Care of the Pulp Flashcards
what does the pulp contain
cells [odontoblasts]
nerves, blood vessels
vital tissue
functions of the pulp
nutrition, sensory, temperature, pressure, pain, protective, tertiary dentine formation via odontoblasts, reparative healing, formative, secondary dentine
examples of injury to the pulp
caries, cavity preperation, restoration, restorative materials, trauma, toothwear, perio pathology, ortho tx, radiation, cutting odontoblasts, direct injury, restoration toxxicity, dehydrattion of dentine
arrangement of dentine and permeability
dentine tubules increase in number and diameter as they approach the pulp, therefore the deeper the cavity, the greater the dentine permeability
pain stimulated by alpha fibres results in
sharp pain
unmyelinated
pain caused by c-fibres results in
dull/aching pain
increased pulpal flow and pressure
unmyelinated
7 types of pulpal diagnosis
- healthy pulp
- reversible pulpitis
- symptomatic irreversible pulpitis
- asymptomatic irreversible pulpitis
- necrotic pulp
- previously treated
- previoiusly initiated therapy
healthy pulp diagnosis
- vital, free of inflammation
- can be removed if indicated for elective/prosthetic, traumatic pulp exposure, toothwear
- treat within 24hr, if not then RCT
reversible pulpitis
- vital, inflammed pulp
- pain to cold, short time
- hydrodrynamic expression microleakage
- can reverse to health
- regular response to sensibility tests
- remove tissue causing issue
symptomatic irreversible pulpitis
- vital, inflammed pulp
- cannot heal
- spontaneous pain, intermittent, sleep disturbance
- negative to cold, pain to hot
- increased pulpal blood flow
tx options for irreversible pulpitis
- pulpectomy followed by vital pulp therapy [if some remaining pulp is not irreversibly inflammed]
- pulpectomy then RCT
- exctraction [unrestorable tooth, pt preference]
asymptomatic irreversible pulpitis
- vital, inflammed pulp
- cannot heal pulpal inflammation
- no symptoms
necrotic pulp
- non-vital pulp
- partial or total necrosis
- no pain as nerve is dead
tx options for necrotic pulp
mature teeth;
- RCT
- extraction
immature teeth [open apice];
- pulpotomy
- pulpectomy then RCT
- extraction
what are the 6 periapical diagnosis
- normal
- symptomatic periapical periodontitis
- asymptomatic periapical periodontitis
- acute apical abscess
- chronic apical abscess
- condensing osteitis
normal periapical tissue diagnosis
not sensitive to percussion or palpation
radiographically = lamina dura intact, PDL space uniform
symptomatic periapical periodontitis
- inflammation of apical periodontium
- pain = biting, percussion, palpation
- may have periapical radiolucency
- severe pain to percussion/palpation indicates degenerative pulp
RCT REQUIRED
asymptomatic periapical periodontitis
- inflammation and destruction of apical periodontium
- apical radiolucency
- no present clinical symptoms = no pain percussion/palpation
acute apical abscess
- inflammatory reaction to pulpal infection and necrosis
- rapid onset, spontaenous pain, extreme tenderness to pressure
- pus formation, swelling
- may be no radiographic signs of destruction
- malaise, fever, lymphadenopathy
chronic apical abscess (sinus)
- inflammatory reaction to pulpal infection and necrosis
- gradual onset, little to no discomfort
- intermittent discharge of pus through sinus tract
- periapical/periradicular radiolucency
- suspect tooth can be identified by placing GP cone in sinus tract and radiograph
condensing osteitis
diffuse radiopaque lesion
represents localised bony reaction to low-grade inflammatory stimulus
usually seen at apex of tooth
signs of a non-vital tooth
discolouration [grey, pink, yellow]
sinus, gross caries, large restoration, radiographically, periapical/radicular radiolucency
sensibility test function
test neuron/nerve function in tooth
subjective
what should you always do when sensibility testing?
compare response with contralateral tooth and then reexamine
what are some problems with sensibility testing
- dont stimulate nerve fibres
- dont assume that nerve fibres in pulp correlates to blood supply
- dont indicate state of blood supply
- tooth vitality is related to blood supply not nerve stimulation
- periradicular inflammation occurs before nerotic pulp
- hard to test multi-rooted teeth
what tool is needed to assess blood flow
laser doppler
electric pulp test
electric current used to stimulate sensory nerves at pulp-dentine
- adelta fibres stimulated
- unmyelinated c fibres may or may not respond
pt sensitive
electric pulp test procedure
- teeth thoroughly dried [prevent current transfer to adjacent teeth]
- isolate tooth
- conducting medium [toothpaste/fluoride gel] required [tip of EPT]
- EPT probe placed on incisal edfe or cusp tip adjecent to pulp horn [most sensory nerves here]
- pt completes circuit by holding EPT handle
- current slowly increased
- pt indicates when tingling/heat sensation if felt [pull probe away]
results of EPT generally
very quick removal = inflammation of tooth
no response = necrotic pup
positive response to EPT
- vital pulp tissue coronally
- no indication of reversibility
- no correlation between pain threshold and pulp condition
negative response to EPT
- reliable indicator for pulpectomy
- EPT of young/open apice or recently traumatised teeth is unreliable
how do thermal tests work
hydrodynamic forces, fluid movement in dentinal tubules
activates pulps sensory nerve receptor units in pulp
cold test
cotton roll with ethyl chloride, endoice, endofrost
1. teeth dried and isolated
2. cold object close to pulp horn
3. negative response indicative of pulpal necrosis
why would you use caution when performing a heat test
too much heat can cause irreversible pulpitis
heat tests
initial stimulation of adelta = sharp pain
continued stimulation results in cfibre activation = dull radiating pain
- vaseline on tooth
- apply hot gutta percha/greenstick on tooth
- negative response indicative of necrotic pulp
cannot ascertain degree of reversibility
test drilling
when full coverage restorations present
renders other test impossible
- pt reports severe or no pain
- sensitivity = vital tooth
alternative to sensibility tests
isolate tooth with rubber dam, no LA, spray with cold water and air, assess pt response
what 4 clinical factors can influence pulp and RCT
- carious pulp exposure
- age
- periodontal disease
- previous pulpal insult/trauma
carious pulp exposure influence on RCT
- exposure to caries/bacteria
- unpredictable outcome so RCT likely to be required
- immature teeth = condier removal of necrotic pulp only
influence of age on endo tx
- continued dentine formation so reduced pulp size/volume
- increased = fibrous, clacification
- decreased = cellular, no. blood vessels, nerves
- the older you are, less lilely of pulp to reverse inflammatory response
influence of periodontial disease on endo/RCT
- moderate/severe PDD => prematurely aged pulp
- pulp in perio tooth => less resistant to inflammation than healthy pulp
influence of previous pulpal insult on endo/RCT
- caries/caries removal
- tubule occlusion => reperative dentine formation, pulpal fibrosis
- premature aging of the pulp => less likely to heal than healthy pulp
maintenance of pulp vitality
step-wise excavation, seal in caries
vital pulp therapy examples
pulp capping
partial pulpotomy
complete pulpotomy
how can you prevent pulpal damage
know the tooth anatomy
pre-assessment xray
avoid drilling too close
caries can be left over the pulp in some cases
- well-sealed restoration, step-wise excavation, remove temporary 6-12m after tertiary dentine formation, remove caries and permanent restoration
what is the point in vital pulp therapy
protect pulp from bacteria and toxic effects during setting phase of restorative materials
needs of materials in vital pulp therapy
- adhere to dentine rather than restorative material
- be thin, otherwise reduces the strength of restorative material
- not dissolve in biological liquids
- form a bacterial-tight seal
examples of materials used in vital pulp therapy
- calcium hydroxide [dycal]
- RMGI [vitrebond]
- bioceramics [MTA, biodentine]
- zinc phosphate
- zinc oxide eugenol
calcium hydroxide info
- bacteriostatic, high pH (12.5) to stimulate fibroblasts
- reparative dentine formation for healing, hard tissue barrier formation
- stimulates recalcification of demineralised dentine by sitmulating pulpal cells
- neutralises low pH from acidic restorative materials
BUT - weak cement, very soluble if not protected
bioceramics
- ## like synthetic tooth tissue, mineral trioxide aggregate
mineral trioxide aggregate (MTA)
- high pH, creates bacterial-tight seal, sets hard enough to act as base for restorative materials
- biocompatible, can be grey or white
BUT - prolonged setting time, discolourtation of crown
biodentine
- similar to MTA BUT
- quicker setting time, no discolouration
- contains tricalcium silicate, dicalcium silicate
partial/cvek pulpotomy
- 1-2mm coronal pulp removed
- stop drilling once vital pulp tissue reached
- rinse with 5% NaOCl, place CaOH, MTA or biodentine over pulp tissue
- place sealing restoration like GI and restoration like composite
complete pulpotomy
- remove whole pulp chamber
- pulp in root canals retained
- rinse with 5% NaOCl, place CaOH, MTA or biodentine over pulp tissue
- place sealing restoration like GI, place restoration like composite
summary of treatment options for unexposed pulp
- indirect pulp cap
- stepwise excavation
- seal caries in
summary of treatment for exposed pulp
- direct pulp cap
- partial coronal pulpal removal
- complete coronal pulp removal
- pulpectomy = progress to RCT
