of certain actions on the part of the doctor. In particular, these include the use of low-quality fillings and improper grinding of the tooth carried out for the subsequent installation of orthopedic structures. It may also be incorrectly produced surgical interventions affecting the periodontium or negative impact, provided by certain chemicals. Medical practice, in addition, indicates the relevance of cases of retrograde pulpitis, in which infection occurs through the apical foramen.

In general, the reasons that lead to inflammation of the pulp are more than diverse, and it can be provoked by acute or chronic irritations.

Mostly pulpitis is the result of a combined effect from microbes that are located deep in carious lesions. In particular, these may be streptococci, lactobacilli or staphylococci, as well as their toxins, waste products and dentin decay products.

As for the routes of penetration and sources of infection entering the pulp, they are also different - in addition to the path in the form of dentinal tubules through a carious cavity, infection can provoke pulpitis during trauma (especially this type, which is combined with a tooth fracture). A fairly common occurrence among children is trauma that occurs in the area of ​​the front teeth. In this case, even the breaking off of even part of the tooth without opening its cavity makes infection possible. In the same case, if the injury leads to exposure of the pulp, the inflammatory process forms within the next few hours from its moment. Accordingly, infection is the leading factor provoking the formation of pulpitis.

As we have already noted, with rough or careless treatment of a carious cavity, exposure and subsequent infection of the pulp also becomes possible, which occurs in combination with the inflammatory process. It should be noted that pulpitis in extremely rare cases forms without dental caries.

Main forms of pulpitis

The following forms of pulpitis are distinguished:

• In accordance with the characteristics characteristic of a particular localization:
• Coronal pulpitis;
• Total pulpitis;
• Root pulpitis.
• In accordance with the nature of the disease:
• Acute pulpitis;
• Chronic pulpitis;
• Chronic pulpitis with exacerbation.

The acute form of pulpitis forms in close proximity to the carious cavity in the form of a focal lesion, after which serous inflammation occurs (that is, serous pulpitis). As a result of this process, one can notice the severity of vascular hyperemia in the microcircular bed, as well as the formation of serous edema in combination with a slight accumulation of leukocytes. In addition, mild degenerative changes are formed in the nerve fibers. The duration of this stage of the course of pulpitis is about several hours, after which the severity of the migration of neutrophils is noted along with dystrophic changes in the nerve fibers of the pulp, which are caused by the breakdown of myelin. Subsequently, the disease develops into a diffuse form of pulpitis or purulent focal pulpitis.

Focal purulent pulpitis is limited in nature of its formation; in addition, it is also characterized by filling in the form of purulent exudate with the formation of an abscess after it. Diffuse purulent pulpitis can occur not only with filling of the coronal part of the pulp, but also with filling of its root part (phlegmon). The pulp has a grayish color, and there is severe damage to all its structural elements.

The communication of the pulp cavity with a carious cavity in combination with the penetration of anaerobic flora can lead to the formation of pulp gangrene. As a result of this process, it takes the form of a gray-black mass with a putrid odor, as a result of which any of its structure is lost. The pulp may also have a granular appearance, and it contains microbes in combination with crystals. fatty acids. Due to the transition of the inflammatory process to the root pulp, apical periodontitis begins to develop. The duration of the acute form of pulpitis in general is about 3 to 5 days.

The development of chronic pulpitis occurs in its form as independent form, however, it can also develop against the background of acute pulpitis.

Morphological characteristics determine the following division of pulpitis:

• Gangrenous pulpitis. Its development begins with an acute form, in particular, its occurrence is accompanied by partial death of the pulp. The part of the pulp that has been preserved has serous inflammation with the characteristic formation of granulation tissue, due to which the dead masses are limited.
• Hypertrophic (granulating) pulpitis. For this type of pulpitis, it is important to comply with the chronic nature of inflammation. The granulation cavity replaces dental cavity, in some cases also filling the carious cavity, which, in turn, communicates with the dental cavity. This course is also characteristic of a pulp polyp, which is characterized by the softness of the formation and its easy bleeding.
• Fibrous pulpitis. IN in this case We are talking about a process in which most of the tooth cavity contains many collagen fibers and plasma cells, as well as cellular infiltrates based on lymphocytes.

Pulpitis: symptoms

Pulpitis in general is characterized, as we have already noted, by continuous or intermittent tooth pain, which is especially acute at night. In addition, there is also a change in temperature.

The initial stage of pulpitis is characterized by infrequent aching pain, while its more advanced forms occur with a gradual increase in painful sensations, and over time they only worsen, becoming pulsating and prolonged. The chronic form of pulpitis, as a rule, occurs with pain only when it worsens. Also for chronic form Pulpitis, along with its purulent form, is characterized by pain that occurs even in the case of slight tapping in the area of ​​the affected tooth.

At acute focal, and also when diffuse In pulpitis, the main symptoms are reduced to very severe pain of a radiating nature (that is, spreading) along the branches of the trigeminal nerve. Increased pain, again, is noted at night, but in general they are characterized by their own periodicity. The affected tooth is extremely sensitive to the irritants affecting it, and even eliminating the irritant does not help reduce the pain or its disappearance. When tapping (percussion), there is a lack of tooth sensitivity or slight sensitivity.

Flow chronic fibrous pulpitis characterized by the absence in most cases of any symptoms, in some cases the occurrence of minor discomfort is noted.

Hypertrophic chronic pulpitis, As a rule, it develops against the background of the fibrous form in those situations in which the crown has been largely destroyed, and the pulp is exposed and is constantly exposed to mechanical irritation and infection in general. When a tooth is tapped, it may become sensitive, but this sign leading and constant is not when considering this disease. The radiograph determines the absence of significant changes in the area of ​​​​the bone tissue of the root apexes.

X-ray examination of pulpitis in relation to temporary teeth indicates in more than 55% of cases the presence of destructive changes arising in the periodontal tissues.

Gangrenous chronic pulpitis can occur with severe pain, the tooth is extremely sensitive to hot influences on it, while cold, on the contrary, has a calming effect on the pain.

As for exacerbations that are relevant for chronic pulpitis, they are characterized by paroxysmal pain that occurs in the tooth, and this pain occurs spontaneously - that is, without the influence of any irritating factors per tooth Long-lasting pain is also possible, arising under the influence of external stimuli with active irradiation along the branches of the trigeminal nerve. Most often, in this case, the tooth cavity is open, and pain occurs when attempting to probe the pulp.

Regarding the complications that pulpitis can entail, it can be noted that the lack of proper treatment, as well as inadequate treatment of the root canal system or lack of tightness during tooth restoration can lead to periodontitis.

Treatment of pulpitis

• Conservative method . In this case, the viability of the pulp is preserved. The method is especially effective in use for young people, but it is used only in the reversibility of pulp disease (for example, with traumatic pulpitis). Treatment is carried out in a similar way to the treatment of caries, with particular attention paid to medicinal treatment of the affected cavity. Antibiotics, antiseptics, and proteolytic enzymes are used for this. The exception is drugs with enhanced action, including ether and alcohol.
• Surgical method. This treatment method involves removing the inflamed pulp. Using filling material, the root canal of the tooth is filled. One of two methods can be used to remove pulp:
• Vital method. Implementation this method possible for any form of pulpitis. For removal, local or general anesthesia is used.
• Devital method. To use this method in pulp removal, it is necessary to first kill the nerve.

Early treatment of pulpitis makes it possible to preserve the nerve, which is necessary to ensure normal nutrition and vital activity of the tooth, and therefore, when the first symptoms characteristic of pulpitis appear, you should immediately contact a dentist.

Pulpitis - inflammation soft fabric tooth (pulp), which is accompanied by severe pain and can lead to tooth loss. It is the most common consequence of caries. Leads to the development of periodontitis and osteomyelitis. Today we will learn what pulpitis is, and also consider the symptoms, causes, consequences, methods of treatment and classification of pulpitis. Let's start with a definition.

The pulp is a neurovascular bundle. It is located under dentin, which is covered with tooth enamel. Its main task is to nourish the tooth from the inside. When the pulp becomes inflamed, a disease called pulpitis occurs. Most often, the disease is a complication of caries. That's why main reason its origin, as in the case of caries, is an infection, for example streptococcus. It follows from this that the prevention of pulpitis should include protecting teeth from infection, which is achieved through proper oral care. Statistics show that 20% of patients who complain of toothache are diagnosed with pulpitis. This problem occurs especially often in children whose baby teeth have not yet been replaced by permanent teeth.

Development of the disease

It all starts with the appearance of plaque on the tooth. Plaque is an “explosive mixture” of food debris and pathogenic microflora. Over time, food debris begins to decompose, and infectious microorganisms produce acid during their life processes. Decaying food, together with this acid, begins to “eat” tooth enamel, which is nothing more than the surface protective layer of the tooth. Damage to the enamel is called caries. How longer teeth do not receive proper care, the more active the processes for their destruction are.

When the infection penetrates the tooth enamel, it begins to attack the dentin. This is the name of the main part of the tooth, which is actually bone. Dentin is the last barrier to infection reaching the pulp. Passing through it, pathogenic microorganisms affect the nerve endings and blood vessels located in the remote control. This is precisely what is connected with strong pain observed with pulpitis.

The onset of the disease is accompanied by throbbing pain and increased sensitivity of the teeth to temperature changes. Pain from pulpitis can spread to several adjacent units or even to the entire jaw. Moreover, if you do not see a doctor in time, the disease can cause headaches.

Symptoms

The main symptom of this disease is pulsating toothache. It can radiate to the head and ears, so people with pulpitis sometimes go for help not to the dentist, but to an ENT doctor. The pain intensifies at night, when chewing food, as well as when the tooth is exposed to low or high temperatures. In addition, pulp inflammation may be indicated by:

• gray enamel of a diseased tooth;
• the presence of an open cavity in the tooth;
• bleeding from a tooth;
• insomnia;
• irritability.

Nonspecific signs of pulpitis include headache and fever.

Complications

If this disease is not treated, it can lead to the following unpleasant complications:

• periodontitis;
• tooth loss;
• sepsis;
• abscess;
• sinusitis.

Causes

The pulp becomes inflamed when it gets infected, usually of a bacterial nature (staphylococcus, streptococcus, lactobacilli, etc.). Usually the infection enters the tooth through its crown (the visible part), but sometimes the infection occurs through the apical foramen. It is the anastomosis of the dental root, through which nerve endings and blood vessels are supplied to the tooth.

Violation of the integrity of a unit can occur for the following reasons:

1. Caries.
2. Failure to comply with the rules of personal oral hygiene.
3. Careless actions of the dentist that resulted in damage to the tooth structure.
4. Sinusitis affecting the upper teeth.
5. Fracture of the root or crown of a tooth. Most often found in children.
6. Increased tooth wear caused by osteoporosis or diabetes.
7. Incorrectly selected or installed braces.

Less common reasons:

1. Overheating of the pulp during dental treatment.
2. Toxic effect of filling material on the tooth.
3. Treatment using low-quality materials.

Having learned what the disease is, how it manifests itself and why it occurs, we move on to the classification of pulpitis.

Classification

Pulpitis is mainly divided into two types: acute (purulent) and chronic. Acute, in turn, is further subdivided into focal and diffuse.

Focal pulpitis- the initial stage of the disease. The source of inflammation is located near the carious cavity. A sign of focal pulpitis is sharp pain of an arbitrary nature, which can last from a couple of minutes to half an hour. After 3-5 hours the pain may return. At night it intensifies sharply. Unpleasant sensations in the tooth, which represent a reaction to an irritant, may not leave the patient long time. With focal pulpitis, the patient clearly understands which tooth hurts. When probing, a sharp pain is observed at one point, usually near the pulp horn. In this case, the tooth cavity may remain unopened.

Diffuse pulpitis- the next stage of the disease, at which inflammation covers the entire pulp. A person may experience prolonged bouts of sharp pain. The intervals between attacks are very short. When the inflammatory process from serous turns into purulent, pulpitis makes itself felt constantly. Severe pain can occur not only in the entire jaw, but also in the temples and even the ears. With diffuse purulent pulpitis, the pain intensifies when the tooth comes into contact with a hot tooth and can weaken when it comes into contact with a cold one. This stage can last up to two weeks. Then the inflammation enters the chronic stage.

Chronic pulpitis is divided into the following types:

1. Fibrous.
2. Hypertrophic.
3. Gangrenous.
4. Retrograde.

Fibrous pulpitis occurs during the transition of acute inflammation to chronic. At this stage, severe, sudden pain is replaced by a weak, aching pain. It can occur from food irritants and when inhaling cold air. Often the disease at this stage occurs latently, without causing complaints from the patient. When the exacerbation of pulpitis passes, many people think that the pain has passed and calm down, but meanwhile the diseased tooth continues to deteriorate from the inside. Upon examination by a doctor, it turns out that a cavity has formed inside the tooth. It can connect to the pulp chamber. The pulp itself at this stage is very painful and may bleed.

Hypertrophic pulpitis- the stage of the disease at which the carious cavity merges with the tooth cavity. In this case, the pulp can grow into a polyp, which fills the entire resulting space. The patient experiences pain when chewing, which is often accompanied by bleeding. Sharp pain may also occur, which is characteristic of acute period diseases.

Gangrenous pulpitis occurs against the background of fibrosis due to putrefactive infection entering the pulp. Characterized by bad smell from the mouth and prolonged aching pain when the tooth comes into contact with irritants. The pain intensifies when eating hot food. With gangrenous pulpitis, a large carious cavity appears in the tooth, inside which you can see the affected pulp gray. Due to the fact that the nerve fibers are already atrophied, the sensitivity of the upper layers of the pulp is low.

Retrograde pulpitis. It is also called tooth root pulpitis. At this stage, periodontal pockets are formed. They occupy most of the root. It is in them that the main source of infection is located. Spreading through root canals, bacteria cause inflammation of the soft tissue of the tooth. Bone at the same time it dissolves. This can be observed using an x-ray.

Diagnostics

The doctor must be able to distinguish chronic pulpitis, the classifications of which we have examined, from deep caries, since in the treatment of these diseases they resort to different methods treatment. When a tooth is affected by caries, the acute pain that occurs when the unit comes into contact with the irritant subsides immediately after the latter is removed. In the case of pulpitis, it can remain for a long time.

To distinguish pulpitis from chronic periodontitis, you just need to knock on the tooth. With periodontitis, tapping will cause discomfort.

When a person has hypertrophic pulpitis, the tooth begins to bleed at the slightest mechanical impact.

In the case of fibrous pulpitis, the pulp can be seen in the carious cavity under a thin layer of dentin. If the dentist touches this place with a probe, the tooth will “respond” with sharp pain.

To distinguish pulpitis from inflammation of the trigeminal nerve, it is worth remembering that with tooth pathology, painful sensations intensify at night, and with neuralgia - vice versa.

Diagnosis of pulpitis consists of the following stages:

1. Detailed survey.
2. Examination of the oral cavity.
3. Probing.
4. Temperature test.
5. Electroodontodiagnostics.
6. Radiography.

Treatment of pulpitis

We have dealt with the symptoms and types of pulpitis, now we will look at how this or that type of disease is treated.

Serous pulpitis represents the stage of the disease preceding the formation of purulent exudate. It is not included in the standard classifications of pulpitis and is treated quite simply. Treatment involves applying a pad or dressing to the pulp with an alkaline solution, calcium, or an antibacterial agent. This simple manipulation helps to destroy the infection, neutralize the acid produced by microbes and form new dentin.

Pulpitis of baby teeth, usually treated by partial surgical removal of the pulp.

Purulent and chronic pulpitis treated by filling. There are two types of such treatment: devital or vital amputation (extirpation).

In the first case, the doctor performs a complete removal of the pulp. Having done local anesthesia, he cleans the tooth cavity and puts devitalizing paste into it. It consists of an anesthetic and paraformaldehyde (previously arsenic was used for this purpose). A week later, the dentist removes the mixture from the tooth, cleans the cavity of dead particles and places a filling.

During vital amputation, the healthy root part of the pulp is preserved, and the upper damaged part is removed along with the damaged areas of the tooth. Then the cavity is treated with antibacterial agents and closed with a temporary filling. After six months, the temporary filling is replaced with a permanent one. To strengthen the enamel, the tooth is sometimes additionally fluoridated. Vital amputation is good because the natural structure and nutrition of the tooth is preserved. With devital amputation, the tooth becomes “dead”. Diagnosis of recurrent diseases is complicated due to the clinical manifestations of the disease.

Folk remedies for treating pulpitis

Of course, with the help traditional treatment It is impossible to completely eliminate the inflammatory process in the pulp and certainly protect the tooth from further infections. Nevertheless, it is possible to relieve pain, destroy infection and partially relieve inflammation with the help of folk remedies. Before using this treatment, it is advisable to consult a specialist!

Baking soda, lemon and hydrogen peroxide. A mixture of the listed components allows you to relieve pain and disinfect the inflamed pulp. To prepare it, you need to mix half a teaspoon of baking soda, 5 drops of lemon juice and 20 drops of hydrogen peroxide. The affected area is treated with this product using a cotton swab.

Propolis. To relieve pain from pulp inflammation, you need to take a small piece of propolis, roll it into a ball and put it in the carious hole. Propolis should be covered with a cotton swab and left for 20 minutes.

For the same purpose, propolis is used in the form of a tincture. By mixing one teaspoon of tincture with one tablespoon of calamus root and two tablespoons of boiled water, you can get excellent remedy for rinsing the tooth.

Horseradish tincture. By applying a cotton swab dipped in grated horseradish tincture to a sore tooth, you can disinfect the pulp and relieve pain from its inflammation.

Onion peel. From onion peels you can prepare an effective means for rinsing the mouth in general and a sore tooth in particular. To do this, pour 3 tablespoons of crushed husks into a glass of boiling water and let the mixture brew for half an hour.

Prevention of pulpitis

Having considered the symptoms and treatment of pulpitis, it is worth talking about its prevention. First of all, the prevention of pulpitis involves careful oral care and timely disposal of caries. If black plaque or holes appear on a tooth, you should immediately contact your dentist. If everything is in order, it is recommended to visit a doctor at least once every six months - for prevention. If chronic diseases occur, they should never be left to chance. Remember that even if the tooth stops hurting, the inflammatory process inside it will not disappear on its own. Well, the last thing worth considering when talking about the prevention of pulpitis: thorough teeth cleaning required! You need to brush your teeth twice a day. And not just clean, but clean properly.

Conclusion

Today we have learned a lot about such a disease as tooth pulpitis: what it is, how it manifests itself, is diagnosed, treated and prevented. Summarizing the above, it can be noted that pulpitis is an inflammation of the soft (nervous and blood) tissues of the tooth that occurs under the influence of pathogenic microflora. For a healthy person, the main cause of pulpitis is caries, which occurs due to insufficient oral hygiene.