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BDS2 BAMS - Oral biology > Care of the pulp > Flashcards

Care of the pulp Flashcards

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1
Q

What cells are found in the pulp

A

odontoblasts

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2
Q

What nerves are found in the pulp

A
  • alpha fibres (myelinated)

- C fibres (unmyelinated)

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3
Q

Are blood vessels found in the pulp?

A

yes

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4
Q

how can you tell that the pulp is vital

A

if it responds to stimuli

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5
Q

can the pulp regenerate

A

yes

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6
Q

what is the relationship with dentine?

A

close relationship, procedures in dentine = treatment of both pulp and dentine

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7
Q

what are the functions of the pulp

A

nutrition

sensory

  • temp
  • pressure
  • pain

protective

  • tertiary dentine formation (odontoblasts)
  • reparative healing

formative
- secondary dentine

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8
Q

how can you injure the pulp

A
  • caries
  • cavity preparation (heat generation, type of bur used)
  • restorations (restorative materials/ microleakage/ etch)
  • dehydration of dentine (air, water)
  • trauma
  • cutting odontoblast processes
  • toothwear
  • periodontal pathology
  • orthodontic treatment
  • radiation therapy
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9
Q

is it better to have more or less remaining dentine thickness

A

more (less damage to pulp)

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10
Q

how can the restoration material cause injury to the pulp

A
  • toxicity
  • water absorption
  • heat of reaction
  • poor marginal adaption/ seal
  • cementation of restoration
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11
Q

Why is it that ‘the deeper the cavity, the greater the dentine premeability’?

A

dentine tubules increase in number(? - see structure of tooth tutorial) and diameter as they approach the pulp

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12
Q

what things can penetrate the pulp via the dentine tubules

A 
bacterial substances
polysaccharides
antibodies
immune complexes
complement proteins
tissue destruction products
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13
Q

what nerve fibres contribute to dental pain

A

Alpha and C

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14
Q

What kind of pain do Alpha fibres contribute to

A

sharp pain

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15
Q

What kind of pain do C fibres contribute to

A

dull/aching pain
increased pulpal blood flow
increased pulpal pressure

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16
Q

Are alpha fibres myelinated or unmyelinated

A

myelinated

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17
Q

Are C fibres myelinated or unmyelinated

A

unmyelinated

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18
Q

how do you test the alpha fibres are responding (vitality)

A

Electric pulp test (EPT)

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19
Q

why is it important to determine/diagnose pulpal health

A

because diagnosis drives treatment plan

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20
Q

what are the 2 types of classification of diagnosis

A

pulpal diagnosis

periapical diagnosis

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21
Q

What are the different pulpal diagnosis’s

A 
Healthy pulp
Reversible pulpitis
Irreversible pulpitis
- symptomatic
- asymptomatic
Necrotic pulp
Previously treated
Previously initiated therapy
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22
Q

What are the different periapical diagnosies

A 
Normal
Periapical periodontitis
- Symptomatic
- Asymptomatic
Acute apical abscess
Chronic apical abscess
Condensing osteitis
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23
Q

What indicates a healthy pulp

A

vital

- free of inflammation

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24
Q

why might a healthy pulp be removed

A

if endodontic treatment is indicated for:

  • elective or prosthetic purposes
  • traumatic pulp exposure (ideally treat within 24 hours, but if not RCT required)
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25
Q

Describe the pulp in reversible pulpitis

A

vital but inflamed pulp

can reverse to health if adequate vital pulp therapy performed

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26
Q

how can you diagnose reversible pulpitis

A

regular response to sensitivity tests (many dianostic mistakes made)

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27
Q

what characterises reversible pulpitis

A
  • pain to cold, lasts a short time
  • hydodynamic expression - microleakage (A fibres)
  • no change in pulp blood flow
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28
Q

what characterises irreversible pulpitis

A
  • vital pulp
  • 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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29
Q

what characterises necrotic pulp

A

non-vital pulp

partial or total necrosis

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30
Q

what are the treatment options for necrotic pulp

A

mature teeth (closed apices):

  1. RCT
  2. extraction

immature teeth with open apices

  1. pulpotomy
  2. pulpectomy then full RCT
  3. extraction
31
Q

what are the treatment options for irreversible pulpitis

A

(investigations suggest pulpal inflammation can not heal)

treatment options:

  1. pulpectomy required then RCT
  2. extraction (unrestorable tooth, patient preference)
32
Q

What characterises normal periapical tissues

A

Not sensitive to percussion or palpation
Radiographically:
1. lamina dura intact
2. PDL space uniform

33
Q

What characterises symptomatic periapical periodontitis

A

inflammation of the apical periodontium

Pain:

  • biting
  • percussion and/or
  • palpation

May have periapical radiolucency

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

34
Q

What characterises asymptomatic periapical periodontitis

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
35
Q

What characterises an acute apical abscess

A
  • inflammatory reaction to pulpal infection and necrosis
  • rapid onset
  • spontaneous pain
  • extreme tenderness to pressure
  • pus formation
  • swelling
  • may be no radiographic signs of destruction
  • malaise
  • fever
  • lymphadenopathy
36
Q

What characterises a chronic apical abscess

A
  • inflammatory reaction to pulpal infection and necrosis
  • gradual onset
  • little or no discomfort
  • intermittent discharge of pus through sinus tract
  • peripapical/periradicular radiolucency

can be identified by:

  • carefully placing GP cone into sinus tract
  • take radiograph
37
Q

What characterises condensing osteitisis

A

diffuse radiopaque lesion

  • represents localised bony reaction to a low-grade inflammatory stimulus
  • usually seen at apex of tooth
38
Q

what are signs of a non-vital tooth

A

Discolouration

  • yellow
  • grey
  • pink

sinus

gross caries

large restoration

radiographic evidence

  • periapical radiolucency
  • periradicular radiolucency
39
Q

What causes a tooth to turn yellow

A

obliteration of dentine tubules

40
Q

What causes a tooth to turn grey

A

blood products in dentine tubules

41
Q

What causes a tooth to turn pink

A

cervical resorption

42
Q

What is the primary function of a sensibility test

A

to differentiate “vital” from “non-vital”

43
Q

how do you get around the fact that sensibility tests are very subjective

A

compare the patient’s response with a contralateral tooth then re-examine same tooth

44
Q

What are the different sensibility tests

A
  1. Electric pulp tests (EPTs)
  2. Thermal tests
    - cold tests
    - heat tests
  3. Test drilling
45
Q

What substance is used in the cold sensibility tests

A
  • frozen sticks of CO2 or ice
  • cotten pellet/ roll sprayed with
    ethyl chloride, difluorodichloromethane or endo-ice
46
Q

What substance is used in the hot sensibility tests

A

hot gutta percha (GP)

47
Q

What are the problems with sensibility tests

A
  • these tests stimulate nerve fibres (don’t assume that nerve fibres in pulp correlates to vital blood supply)
  • these tests do not indicate state of blood supply
  • tooth vitality is related to blood supply, not nerve stimulation (laser doppler needed to assess blood flow)
48
Q

What fibres are stimulated using an EPT

A

A delta fibres (?)

unmyelinated C fibres may or may not respond

49
Q

What is the procedure for the EPT

A

Teeth thoroughly dried
- Prevents current transfer to adjacent teeth

Isolate tooth/teeth

Conducting medium (toothpaste/ fluoride gel) required 
- Tip of EPT probe

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

  • Occurs automatically
  • Pt. indicates when a tingling/ heat sensation is felt (Can pull probe away from tooth)
50
Q

What does a positive response from the EPT indicate

A
  1. Vital pulp tissue in coronal aspect of pulp chamber
  2. No indication of reversibility of inflammation (healing)
  3. No correlation between pain threshold and pulp condition (measurement of electric voltage/ score is not accurate)
51
Q

What does a negative response from the EPT indicate

A
  1. Reliable indicator for pulpectomy procedure in 97.7% cases
  2. EPT of young pulps (teeth with open apices) or recently traumatised teeth
    (unreliable)
52
Q

How does thermal testing work

A

believed to work by hydrodynamic forces

  • fluid movement in dentinal tubules (due to thermal stimulus)
  • activates pulp’s sensory nerve receptor units in pulp
53
Q

What is a negative response to cold test indicate

A

highly indicative of pulpal necrosis

54
Q

what is the procedure for cold test

A

teeth carefully dried and isolated
place cole object close to pulp horn
either frozen stick or cotton pellet/ roll sprayed with e.g. ethyl chloride

55
Q

Why do you have to be super cautious with heat tests

A

too much heat may cause irreversible pulpitis

56
Q

what pain happens with heat tests

A

Initial stimulation of A-delta fibres
(Sharp pain)
Continued stimulation results in C-fibre activation
(Dull radiating pain)

57
Q

What is the procedure for heat tests

A

Vaseline on tooth

Apply hot gutta percha/ green stick to tooth

58
Q

what is a negative heat test indicative of

A

necrotic pulp

Not possible to ascertain degrees of reversibility of inflamed symptomatic pulp

59
Q

When is test drilling used

A

Used when full coverage restorations present

60
Q

what is the procedure for test drilling

A

No local anaesthetic given

Cut into tooth

61
Q

what does a negative response to test drilling indicate

A
  • Patient reports severe pain or no pain felt when cutting dentine
  • Sensitivity-like response to dentine preparation – tooth is vital
62
Q

What is an alternative to test drilling

A

Isolation crowned tooth with rubber dam
(No LA)
Spray cold water and air
Assess patient response

63
Q

what are the different clinical factors which affect tooth vitality

A
  • carious pulp exposure
  • age
  • periodontal disease
  • previous pulpal insult/ trauma
64
Q

how does carious pulp exposure impact treatment

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)

65
Q

How does increasing age affect the pulp

A

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

66
Q

How does periodontal disease affect the pulp

A

Moderate to severe periodontal disease
Result: “prematurely aged” pulp

Pulp in periodontally involved tooth
less resistant to inflammation than healthy pulp (not universally accepted)

67
Q

how does a previous pulp insult affect pulp

A

Caries, caries removal and restorative procedures
- Tubule occlusion (Reparative dentine formation,
Pulpal fibrosis)

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

68
Q

how do you maintain pulp vitality

A

prevention of pulpal damage

treatment of pulpal damage

69
Q

How can you prevent pulpal damage

A

Know tooth anatomy

  • Size, location and proximity of pulp
  • Pre-assessment (Radiographs)

Avoid drilling into pulp
- Stop if close to pulp
- Caries can be left over pulpal floor in some cases
(Placement of well-sealed restoration)

Cavity close to pulp

  • Use of cavity sealers
  • Indirect pulp cap

Cavity into pulp (exposure)
- Direct pulp cap

70
Q

How can cavity sealers help prevent pulpal damage

A

Protect pulp from:

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

Whole exposed pulpal dentine must be covered

Material must:
- adhere to dentine rather than restorative material
be thin
(Otherwise – reduces strength of restorative material)
- Not dissolve in biological liquids

Types 
- Varnishes
(Material dissolved in organic solvent e.g. ether)
- Liners
- Base materials
71
Q

How can a cavity base/liner help prevent pulpal damage

A

Thicker sealant
- Thermal protection
(Thermal effects arising through restorative material)

Examples:

  • Zinc phosphate
  • Zinc oxide eugenol
  • Calcium hydroxide
    e. g. Dycal
  • Resin modified glass ionomers (RMGI)
    e. g. Vitrebond
72
Q

What are the advantages and disadvantages of calcium hydroxide

A

Advantages
Bacteriocidal/ bacteriostatic
- High pH – Stimulates fibroblasts
(Reparative dentine formation (healing))
- Stimulates recalcification of demineralised dentine
(by stimulating pulpal cells)
- Neutralises low pH from acidic restorative materials

BUT: 
- Cytotoxic 
(Can kill pulp cells)
- Weak cement
- Very soluble if not protected
73
Q

How do dentine bonding agents help protect the pulp

A

Dentine primers with/ without adhesives are both tolerated by the pulp

Marked reduction in microleakage demonstrated by dentine bonding agents

However
Use is VERY “technique sensitive”

74
Q

What is a summary of treatment options for pulpal damage

A

Which liner and when?
Dependent upon the RDT

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

BDS2 BAMS - Oral biology (9 decks)

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