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D1 Spring - Operative Dentistry I > 4/18: Deep Caries Removal Considerations > Flashcards

4/18: Deep Caries Removal Considerations Flashcards

1
Q

What is a sensitive part of the tooth?

A

The dentino-enamel junction (DEJ)

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2
Q

Where do enamel and dentin meet?

A

At the dentino-enamel junction

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3
Q

What is the most accepted theory of pain transmission?

A

Hydrodynamic theory of pain transmission

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4
Q

What are dentinal tubules filled with?

A

Odontoblastic processes

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5
Q

What are odontoblastic processes wrapped in?

A

Afferent nerves and dentinal fluid

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6
Q

What happens when enamel or cementum are removed during cavity preparation?

A

The external seal of dentin is lost

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7
Q

What happens when enamel or cementum are removed during cavity prep?

A

Small fluid movements in the tubules
Movement causes distortions in the afferent nerve endings, hence, pain

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8
Q

What do hydrostatic pressure changes within the tubules caused by external stimuli cause?

A

Pain to the pulp through fluid movements within the tubules

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9
Q

What are examples of external stimuli?

A

temperature change, high speed handpiece, air drying,
osmotic changes from various chemicals, caries

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10
Q

What must be treated with great care during restorative procedures?

A

Dentin

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11
Q

What must be used whenever cutting high speed handpieces?

A

Air water sprat

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12
Q

What does air water spray avoid?

A

Heat build up and the destruction of the odontoblastic processes in the dentin (dead tracts)

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13
Q

What should not be dehydrated by air blasts?

A

Dentin
- this could cause aspiration of odontoblasts into tubules

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14
Q

Caries control restorations are performed, as part of a larger caries control plan, when one or more of these conditions exist:

A
  1. Caries is extensive enough that pulpal complications are likely to occur soon.
  2. It is desirable to quickly eliminate large carious lesions that are a source for caries infection in the
    patient’s mouth.
  3. Time does not permit definitive restoration of one or many large lesions.
  4. The prognosis for the pulp is questionable, and definitive restoration should be deferred until the pulp’s condition can be better assessed.
  5. Removing the infected dentin
  6. Medicating the pulp, if necessary
  7. Restoring the defects with a temporary material. If a temporary material is used, undermined enamel can be
    left to better retain the temporary.
    THESE ARE NOT DONE OFTEN AT UMKC
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15
Q

What is infected dentin?

A

Microorganisms are present
Soft, leathery

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16
Q

What is affected dentin?

A

Dry, powdery

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17
Q

Its not always possible to tell with 100% certainty where __________________________________________________________

A

Affected dentin ends and infected dentin begins

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18
Q

When is an indirect pulp cap used?

A

when a deep carious lesion occurs and there is no clinical or radiographic evidence of irreversible pulp damage (such as a history of spontaneous pain, heat sensitivity relieved by cold, or a P. A. lesion)

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19
Q

What are the qualifications of a tooth for an indirect pulp cap?

A
  • Be completely asymptomatic
  • Show signs of reversible pulpitis
    Ex: moderate cold sensitivity, with pain subsiding within about 15 seconds
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20
Q

What should you remember when looking at caries on a radiograph?

A

Usually deeper than it appears on a radiograph

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21
Q

What is the object of an indirect pulp cap?

A

Avoid a direct pulp exposure

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22
Q

Is this a candidate for a pulp cap?

A

Upper arrow: may be candidate
Lower arrow: certainly not a candidate for indirect cap - probably already a direct exposure

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23
Q

What are the two approaches that might be termed “indirect pulp cap”?

A

Two appt approach:
One appt approach

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24
Q

What pulp capping approach do we use at UMKC?

A

One appointment approach

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25
Q

What happens during the first appointment of the two-appt approach?

A
  • All caries are removed from all areas EXCEPT the deepest, nearest pulp
  • Leave the last bit of infected dentin to avoid exposing pulp
  • Cover remaining infected dentin with calcium hydroxide (Dycal or Life) then glass ionomer (Vitrbond)
  • Place a temporary restoration (IRM)
  • It may be acceptable to leave some undermined enamel temporarily to help hold in the temporary restoration
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26
Q

How long should you wait to allow the body to form reparative dentin in the site near exposure?

A

6-12 weeks

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27
Q

What is the desired result after waiting 6-12 weeks?

A

Dentin bridge formation

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28
Q

What happens at the end of 12 weeks in the two appt approach?

A

Confirm that the patient is asymptomatic and the tooth is vital

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29
Q

What is the traditional approach of the indirect pulp cap?

A
  • Remove the temporary restoration, the glass ionomer, and the CaOH
  • Carefully remove the remaining infected dentin (soft, leathery caries)
  • Leave the affected dentin (dry, powdery caries)
    A #4 round bur on the slow speed just above stall speed, with a light, shaving touch is the best choice for this function. It is better than a spoon excavator, since the larger bur will put less force per unit area than the hand instrument would do, therefore making it less likely that one would break
    through into the pulp.
    Place a new liner of Dycal covered by Vitrebond. Remove all undermined enamel, modify the prep. to properly retain the restoration, and restore with your selected permanent material.
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30
Q

Research has suggested that if the cavity has been well sealed during the twelve-week interval,
and that if the patient is asymptomatic and the tooth tests vital, the tooth ___________

A

May not need to be reentered
- this avoids risking a pulp exposure at the second appt

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31
Q

What is the theory behind the cavity being well sealed?

A

the food supply to the bacteria is cut off by the well sealed restoration and that the bacteria will die or become dormant
Caries progression will be arrested and the pulp will remain in good health

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32
Q

What is the single appt approach?

A

Remove infected (soft, leathery) dentin. Remove affected dentin (dry, powdery caries) from
any areas where a pulp exposure is not likely to occur
* The DEJ must be completely caries-free

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33
Q

Where can the dentin be left in the single appt approach?

A

*Leave the affected dentin only in the deepest area where the possibility of a direct pulp
exposure is a concern.
- You want to remove ALL affected dentin, if at all possible

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34
Q

What should you do in the single appt approach to avoid pulp exposure?

A

May be permissible to leave a small amount of affected dentin in
deep areas
* Place CaOH (Dycal or Life) over the deepest area close to the pulp
* Place glass ionomer (Vitrebond) over the CaOH
* There is fluoride release from the Vitrebond allowing possibility of remineralization of the affected
dentin as long as restoration is well-sealed

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35
Q

What is no longer an option for pulp exposure?

A

Indirect pulp cap

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36
Q

When are direct pulp caps used?

A

When a small pulpal exposure occurs during cavity prep

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37
Q

What do you do during a direct pulp cap?

A

*A thin layer of calcium hydroxide is placed over the
exposed pulp
* A layer of glass ionomer is placed over the CaOH
* stimulate the pulp to form secondary odontoblasts,
which can produce a dentin bridge across the
exposure site.

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38
Q

When is a direct pulp cap most successful?

A
  • When exposure is mechanical rather than carious
  • If bleeding at the site is easily controlled and there is no pus or serous exudate
  • if the area has not been contaminated by saliva, and
  • if there has been little or no mechanical damage to the
    pulp tissue
  • young patient
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39
Q

What is the exposure site size when the patient is young?

A

0.5mm

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40
Q

What is becoming more recommended at UMKC?

A

Direct pulp cap

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41
Q

What should you do on boards if there is need for a direct pulp cap?

A

Do NOT leave affected dentin, direct pulp cap is indicated

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42
Q

Whats this?

A

A Large Amalgam with a Liner of Calcium Hydroxide over the
Pulp Horns and a Base of Glass Ionomer

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43
Q

Who are pulp caps most effective on?

A

young patients with large pulp chambers and open root
canals that provide better circulation to the area where we are trying to induce dentin
bridge formation

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44
Q

Where do direct pulp caps work better at?

A

the tips of pulp horns than they do on an exposure on the side of a pulp chamber (as from a class V lesion)

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45
Q

What can mild to moderate spontaneous pain for three days after a direct pulp cap indicate?

A

not indicate the need for endodontics, but after that, spontaneous pain is more
ominous.
Some cold sensitivity may linger for several weeks.

46
Q

If the tooth will require a crown to adequately restore it, DO NOT RELY ON

A

A direct pulp cap
- Complete root canal therapy before crowning teeth that have had direct exposures

47
Q

Whether Doing an Indirect or Direct Pulp Cap, Temporary or “Permanent” Restoration,

A

Seal the cavity

48
Q

What can a broken or leaky restoration cause?

A

Failure because bacteria will leak into the pulp and kill it

49
Q

Why must all restorations adequately seal the cavity?

A

To avoid microleakage, bacterial penetration, and recurrent decay

50
Q

Describe a pulp cavitys contour

A

A miniature of the external surface of the tooth

51
Q

When does the size of a pulp cavity decrease?

A

With age
- younger children have larger pulps than older adults and younger pulps are more reparative than older pulps

52
Q

What is the defensive function of the pulp related to?

A

Its response to irritation by mechanical, thermal, chemical, or bacterial stimuli

53
Q

What does the deposition of reparative dentin by the replacement odontoblasts lining the pulp cavity act as?

A

a protective barrier against caries and various other irritating factors

54
Q

Describe the formation of reparative dentin

A

a continuous but slow process, taking 100 days to form a reparative dentin layer 0.12 mm thick

55
Q

What happens to the pulp in cases of severe irritation?

A

the pulp responds by an inflammatory reaction similar to any other soft tissue injury

56
Q

What happens in some cases of inflammation of the pulp?

A

The inflammation may become irreversible and can result in the death of the pulp because the confined, rigid structure of the dentin limits the inflammatory response and the ability of the pulp to recover

57
Q

Why do many teeth have pulpal sensitivity?

A

Due to caries or following cavity preparation and restoration

58
Q

What are symptoms of reversible pulpitis?

A

twinge of pain may be due to sugar, cold, or acid from caries first contacting dentin. Pain lasting a few seconds may be due to the irritant continuously present or applied repeatedly

59
Q

What do twinges of pain due to reversible pulpitis cause?

A

An increased blood flow and volume (hyperemia) and inflammation of the pulp

60
Q

What is reversible pulpitis?

A

As long as an irritant, such as touching an ice stick to the tooth causes pain that lingers no more than 10 to 15 seconds after removal, it’s called reversible
pulpitis and can be treated with a restoration

61
Q

What is irreversible pulpitis?

A

When pain is either spontaneous, or–if elicited by an irritant–lingers more than 15 seconds, infection of the pulp often has occurred and resolution by operative dentistry treatment is usually not possible

62
Q

What is treatment for irreversible pulpitis?

A

root canal therapy

63
Q

What is pulpal necrosis?

A

When irreversible pulpitis is left untreated

64
Q

What is symptoms of pulpal necrosis?

A

spontaneous, continuous, throbbing pain or pain elicited by heat that can be relieved by cold, and then, later, with no response to any stimulus

65
Q

What happens in pulpal necrosis as inflammation and infection move beyond the root apex?

A

The tooth becomes sensitive to percussion

66
Q

What is treatment for pulpal necrosis?

A

Root canal therapy

67
Q

What is the primary objective during operative procedures?

A

the preservation of the health of
the pulp

68
Q

All caries must be removed EXCEPT in the event of a?

A

Indirect pulp cap

69
Q

What should you avoid during operative procedures?

A

Overheating the dentin- for instance, by using a high speed handpiece without water coolant

70
Q

All restorations must be well _______

A

Sealed

71
Q

What does maxillary sinusitis manifest as?

A

cold sensitivity, and sometimes spontaneous pain, in the maxillary
posterior teeth
Often hard to isolate to a single tooth.

72
Q

What do cracked teeth manifest as?

A

Cold sensitivity, or a sudden unreproducible pain when chewing

73
Q

What can a tooth sleuth do for a cracked tooth?

A

elicit the pain when placed
between the teeth in the central groove areas or at the tips of individual cusps

74
Q

Where can cracks progress into?

A

The pulp chamber and cause pulp necrosis, or cusps may eventually fracture off

75
Q

What can cracks sometimes be seen externally with?

A

a fiber optic light, or it may be necessary to remove restorations to see them

76
Q

What is treatment for cracked teeth?

A

Crowning

77
Q

What does occlusal trauma manifest as?

A

cold sensitivity, or pain in chewing

78
Q

What may be seen (not always) in occlusal trauma?

A

Slight tooth movements when the teeth are clenched and then moved from side to side

79
Q

What is fremitis?

A

Slight tooth movements when the teeth are clenched and then moved from side to side

80
Q

How is pain relieved for occlusal trauma?

A

Occlusal adjustments

81
Q

What tissue is softer than dentin?

A

Cementum

82
Q

What does cementum consist of?

A

45-50% inorganic material by weight

83
Q

What does cementum cover?

A

Apical root

84
Q

What is cementum permeable to?

A

Variety of materials

85
Q

What is the color of cementum?

A

Yellow and slightly lighter in color than dentin

86
Q

What has the highest fluoride content of all mineralized tissue?

A

Cementum

87
Q

What happens in 10% of teeth where enamel and cementum do not meet?

A

Sensitive area

88
Q

What does abrasion, erosion, caries, scaling, and the procedures of finishing and polishing result in?

A

Removing from the dentin its cementum covering, which can cause the dentin to be sensitive

89
Q

What is tooth sensitivity caused by?

A

Exposed dentin

90
Q

What is this?

A

Abrasion lesion

91
Q

What is the form of an abrasion lesion?

A

Angular in form

92
Q

What is the form of an erosion lesion?

A

Rounded in form

93
Q

Why can abrasive and erosive lesions cause hypersensitivity?

A

because of exposed dentin

94
Q

What should you do about root sensitivity?

A
  • Gluma
    Topical desensitizer
  • Fluoride
    Varnish or prescription Fluoride toothpaste
  • Toothpaste
    Sensodyne, “sensitivity formula” in most brands
    Potassium nitrate
95
Q

Describe these

A

A = Overcontouring is the worst. It results in flabby, red-colored,
chronically inflamed gingiva and increased plaque retention.
B = Undercontour results in trauma to the gingival tissues.
C = just right

96
Q

What do facial and lingual surface convexity do?

A

Protects and allows stimulation to gingival tissues during mastication

97
Q

What do normal tooth contours do?

A

deflect food only to the extent that the passing food stimulates the
gingival by gentle massage rather than by irritating it

98
Q

What happens if tooth curvature is too great?

A

the tissues usually receive inadequate stimulation, and a potential plaque trap is created

99
Q

What do closed gingival embrasures impinge on?

A

Papilla

100
Q

When embrasures are properly open, where is contact?

A

At junction of occlusal and middle third

101
Q

What can improper contacts result in?

A

food impaction, producing periodontal disease, carious lesions, and possible movement of the teeth

102
Q

Where are contacts in max and mand central incisors?

A

Incisal third

103
Q

Where is contact as it proceeds posteriorly?

A

Junction of the occlusal and middle thirds which creates a larger occlusal embrasure

104
Q

Where should marginal ridges be?

A

Same height to prevent food impact

105
Q

Where are proximal contact?

A

Slightly facial to the center of the proximal surface faciolingually

106
Q

What happens when there is open contact between a restoration?

A
107
Q

What is an important factor in restorative dentistry?

A

Level of the gingival attachment and gingival sulcus

108
Q

How is soft tissue health maintained?

A

By teeth having correct form and position, if not, apical recession of gingiva and possible abrasion and erosion of roots can occur

109
Q

Where should the margin of the cavity prep ideally not be?

A

positioned subgingivally (at levels between the marginal crest of the free gingival and the base of the sulcus) unless dictated by caries, previous restoration, or esthetics

110
Q

It is extremely important to not destroy _________________ tissue in the restorative process

A

Attached keratinized tissue
- this must be preserved

D1 Spring - Operative Dentistry I (12 decks)

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