As the saying goes, a toothache is not a disease, but a pain that really kills you. So what is the disease that most often causes it? This is what I want to introduce to you, the acute attack of chronic pulpitis. Chronic diseases such as caries, periodontal disease and other chronic injuries to the teeth such as cryptocracks and wedge-shaped defects can cause chronic inflammation of the dental pulp, as we have already described earlier. As the name suggests, the acute attack of chronic pulpitis is caused by the strengthening of external stimuli, the weakening of systemic resistance or the obstruction of local drainage and other factors. 1, pathological characteristics On the basis of the original chronic pulpitis pathology, local blood vessels are significantly dilated, congested, B out and edematous, and the infiltration of acute inflammatory cells such as neutrophilic polymorphonuclear leukocytes is significantly increased. Moreover, due to the anatomical and physiological characteristics of the pulp tissue, the pulp cavity pressure was significantly increased. This is our animal model of acute pulpitis in SD rats induced by endotoxin lipopolysaccharide, and it is seen that the blood vessels in the pulp tissue are obviously dilated and congested, and a large number of neutrophil infiltrates. 2. Clinical manifestations conformed to the general pattern of acute inflammation, i.e., redness, swelling, heat, pain, and dysfunction, but due to the special anatomical environment in which the pulp tissue is located and surrounded by dental hard tissues, it has its unique clinical manifestations. First of all, redness, swelling and heat are not obvious due to the factors of dentin and enamel, and their clinical manifestations are mainly based on unique pain, which affects normal diet and even sleep, and leads to functional disorders. 3, pain characteristics spontaneous pain, severe pain, and can be dissipated to the same side, the patient often can not clearly point out the affected tooth, hot and cold sweet and sour stimulation aggravate the pain. At the beginning of acute attack, there is sudden sharp and throbbing pain, the attack time is short, and the pain is obvious after stimulation; with the development of inflammation, the pain time is gradually prolonged, and it can last for a long time even after the stimulation is removed, the pain interval is shortened, and the degree is gradually increased until the pain turns from paroxysmal pain to continuous pain, and the pain is obvious at night, and the patient often fidgets and keeps massaging the painful part with his hand, and can wake up even after falling asleep. At the same time, the pain is dissipated along the ipsilateral trigeminal nerve, such as maxillary toothache dissipated to the auricotemporal region, and mandibular toothache dissipated to the subauricular, postauricular and mandibular regions, so that the patient often cannot clearly specify the affected tooth, or the specified painful tooth is not the affected tooth, which makes the diagnosis difficult. 4.Diagnosis Through detailed medical history, it is generally possible to make a clear diagnosis based on the characteristics of the toothache. Meanwhile, in oral examination, it is generally possible to find that the affected tooth has caries, periodontal disease, other chronic damage to the tooth or dental treatment, and in addition, it is possible to help confirm the diagnosis through necessary auxiliary examinations, such as X-ray and pulpal electrical vitality test. What is often more problematic in the diagnosis is the identification of the affected tooth. As we have described before, patients with acute attacks of chronic pulpitis often cannot clearly identify the affected tooth, and sometimes even the indicated painful tooth is not the affected tooth, so we cannot simply rely on the patient’s complaints, but must make a comprehensive analysis and judgment, which requires proper clinical thinking and certain experience. First of all, we should pursue the medical history in detail, especially paying attention to the initial onset and the patient’s dental treatment history, this is because chronic pulpitis can usually specify the affected tooth before the acute attack, while some poor dental treatment often causes acute attacks despite the fact that no abnormality can be found on the surface of the tooth. Secondly, in the oral examination, it is necessary to follow the step-by-step procedure, meticulously and without omission, especially when no clear pathogenic tooth is found on the affected side, do not forget to check the situation of the opposing teeth or even the teeth on the opposite side; very often, multiple teeth with caries, periodontal disease or other chronic damage to the dentition are often found in the painful area, which requires careful probing to determine the stage of development of each tooth condition and comprehensive analysis. Since the stimulation threshold of the affected tooth is reduced during the acute attack of chronic pulpitis, the pulp vitality test can not only exclude teeth with necrotic pulp, but also provide some reference for the diagnosis. X-ray examination can observe the degree of caries and periodontal disease on the adjacent surface of the tooth, and also analyze the condition of the tooth that has been treated by dentistry. Finally, for patients who still cannot clearly identify the affected teeth by the above methods, local anesthetic closure of individual teeth can be used if necessary, so as to identify the affected teeth. In short, the affected tooth must be clearly identified before treatment to avoid misdiagnosis and mistreatment! 5. Differentiation Acute pulpitis is not significantly different from the acute attack of chronic pulpitis in terms of symptoms, but acute pulpitis does not have a history of caries, periodontal disease or other chronic injuries to the teeth, and often has a history of trauma or recent dental treatment. The pain of acute periapical periodontitis is generally persistent and relatively mild, cold, hot, sour and sweet stimulation cannot induce or aggravate the pain, but the pain is obvious when the affected tooth bites, the pain is not obvious on probing during examination, but pain is obvious on percussion, the affected tooth may have up and down floating or slight loosening, there is a bone sparse area at the root tip of the affected tooth on X-ray examination, and the affected tooth is mostly dead pulp tooth on vitality examination. The pain of trigeminal neuralgia is also more intense, but more clear trigger points, cold, hot, sour and sweet stimulation can not aggravate or induce pain, and the pain episodes are brief, generally not more than 5 minutes, less pain at night, in addition to carbamazepine and other drugs can generally be effective in treating or relieving symptoms, while acute attacks of chronic pulpitis are generally subject to specialist treatment. 6. Principles of treatment Pain relief, preservation of the affected tooth, and restoration of function. These are also the goals of the three phases of treatment. Patients with an acute attack of chronic pulpitis are characterized by severe pain, so the first step must be to relieve the patient of unbearable pain through emergency treatment. The most effective emergency treatment is pulp opening and drainage under local anesthesia to reduce the high pressure in the pulp cavity, and soothing with drugs such as eugenol, which can be supplemented with some other pain relief methods. Pulp opening should be performed under local anesthesia with a small sharp ball drill grinding through the pulp at the site closest to the pulp (such as the bottom of the cavity) to allow the inflammatory exudate to spill out; sometimes a sharp digging spoon or a sharp probe can be used instead when conditions are not available. After 1-3 days of pulpotomy, the acute symptoms are usually relieved, and further treatment with pulpotomy or dry pulpotomy can then be used to preserve the affected tooth and restore its function. In addition, since the patient is in severe pain during the consultation, we must be more patient and meticulous during the consultation and treatment, firmly establish the concept of love and injury, and relieve the patient’s pain with noble medical ethics and excellent technology.