Irreversible Pulpitis (The Toothache That Won't Stop)

• •Severe, sharp pain to cold that lingers for thirty seconds or longer after the cold is removed (the diagnostic hallmark).
• •Spontaneous, throbbing pain that arrives without an obvious trigger.
• •Pain that wakes you up at night or worsens when you lie down.
• •Difficulty pinpointing exactly which tooth hurts (referred pain is common).
• •Pain that is poorly relieved by over-the-counter analgesics.

A deep cavity that has worked its way to within a millimeter or two of the pulp is the most common cause. Other causes include a cracked tooth, traumatic injury, a recently placed deep filling or crown, and grinding habits.

The cold test is the single most useful tool: if a brief touch of cold produces pain that lingers for thirty seconds or more, irreversible pulpitis is the working diagnosis. Periapical X-rays may look entirely normal in early stages. The endodontist also percusses the tooth, palpates the surrounding bone, and may use selective anesthesia to confirm which tooth is the source.

The only two definitive treatments are root canal therapy (which preserves the tooth) or extraction. Antibiotics do not relieve pulpitis pain because the pulp is enclosed in a rigid chamber the body cannot drain — only mechanical removal of the inflamed tissue resolves the symptom. Vital pulp therapy with bioceramic materials may be an option in a minority of carefully selected cases where the inflammation is still confined.