3. Vital Pulp Therapy Flashcards
Apical Periodontitis
- Disease -
There is a lesion, so the aim of the treatment for this root canal treatment is going to be to cure or allow the body to heal that lesion so what are you removing from the pulp or from the pulp Canal space when you do Endo here?
____ you actually removing tissue. what are you removing from the tooth when you do instrumentation here?
____, what what causes infection? bacteria so here your concentration is on removing bacteria that are present in the tooth. here your concentration is to remove an inflamed pulp.
Generally there is very little or no bacteria in this portion of the tooth most of the infection is just on the top portion of the pulp is probably almost sterile so what is important is your ____ seal that you don’t introduce any bacteria into the tooth. in this case you’re going to do whatever it takes to remove the bacteria that is already settled down in the root canal system.
inflamed pulp
infection
rubber dam
Apical Periodontitis
- Disease Process
Pulpitis Periapical Periodontitis
Stragulation Theory vs. Domino Effect
we believed that we went from pulpitis to apical periodontitis by strangulation which means there’s decay, decay reaches the pulp, the pulp gets inflamed, inflammation causes those ____ signs (inflammation, redness, swelling, pain, color, loss of function) the pulp is in enclosed hard tooth structure, it was assumed that the whole pulp swell up strangulate itself and die.
bit now we know for sure that does not happen. the pulp gets ____ in stages so at a certain point if you don’t do the restoration by removing this decay that inflammation front progresses all the way to the Apex like a ____.
five
inflamed
domino
Apical Periodontitis
there’s enough literature to show us that ____ are the cause of apical periodontitis and they’re just three literature I’m sure he’s going over all of this with you so today the aim of the lecture is to figure out at what point I can save the pulp.
microbes
Apical Periodontitis
so there is decay in enamel maybe a little bit in the Dentin but quite far from the pulp even when you have the decay on outside of the tooth, the dentinal tubules corresponding to that outside region will transmit ____ and you will start to see inflammation only in that ____ of the pulp.
endotoxins
portion
Apical periodontitis
Because the decay is so far away pulp is a robust organ it knows how to protect itself it’ll protect itself by laying down ____ dentin that dentin blocks off the dentinal tubules that was trying to send that endotoxin this way and that will stop the inflammation and the pulp dentin junction will reform again the pulp will go back to normal state
tertiary
Apical periodontitis
- disease process -
You still do not go and do that restoration or the patient doesn’t come to you for the restoration the pulp keeps defending itself. look at the amount of ____ Dentin that has happened this is where the original pulp was that’s the amount of Dentin that has laid down trying to protect itself and that’s still normal pulp trying to protect itself. so this pulp has a tremendous capacity to ____ itself and ____ that’s why not every Decay ends up in a root canal. the decay has to progress for a long period of time and cause injury to the pulp which is irreversible for you to do in an endodontic procedure
reparative
defend
heal
Apical periodontitis
- Disease process -
look at the pulp chamber here this is a normal tooth with no Decay (premolar). look at the structure of the pulp chamber there is large decay (first molar) but if you look at the structure of the pulp chamber here it’s completely ____ then you access the tooth like this this glassy stuff that you see is the ____ dentin so that pulp has been protecting itself or trying to protect yourself for a long period of time.
calcified
reparative/tertiary
Apical periodontitis
Strangulation theory vs. domino effect
this tooth was extracted and this is the pulp chamber right here this is your decay on both those different staining that he did look at the inflammation and the necrosis right underneath the decay all of this all of this pulp tissue is histologically normal has no inflammation in it.
Anyone here wants to be a billionaire? those of you who have the capacity to think come up with inventions this is what we need, what we need is a diagnostic tool that you would apply to a patient’s tooth when he is sitting in your chair and it gives you a picture on the screen that looks like this. what would happen to Endodontics?
it will change dramatically because for a tooth like this what is the endo that I truly need? I need to do an endodontic procedure where if I knew exactly where to cut off the pulp so let’s say I take a high-speed bur and I cut off the pulp right at this point I could put a material here which is the biocompatible well sealing material and put a composite restoration on top my, Endo is done because I’ve left behind good Pulp but the problem is we have no diagnostic tool to tell us where this demarcation line is so what do we do?
we pick up a round bur and a rotary files and we go all the way to where we know is the ____ place to stop and that’s your working length so we have sacrificed all this good ____ because we have no true tool to tell us where exactly that demarcation between good and bad pulp happens.
predictable
pulp
Apical periodontitis
- Nerves
Nobody has come up with it as yet so think about it how can we come up with an image like this? there is future here it is MRIs that they’re talking about which might be able to give you this but clinically we don’t have anything available to us so what do we do?
we go through the process of diagnosis that we’ve been talking about all this time where we test for nerves. you’re testing for ____ fibers. explains the picture (DT, odontoblastic processes, A delta fibers wrapped around the ____, blood vessels in the pulp proper with ____ around it, ignore the green cell)
a delta
odontoblastic processes
c fibers
Normal pulp
Dentin-pulp complex
Nerve supply
A-delta fibers
- ____ and conduct rapid and ____ pain sensations
C-fibers
- ____ and ____, and are involved in ____ aching pain
if you stimulate your A Delta fibers you getting a sharp shooting pain if you stimulate your C fibers you getting a dull throbbing pain that’s an example of a Delta fibers that’s one A delta fiber coming into the pulp at the pulp dentin junction dividing into millions of branches and supplying a certain portion of the dentin so that one fiber is supplying this portion of the dentin.
myelianted
sharp
unmyelinated
thinner
dull
Normal pulp
a delta:
- ____ pain
- primarily ____
- can be ____
c
- ____ pain
- ____ receptors
- poorly ____
So on a normal tooth if you were to put cold not necessarily heat but if you were to put ____ you would have the dental fluids move out in a quick motion stretch the amount of ____, stretch the A Delta fiber that is wrapped around it the patient will feel sharp shooting pain the C fiber around the ____ does nothing, that’s what a normal response of to a cold test.
sharp
mechanoreceptors
localized
dull
mech and chemo
localized
cold
odontoblastic processes
blood vessels
Normal pulp response
-COLD
so if I were to make a chart out of it, ____ fibers give you a sharp shooting response the ____ do nothing.
a-delta
c-fibers
Nerve sprouting
so now let’s say this inflammation starting in the pulp, have you heard of nerve sprouting? so information starts in the pulp, this normal nerve cell starts to ____ another branch so this is that I showed you before now it starts to sprout another branch so this is A Delta fiber which was just supplying this portion of the dentin now is supplying a ____ portion of the dentin. this is called nerve sprouting, the cool part about it is, that if you take OUT? the stimulus that’s causing the inflammation, this extra sprouted nerve fiber will go through ____, will kill itself, will die and the nerve can go back to normal as it was before.
sprout
larger
apoptosis
Nerve sprouting
What does that all mean? this is your pulp, this is your a Delta fibers, it is supplying a certain number of dentinal tubules which is called the ____ or the receptive field, if I want to take a cold test or use a sharp instrument and scrape this open dentin, this A Delta fiber will get stimulated the patient’s hand will go up. right now there’s inflammation in the pulp, that same a Delta fiber has sprouted and is supplying a ____ area of dentin so the receptive fields are much larger and ____ if I were to stimulate this portion of the dentin right here I’m not just stimulating 1 A delta fiber I’m stimulating the other one as well so larger number of nerves are being stimulated the ____ the patient’s hand goes up and it stays up a little bit ____ because the stimulation was to a larger number of nerves however as I said if you could take away the stimulation that was causing this inflammation which is usually decay this can go back to ____.
receptive field
larger
overlapping
sooner
longer
normla
Reversible Pulpitis
Now when you put cold on the tooth the patient response is sharper and slightly longer. the ____ still don’t do anything.
have you guys heard the terminology “lingering” in my opinion that the term needs to go why? because what is lingering? 10 seconds? 11 seconds 9 seconds is lingering? it’s a very subjective term so what we want to substitute that terminology with or replace that terminology with is ____ response which means in an inflamed pulp if I were to stimulate the A Delta fibers the patient’s pain goes up ____ and stays longer it doesn’t matter how long the hand stays up 5 Seconds 10 seconds 11 seconds the point is what happens after that.
if the C fibers get stimulated and now the patient move from (Aww) to (now that’s hurting and throbbing) that’s your biphasic response which means you got the first pain from your ____ fibers and the second pain from your ____. the A delta fibers will Linger on but it’s the C fiber stimulation that you’re looking for the pulsing and throbbing pain that you’re looking for.
c-fibers biphasic quicker a delta c fibers
Reversible pulpitis
So that’s reversible pulpitis is going on larger receptor field. now you this is your decay you remove the decay and put a nice composite restoration, this inflammation subsides the cells go through ____ via back to norma. so patient walks into your office says “I have a tooth that is sensitive to ____ and I drink something cold it just send me through the roof or I feel sensitive” you do a ____ that sensitivity will go away there is no ____ a biphasic response as yet
apoptosis
restoration
c-fiber
Irreversible pulpitis
A-delta: ____ and longer lasting pain
- can be ____
C: ____ throbbing pain
- poorly ____
In irreversible pulpitis, the information is not just here the inflammation is down into the pulp proper along the blood vessels which opposing and the C fibers that are around it.
In Irreversible pulpitis case if you put cold on the tooth you will get not just a sharp shooting pain from the ____ fibers you will get a pulsing pain from the ____ that is your distinction of whether this is reversible or ____.
Just a slight lingering of hand with the A delta fibers is still ____ but if the hand goes down the cheek out throbbing that’s your ____ pulpitis or at least some signs of it again the signs are not 100% but that’s what you’re looking for
sharper
localized
dull
localized
a delta
c fibers
irreversible
reversible
irreversible
Irreversible pulpitis
However it is common to find cases with histologic evidence of ____ inflammatory responses, including partial necrosis, but little or no clinical ____
Incidence of painless pulpitis that leads to pulp necrosis and chronic periradicular periodontiis is about ____% of pulpitis cases
I did tell you some patients will go from pulpitis to necrosis without any kind of symptoms they will go from no lesion to a large lesion on this and “I didn’t feel anything” and that’s because of perception of pain and we did speak about this last time that histology doesn’t always correspond with what the patient is experiencing
severe
symptoms
40-60
Irreversilbe pulpitis
History of pain
Spontaneous pain
80% of teeth with history of pain had ____ inflammation and necrosis
- only significant correlation between clinical signs and pulpal pathology was with a history of ____
what were the two things which were important? remember from the last lecture? ____ pain history of pain on history of spontaneous pain so the patient walks into your office and sits down and he says “I had some throbbing pain yesterday or day before yesterday when I was watching TV but now it’s gone I think I’m fine” any kind of history of spontaneous pain is an indication of ____ pulpitis and that usually means an endodontic procedure
moderate to severe
spontaneous pain
spontaneous
irreversible
Disease process
Irreversible pulpitis vs reversilbe pulpitis
Diagnostic process
- subjective data
- objective tests
so let’s see how you’re doing your diagnostic test for this patient to decide whether this is irreversible or reversible pulpitis you went to the subjective data the patient has some sensitivity to cold but it does not ____ , it has never woken them up at night, it doesn’t ____ hurt never really bothered him unless he drink something cold. That’s an indication of ____ pulpitis that’s a ____ data what about the objective data, the objective data is what you do, the test you do.
throb
woken
reversible
subjective
Disease process
Irreversible pulpitis vs reversilbe pulpitis
Diagnostic process
- objective tests
- NO bi-phasic response to ____
- NO ____ to percussion palpation
- NO ____ on the x-ray
you put cold on the tooth the patient’s hand goes up stays up maybe a few seconds longer but there’s no biphasic response there is no pulsing response from the tooth that’s indication of ____ pulpitis they should ideally be no tenderness to percussion which means there’s no information in the PDL they should be no lesions on the X-ray so if these points are met you can safely say that the students probably just reversibly inflamed and a candidate for ____
cold tenderness lesion reversible vital pulp therapy
- Decision process -
iatrogenic exposure during tooth prep with no or minimal caries
exposure during trauma
exposure during caries excavation
there’s a distinction that needs to be made here and we’re going to talk about this more when we do trauma. there’s a difference in what is going on histologically in the pulp when the tooth has ____ vs when the pulp is exposed when the patient has ____
caries
trauma
- trauma exposure -
inflammation up to ____mm of pulp after as long as ____ days
let’s see he get hit in the face, the front tooth breaks and the pulp is exposed that’s an accidental exposure of the pulp that is actually very very good pulp that pulp can stay healthy for as long as seven days except for the top ____ millimeters that can get inflamed this is your occlusal trauma and how do you address this pulp?
will talk about it when we talk about trauma. the distinction that you need to make is that in traumatic exposure of the pulp, the pulp is near normal except for the two mm on the top that’s a given you can’t doubt that up to 7 days but in ____, you don’t really know how ____ that information is. That the distinction in traumatic pulp you know the information is 2 millimeters deep the rest of the pulp is normal up to seven days however in caries pulp you don’t know how deep that information is your rely on the patient’s ____ and your tests to guess where that demarcation is
2
7
2
caries
deep
symptoms
