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BDS2 CLINICAL Endodontics > Care of the Pulp > Flashcards

Care of the Pulp Flashcards

1
Q

what does the pulp contain

A

cells
nerves
blood vessels

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2
Q

what nerves does the pulp contain

A

alpha fibres

c fibres

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3
Q

why is pulp being a vital tissue relevant to treatment

A

has regenerative potential

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4
Q

what does pulp being part of the dentine pulp complex mean

A

that if you have a procedure that treats dentine then this will also have an effect on the pulp.

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5
Q

what are the functions of the pulp

A

nutrition
sensory
protective
formative

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6
Q

what is a problem in diagnosis of diseases of the pulp

A

there is a poor correlation between clinical symptomatology (what the patient is feeling) and pulpal histopathology (what is actually going on in the tooth)

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7
Q

what are possible injuries to the pulp

A 
caries
cavity preparation 
restoration 
trauma
toothwear
orthodontic treatment
radiation therapy
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8
Q

how does periodontal pathology effect the pulp?

A

pulp and PDL have close relationship, especially at apex where the pulp enters and exits tooth so anything damaging periodontal tissue has the potential to damage the pulp inside as well

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9
Q

how does radiation therapy injury the pulp

A

radiation therapy damages cells so it can damage the pulp, very relevant for those receiving radiation therapy for head and neck cancers

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10
Q

how can cavity/crown prep injure the pulp

A 
heat generation from handpieces
type of bur used
dehydration of dentine
cutting odontoblast processes
direct injury to pulp
restoration material
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11
Q

how do we prevent heat generation from hand pieces damaging the pulp

A

we use water as a coolant

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12
Q

what burs have more control

A

large burs while small burs tend to go right into the tooth very quickly

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13
Q

how do we dehydrate dentine in a cavity prep

A

we wash that fluid away by blowing it away with air

through the water on the handpick

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14
Q

what is the remaining dentine thickness

A

distance between pulp and base of cavity

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15
Q

how can the restoration material injure the pulp

A

some of the materials are highly chemical and can be toxic
water absorption
heat of reaction
poor marginal adaption/seal - may get micro leakage
cementation of restoration

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16
Q

how does dentine permeability change as you go deeper into dentine

A

Dentine tubules increase in diameter as they approach the pulp therefore the deeper the cavity the greater the dentine permeability.

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17
Q

what is dentine permeable to

A 
bacterial substances
polysaccharides
antibodies
immune complexes
complement proteins
tissue destruction products
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18
Q

what are the bacterial substances that the dentine is permeable to

A

enzymes
peptides
exotoxins
endotoxins

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19
Q

what is key to initiating and maintaining pulpal and perirradicular pathology

A

microorganisms

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20
Q

describe alpha fibres

A

myelinated
produce sharp pain
stimulated by EPT

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21
Q

describe C fibres

A

non myelinated

stimulate a dull aching pain, an increase in pulpal blood flow and an increased pulpal pressure

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22
Q

what are the two AAE classifications

A

pulpal diagnosis

periapical diagnosis

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23
Q

Why do we also require a periapical diagnosis

A

we also diagnose what is going on periapically due to the close relationship of the pulp and other tissues

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24
Q

what are the different pulpal diagnosis

A
  • Healthy pulp
  • Reversible pulpitis
  • Irreversible pulpitis (symptomatic or asymptomatic)
  • Necrotic pulp
  • Previously treated
  • Previously initiated therapy
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25
Q

describe healthy pulp

A

vital and free of inflammation

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26
Q

when would we remove a healthy pulp

A

elective prosthetic purposes

traumatic pulp exposure

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27
Q

why do we remove the pulp in some elective prosthetic treatments

A

in a post crown

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28
Q

why do we have to remove healthy pulp sometimes in traumatic exposure

A

o If it has been exposed for more than 24 hours then we know that the pulp is going to die off and become infected.
o If presented less than 24 hours then we can just cover the pulp and monitor the tooth and in most cases it will be fine

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29
Q

what is reversible pulpitis

A

It is a reversible state of inflammation and this is because the pulp is vital but it is inflamed

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30
Q

how do we reverse reversible pulpitis

A

We treat the cause of the inflammation which in most cases is caries so we restore the tooth and the pulp essentially settles on

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31
Q

what is the response to sensibility tests with reversible pulpits

A

regular

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32
Q

why is irreversible pulpits sometimes symptomatic and sometimes asymptomatic

A

Some patients present in pain but some patients will not complain of anything but we may pick up on the fact that the tooth has the potential of dying.

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33
Q

describe irreversible pulpitis

A

Pulp is still vital as still has a degree of blood flow and severely inflamed

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34
Q

what are the treatment options for irreversible pulpitis

A

pulpectomy required then RCT

extraction when the tooth is unrestorable or if patient prefers

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35
Q

what does the difference between irreversible pulpitis and reversible pulpitis depend on

A

clinical symptoms – importance of the patient history

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36
Q

How does reversible pulpitis present compared to irreversible pulpitis

A
  • Pain to cold, lasts a short time (because of the A fibres getting stimulated)
  • Hydrodynamic expression – microleakage (A-fibres)
  • No change in pulp blood flow
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37
Q

How does irreversible pulpitis present compared to reversible pulpitis

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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38
Q

what is necrotic pulp

A

all nerves and blood vessels have died off resulting in a brown ‘mush’

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39
Q

how can necrotic pulp present

A

Can be partial or total necrosis – if it is a multirooted tooth it may be partial but in most cases it is total necrosis

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40
Q

what is the treatment options for necrotic pulp in mature teeth (closed apices)

A
  • Root canal treatment

* Extraction

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41
Q

what are the treatment options for necrotic pulp in immature teeth (open apices)

A
  • Pulpotomy
  • Pulpectomy then full RCT
  • Extraction
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42
Q

why does treatment differ for mature patients and immature patients

A

immature patients have better regenerative potential

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43
Q

what is a pulpotomy

A

remove some of the diseased or necrotic pulp and seal the vital pulp in the tooth

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44
Q

what are the different perioapical diagnoses

A
  • Normal
  • Periapical periodontitis (symptomatic or asymptomatic)
  • Acute apical abscess
  • Chronic apical abscess
  • Condensing osteitis
45
Q

describe normal periapical tissue

A

Not sensitive to percussion (tapping) or palpation (pressing buccally or lingually with fingers

46
Q

how does normal periapical tissue present radigraphically

A

lamina dura intact

pdl spaces uniform

47
Q

what does an intact lamina dura look like on a radiograph

A

clear outline around all the apices of the teeth and the periradicular side of the tooth. If there is a blurring effect then there is loss of the lamina dura

48
Q

describe symptomatic periapical periodontitis

A

Inflammation of the apical periodontium

49
Q

what are the symptoms of symptomatic periapical periodontitis

A

pain when:
biting
percussion
palpation

50
Q

why does patient get pain when biting in periapical periodontitis

A

Because there is inflammation of periodontal tissue then when the patient bites down they will get pain as when we bit the tooth bounces off the PDL.

51
Q

how does symptomatic periapical periodontitis present radiographically

A

periapical radiolucency

52
Q

what does severe pain to percussion mean in symptomatic periapical periodontitis

A

degernating pulp meaning RCT required

53
Q

what happens in asymptomatic periapical periodontitis

A

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

54
Q

how does asymptomatic periapical periodontitis present radiographically

A

apical radiolucency

55
Q

what is an acute apical abscess

A

Inflammatory reaction to pulpal infection and necrosis
Rapid onset
Spontaneous pain

56
Q

what are the symptoms of acute apical abscess

A 
extreme tenderness to pressure
pus formation
swelling 
malaise
fever 
lymphadenopathy
57
Q

what is treatment for acute apical abscess

A

Treatment we usually incise and drain the pulp. Then open the tooth to remove infected pulp, dress that and then get patient back to either extract or RCT. Could extract tooth on day if patient wishes.

58
Q

what is a chronic apical abscess

A

Inflammatory reaction to pulpal infection and necrosis

Gradual onset

59
Q

what are symptoms of chronic apical abscess

A

Little or no discomfort

Intermittent discharge of pus through sinus tract

60
Q

how chronic apical abscess present clinically

A

Periapical/periradicular radiolucency - dark area around the tooth and it can be difficult to know which tooth the dark area is coming from

61
Q

how can the suspect tooth be identified in a chronic apical abscess

A
  • Carefully place GP cone into sinus tract

* Take radiograph

62
Q

what are the treatment options for a chronic periapical abscess

A

RCT or extraction

63
Q

what is condensing osteitis

A

Represents localized bony reaction to a low grade inflammatory stimulus
Usually seen at apex of tooth
We usually just monitor the tooth in this case if the patient is asymptomatic.
Tooth is sometimes okay even if there is condensing osteitis

64
Q

how does condensing osteitis appear radiographically

A

Diffuse radiopaque lesion

65
Q

what are signs of a non-vital tooth

A 
discoloration 
sinus
gross caries
large restoration
radiographic evidence
66
Q

what are the different types of discoloration in non vital teeth

A

yellow
grey
pink

67
Q

what is a yellow non vital tooth due to

A

obliteration of dentine tubules and so as a result light does not pass through tooth as much

68
Q

what is a grey non vital tooth due to

A

blood products in dentine tubules

69
Q

what is a pink non vital tooth due to

A

a sign of resorption taking place, presents around neck of the tooth

70
Q

what is the primary function of a sensibility test

A

Primary function is to differentiate ‘vital’ from ‘non vital’ pulp

71
Q

why do we sensitivity tests on contralateral tooth too

A

patient response is very subjective

72
Q

what are the different sensibility tests

A

electric pulp tests
thermal tests (cold/heat)
test drilling

73
Q

what are the problems in sensibility tests

A

they do not indicate the state of blood supply but stimulate nerve so do not actually test vitality
periradicular inflammation occurs before pulp is totally necrotic
difficulties in testing multirooted teeth

74
Q

what is needed to assess blood flow

A

laser doppler

75
Q

what happens in an electrical pulp test

A

Electrical Pulp test:
Electric current is used to stimulate sensory nerves at the pulp-dentine junction
A-delta fibres are stimulated
Unmyelinated C fibres may or may not response

76
Q

what is procedure for EPT

A

• Teeth thoroughly dried – prevents current transfer to adjacent teeth
• Isolate tooth/teeth
• Conducting medium (toothpaste/fluoride gel) required and is put on the tip of EPT probe
• EPT probe placed on incisal edge or cusp tip adjacent to pulp horn as the most sensory nerves are found here
• Patient completes circuit by holding handle of EPT
• The current is slowly increased - Occurs automatically
o The patient indicates when a tingling/heat sensation is felt by pulling the probe away from the tooth and the reading is taken.

77
Q

how many readings do we take in EPT

A

3

78
Q

what happens if EPT reading is 80

A

means no response

79
Q

what diagnostic info does a positive response to EPT give

A

o Vital pulp tissue in coronal aspect of pulp chamber
o No indication of reversibility of inflammation (healing)
o No correlation between pain threshold and pulp condition (measurement of electric voltage/score is not accurate)

80
Q

what diagnostic info does a negative response to EPT give

A

o Reliable indicator for pulpectomy procedure in 97.7% of cases
o EPT of young pulps (teeth with open apices) or recently traumatized teeth is unreliable

81
Q

how does a thermal test work

A

Thermal tests are believed to work by hydrodynamic forces – fluid movement in dentinal tubules (due to thermal stimulus) activated pulp’s sensory nerve receptor units in pulp.

82
Q

what are the different types of cold tests

A

frozen sticks of carbon dioxide or ice used but not reliable

cotton pellet role sprayed with ethyl chloride, difluorodichloromethane, endoice (most reliable)

83
Q

what is the procedure for a cold test

A
  • Teeth carefully dried and isolated
  • Spray cotton and hold with tweezers
  • Place cold object close to pulp horn
84
Q

what is a negative response to a cold test mean

A

highly indicative of pulpal necrosis

85
Q

why should caution be taken in a heat test

A

too much heat may cause irreversible pulpitis

86
Q

what happens in in a heat test

A

Initial stimulation results in A delta fibres producing a sharp pain and a continued stimulation results in C fibre activation resulting in a dull radiating pain.

87
Q

what is the procedure for a heat test

A
  • Vaseline on tooth
  • Apply hot gutta percha/green stick to tooth
  • Ask patient if they can feel
88
Q

what is a negative response for a heat test

A

Negative response indicative of necrotic pulp – not possible to ascertain degrees of reversibility of inflamed symptomatic pulp

89
Q

what is test drilling

A

Used when full coverage restorations are present – renders other forms of testing impossible
No local anaesthetic given
Cut into teeth

90
Q

what is the diagnosis from test drilling

A
  • Patient reports severe pain, or no pain felt when cutting dentine
  • Sensitivity-like response to dentine preparation – tooth is vital
91
Q

what is the alternative to test drilling

A

Isolation crowned tooth with rubber dam
No local anaesthetic
Spray cold water and air
Assess patient response

92
Q

what are the 4 things that can influence your decision

A
  • Carious pulp exposure
  • Age
  • Periodontal disease
  • Previous pulpal insult/trauma
93
Q

what should we take into account when removing caries

A

remove caries from wall first so that if we expose the pulp cavity the caries cannot get in

94
Q

how does age affect our clinical decision making

A

Continued dentine formation means reduced pulp size and volume so for that reason there is more leeway when drilling as the pulp will be further away in a older patient.
Increased fibrous components and calcification
Decreased cellular components and number of blood vessels and nerves meaning regenerative potential is less so if you damage pulp in a younger patient then there is more scope for them to recover
Overall pulp is less likely to reverse an inflammatory response in an older patient

95
Q

how does periodontal disease effect decision making

A

Moderate to severe periodontal disease results in a prematurely aged pulp because it has been inflamed and had to recover from it.
Pulp in periodontically involved tooth is less resistant to inflammation than healthy pulp

96
Q

how does previous pulp insult affect clinical decisions

A

Caries, caries removal and restorative procedures still has an effect of tooth as it still lays down tertiary dentine so pulp shrinks back from disease process rather than aging
Tertiary dentine is starting to occlude the dentinal tubules and causing the pulp to become smaller
Pulpal fibrosis occurs
Premature aging of the pulp meaning it is less likely to heal than healthy pulp

97
Q

how do we prevent pulpal damage

A

knowing tooth anatomy
avoid drilling into pulp
use cavity sealer and an indirect pulp cap
if you expose pulp use direct pulp cap

98
Q

what is a pulp cap

A

something you can put directly on the pulp (used for exposure) or if you have a small remaining dentine thickness then you can put an indirect pulp can to thicken the base of the cavity so that its further away from the pulp.

99
Q

what is a cavity sealer

A

Cavity sealers protect pulp from bacteria and their products and the toxic effects during the setting phase of restorative materials

100
Q

what must a cavity sealer material be

A
  • Able to adhere to dentine rather than the restorative material because otherwise if you remove the restorative material you will rip out the sealer too
  • Be thin otherwise it reduces the strength of the restorative material
  • Not dissolve in biological liquids
101
Q

what are the different types of cavity sealers

A
  • Varnishes – material dissolved in organic solvents e.g ether
  • Liners
  • Base materials
102
Q

what are cavity base liners

A

Thicker sealants (thicker than varnishes) provide thermal protection as there are thermal effects arising through restorative material

103
Q

what are examples of cavity bases/liners

A
  • Zinc phosphate
  • Zinc oxide eugenol
  • Calcium hydroxide e.g dycal
  • RMGI e.g vitrebond
104
Q

what are the advantages of calcium hydroxide

A

Bactericidal/bacteriostatic
Has a high pH which stimulates fibroblasts to produce reparative dentine which is good as remaining dentine thickness is increasing
Stimulates the recalcification of demineralized dentine by stimulating pulpal cells
Neutralizes low pH from acidic restorative material

105
Q

what are the disadvantages of calcium hydroxide

A

Cytotoxic- can kill pulp cells (not necessarily true as it is used as a direct pulp cap)
Weak cement – difficult to place
Very soluble if not protected

106
Q

can dentine bonding agents be put directly onto the pulp?

A

Dentine primers with/without adhesives are tolerated by the pulp – you can put this directly over the pulp
Marked reduction in microleakage demonstrated by dentine bonding agents
However, use is very technique sensitive so make sure you don’t get it wet

107
Q

what is step wise excavation

A

leave a little bit of caries at the base, restore tooth with GI which gives time for tertiary dentine to be laid so the RDT is increased so we can go in at a later date and remove the last bit of caries.

108
Q

what happens in seal in caries

A

drill caries away from walls and leave a bit at the base of the cavity and place a permanent restoration as bacteria cannot get access to food source.

109
Q

what are the treatment options for pulp damage

A
  • Indirect pulp cap – or stepwise excavation or seal caries in
  • Direct pulp cap
  • Partial pulpal removal – pulpotomy
  • Full pulpal removal – pulpectomy which is the progress to root canal treatment

BDS2 CLINICAL Endodontics (1 decks)

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