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BDS4 CDS Endo > Care of The Pulp > Flashcards

Care of The Pulp Flashcards

1
Q

what are the 3 components of pulp?

A
  • cells
  • nerves
  • blood vessels
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2
Q

what cells are in pulp?

A

odontoblasts

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3
Q

what is the nerve plexus in pulp called?

A

plexus of Raschkow

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4
Q

what types of nerves are in pulp?

A
  • Alpha fibre (myelinated)

- C-fibres (unmyelinated)

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5
Q

is pulp a vital tissue?

A

yes has a blood supply

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6
Q

what is pulp apart of?

A

dentine-pulp complex
- closely related

procedures in dentine will have effect of treatment of pulp and dentine
- don’t consider in isolation

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7
Q

what are the 4 main functions of pulp?

A
  • nutrition
  • sensory (temperature, pressure, pain)
  • protective (tertiary dentine formation)
  • formative
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8
Q

why is it hard to diagnose pulp issues?

A

poor correlation between clinical symptomatology and pulpal histopathology

  • due to misaligned symptoms and histopathology to what is happening in the tooth
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9
Q

more negative tests mean….

A

more likely a disease process

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10
Q

possible injuries to pulp

A
  • caries
  • cavity/crown preparation
  • dehydration of dentine
  • cutting odontoblast processes
  • direct injury to pulp
  • remaining dentine thickness too small
  • restorations
  • trauma
  • tooth-wear
  • periodontal pathology
  • orthodontic treatment
  • radiation therapy
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11
Q

how can cavity/crown prep injure the pulp?

A
  • Heat generation- use coolant!

- Type of bur used (Size, speed, sharpness, force, vibration)

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12
Q

how can dehydration of dentine injure pulp?

A

air or water infiltrating???

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13
Q

how can cutting odontoblast processes injure the pulp?

A

Odontoblast trail through tooth leaving trail of cell – cut them will damage the pulp

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14
Q

why is it important to keep in mind remaining dentine thickness?

A

Keep in mind potential remaining dentine thickness RDT (top of pulp to base of cavity)
- larger = less chance of pulp damage

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15
Q

how can restorations damage the pulp?

A 
Restoration materials can be highly chemical and toxic 
•	Toxicity
•	Water absorption
•	Heat of reaction
•	Poor marginal adaptation/ seal
•	Cementation of restoration
•	Microleakage 
etch
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16
Q

how can trauma lead to pulp injury

A

teeth are in vulnerable area of body

- exposed to external onslaught

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17
Q

how can periodontal pathology lead to pulp injury?

A

close relationship to perio tissue around the pulp

microtubules that go through dentine to periodontal ligament

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18
Q

how can radiation injure the pulp?

A

X rays can kill pulp cells

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19
Q

describe dentine permeability

A

Dentine tubules increase in number and diameter as they approach the pulp

  • Tubules more numerous and wider the deeper in dentine
  • Easier for substance to enter and exit pulp

therefore, the deeper the cavity the greater the dentine permeability

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20
Q

what bacteria substances can enter the pulp via the dentine?

A
  • enzymes
  • peptides
  • exotoxins
  • endotoxins (e.g. LPS)
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21
Q

what substances can enter the pulp via the dentine?

A
  • bacterial substances
  • polysaccharides
  • antibodies
  • immune complexes
  • complement proteins
  • tissue destruction products
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22
Q

what are a key factor in causing pulp problems?

A

micro-organisms

  • causes inflammatory process
  • manifests as clinical pain in patient
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23
Q

what are the fibres responsible for the 2 types of pain/

A

Alpha fibres
- sharp

C fibres
- dull/aching

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24
Q

are alpha fibres myelinated?

A

yes

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25
Q

are C fibre myelinated?

A

no

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26
Q

what is the effect of C fibres stimulation/

A
  • increased pulpal blood flow
  • increased pulpal pressure
  • can’t expand pulp chamber so increase in pressure results in crushing pain (dull/ache)
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27
Q

what fibres are stimulated by Electric Pulp Tester (EPT)?

A

Alpha fibres

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28
Q

how to determine and diagnose pulpal health?

A

SOCRATES history taking acronym

Diagnose pulp and periapical together – due to close relationship

AAE classification
- 2 parts: a pulpal diagnosis and a periapical diagnosis

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29
Q

4 types of pulpal diagnosis

A
  • healthy pulp
  • reversible pulpitis
  • irreversible pulpitis
  • necrotic pulp
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30
Q

what is health pulp diagnosis?

A

Vital

  • free of inflammation
  • No symptoms

Removed if endodontic treatment indicated for:

  • Elective or prosthetic purposes
  • Traumatic pulp exposure

Ideally treat exposure within 24 hours, but if not – RCT required
- Sometimes still worthwhile doing endodontic treatment – extreme tooth wear as pulp had time to lay done tertiary dentine, no tooth tissue to restore tooth so need to put in post into pulp and so need to carry out root treatment first to get rid of pulp as healthy pulp would be sore if inserted
- Traumatic mouth exposure – pulp exposed, don’t go dentist for 24hours so pulp died off, if before 24 hours can cover pulp and potentially cure
See paediatric dentistry lectures

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31
Q

what is reversible pulpitis diagnosis?

A

Vital
Inflamed pulp
- Reversible state of inflammation – if remaining vital can go back from inflamed state

Treat cause of inflammation e.g. caries
Investigations suggest:
- Can reverse to health if adequate vital pulp therapy performed

Many diagnostic mistakes made
- Most difficult to diagnose – need good history and tests (if don’t think it is can carry out unnecessary root treatment)

Regular response to sensibility tests

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32
Q

what is irreversible pulpitis diagnosis?

A

Vital
Inflamed
- Still has blood supply but in dying process

Investigations suggest:
- Pulpal inflammation can not heal

Treatment options:

  • Pulpectomy required then RCT
  • Extraction (Unrestorable tooth - Caries spread beyond crestal bone or Patient preference)
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33
Q

what is necrotic pulp diagnosis?

A

Non-vital pulp
- Partial or total necrosis
- Brown mush in tooth
Can have necrotic tissue in some canals but others vital especially in multi-rooted tooth

Treatment options:
- Mature teeth (closed apices, adults): Root canal treatment or Extraction
- Immature teeth with open apices (children): Pulpotomy; Pulpectomy then full RCT or Extraction
(open apices so more regenerative potential, seal remaining vital pulp and remove necrotic tissue )

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34
Q

reversible Vs irreversible pulpitis

A

Difference between reversible or irreversible pulpitis depends on clinical symptoms
- Mainly from history

Reversible pulpitis:

  • Pain to cold, lasts a short time
  • Hydrodynamic expression- microleakage (A-fibres)
  • No change in pulp blood flow

Irreversible pulpitis:

  • Spontaneous pain, intermittent, sleep disturbance
  • Negative to cold, pain to hot (e.g. tea/ coffee) (C-fibres)
  • Increase in pulpal blood flow
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35
Q

reversible pulpitis charavteristics

A
  • Pain to cold, lasts a short time
  • Hydrodynamic expression- microleakage (A-fibres)
  • No change in pulp blood flow
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36
Q

irreversible pulpitis characteristics

A
  • Spontaneous pain, intermittent, sleep disturbance
  • Negative to cold, pain to hot (e.g. tea/ coffee) (C-fibres)
  • Increase in pulpal blood flow
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37
Q

5 types of periapical diagnosis

A
  • normal
  • periapical periodontitis (symptomatic or asymptomatic)
  • acute apical abscess
  • chronic apical abscess
  • condensing osteitis
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38
Q

what is normal periapical diagnosis?

A

Not sensitive to percussion or palpation

Radiographically,:
- Lamina dura intact 
- PDL space uniform. 
See clear outline round all apices
(Blurring effect is loss of lamina dura)
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39
Q

what is symptomatic periaplical periodontitis diagnosis?

A

Inflammation of the apical periodontium (Inflammation gone through all pulp to periodontal ligament and tissue)
- PDL is like a hammock round tooth – spongey around when bite, inflammation causes this to hurt

Pain:

  • Biting
  • Percussion and/or
  • Palpation

May have periapical radiolucency (dark shadow)

Severe pain to percussion and/or palpation highly indicative of degenerating pulp

RCT required

40
Q

what is asympotamtics periaplical periodontitis diagnosis?

A

Inflammation and destruction of the apical periodontium (of pulpal origin)

Appears as an apical radiolucency

  • No present clinical symptoms
  • No pain on percussion
  • No pain on palpation
  • No problems

get X rays for other reasons and notice big dark shadow – chance finding

41
Q

what is acute apical abscess diagnosis?

A

Inflammatory reaction to pulpal infection and necrosis

  • Emergency clinics often
  • Rapid onset
  • Long manifestation time, lot of pus formation and increase in pressure
Spontaneous pain
Extreme tenderness to pressure
Pus formation 
Poor taste
May be no radiographic signs of destruction 
Malaise
Fever
Unable to sleep
Lymphadenopathy (Inflammation in lymph nodes – trying to fight back)

Treatment
- drain abscess numb tooth and incision, pus removed, open tooth to removed infected pulp, dressing and come back to extract/RCT

Can cause a huge facial swelling – requires additional treatment (max fax)

42
Q

what is chronic apical abscess diagnosis?

A

Inflammatory reaction to pulpal infection and necrosis
- Pus slowly finds a way through mucosa and present buccally or labially

Intermittent discharge of pus through sinus tract.
- Draining itself – so less pressure build up, so less constant pain compared to other

Gradual onset
Little or no discomfort
Periapical/periradicular radiolucency.

Suspect tooth can be identified:
- Carefully place GP cone into sinus tract
- Take radiograph
(Sinus is trapped where pus draining into. Put GP point into sinus and take X-ray and will point to source of infection )

43
Q

what is condensing osteitis diagnosis?

A

Diffuse radiopaque lesion

Represents localised bony reaction to a low-grade inflammatory stimulus
- Usually seen at apex of tooth
(White area on X ray)

Monitor tooth if asymptomatic

44
Q

how can dehydration of dentine injure pulp?

A

taking away natural dentinal fluid

45
Q

5 signs of non-vital teeth

A
  • discolouration
  • sinus
  • gross caries
  • large restorations
  • radiographic evidence
46
Q

what discolouration can occur in non-vital teeth?

A

yellow
grey
pink

47
Q

what are yellow non-vital teeth a sign of?

A

obliteration of dentine tubules, less light passes through

48
Q

what are grey non-vital teeth a sign of?

A

blood products in dentine tissue

49
Q

what are pink non-vital teeth a sign of?

A

sign of resorption, eating away at itself, tends to be round the cervical of the tooth

50
Q

what is the sinus sign for non-vital teeth?

A

presentation of sinus = dead tooth

51
Q

how can gross caries cause a non-vital tooth?

A

enters pulp

52
Q

how can a large restoration cause a non-vital tooth?

A

encroached on pulp by error, can lead to slow death

53
Q

what radiographic evidence shows a non-vital tooth?

A
  • periapical radiolucency

- periradicular radiolucency

54
Q

what is the old term for sensibility tests?

A

vitality tests

55
Q

what do sensibility tests test for?

A

Primary function is to differentiate “vital” from “non-vital” pulp
- nerve supply (not blood supply, tooth vitality is blood supply dependent but these are for nerve stimulation)

Patient response very subjective
- Compare patient’s response with a contralateral tooth then re-examine same tooth

56
Q

3 types of sensibility tests

A

Electric pulp tests (Electric Pulp Tester (EPT))

Thermal tests:

  • Cold tests (Ethyl chloride)
  • Heat tests (Hot gutta percha (GP))

Test drilling

57
Q

some issues that can occur in sensibility tests

A

TEST NERVE SUPPLY AND SENSIBILITY, NOT BLOOD FLOW

periradicular inflammation occurs before pulp totally necrotic
- so partially necrotic but still response as alive

Difficulties in testing multi-rooted teeth

58
Q

what does an electric pulp test do?

A

stimulates nerves at pulp-dentine junction

mainly Alpha fibres
unmyelinated C fibres may not respond

59
Q

procedure for electric pulp test

A

Teeth thoroughly dried with air or cotton wool
- Prevents current transfer to adjacent teeth

Isolate tooth/teeth

Conducting medium (toothpaste/ fluoride gel) required

  • Place on Tip of EPT probe
  • Allows current to pass through

EPT probe placed on incisal edge or cusp tip adjacent to pulp horn
- Most sensory nerves found here

Patient completes circuit by holding handle of EPT

Current slowly increased from 0 to 80
- Occurs automatically

Patient indicates when a tingling/ heat sensation is felt
- Can pull probe away from tooth and number will stop

Specific number ranges for different teeth – guide on EPT
take 3 readings from tooth – patient’s response can be different

Always test the contralateral tooth (upper left second incisor test upper right second incisor)

60
Q

what must you always do when carrying out an electric pulp test?

A

Always test the contralateral tooth (upper left second incisor test upper right second incisor)

61
Q

positive response to electric pulp test

A

Vital pulp tissue in coronal aspect of pulp chamber

No indication of reversibility of inflammation (healing)

No correlation between pain threshold and pulp condition (measurement of electric voltage/ score is not accurate)

close to reading

62
Q

negative response to electric pulp test

A

Reliable indicator for pulpectomy procedure in 97.7% cases

EPT of young pulps (teeth with open apices) or recently traumatised teeth
- unreliable

above reading

63
Q

how is thermal tests believed to work?

A

hydrodynamic forces

fluid movement in dentinal tubules (due to thermal stimulus

  • when apply a thermal stimulus on the tooth the fluid wants to move towards the stimulus
  • jars the odontoblast processes

Activates pulp’s sensory nerve receptor units in pulp

64
Q

what are the types of thermal tests?

A

cold tests (most typical, ethyl chloride used in clinic, endo ice is better)

heat tests

65
Q

cold test procedure

A

Teeth carefully dried and isolated

Place cold object close to pulp horn (spray cotton wool with chemical)

Ask if they feel the cold stimulus

  • Yes – positive result
  • No – negative result

Negative response highly indicative of pulpal necrosis

66
Q

types of chemical used for cold tests

A
  • ethyl chloride – (not reliable)
  • Difluorodichloromethane – -500 degrees C
  • Endo-Ice (-27.2 degrees C)
67
Q

what should be remembered when carrying out a heat test?

A

rare

need caution
- Too much heat may cause irreversible pulpitis!

Initial stimulation of A-delta fibres
- Sharp pain

Continued stimulation results in C-fibre activation
- Dull radiating pain

68
Q

procedure for heat test

A

Vaseline on tooth

Apply hot gutta percha (used in RCT)/ green stick to tooth
- Negative response indicative of necrotic pulp

Not possible to ascertain degrees of reversibility of inflamed symptomatic pulp

69
Q

when is test drilling used as a sensibility test?

A

Used when full coverage restorations present

  • Renders other forms of testing impossible
  • Really unsure – inconclusive results and history
70
Q

what is the procedure for test drilling?

A

No local anaesthetic given

Cut into tooth

Diagnosis

  • Patient reports severe pain or no pain felt when cutting dentine
  • Sensitivity-like response to dentine preparation – tooth is vital
71
Q

what is an alternative to test drilling if inconclusive pulp diagnosis from other test sand history?

A

Isolation crowned tooth with rubber dam (No LA)

Bombard with spray of cold water and air

Assess patient response

72
Q

what 4 clinical factors can influence pulp health

A
  • carious pulp exposure
  • age
  • periodontal disease
  • previous pulpal insult
73
Q

carious pulp exposure impact on pulp health

A

Pulp exposed to caries and bacteria

Vital treatment of carious exposures less than 50% successful
- Therefore, RCT required
However – not in all cases
- E.g. Immature teeth with incomplete root development – Consider removal of necrotic parts of pulp only (Pulpotomy)

Want to remove caries from wall of cavity first rather than base
- as if accidentally drill into pulp and still have caries, flakes of caries can enter and cause infection

74
Q

age impact on pulp health

A

Continued dentine formation (secondary dentine)

  • Reduced pulp size and volume
  • More leeway when drilling as less likely to encroach

Increased:

  • Fibrous components
  • Calcification

Decreased:

  • Cellular components
  • Number of blood vessels and nerves

Overall, pulp is less likely to reverse an inflammatory response

75
Q

what are the changed characteristics of older pulp?

A

Increased:

  • Fibrous components
  • Calcification

Decreased:

  • Cellular components
  • Number of blood vessels and nerves

Overall, pulp is less likely to reverse an inflammatory response

76
Q

periodontal disease impact on pulp health

A

Moderate to severe periodontal disease, Result: “prematurely aged” pulp
- increased fibrous component of periodontal disease

  • less resistant to inflammation than healthy pulp
  • Close relationship between pulp and periodontal tissues
  • Can prematurely age pulp
77
Q

previous pulpal insult effect on pulp health

A

Caries, caries removal and restorative procedures
- Close to pulp in caries treatment, pulp responds - shrink back as part of disease process as tertiary dentine is laying done

Tubule occlusion

  • Reparative dentine formation
  • Pulpal fibrosis

“Premature aging” of pulp
- Less likely to heal than healthy pulp

78
Q

what are the 2 maintenance techniques of pulp health?

A
  • prevention of pulpal damage
  • treatment of pulpal damage

prevention better than care

79
Q

what are 4 points of prevention of pulpal damage?

A
  • know tooth anatomy
  • avoid drilling into pulp
  • cavity close to pulp
  • cavity into pulp (exposure)
80
Q

why knowledge of tooth anatomy is important in pulpal prevention?

A

Size, location and proximity of pulp (canals related to pulp horns)

Pre-assessment
- Radiographs

81
Q

why is avoiding drilling into pulp important in pulpal prevention?

A

Stop if close to pulp

Caries can be left over pulpal floor in some cases
- Placement of well-sealed restoration

Deep cavity drill maybe stop and place lining, step wise excavation, sealing caries and restoring tooth

82
Q

what should be done if a cavity is close to the pulp to aid pulpal prevention?

A

Use of cavity sealers

Indirect pulp cap
- Or small remaining thickness of dentine place to thicken

83
Q

what should be done is pulp exposure has occurred to aid pulpal prevention?

A

Direct pulp cap

- material over pulp directly

84
Q

what do cavity sealers protect pulp from?

A
  • bacteria and their products
  • toxic effects during setting phase of restorative material

Whole exposed pulpal dentine must be covered

85
Q

what are the 3 key characteristics for cavity sealers?

A

adhere to dentine rather than restorative material
- don’t want sealer to be removed if need to remove the restoration in furture

be thin
- Otherwise – reduces strength of restorative material (requires a certain thickness or will fracture and fail)

Not dissolve in biological liquids

86
Q

what are 3 types of cavity sealers?

A
  • varnishes (rare)
  • liners
  • base materials
87
Q

why are liners and bases used more than varnishes as cavity sealers?

A

thicker so greater thermal protection from external things and restorative materials

88
Q

examples of cavity bases/liners

A
  • Zinc phosphate
  • Zinc oxide eugenol
  • Calcium hydroxide e.g. Dycal (most)
  • Resin modified glass ionomers (RMGI) e.g. Vitrebond
89
Q

positive properties of calcium hydroxide

A 
High pH (alkaline) – Stimulates fibroblasts
- reparative dentine formation (tertiary/healing)

Stimulates recalcification of demineralised dentine
- by stimulating pulpal cells

Neutralises low pH from acidic restorative materials

bacteriostatic

90
Q

negative properties of calcium hydroxide

A

Cytotoxic
- Can kill pulp cells

Weak cement – so hard to place

Very soluble if not protected– tiny bit moist from saliva, it will dissolve

91
Q

what are dentine bonding agents?

A

Dentine primers with/ without adhesives

  • tolerated by the pulp
  • can be placed directly over pulp without killing it off

Marked reduction in microleakage demonstrated by dentine bonding agents

However
- Use is VERY “technique sensitive”

92
Q

4 treatment options for pulp damage

A

Treatment of pulpal damage

  • Indirect pulp cap
  • Or stepwise excavation or seal caries in

Direct pulp cap

Partial pulpal removal – Pulpotomy

Full pulpal removal – Pulpectomy
- Progress to RCT

93
Q

step wise excavation

A
  • Leave a bit of caries at base restore with glass ionomer buys time for tertiary dentine being laid down
  • Don’t expose pulp
  • Restore permanent – encase bacteria in tooth – no food source access no more caries
94
Q

what is the change in theory behind new treatment options for caries?

A

remove one of the 4 caries elements
- without one cannot occur

e.g. Cut off bacteria from substrate can arrest caries, if scared to expose the pulp

95
Q

bacteriostatic

A

biological or chemical agent that stops bacteria from reproducing, while not necessarily killing them otherwise

96
Q

bactericidal

A

is a substance that kills bacteria

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