Care of the Pulp Flashcards
What cells are found in the pulp?
- Odontoblasts
What nerves are found in the pulp? (3 points)
- Plexus of Raschkow
- Alpha fibres (myelinated)
- C-fibres (unmyelinated)
What is the nerve plexus of Raschkow? (3 points)
- Sensory nerve fibres that originate from superior and inferior alveolar nerves innervate the odontoblastic layer of the pulp cavity
- These nerves enter the tooth through the apical foramen as myelinated nerve bundles
- They branch to form subodontoblastic nerve plexus of Raschkow
Are blood vessel present in the pulp?
- Yes, so the pulp is vital
Pulp is a vital tissue, What are 2 properties of this? (2 points)
- Responds to stimuli
- Has regenerative potential
What are the 4 main functions o f the pulp?
- Nutrition
- Sensory (temperature, pressure pain)
- Protective (tertiary dentine formation - reparative healing)
- Formative (secondary dentine)
What is there a poor correlation between in relation to the pulp?
- The clinical symptomatology and pulpal histopathology
In relation to restorations what can damage the pulp? (4 points)
- Placement of the restoration
- restorative material s
- Microleakage
- Etch
How can radiation therapy damage the pulp?
- Blasting and killing of a lot of cells - will potentially damage the pulp cells
What different things do you need to know what the reaction if the pulp will be to? (4 points)
- Caries
- Operative manipulations
- Trauma
- Periodontal tissue
How can cavity/crown preparations damage the pulp? (6 points)
- Heat generation from high speed
- Type and size of bur used
- Dehydration of dentine
- Cutting odontoblastic processes
- Direct injury to the pulp (handpieces going all the way into the pulp)
- How thick the remaining dentine is
What considerations need to be made about restorative materials that could damage the pulp?(5 points)
- Toxicity
- Water absorption
- Heat of reaction
- Poor marginal adaptation/seal
- Cementation of restoration
What happens to dentine tubules as they go towards the pulp?
- They increase in number and diameter as they approach the pulp
- Therefore the deeper the cavity the greater the dentine permeability
What things can travel through the dentinal tubules? (6 points)
- Bacterial substances (enzymes, peptides, exotoxins, endotoxins)
- Polysaccharides
- Antibodies
- Immune complexes
- Complement proteins
- Tissue destruction products
What is key towards initiating and maintaining pulpal and periradicular pathology?
- Micro-organisms
Are alpha fibres myelinated?
- Yes
What kind of pain is stimulated by alpha fibres and name a way in which this can be stimulated?
- Sharp pain
- Stimulated by electric pulp test
Are C-fibres myelinated?
- No, they are non-myelinated
What does stimulation of C-fibres cause and what type of pain is stimulated by C-fibres? (3 points)
- Dull/aching pain
- Increased pulpal blood flow
- Increased pulpal pressure
What is the acronym for pain assessment?
- SOCRATES
What does SOCRATES mean?
- Site
- Onset
- Character
- Radiates
- Associated systems
- Time/duration
- Exacerbating/relieving factors
- Severity
What does the first ‘S’ in SOCRATES mean?
Site - Where exactly is the pain?
What does the ‘O’ in SOCRATES mean?
Onset - What were they doing when the pain started?
What does the ‘C’ in SOCRATES mean?
Character - What does the pain feel like?
What does the ‘R’ in SOCRATES mean?
Radiates - Does the pain go anywhere else?
What does the ‘A’ in SOCRATES mean?
Associated symptoms - e.g. nausea, vomiting
What does the ‘T’ in SOCRATES mean?
Time/duration - How long have they had the pain?
What does the ‘E’ in SOCRATES mean?
Exacerbating/relieving factors - Does anything make the pain better or worse?
What does the last ‘S’ in SOCRATES mean?
Severity - Obtain an initial pain score
What are the possible diagnoses of the pulp? (6 points)
- Healthy pulp
- Reversible pulpitis
- Irreversible pulpitis
- Necrotic pulp
- Previously treated
- Previously initiated therapy
What are the 2 different types of irreversible pulpitis?
- Symptomatic
- Asymptomatic
What is necrotic pulp?
The death of most or all of the pulp
What is symptomatic irreversible pulpitis?
- The vital inflamed pulp is incapable of healing
- There may be lingering thermal pain, spontaneous pain, referred pain
What is asymptomatic irreversible pulpitis?
- The vital inflamed pulp is incapable of healing
- There are no clinical symptoms but inflammation produced by caries, caries excavation, trauma etc
What is previously treated pulp?
A clinical diagnostic category indicating that the tooth has been endodontically treated and that the canals are obstructed with various filling materials, other than intercanal medicaments
What is previously initiated therapy pulp?
-A clinical diagnostic category indicating that the tooth has been previously treated by partial endodontic therapy e.g. pulpotomy/pulpectomy
What are the different classifications of periapical disease? (5 points)
- Normal
- Periapical periodontitis (symptomatic/asymptomatic)
- Acute apical abscess
- Chronic apical abscess
- Condensing osteitis
What are the 2 different classifications of periapical periodontitis?
- Symptomatic
- Asymptomatic
What is symptomatic apical periodontitis and what are some clinical symptoms? (4 points)
- A painful inflammation of the periodontium as a result of trauma, irritation, or infection through the root canal, regardless of wether the pulp is vital or non-vital
- Producing clinical symptoms including painful response to biting and percussion
What is asymptomatic apical periodontitis?
- The symptomless sequelae of symptomatic apical periodontitis and is characterised radiographically by periradicular radiolucent changes and histologically by the lesion dominated with macrophages, lymphocytes and plasma cells
What is an acute apical abscess?
- An inflammatory reaction to pulpal infection and necrosis characterised by rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus formation and eventual swelling of associated tissues
What is a chronic alveolar abscess?
- A long standing, low grade infection of the periradicular alveolar bone generally symptomless and characterised by the presence of an abscess draining through a sinus tract
What is Condensing Osteitis?
- A diffuse radiopaque lesion believed to represent a localised bony reaction to a low grade inflammatory stimulus, usually seen at the apex of a tooth in which there has been a long standing pulpal infection
Under what circumstances should healthy, vital pulp be removed? (2 points)
Removed if endodontic treatment indicated for:
- Elective or prosthetic purposes
- Traumatic pulp exposure (ideally treat pulp exposure in 24hours, bit if not - RCT is required)
Is the pulp vital or non-vital in reversible pulpitis?
- Vital
What is the pulp like in reversible pulpitis?
- Inflammed
What do investigations about reversible pulpitis suggest?
- It can reverse to health if adequate vital pulp therapy is performed
What kind of test does reversible pulpitis regularly respond to?
- Sensibility tests
Is the pulp in irreversible pulpitis vital or non-vital?
Still vital but in the process of dying off
What is the pulp like in irreversible pulpitis?
- Inflamed
What do investigations suggest for irreversible pulpitis?
- That the pulpal infection can not heal
What are the treatment options for irreversible pulpitis? (2 points)
- Pulpectomy required then RCT
2. extraction (unrestorable tooth or patient preference)
In reversible pulpitis what do you get pain to and how long does it last?
- Pain to cold, lasts only a short time
Is there a change in pulp blood flow in reversible pulpitis?
- No change in blood flow
What kind of pain do you get with irreversible pulpitis and what can this cause?
- Spontaneous pain, intermittent
- Can cause sleep disturbance
What is a tooth with irreversible pulpitis’ response to heat and cold?
- Negative to cold
- Pain to heat (C-fibres)
Is there a change in pulpal blood flow with irreversible pulpitis?
- Yes, increase in pulpal blood flow
Is necrotic pulp vital or non-vital?
- Non-vital
- Can get partial or total necrosis
What are the treatment options for mature teeth (with closed apices) with necrotic pulp? (2 points)
- RCT
- Extraction
What are the treatment options for immature teeth (with open apices) that have necrotic pulp? (3 points)
- Pulpotomy
- Pulpectomy - then full RCT
- Extraction
What is a pulpotomy?
- Remove some of the pulp (the necrotic pulp) then seal over the vital pulp
What is a pulpectomy?
- Removal of the entire structure of a tooth, including the pulp tissue in the roots
Are normal periapical tissues sensitive to percussion or palpation?
- No
What does normal periapical tissue look like radiographically? (2 points)
- Lamina Dura intact
- PDL space uniform
What would damage to the lamina dura look like on a radiograph?
- A blurring effect where you can’t clearly see the outline of a tooth on a radiograph
When will pain be felt in symptomatic periapical periodontitis? (3 points)
- Biting
- Percussion
- Palpation
What is the treatment option for symptomatic periapical periodontitis?
- RCT required
What will a patient complain of if they have asymptomatic periapical periodontitis?
- Patient complains of no problems
- If take x-ray for some other reason you may get a chance finding on the x-ray
What does asymptomatic periapical periodontitis look like on an x-ray?
- Appears as an apical radiolucency
What are the present clinical symptoms of asymptomatic periapical periodontitis? (3 points)
No present clinical symptoms:
- No pain on percussion
- No pain on palpation
How quickly does acute apical abscesses appear?
- Rapid onset
What type of pain do you get from an acute apical abscess?
- Spontaneous pain
What is the response of an acute apical abscess to pressure?
- Extreme tenderness
Is there pus and swelling in an acute apical abscess?
- Yes
What are the radiographic signs of destruction of an acute apical abscess?
- May be no signs of destruction
What is malaise?
- A general feeling of discomfort, illness or unease whose exact cause is difficult to identify
Can you have a feeling of malaise when you have an acute apical abscess?
- Yes
Is a fever a common symptom when someone has an acute apical abscess?
- Yes
Acute apical abscesses can cause lymphadenopathy, what is this?
- A disease affecting the lymph nodes
What is the treatment for acute apical abscesses?
- Try to drain abscess
- Make an incision at abscess
- Remove puss
- Open up the tooth and remove infected pulp
- Place a dressing
- Get patient back at later point to do RCT or an extraction
How fast is the onset of a chronic apical abscess?
- Gradual onset
How much discomfort do you get when you have a chronic apical abscess?
- Little or no discomfort
How often is puss discharged through the sinus tract in a chronic apical abscess?
- Intermittently
How may a chronic apical abscess be identified in an x-ray?
- Periapical/periradicular radiolucency
How can a suspect tooth be identified as having a chronic apical abscess? (2 points)
- Carefully place GP cone into sinus tract
- Take radiograph
How would condensing osteitis present on a radiograph?
- Radiopaque lesion:
- Represents localised bony reaction to a low-grade inflammatory stimulus
- Usually seen at the apex of a tooth
What are signs of a non-vital tooth? (5 points)
- Discolouration (yellow, grey, pink)
- Sinus
- Gross caries
- LArge restoration
- Radiographic evidence (periapical radiolucency, periradicular radiolucency)
When a tooth is non-vital it may turn pink. What is this a sign of?
- Typically a sign of resorption taking place (tooth is eating away at itself)
When a tooth is non-vital it may turn yellow. What is this a sign of?
- Obliteration of the dentinal tubules
When a tooth is non-vital it may turn grey. What is this a sign of?
- Blood products in the dentinal tubules
What did sensibility tests used to be called?
- Vitality tests
What is the primary function of a sensibility test?
- To differentiate vital from non-vital pulp
What are the different sensibility tests that are used? (3 points)
- Electric pulp test
- Thermal tests (cold and heat tests)
- Test drilling
What are the problems with sensibility tests? (4 points)
- A bit subjective for different patients
- Don’t really rest vitality (related to blood flow), they just test the nerve response within the tooth
- Periradicular inflammation can occur before the pulp is fully necrotic so tooth might respond to tests but the tooth is in the stages of dying off
- Difficulties in testing multi-rooted teeth
How does the electric pulp test work and what does it stimulate?
- Electric current used to stimulate sensory nerves at pulp-dentine junction
- A-delta fibres are stimulated
- Unmyelinated C-fibres may or may not respond
What is the procedure of using the electric pulp tester? (6 points)
- Teeth thoroughly dried
- Isolate tooth
- Conducting medium required (placed on tip of EPT probe)
- EPT probe placed on incisal edge or cusp tip adjacent to pulp horn
- Patient completes circuit by holding handle of EPT
- Current slowly increased (patient indicates when a tingling/heating sensation is felt)
Why are teeth dried thoroughly at the beginning of electric pulp testing?
- To prevent the current transfer to adjacent teeth
What are 2 examples of conducting mediums that can be used in electric pulp testing?
- Toothpaste
- Fluoride gel
What type of forced are thermal tests 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 are 2 different types of thermal tests?
- Heat tests
- Cold tests
What is the procedure for cold tests?
- Teeth carefully dried and isolated
- Place cold object close to pulp horn (can be frozen sticks of carbon dioxide or a cotton pellet sprayed with - ethyl chloride, difluorodichloromethane, endo-ice)
What does a negative response in a cold test highly indicate ?
- Pulpal necrosis
Why do you need to be careful when carrying out a heat test?
- Too much heat msasy cause irreversible pulpitis
Which nerve fibres does a heat test stimulate and what response does this get?
- Initial stimulation of A-delta fibres (sharp pain)
- Continued stimulation results in C-fibre activation (dull radiating pain)
What is the procedure for carrying out heat tests?
- Vaseline on tooth
- Apply hot gutta perch/green stick to tooth
What does a negative response from a heat test suggest?
- Indicative of necrotic pulp (not possible to determine degrees of reversibility of inflamed symptomatic pulp)
When is test drilling used?
- when full coverage restorations are present (renders other forms of testing impossible)
Is LA given when carrying out test drilling?
- No
For test drilling you cut into a tooth with no LA given. What are the possible diagnoses of the tooth?
- Patient reports severe pain or no pain felt when cutting dentine
- Sensitivity-like response to denting preparation suggests the tooth is vital
What is an alternative way of pulp vitality testing that involves cold water?
- Isolation of crowned tooth with rubber dam
- No LA given
- Spray cold water and air
- Assess the patient response
What are clinical factors that can increase the chances of a pulpal or periapical infection? (4 points)
- Carious pulp exposure
- Age
- Periodontal disease
- Previous pulpal insult/trauma
If you drill into the pulp, what are you exposing it to? (2 points)
- Caries
- Bacteria
Vital treatment of carious pulp exposures are less than 50% successful. Therefore, what are the treatment options? (2 points)
- RCT - however, not all cases
- e.g. immature teeth with incomplete root development - consider removal of necrotic parts of the pulp only (pulpotomy)
As someone gets older, what changes happen to the pulp? (4 points)
- Continued dentine formation (reduces pulp size and volume)
- Increased fibrous components and calcification
- Decreased cellular components and number of BV and nerves
- Overall: pulp is less likely to reverse an inflammatory response
What does moderate to severe periodontal disease cause the pulp to do?
- Age prematurely
How do you maintain pulp vitality?
- Prevent and treat pulpal damage
What is a direct pulp cap?
- Cap placed onto pulp that has been exposed
What is an indirect pulp cap?
- When there is still a bit of dentine present over the pulp, a cap is put onto the dentine on top of the pulp
How can you prevent pulp damage?
- Know tooth anatomy and use radiographs
- Avoid drilling into pulp
- If have a cavity close to the pulp either use sealers or an indirect pulp cap
- If have a cavity that goes into the pulp (exposure) then place a direct pulp cap
What do cavity sealers protect the pulp from? (2 points)
- Bacteria and their products
- Toxic effects during setting phase of restorative material
What are the requirements of cavity sealers to make them successful? (4 points)
- Must cover all of pulp
- Must Adhere to dentine rather than restorative material
- Must be thin - otherwise reduces strength of restorative material
- Must not dissolve in biological liquids
What are the different types of cavity sealer? (3 points)
- Varnishes (materials dissolved in organic solvent - rarely use)
- Liners
- Base materials
What are thicker sealants (cavity liners) used for and give some examples of these? (5 points)
- Used for thermal protection
Examples:
- Zinc phosphate
- Zinc oxide eugenol
- Calcium hydroxide (Dycal)
- RMGI (Vitrebond)
What are the positive effect of calcium hydroxide as a pulp sealant? (4 points)
- Bactericidal
- High pH - Stimulates fibroblasts causing tertiary dentine formation
- Stimulates recalcification of demineralised dentine
- Neutralises low pH from acidic restorative material
What are the negative effects of calcium hydroxide as a pulp sealant? (3 points)
- Cytotoxic (can kill pulp cells)
- Weak cement
- Very soluble if not protected
What is there a marked reduction in when using dentine bonding agents?
- Microleakage
What is step-wise excavation?
- If have caries very close to pulp can leave a bit of the caries, restore the tooth with RMGI, leave the tooth so it can set down tertiary dentine. Give it time then drill out temporary filling and caries and then put in dentine restoration
