Care of the Pulp Flashcards
Whatt type of nerves are in the pulp?
A-Beta
A-Delta
C fibres
What does it mean if the pulp is a vital tissue?
Responds to stimuli and has regenerative potential
What is the main nerve plexus in the tooth?
plexus of Raschkow
What are the functions of the pulp?
Nutrition, sensory, protective, formative
What type of sensations can the pulp feel?
Temperature, pressure, pain
what type of protective functions does the pulp have?
Tertiary dentine formation for reparative healing
What is the formative function of the pulp?
Secondary dentine production
Name the types of injury that can occur to the pulp.
Caries
Cavity preparation
Restorations
Trauma
Tooth wear
Periodontal pathology
Orthodontic treatment
Radiation therapy
How can restoration materials damage the pulp?
Toxicity, water absorption, heat of reaction, poor marginal adaptation/seal, cementation of restoration
What happens to the structure of dentine tubules closer to the pulp?
They increase in number and diameter
Where is dentine permeability the greatest?
At the pulp
What types of cells can pass through dentine tubules?
Bacterial substances, polysaccharides, antibodies, immune complexes, complement proteins, tissue destruction products
What is the key part of pulpal and periradicular pathology?
Micro-organisms
What types of pain does alpha fibres feel?
Sharp pains
What type of pain does C fibres feel?
Dull/aching pain
What are alpha fibres stimulated by?
Electric pulp test
What are c fibres stimulated by?
Increased pulpal blood flow and increased pulpal pressure
What are the two AAE classifications?
Pulpal diagnosis, periapcial diagnosis
What are the types of pulpal diagnosis?
Healthy pulp
Reversible pulpitis
Irreversible pulpitis (symptomatic/asymptomatic)
Necrotic pulp
Previously treated
Previously initiated therapy
What are the different types of periapical diagnosis?
Normal
Periapical periodontitis (symptomatic, asymptomatic)
Acute apical abscess
Chronic apical abscess
Condensing osteitis
What does a healthy pulp mean?
Vital and free of inflammation
When are healthy pulps removed?
For elective/prosthetic purposes, for traumatic pulp exposure
Is a pulp with reversible pulpitis vital or non-vital?
Vital
What is reversible pulpitis?
Inflamed pulp which can be reversed back to health
What sort of response to reversible pulpitis pulps have to sensibility test?
regular response
Are pulps with irreversible pulpitis vital or non-vital?
vital
What is irreversible pulpitis?
Inflamed pulp which cannot be reversed back to normal
What are the treatment options for irreversible pulpitis?
Pulpectomy then RCT/extraction if the tooth is unrestorable and patient would prefer this
How do you know if a pulp has irreversible pulpitis?
If investigations suggest that pulpal inflammation cannot heal
What are the clinical symptoms of reversible pulpitis?
Pain to cold
Lasts a short time (A fibres)
Hydrodynamic expression (microleakage)
No change in blood flow
Not keeping patient up at night
Doesn’t occur spontaniously
What are the clinical symptoms of irreversible pulpitis?
Spontaneous pain, can last hours
Intermittent
Sleep disturbance
Pain to hot (C fibres)
Increase in pulpal blood flow
What is the vitality of a necrotic pulp?
Non-vital
What is a necrotic pulp?
Partial or total necrosis of the pulpal tissue.
What are the treatment options for mature teeth with a necrotic pulp?
Root canal treatment or extraction
What are the treatment options for immature teeth with a necrotic pulp?
Pulpotomy, pulpectomy then full RCT, extraction
What does it mean if a tooth is mature?
The apices are closed
What are normal periapical tissues like?
Not sensitive to percussion or palpation, lamina dura intact, PDL space uniform
What is symptomatic periapical periodontitis?
Inflammation of the apical periodontium
What are the symptoms of symptomatic periapical periodontitis
Pain when biting, applying percussion, palpation, periapical radiolucency
What is highly indicative of a degenerating pulp?
Pain to percussion and/or palpation
What treatment is needed for symptomatic periapical periodontitis?
RCT or XLA
What is asymptomatic periapical periodontitis?
Inflammation and destruction of the apical periodontium
What does an asymptomatic periapical periodontitis appear like?
An apical radiolucency on a radiograph
What can symptomatic periapical periodontitis look like on a radiograph?
Periapical radiolucency
What is an acute apical abscess?
Inflammatory reaction to pulpal infection and necrosis, reslting in suppative infection of the apical tissues.
What are the symptoms of acute apical abscess?
Rapid onset, spontaneous pain, extreme tenderness to pressure, pus formation, swelling
What are the systemic signs of acute apical abscess?
Malaise, fever, lymphadenopathy
What are the symptoms of chronic apical abscess?
Little or not discomfort, intermittent discharge of pus through sinus tract
What shows on a radiograph with chronic apical abscess?
Periapical/periradicular radiolucency
How do you identify the tooth affected by the chronic apical abscess?
carefully place GP cone into sinus tract and take a radiograph
what is condensing osteitisis?
diffuse radiopaque lesion which represents localised bony reaction to a low-grade inflammatory stimulus
where are condensing osteitisis usually seen?
at the apex of tooth
what are the signs of a non-vital tooth?
discolouration, sinus, gross caries, large restorations, radiographic evidence (periapical radiolucency and periradicular radiolucency)
what types of colours do non-vital teeth display?
yellow, grey, pink
what does a yellow tooth mean?
obliteration of dentinal tubules
what does a grey tooth mean?
blood break down products in tooth
what does a pink tooth mean?
resorptive process, tooth eating itself away
where is a periapical radiolucency?
only around the apex
where is a periradicular radiolucency?
round more surfaces of the root
what is the function of a sensibility test?
to differentiate vital from non-vital pulp
how do you conduct a sensibility test?
compare patients response with a contralateral tooth then re-examine same tooth
what tests are used for sensibility tests?
electric pulp tests, thermal tests, test drilling
what cold test is used as a sensibility test?
ethyl chloride
what hot test is used for sensibility?
hot gutta percha
what are the problems of sensibility tests?
stimulate nerve fibres but dont assume that nerve fibres in pulp correlates to vital blood supply, they do not indicate the state of the blood supply, tooth vitality is related to blood supply and not nerve stimulation, periradicular inflammation occurs before pulp is totally necrotic, difficulties in testing multi-rooted teeth
what does an electric pulp test do and which nerve fibres does it stimulate?
stimulate sensory nerves at pulp-dentine junction, A delta fibres stimulated (C fibres sometimes respond)
how do you conduct an electric pulp test?
teeth thoroughly dried, isolate tooth, conducting medium (toothpaste), EPT probe placed on incisal edge or cusp tip, patient completes circuit by holding handle of EPT, current slowly increased, patient indicates when feeling a tingling sensation
what is a positive response of an EPT?
vital pulp tissue in coronal aspect of pulp chamber, no indication of reversibility of inflammation, no correlation between pain threshold and pulp condition
what is a negative response of an EPT?
reliable indicator for pulpectomy procedure in 97.7% (apart from young pulps or recently traumatised teeth)
how do thermal tests work?
by hydrodynamic forces (fluid movement in dentinal tubules)
what is the procedure of a cold test?
teeth carefully dried and isolated, place cold object close to pulp horn
if a cold test gives a negative response what is it indicative of?
pulpal necrosis
what is the procedure of a heat test?
vaeline on tooth, apply hot gutta percha/green stick on tooth
what is a negative response to a heat test indicative of?
necrotic pulp
when is test drilling used
when full coverage restorations are present
how do you conduct test drilling?
no LA given, cut into tooth
if a patient reports pain when cutting into the tooth what does this mean
tooth is vital
what is an alternative to a tooth drilling test?
spray with cold water and air and assess patient response
what influences the clinical factors?
carious pulp exposure, age, periodontal disease, previous pulpal insult/trauma
what treatment is usually needed for carious pulp exposure?
RCT
what happens to the pulp with age?
continued dentine formation so reduced pulp size and volume, increased fibrous components and calcification, decreased cellular components and number of blood vessels and nerves, pulp less likely to reverse an inflammatory response
how does periodontal disease influence the pulp?
moderate/severe periodontal disease results in prematurely aged pulp, pulp in periodontal tooth is less resistant to inflammation than healthy pulp
what is the results of previous pulpal insult on the pulp?
tubule occlusion so pulpal fibrosis, premature aging of pulp so less likely to heal
how do you maintain pulp vitality?
prevent pulpal damage and treat the pulp
how do you prevent pulp damage?
know tooth anatomy, use radiographs, avoid drilling into pulp, cavity close to pulp use sealers, cavity into the pulp use direct pulp cap
what are the effects of calcium hydroxide?
bacteriocidal/bacteriostatic, stimulates fibroblasts through a high pH, stimulates recalcification of demineralised dentine, neutralises low pH, cytotoxic, weak cement, soluble if not protected
what are the possible treatment options for pulpal damage?
indirect pulp cap, direct pulp cap, partial pulpal removal, full pulpal removal then RCT
what is partial pulpal removal called?
pulpotomy
what is full pulpal removal called?
pulpectomy
