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Moursi > 3 - Complex Pulp Therapy > Flashcards

3 - Complex Pulp Therapy Flashcards

1
Q

How much caries can you leave behind in an IPT?

A

The carious tissue that should remain is a quantity that, if removed, would result in overt exposure. The best clinical marker is the quality of the dentin: soft, mushy dentin should be removed, and hard, discolored dentin can be indirectly capped.

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2
Q

How does IPT maintain pulp vitality?

A
  1. Arrest the carious process
  2. Promote dentin sclerosis (reducing permeability)
  3. Stimulating the formation of tertiary dentin (increases the distance between the affected dentin and the pulp)
  4. Remineralizing the carious dentin
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3
Q

What materials are commonly used in IPT?

A
  1. CaOH2
  2. ZOE
  3. GI cements
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4
Q

What are the contraindications to IPT in primary teeth?

A
  1. History of spontaneous pain

2. Any clinical or radiographic pathological signs.

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5
Q

Why is crown fracture with a luxation injury so bad?

A

Compromised pulp circulation due to luxation injury. It causes increased incidences of pupal necrosis.

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6
Q

What is the success rate of partial pulpotomy with CaOH2 on traumatically exposed permanent pulps in the Cvek study?

A

96%

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7
Q

What are the advantages of partial pulpotomy?

A
  1. Preserves cell-rich coronal pulp
  2. Increases healing potential due to preserved pulp
  3. Physiologic apposition of cervical dentin
  4. Obviates need for root canal therapy
  5. Preserves natural color and translucency
  6. Maintains pulp test responses
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8
Q

About how much pulp tissue should be removed in a partial pulpotomy?

A

About 2mm. The inflammation extends only a few millimeters into the pulp.

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9
Q

What is the instrument of choice for pulp tissue removal in a pulpotomy procedure?

A

An abrasive diamond bur, using high speed with adequate water cooling. This technique has been shown to create the least damage to the underlying tissue.

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10
Q

In a pulpotomy procedure, why should you control hemorrhage with cotton pellets slightly moistened with saline as opposed to completely dry cotton pellets?

A

Completely dry cotton pellets should not be used bc fibers of the dry cotton will be incorporated into the clot and when removed, will cause hemorrhage.

After placing the moist cotton pellets, place dry cotton pellets over it and put slight pressure on the mass to control the hemorrhage.

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11
Q

What is the benefit of using sodium hypochlorite (2.5% NaOCl) before pulp capping?

A
  1. Cause hemostasis
  2. Kills bacteria
  3. Does not damage the pulpal cells

When used as a hemostatic agent, it causes no damage to pulpal cells and it did not inhibit pulpal healing, odontoblastic cell formation, or dentinal bridging.

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12
Q

What do you place on top of a direct pulp cap with MTA or CaOH2?

A

A thin layer of intermediate restorative material or flowable composite resin and light cured. Bc the pulp cap material would wash out during the acid etching procedure.

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13
Q

What is the recommended treatment for traumatized primary teeth with pulp exposure?

A

Pulpectomy and full coverage SSC or composite strip crown.

Edit: Dental Trauma Guide states that the treatment for a complicated crown fracture is pulp cap, partial pulpotomy or extraction.

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14
Q

What can cause complications after a partial pulpotomy?

A
  1. Chronic irritation due to microleakage from an improperly adapted SSC or defective strip crown.
  2. Recurrent trauma
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15
Q

What percentage of teeth with carious pulp exposures have “normal” pulps?

A

One-third

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16
Q

What percentage of teeth with deep caries with no pulpal exposures have “abnormal” pulps?

A

One-third

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17
Q

What is the dilution for formocresol to use in pulpotomy?

A

Dilute FC using one part FC to four parts vehicle (three parts glycerine: one part water).

If dilution mixture settles out, re-mixing indicated.

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18
Q

What percent ferric sulfate is used in pulpotomy?

A

15.5% in aqueous base, pH = 1

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19
Q

What is the application time of formocresol and ferric sulfate?

A

Formocresol = 5 minutes

Ferric sulfate = 10 to 15 seconds

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20
Q

Can you do a pulpotomy in a tooth with mobility.

A

If physiologic mobility, than yes

If pathologic mobility, than no

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21
Q

What are the contraindications to a pulpectomy?

A
  1. Infection involving the crypt of the succedaneos tooth
  2. Non-restorable crown
  3. Perforation of the pulpal floor
  4. Internal resorption perforating into the underlying bone
  5. External resorption of more than one-third of the root
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22
Q

What are the indications for a pulpectomy?

A
  1. Irreversible pulpitis - continuous bleeding exceeding 5 minutes, dark to purple blood color, or pulp necrosis
  2. Radiographic periapical or inter-radicular radiolucencies w/o involvement of the follicle of the permanent tooth
  3. Internal resorption w/o perforation
  4. External resorption not involving the permanent tooth follicle, as long as more than two-thirds of the root is intact
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23
Q

In a pulpectomy, what size and type of file is used?

A

A series of 21-mm K-type endodontic files up to file number 30.

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24
Q

How is working length determined in a pulpectomy?

A

Working length is estimated from pre-op radiograph.

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25
Q

What clinical situations may justify pulpectomy when prognosis may not be ideal?

A
  1. Pulp destruction of a primary second molar that occurs before the permanent first molar erupts. A premature extraction of the primary second molar without placement of a space maintainer usually results in mesial eruption of the permanent first molar with subsequent loss of space for the second premolar.
26
Q

What are the indications for a partial pulpotomy in a young permanent tooth?

A
  1. A small (<2mm) carious exposure in which pulpal bleeding can be controlled in one to two minutes.
    - -Tooth must be vital with normal pulp or reversible pulpitis
    - -Little or no history of pain
    - -No radiographic signs of pathology
    - -No clinical signs of percussion sensitivity, swelling or mobility
27
Q

How much pulp tissue is removed in a partial pulpotomy in a young permanent tooth?

A

Remove pulp tissue beneath the exposure site judged to be inflamed (1 to 3 mm) to reach healthy tissue below.

28
Q

What is the mixture percentage of MTA?

A

The powder should be mixed with sterile water in 3:1 powder/liquid ratio. It is recommended that a moist cotton pellet may be temporarily placed in direct contact with the material and left until a follow-up appointment.

29
Q

How long does it take MTA to solidify?

A

Upon hydration, MTA forms a colloidal gel that solidifies to a hard structure in approximately 3 to 4 hours. Moisture from the surrounding tissues assists in the setting reaction.

30
Q

What is the pH of MTA?

A

Hydrated MTA had an initial pH of 10.2, which rises to 12.5 three hours after mixing.

31
Q

How is MTA better than Ca(OH)2?

A
  1. Greater ability to maintain the integrity of pulp tissue.
  2. Produce a thicker dentinal bridge.
  3. Less inflammation.
  4. Less hyperemia.
  5. Less pulpal necrosis.
32
Q

What does the the high alkalinity of Ca(OH)2 cause in a pulpotomy?

A
  1. Superficial tissue necrosis
  2. Stimulation of tertiary dentin formation
  3. Antibacterial effect
33
Q

What is the importance of the dentin matrix in dentin repair?

A

The dentin matrix is a reservoir of growth factors and other bio-active molecules that have been sequestered during dentinogenesis. These molecules may be released into the pulp tissue and contribute to dentin repair and regeneration.

34
Q

What materials beneficially affect the dentin matrix causing release of growth factors from the dentin matrix?

A

Ca(OH)2 and MTA

35
Q

What are the treatment options for use of MTA for a pulpotomy or apexogenesis?

A
  1. One appointment; coverage of the radicular pulp stump with MTA. Temporary restoration with Coltosol and IRM.
  2. One appointment: place glass ionomer liner over the MTA and do a permanent restoration.
  3. Two appointments: place a wet cotton pellet over the MTA and on the second appointment verify the setting of the MTA and place a permanent restoration.
36
Q

What do you do if the pulpotomy fails in teeth with immature roots (apexogenesis fails)?

A

Apexification or apical closure with MTA, followed by RCT.

37
Q

Why is sodium hypochlorite solution the most common irrigant in root canal procedures?

A
  1. Broad antimicrobial spectrum

2. Unique capacity to dissolve necrotic tissue remnants

38
Q

Why is chlorhexidine not advocated as the main irrigant in root canal procedures?

A

Chlorhexidine, in concentrations up to 2%, will not dissolve necrotic tissue remnants.

39
Q

Compare the toxic effects of chlorhexidine and sodium hypochlorite?

A

Chlorhexidine (2% concentration) causes less inflammatory response than 0.5% sodium hypochlorite.

Sodium hypochlorite has a cytotoxic effect when injected into the periapical tissues.

40
Q

Why is it more difficult to do root canal procedures on an immature permanent tooth?

A
  1. Difficult to establish correct working length in immature teeth
  2. Risky to file a tooth with thin root canal walls
  3. Obturation of a tooth with wide open apex may result in overfilling
  4. Cold test and EPT are unreliable in immature teeth
  5. Difficult to differentiate between the radiographic appearance of a dental sac and chronic apical periodontitis.
41
Q

What is the follow up interval for apexification?

A

Recall after one year, followed by yearly clinical and radiographic examination for five years. (Basically follow up every year for five years)

42
Q

Why does Ca(OH)2 dressing have a good success rate in apexification?

A
  1. High pH
  2. Calcium ions
  3. Hydroxyl ions
  4. Antibacterial effect
43
Q

For apexification with Ca(OH)2, how many visits are there and what is done at each visit?

A
  1. First visit - Ca(OH)2 dressing is placed
  2. Second visit (two weeks to a month later) - complete the debridement and remove the tissue remnants. A thick paste of Ca(OH)2 is packed in the root canal using endodontic pluggers.
  3. Third visit - If the barrier is incomplete and the pt feels the touch of a file, the apexification procedure is repeated until a complete barrier is formed.
  4. Subsequent visit (if necessary) - when an apical barrier is formed, a root canal filling is performed using either lateral condensation with Gutta Percha point or using the warm Gutta Percha technique.
44
Q

For apexification with MTA, how many visits are there and what is done at each visit?

A
  1. First visit - place Ca(OH)2 paste, followed by IRM temporary filling
  2. Second visit - Place MTA to create apical barrier, place IRM as temporary filling
  3. Third visit (a week later, after the MTA is set) - verify MTA apical plug, perform root canal filling
45
Q

How do you determine the length of the root canal in immature permanent teeth?

A

Use the paper point method confirmed by a radiograph.

  1. Radiographically
  2. Using the paper point method - the new generation of paper points have markings on them. Bleeding at the end of the paper point or a wet paper point indicates overextension.
46
Q

What are the precautions for the pt after apexification?

A

These teeth are prone to fracture and may be lost in the future. A mouth guard is suggested to decrease the risk of injury in risky situations (sports, biking, etc.)

Long-term Ca(OH)2 dressing, as required in apexification procedures, markedly decreases dentin fracture strength with time. Thus, the use of Ca(OH)2 in apexification should be re-evaluated.

47
Q

What are the complications for restoration of a tooth after apexification?

A
  1. The crown-root ratio is not favorable bc the root is shorter than in a mature tooth, therefore, the prognosis of the tooth may be hampered.
  2. Post placement (if needed) is difficult due to the width of the root canal.
  3. Placement of a permanent crown should be delayed due to pt’s continuous growth and maturing of the gingival tissues.
48
Q

What special care should be taken in performing irrigation during root canal treatment of an immature tooth?

A

Copious irrigation is performed carefully so as to not pass solutions beyond the apex and to avoid the risk of cytotoxic effect on periapical tissues.

49
Q

In an apexification procedure, how can you verify that the Ca(OH)2 paste filled the canal to its entire length?

A

Ca(OH)2 packing must be verified by a radiograph. All of the root canal should have the same opacity as the dentin.

50
Q

In an apexification procedure, what is the suggested technique for obturation?

A
  1. One way is to use the custom cone technique in which an “imprint” of the canal is taken using softened Gutta Percha.
  2. An alternative is to use warm vertical condensation; however, a complete apical barrier is necessary to avoid overfilling.
51
Q

What are the benefits of using MTA in an apexification?

A
  1. Consistently allows overgrowth of cementum.

2. It may facilitate the regneration of the PDL

52
Q

Why is MTA better than Ca(OH)2 for apexification?

A
  1. Apical closure with MTA is more predictable.
  2. Reduction in treatment time, number of appointments and radiographs.
  3. The tooth can be restored with minimal delay, preventing the risk of root fracture and re-infection.
  4. Use of MTA can also avoid the detrimental effects on the mechanical strength of dentin found with prolonged exposure to Ca(OH)2. In other words, Ca(OH)2 makes the teeth more prone to fracture, whereas, MTA strengthens the root.
  5. It is assumed that MTA creates a better biological seal.
53
Q

Why can’t you restore a tooth that has undergone apexification with metal posts and pins?

A
  1. The post only retains the core and crown, but does not strengthen the tooth itself.
  2. Immature root filled teeth are often compromised by inappropriate post space preparation, coronal leakage, and secondary caries around prefabricated posts, or too large custom posts.
  3. It may be advantageous to use a light transmitting post and composite resin to internally strengthen the tooth.
54
Q

How is formation of an apical barrier verified in Ca(OH)2 apexification?

A

A gutta percha point is gently pushed toward the apex, until a barrier is felt. The pt should not feel anything. This should then be radiographically verified.

55
Q

In a revascularization procedure for a necrotic immature permanent tooth, what antibiotic is used?

A

Tri-antibiotic paste (3Mix):

  1. Ciprofloxacin
  2. Minocycline
  3. Metronidazole
56
Q

What are the complications that can happen after revascularization of a necrotic immature permanent tooth?

A
  1. Green-gray discoloration of the crown is sometimes evident after using 3Mix, which presents an esthetic problem.
  2. Drug tolerance is a potential risk and, as a result, the disinfecting action will be impaired.
  3. A systematic allergic reaction to the antibiotics can be life threatening.
57
Q

What should be used to disinfect the canal space in the revascularization procedure?

A

5.25% NaOCl followed by 2% chlorhexidine followed by a mixture of antibiotics (ciprofloxacin, metronidazole, and minocycline).

58
Q

Summarize the steps in the revascularization of necrotic immature permanent tooth?

A
  1. First step - disinfect the root canals.
    - -5.25% NaOCl followed by 2% chlorhexidine followed by a mixture of antibiotics (ciprofloxacin, metronidazole, and minocycline).
  2. Second step (four weeks later) - create a scaffold and seal the canal orifice.
    - -Insert file or endo explorer into periapical tissues to induce bleeding to fill the canal spaces.
    - -Stop the bleeding 2 to 3 mm below the level of the CEJ and leave it for 15 minutes to create a blood clot at that level.
    - -Place MTA
  3. Third step (two weeks later) - seal the access cavity
    - -Place final coronal restoration with bonded composite restoration.
59
Q

How long do you splint for an alveolar fracture of the permanent teeth?

A

4 weeks

60
Q

What kind of splint should be used for an alveolar fracture of the permanent teeth?

A

Splint should be passive and allow physiologic movement - materials such as 40 lb test fishing line or a light stainless steel orthodontic wire (0.16 to 0.18).

Moursi (9 decks)

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