7. Vital Pulp Treatment

Question 1

what is the definition of vital pulp treatments

Answer 1

“strategies aimed at maintaining the health of all or part of the pulp” - european society of endo

Question 2

What are the 4 clinical pulp diagnosis according to the new diagnostic system by the international endodontic journal?

Answer 2

Initial pulpitis
Mild pulpitis
Moderate pulpitis
Severe pulpitis

Question 3

What is the definition of indirect pulp capping?

Answer 3

Application of a biomaterial onto a thin dentine barrier in a one-stage carious tissue removal technique generally to hard dentine

Question 4

What is the definition of selective carious-tissue removal in one stage?

Answer 4

removal of soft or firm dentine - immediate placement of a permanent restoration

Question 5

What is the definition of stepwise excavation?

Answer 5

first stage involves selective carious removal to soft dentine, to an extent that facilitates proper placement of a temporary restoration, and second stage removal to firm dentine. Final placement of permanent restoration

Question 6

What are the 2 classes of direct pulp capping?

Answer 6

Class I - exposure due to a traumatic injury to the tooth or an iatrogenic exposure
Class II - pulp exposure judged clinically to be through a zone of bacterial contamination

Question 7

What is the definition of direct pulp capping?

Answer 7

Following the preservation of an aseptic working field, application of a biomaterial directly onto the exposed pulp, prior to immediate placement of a permanent restoration

Question 8

What is the definition of a partial pulpotomy?

Answer 8

Removal of a small portion of coronal pulp tissue after exposure, followed by application of a biomaterial directly onto the remaining pulp tissue prior to placement of a permanent restoration

Question 9

What is the definition of a full pulpotomy?

Answer 9

Complete removal of the coronal pulp and application of a biomaterial directly onto the pulp tissue at the level of the root canal orifice(s), prior to placement of a permanent restoration

Question 10

What is the definition of a pulpectomy?

Answer 10

Total removal of the pulp from the root canal system followed by root canal treatment, prior to placement of a permanent restoration

Question 11

What responds to trauma to the dentine?

Answer 11

the dentine-pulp complex

Question 12

What does damaged dentine release when experiencing trauma or a carious lesion?

Answer 12

Bioactive dentine matrix components (DMCs)

Question 13

What are the roles of bioactive dentine matrix components?

Answer 13

Releases - cytokines, chemokines and growth factors
Orchestrates - recruitment, migration, proliferation and differentiation of pulpal progenitor cells which are critical for formation of newly deposited dentine

Question 14

What is the difference of reparative vs reactionary dentine

Answer 14

Reactionary dentine is formed when stimulated by a mild stimulus or slowly advancing caries. It is formed by surviving odontoblasts and forms new tubular dentine

Reparative dentine is formed when stimulated by a severe/aggressive stimuli or rapidly carious lesions. It is formed when the primary odontoblasts die due to severe stimulus, so odontoblast-like cells produce low quality atubular mineralised tissue

Question 15

Why would you use selective/stepwise caries removal over complete caries removal?

Answer 15

to reduce the risk of pulp exposure

Question 16

Would light yellow caries clinically represent active/quick progressing carious lesion or slow?

Answer 16

Active at a fast rate

Question 17

Would dark brown caries represent active/quick progressing or slow progressing/arrested caries

Answer 17

slow progressing/arrested

Question 18

For direct pulp capping, there is low evidence due to high risk of bias, but what dental material was showed to be superior to Ca(OH)2?

Answer 18

MTA - mineral trioxide aggregate

Question 19

Endodontic diagnosis - irreversible pulpitis with normal apical tissues.
What is the management of this?

Answer 19

Partial or full pulptomy initially

Question 20

Why use pulpotomy?

Answer 20

• To preserve the pulp vitality and its functions while retaining more structural integrity of the tooth
• To simplify treatment protocol and avoid procedural errors associated with root canal treatment
• Minimally invasive endodontic procedures are meant to be less painful
• Potential for more efficient procedures reducing costs and number of appointments for patients which would be more sustainable and open access to treatment for more patients

Question 21

What is the sequence for a full pulpotomy for protocol?

Answer 21

• LA
• Rubber dam placement
• Disinfect tooth surface with NaOCI (Sodium hypochlorite)
• Excavate caries with low-speed bur
• prepare cavity with high-speed bur under water coolant
• rinse cavity with NaOCI
• access and unroof pulp chamber
• Disinfect pulp chamber with 5% NaOCI
• Amputate exposure pulp tissue with high speed diamond to the level of the canal orifices
• Identify all canal orifices and assess bleeding
• achieve haemostasis - apply moistened cotton pelet with NaOCI for 2 mains with dry pellet on top
  (if bleeding persists re-apply for up to 5 mins)
• record bleeding time
• dry pulp chamber with cotton pellet
• reassess status in all canal orifices
• mix biodentine and place into cavity 3mm layer
• wait 12 mins for initial set
• apply gic layer (glass ionomer cement) - allow at least 2mm space
• restore with composite
• post-op radiograph

Question 22

How would you assess the success of a vital pulp treatment?

Answer 22

• pulp sensibility testing (EPT or cold test)
• if there has been a full pulpotomoy and tooth has been restored with a crown - you would need to do a clinical and radiograph assessment with a PA radiograph

Question 23

what materials are most evidenced success for vital pulp treatments?

Answer 23

hydraulic calcium silicate cements (MTA, biodentine, bioroot, totalfill etc)

Question 24

what is the most historic filling material which is still used today?

Answer 24

MTA - mineral trioxide aggregate

Question 25

what are the advantages of MTA?

Answer 25

• excellent sealing ability
• biocompatibility with the pulp
• can be used for pulp capping in both primary and permanent teeth
• root-end filling
• perforation repair
• apical plug for teeth with open apices

Question 26

What dental material is made of calcium silicate cement and has been designed as a dentine replacement material?

Answer 26

Biodentine

Question 27

In 2023, septodont released a new version of biodentine, what are the advantages of this?

Answer 27

• involves a compule that removes the handling of the powder and liquid component (you dont need to mix yourself any more, more reliable consistency)
• optimised delivery with gun and bendable nozzle than the flat plastic

Question 28

what are the advantages of calcium silicate bioceramic putty?

Answer 28

• superior handling
• moldable/condensable putty consistency
• extreme resistance to washout
• shortened set time (20 mins)
• excellent healing
• highly biocompatible
• osteogenic
• non-staining

Question 29

what are the clinical applications of calcium silicate bioceramic putty?

Answer 29

• root endo filling (retrograde fills)
• repair of root perforations
  = repair of root resorption
• apexification and pulp capping