Pulpitis (Inflamed Tooth Nerve)

How pulpitis develops

The pulp sits inside a hard shell of enamel and dentin. When bacteria from decay or a crack get close, or when the tooth is repeatedly irritated, the pulp becomes inflamed. Because it is enclosed in rigid walls, swelling increases pressure on the nerve, causing pain. Unlike soft tissues elsewhere, the pulp has limited room and a narrow blood supply, so severe inflammation can cut off its circulation and the pulp dies (necrosis). Bacteria can then spread out of the root tip into the bone, forming a tooth abscess.

Reversible vs irreversible pulpitis

As pulpitis progresses to necrosis, the tooth may stop responding to cold, and pain on biting or a swollen gum signals infection around the root.

Causes

• tooth decay: the most common cause
• cracked tooth: pain on biting or releasing, especially with grinding. See cracked tooth syndrome
• trauma: a blow to the tooth can injure the pulp even without visible damage
• dental work: deep fillings, crowns or multiple procedures on the same tooth
• gum disease reaching the root tip, rarely
• grinding and clenching (bruxism)

Symptoms

• toothache triggered by temperature or sweet foods
• lingering or throbbing pain
• spontaneous pain, especially at night or lying down
• pain spreading to the jaw, ear, temple or other teeth
• in later stages: pain on biting, tenderness, swelling and a bad taste

Diagnosis

A dentist will:

• ask about the pain: triggers, duration, night pain, previous dental work
• examine the teeth and gums for decay, cracks and swelling
• perform cold testing: applying a cold stimulus and timing the response
• tap and bite tests to check for inflammation around the root
• take X-rays to see deep decay and changes around the root tip

Pain from sinusitis, TMJ disorders, trigeminal neuralgia and even heart pain can mimic toothache, so the dentist will also consider these.

Treatment

Reversible pulpitis

• remove the decay and place a filling
• protective liners or a temporary sedative filling for deep cavities
• treat sensitivity, cracks or grinding

Irreversible pulpitis

• root canal treatment: the inflamed pulp is removed, the canals cleaned and sealed, and the tooth restored, often with a crown. The tooth is kept
• pulpotomy: partial pulp removal, sometimes used in mature teeth with limited inflammation and routinely in children's teeth
• extraction if the tooth cannot be saved or root canal treatment is not wanted

Pain relief while waiting

The American Dental Association's 2024 guideline recommends:

• ibuprofen combined with acetaminophen (paracetamol), which is more effective than either alone for dental pain. Follow the label doses, and avoid NSAIDs if you have kidney disease, stomach ulcers or take blood thinners
• avoiding opioids when possible
• antibiotics are not recommended for pulpitis without spreading infection, because they do not relieve the pain

Other measures:

• avoid very hot, cold or sweet foods
• sleep with the head raised
• a cold compress on the cheek

Prevention

• brush twice daily with fluoride toothpaste and clean between teeth
• limit sugary foods and drinks
• regular dental checkups to catch decay early
• wear a night guard if you grind your teeth
• use a mouthguard for contact sports

Frequently asked questions

What is pulpitis?

Pulpitis is inflammation of the pulp, the soft tissue inside a tooth that contains nerves and blood vessels. It is usually caused by deep decay, a crack or trauma, and causes toothache that ranges from brief sensitivity to severe throbbing pain.

How do I know if my pulpitis is reversible or irreversible?

Reversible pulpitis causes short, sharp pain to cold or sweet foods that stops within seconds. Irreversible pulpitis causes pain that lingers after the trigger, comes on by itself, throbs, or wakes you at night. A dentist confirms which one with tests and X-rays.

Can pulpitis heal on its own?

Reversible pulpitis can settle once the cause, such as decay or a leaky filling, is treated. It does not heal while the cause remains. Irreversible pulpitis cannot heal and needs a root canal treatment or extraction.

Will antibiotics cure pulpitis?

No. Antibiotics do not relieve pulpitis pain or save the nerve, because the problem is inflammation inside the tooth. Treatment is dental: a filling, root canal or extraction. Antibiotics are reserved for infections spreading beyond the tooth with swelling or fever.

What is the best painkiller for pulpitis?

Dental guidelines recommend combining ibuprofen and acetaminophen, taken at the label doses, for the best pain relief. This combination works better than opioids for most toothaches. See a dentist promptly, because pain relief does not treat the cause.