Care of the Pulp Flashcards
What is present in the pulp?
Cells
¡ Odontoblasts
Nerves (plexus of Raschkow)
¡ Alpha fibres (myelinated)
¡ C-fibres (unmyelinated)
Blood vessels
What are the functions of the pulp?
Nutrition, sensory, temperature, pressure, pain, protective, reparative healing, and formative functions.
What are possible injuries to pulp?
caries
cavity preparation (heat, air, vibration, cutting processes)
restorations
restorative materials (toxic, exothermic)
trauma
tooth wear
periodontal pathology
orthodontic treatment
radiation therapy
What is RDT and what is the size?
remaining dentine thickness
approximately 2mm of dentin or an equivalent thickness of materials should exist to protect the pulp.
How does dentine permeability change with cavity depth?
The deeper the cavity, the greater the dentine permeability due to the increase in number and size of dentine tubules.
What are things that can enter pulp due to dentine permeability?
¡ Bacterial substances
¡ Enzymes
¡ Peptides
¡ Exotoxins
¡ Endotoxin (e.g. LPS)
¡ Polysaccharides
¡ Antibodies
¡ Immune complexes
¡ Complement proteins
¡ Tissue destruction products
What are the types of dental pain and their stimulation?
sharp pain, stimulated by alpha fibers
dull/aching pain, stimulated by C fibers.
What are the possible pulpal diagnosises?
Healthy pulp
reversible pulpitis
irreversible pulpitis
necrotic pulp.
What are the possible periapical diagnosises?
Normal periapical tissues
periapical periodontitis (symptomatic/asymptomatic)
acute apical abscess
chronic apical abscess
condensing osteitis.
What are the qualities of reversible pulpits?
Vital, inflamed pulp
Can reverse to health if adequate vital pulp therapy performed
Regular response to sensibility tests
What are the qualities of irreversible pulpits and what are treatment options?
¡ Vital, chronic inflammation can not heal
Spontaneous pain
¡ Treatment options:
1. Pulpotomy followed by “vital pulp therapy”
1. Only if some remaining pulp tissue is not irreversibly inflamed
2. Pulpectomy then RCT
3. Extraction
What is the difference of reversible vs irreversible pulpitis?
Reversible pulpitis:
Short pain to cold
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
What is the treatment options for necrotic teeth (closed apices vs open apices)?
mature teeth
rct
extraction
immature teeth
pulpotomy then RCT
extraction
What is the sensitivity of normal periapical tissues and how do they appear radiographically?
Not sensitive to percussion or palpation
Radiographically,: Lamina dura intact, PDL space uniform.
symptomatic periapical periodontitis
VS
asymptomatic periapical periodontisis
Symptomatic Periapical Periodontitis:
* Painful, especially when biting down or chewing, hot/cold
* Develops suddenly and may worsen quickly
* X-ray may have periapical radiolucency
Asymptomatic Periapical Periodontitis:
* No pain or discomfort
* Develops gradually over time
* X-ray has apical radiolucency
What are qualites of acute apical abscess?
inflammatory reaction to pulpal infection and necrosis
Rapid onset, spontaneous pain
Extreme tenderness to pressure, pain
Pus formation, swelling
Malaise, lymphadenopathy, fever
What are the qualities of chronic apical abscess?
inflammatory reaction to pulpal infection and necrosis
Gradual onset
Little or no discomfort
Intermittent discharge of pus through sinus tract.
Periapical/periradicular radiolucency.
What should be done for a chronic apical abcess?
Carefully place GP (gutta percha) cone into sinus tract of suspected tooth and take radiograph
What are the qualities of condesing osteitisis?
diffuse radiopaque lesion
localised bone hardening to a low-grade inflammatory stimulus
usually seen at apex of tooth
no symptoms
What are the types of sensibility tests?
¡ Electric pulp tests (Electric Pulp Tester (EPT))
¡ Thermal tests:
¡ Cold tests (Ethyl chloride)
¡ Heat tests (Hot gutta percha (GP))
¡ Test drilling
What are the problems of these tests?
¡ These tests stimulate nerve fibres
¡ Tooth vitality is related to blood supply, not nerve stimulation
¡ Laser doppler needed to assess blood flow
¡ Periradicular inflammation occurs before pulp totally necrotic
¡ Difficulties in testing multi-rooted teeth
What is the EPT?
Electric current used to stimulate sensory nerves at pulp-dentine junction
¡ A-delta fibres stimulated
¡ Unmyelinated C-fibres may or may not respond
electric pulp test
What is the scale of EPT?
0 -80
if number reaches 80 and no sensation, there is a loss of vitality (necrotic)
if number is too low, the tooth is inflammed
How do thermal tests work?
Believed to work by hydrodynamic forces
¡ Fluid movement in dentinal tubules (due to thermal stimulus)
¡ Activates pulp’s sensory nerve receptor units in pulp:
What can too much heat cause?
irreversible pulpitis
How do heat tests work?
¡ Initial stimulation of A-delta fibres
¡ Sharp pain
¡ Continued stimulation results in C-fibre activation
¡ Dull radiating pain
¡ Procedure
¡ Vaseline on tooth (gutta percha becomes sticky)
¡ Apply hot gutta percha/ green stick to tooth
What does a negative response to a heat/ cold test indicate?
necrotic pulp
When is test drilling used and how is it done?
Used when full coverage restorations present, other forms of testing impossible
no LA given, cut into tooth dentine. if pain is felt, tooth is vital
What is an alternative to drilling?
¡ Isolation crowned tooth with rubber dam
¡ (No LA)
¡ Spray cold water and air
¡ Assess patient response
What are the clinical factors that may affect pulp?
¡ Carious pulp exposure
¡ Age
¡ Periodontal disease
¡ Previous pulpal insult/ trauma
What changes with age?
¡ Continued dentine formation
¡ Reduced pulp size and volume
¡ Increased:
¡ Fibrous components
¡ Calcification
¡ Decreased:
¡ Cellular components
¡ Number of blood vessels and nerves
¡ Overall:
¡ Pulp less likely to reverse an inflammatory response
What happens to pulp in moderate/severe PD?
prematurely aged pulp
less resistant to inflammation than healthy pulp
What can previous pulpal insult cause?
¡ Tubule occlusion
¡ Reparative dentine formation
¡ Pulpal fibrosis
¡ “Premature aging” of pulp
¡ Less likely to heal than healthy pulp
How can pulp vitality be maintained?
¡ Prevention of pulpal damage
¡ Step-wise excavation
¡ Seal in caries
¡ Vital pulp therapy
¡ Pulp capping
¡ Partial/Cvek pulpotomy
¡ Complete pulpotomy
What are examples of MATERIALS FOR VITAL PULP THERAPY?
¡ Zinc phosphate
¡ Zinc oxide eugenol
¡ Calcium hydroxide - e.g. Dycal
¡ Tricalcium phosphate
¡ Resins – e.g. composite
¡ RMGI - e.g. Vitrebond
¡ Bioceramics – e.g. MTA, Biodentine
advantages VS disadvantages of calcium hydroxide?
ADVANTAGES
High pH – Stimulates fibroblasts and reparative dentine formation due to irratation, kills acidic bacteria
Easy to use - quick set time
Radiopaque
DISADVANTAGES
Weak (low CS)
Soluble
Does not bond
advantages VS disadvantages of MTA?
ADVANTAGES
High pH
Creates bacterial-tight seal
Sets hard enough to act as base for restorative material
Biocompatable
DISADVANTAGES
Prolonged setting time
Discolouration of crown (grey MTA contains iron)
What is biodentine?
Similar to MTA, but
¡ Quicker setting
¡ No discolouration
What is the process of cvek pulpotomy?
¡ 1-2mm coronal pulp removed initially (with high speed)
¡ Additional pulp removed if bleeding excessive
¡ Once healthy/vital pulp tissue reached – stop
¡ Rinse with 5% NaOCl
¡ Place Ca(OH)2, MTA or Biodentine over pulp tissue
¡ Place sealing restoration (e.g. GI)
¡ Place restoration (e.g. composite)
What colour is healthy pulp and how is bleeding controlled in healthy pulp?
light red
with saline
What does inflammed tissue look like?
crimson and bleeds a lot
What is difference between a partial and a CVEK pulpotomy?
CVEK is 1-2mm removel
partial is additional
What is a complete pulpotomy?
Same as previous procedure except entire pulp removed from pulp chamber
Pulp in root canals retained
What are treatment options for unexposed pulp?
¡ Indirect pulp cap
¡ Stepwise excavation
¡ Seal caries in
What are treatment options for exposed pulp?
Direct pulp cap
Partial coronal pulpal removal – Partial pulpotomy
Complete coronal pulp removal – Complete pulpotomy
Full pulpal removal – Pulpectomy
Progress to full RCT
