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Pediatric Dentistry Handbook > Chapter 7: Pulp Therapy > Flashcards

Chapter 7: Pulp Therapy Flashcards

1
Q

Findings consistent with reversible pulpitis - primary teeth

A

Transient tooth pain associated with thermal or chemical stimulus
Lack of nocturnal and spontaneous tooth pain

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2
Q

Findings consistent with irreversible pulpitis - primary teeth

A

Spontaneous tooth pain
Nocturnal tooth pain
Constant or persistent thermal or chemical pain

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3
Q

Purpose of vital pulp therapy in primary teeth

A

Maintain vitality of tooth and prevent pain and infection

Allow for normal exfoliation and prevent need for space maintenance

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4
Q

Protective bases

A

Indications: normal pulp with deep, complete caries excavation
Objectives: preserve vitality, prevent sensitivity, promote pulpal healing, minimize microleakage
Technique: thin layer of calcium hydroxide or glass ionomer placed directly over dentin following complete deep caries excavation

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5
Q

Indirect Pulp Treatment (IPT) indications and objectives

A

Indications: normal pulp, asymptomatic tooth with deep caries approximating pulp, clinically and radiographically sound tooth
Objectives: avoid pulp exposure, seal/arrest deep decay, maintain tooth vitality, promote healing

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6
Q

IPT Technique

A

Remove most affected carious dentin
Leave caries over deepest portion of lesion
Clean periphery of lesion
Place Ca(OH)2, zinc oxide, or glass ionomer over lesion to provide initial seal
Restore appropriately to ensure seal

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7
Q

Conditions Favoring Vital Pulp Therapy

A

Deep caries approximating pulp
Traumatic, mechanical, or carious pulp exposure
Dependable diagnosis of reversible pulpitis
Proper isolation with rubber dam/equivalent
Restorable tooth that is desirable to maintain
Radiograph displaying tooth’s support structure
Intact PDL
Intact bone (no furcation)

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8
Q

Conditions Favoring Non-Vital Pulp Therapy

A

Diagnosis of irreversible pulpitis/necrosis
Pulp exposure revealing hyperemic pulp or necrotic pulp
Proper isolation with rubber dam or equivalent
Restorable tooth that is desirable to maintain
Radiograph displaying tooth’s support structure
Minimal or no physiologic root resorption

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9
Q

Conditions Favoring Extraction

A

Diagnosis of irreversible pulpitis or necrotic pulp with advanced root resorption
Odontogenic infection resulting in compromised systemic health

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10
Q

Direct Pulp Cap Indications and Objectives

A

Indications: small traumatic or mechanical pulp exposure; not recommended for carious exposure
Objectives: to maintain vitality and allow pulpal healing

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11
Q

Direct Pulp Cap Technique (primary teeth)

A

Place biocompatible material such as Ca(OH)2, or MTA directly over pulp exposure after bleeding is controlled

Prognosis is questionable - coronal pulpotomy has more predictable outcomes

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12
Q

Coronal pulpotomy indications and objectives

A

Indications: pulp exposure, restorable tooth, coronal pulp inflamed, radicular pulp judged to be healthy by controlled bleeding, no evidence of furcal or periradicular pathology
Objectives: to maintain symptom-free tooth that acts to hold space for successor, no radiographic signs of infection, normal resorption occurs, succadaneous tooth undamaged

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13
Q

Pulpotomy Technique

A

Remove inflamed/affected coronal pulp tissue
Vital/healthy tissue is left behind in roots
Medicament/technique is utilized to treat remaining radicular pulp
Restore definitively

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14
Q

Best long-term restoration after pulpotomy?

A

SSC

Amalgam and composite is acceptable if sufficient tooth structure remains

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15
Q

Pulpotomy Medicaments

A 
Formocresol
Ferric sulfate 
Sodium hypochlorite 
MTA
Calcium silicate (biodentine)
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16
Q

Formocresol

A

Buckley’s full-strength FC is commonly used with 5 min application
Evidence suggests 1 minute application has equivalent success
Dilute FC (1/5 concentration) has comaprable success
Still most commonly taught pulpotomy technique
Bactericidal
Causes tissue fixation and persistent inflammation of radicular pulp
Exfoliation of primary teeth is accelerated
Controversial: mutagenic and carcinogenic potential

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17
Q

Ferric Sulfate

A

Hemostatic agent
Potential to mask diagnosis if used prior to evaluation of bleeding
Causes coagulation of blood
Reports of internal resorption

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18
Q

Sodium Hypochlorite

A

Proven endodontic irrigant and anti-microbial agent
Biocompatible and non-irritating to pulp tissue
Limited studies on success but on par with FC
Injection into soft tissue can lead to NaOCl accidents

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19
Q

How to avoid sodium hypochlorite accidents

A

Determine working length
Avoid binding syringe tip
Use side-venting needle
Extrude liquid slowly

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20
Q

Mineral Trioxide Aggregate (MTA)

A

Portland cement with calcium silicates, gypsum and bismuth oxide
High biocompatibility
Alkaline pH
Induces hard tissue formation - dentin bridge
Success rates high, surpassing FC
Pulp canal obliteration is common

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21
Q

Negatives of MTA

A

Technique sensitive to mix and handle
Can cause discoloration due to presence of bismuth oxide
Cost is high

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22
Q

Calcium Silicate (Biodentine)

A

Bioactive properties
Faster setting time than MTA
Alkaline pH
Early studies do not show discoloration

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23
Q

Lasers and Pulpotomy

A

Hemorrhage control and bacterial reduction
Possible stimulation of regenerative cells
Multiple types used (CO2, Er:YAG, Nd:YAG, diode)
Research heterogeneous and only one RCT shows survival rates
Cannot draw conclusions based on available literature

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24
Q

Electrosurgery

A 
Few randomized trials on human subjects 
Preservative technique
Heat produced may be detrimental to surrounding tissue 
Short term success comparable to FC 
Coagulation incited at pulp stums
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25
Q

Non-vital pulp therapy for primary teeth

A

Pulpectomy or Extraction

LSTR potential

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26
Q

Indications for Pulpectomy

A

Preserve a tooth with irreversible pulpitis or necrosis
Good option for restorable teeth with normal root resorption
Good option for “key teeth” for arch development

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27
Q

Objectives of Pulpectomy

A

Remove necrotic or irreversibly inflamed tissue
Halt spread of inefction
Maintain a healthy/asymptomatic tooth until exfoliation

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28
Q

Pulpectomy Technique

A

Remove coronal and radicular pulp tissue
Debride canal system with hand file or rotary file
Irrigate with sodium hypochlorite or antimicrobial
Dry and fill canal with resorbable material
Place definitive restoration that is well-sealed

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29
Q

Treatment of sodium hypochlorite accident

A

Careful not to extrude sodium hypochlorite beyond apex
Supportive care sufficient - close monitoring, analgesics, prophylactic antibiotics
More severe cases of swelling should be referred to medical professionals

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30
Q

Success of Pulpectomies

A

No signs of symptoms or pathology
Radiographic success is characterized by good fill without over-extension, bone deposition in radiolucent areas, and normal root resorption
Protect developing succedaneous tooth
Success rates high (80%) when quality definitive restorations is placed

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31
Q

Pulpectomy Root Filling Materials Desirable Properties

A 
Resorbable
Biocompatible
Harmless to succedaneous teeth
Easy to place
Easy to remove
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32
Q

Pulpectomy Materials

A

Zinc Oxide Eugenol
-under-filling produces better results than over
-overfill can produce inflammatory reaction
Calcium Hydroxide
-Resorbs quickly
-can be applied with syringe or lentulo spiral
-biocompatible
Vitapex
-Ca(OH)2 and iodoform
-slower resorption than calcium hydroxide alone
-radiopaque
-overfill will resorb within 8 weeks
-friendly to permanent successor

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33
Q

Indications for Extraction rather than Pulpectomy

A

Severe odontogenic infection
If tooth is not restorable
If infection envelops developing premolar
Space maintenance often required

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34
Q

Assessing Pulp Status for Young Permanent Teeth

A

Accurate diagnosis is key to successful outcomes
Can be challenging in young children
Diagnostic data from patient/parent description, pulp testing, clinical exam/radiographic exam

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35
Q

Deep caries lesions in permanent teeth

A

Present when penetration depth is in range of 3/4 of dentin thickness or more on BW radiograph

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36
Q

Young Permanent Teeth - Reasons to Maintain Pulp Vitality if Possible

A

Development of favorable crown:root ratio
Apical closure
Formation of secondary radicular dentin
Long-term tooth survival is 7x better if pulp vitality is maintained compared to de-vitalized tooth

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37
Q

Conservative Treatment Approaches for Young Permanent Teeth with Deep Carious Lesions

A 
Protective Base 
Indirect Pulp Treatment 
Stepwise Caries Removal
Direct Pulp Cap
Partial Pulpotomy
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38
Q

Aggressive Treatment Approaches for Young Permanent Teeth with Deep Carious Lesions

A

Coronal Pulpotomy

Partial Pulpectomy

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39
Q

Protective Base

A

Definition: thin liquid applied to pulpal surface of deep cavity prep covering exposed dentin tubules
Indications: tooth with deep carious lesion, normal pulp after caries removal
Objectives: preservation of vitality, minimize pulp injury, promote pulp healing, tertiary dentin formation
Must be followed by well-sealed restoration
Choice of material belongs to clinician - no difference in success rate

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40
Q

Indirect Pulp Treatment Indications

A

Deep caries in close proximity to pulp
Asymptomatic tooth or reversible pulpitis
Chronic/arrested/inactive/slow progressing lesion
No periradicular pathosis
Well-defined radiopaque dentin bridge between pulp and caries
No history of pain/may have no lingering cold sensitivity

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41
Q

Objectives of Indirect Pulp Treatment

A 
Maintain pulp vitality
Avoid pulp exposure
Remove soft demineralized dentin 
Biocompatible and radiopaque liner 
Placement of definitive leakage-free restoration
42
Q

Indirect Pulp Treatment Technique

A

Removal of soft infected dentin, but affected dentin is left
Clean periphery and DEJ
GI or Ca(OH)2 placed to stimulate odontoblasts to form reactionary dentin and remineralize dentin
Tooth is restored with high quality restoration

43
Q

Advantages of Indirect Pulp Treatment

A

One visit

Lower cost

44
Q

Disadvantages of Indirect Pulp Treatment

A

More tooth structure removed
Sclerosis of dentinal tubules and dentin formation not promoted
Greater risk of pulp exposure

45
Q

Success of Indirect Pulp Treatment

A

High survival rate (>90%) without adverse clinical symptoms or pathology
MTA has higher success rate than calcium hydroxide (98% vs 60-100%)

46
Q

Stepwise Caries Removal Indications

A

Active/soft/rapidly progressing carious lesion
Primary carious lesion or recurrent caries under shallow restoration
Reversible pulpitis
No periradicular pathosis

47
Q

Stepwise Caries Removal Objectives

A

Maintain pulp vitality
Promote remineralization and tubule sclerosis
Two appointments required (1 to place transitional restoration, 1 in 6-12 months for re-evaluation and definitive treatment)
Well-defined radiopaque dentin bridge
No history of pain or lingering cold sensitivity
Compliant patient willing to wait 6 months for re-evaluation

48
Q

Advantages of Stepwise Caries Removal

A

Preserve tooth structure/minimally invasive
Promotes formation of secondary/sclerotic dentin
Allows/maintains thicker remaining dentin
Clarifies pulpal diagnosis and prognosis

49
Q

Disadvantages of Stepwise Caries Removal

A

Time - 2 visits
Patient compliance
Higher cost

50
Q

Direct Pulp Cap Indications

A

Permanent teeth with normal pulp status with small mechanical or traumatic exposure

51
Q

Direct Pulp Cap Objectives

A

Tooth vitality maintained
No post-treatment signs/symptoms
Pulp healing and reparative dentin formation
No radiographic evidence of internal or external resorption or PA pathosis
Immature teeth show continued root development

52
Q

Direct Pulp Cap Technique

A

Pinpoint pulp exposure encountered after trauma or during cavity preparation
Hemorrhage control is obtained, pulp is capped with material like Ca(OH)2
5 year success rate: Ca(OH)2 is 59-69%, MTA is 78-98%

53
Q

Partial Pulpotomy Definition

A

Procedure in which inflamed pulp tissue beneath an exposure is removed to reach healthy pulp tissue

54
Q

Partial Pulpotomy Indications

A

Young Permanent tooth with carious pulp exposure

Vital tooth with diagnosis of normal pulp or reversible pulpitis

55
Q

Partial Pulpotomy Objectives

A

Preserve pulpal vitality in order to allow continued root development
No adverse clinical or radiographic signs or symptoms of bone loss or root resorption
Immature roots should continue normal root development

56
Q

Partial Pulpotomy Technique

A

Pulp bleeding controlled by bactericidal agent (NaOCl, CHX) before site is covered by Ca(OH)2, or MTA

57
Q

Success of partial pulpotomy

A

High rates of success (91-96%)
Ca(OH)2 in permanent teeth: 91-200% after 2 years
MTA in permanent teeth 95-100%

58
Q

Coronal Pulpotomy in Permanent Teeth

A

Objective: maintain vitality of radicular pulp
Objectives vary with treatment choice (root end-closure: apexogenesis, eliminate need for surgery, facilitate gutta percha fill with apical stop)
Ca(OH)2 success rates higher for traumatic exposures (72-96%) than carious exposure (50-92%)
Higher success with MTA

59
Q

Partial Pulpectomy

A

Definition: partial extirpation of radicular pulp
Indicated for persistent hemorrhage from pulp stumps
Ca(OH)2 is medicament of choice
Good results with MTA reported

60
Q

Pulp Therapy for Traumatized Young Permanent Teeth (Cvek Pulpotomy)

A

Indications: vital, traumatically-exposed young permanent tooth
Objectives: encourage root development, promote tertiary dentin
Technique: inflamed pulp tissue beneath pulp exposure is removed to reach healthy pulp tissue

61
Q

Cvek Pulpotomy Additional Information

A

Neither time nor exposure time is critical if healthy pulp is reached
Success rate is 91-98%
Preservation of cell-rich coronal pulp
Increased healing potential due to preserved pulp
Physiologic apposition of cervical dentin
Obviate need for RCT
Natural color and translucency preserved
Maintenance of pulp test responses

62
Q

Treatment of Necrotic Immature Permanent Teeth Objectives

A

Promote continued apical tooth development
Achieve apical closure
Alleviate pain
Maintain a functional tooth

63
Q

Definition of success in treatment of necrotic immature permanent teeth

A

Asymptomatic
Radiographic absence of pathology
Continued root development (sometimes)
Hard tissue barrier at apex

64
Q

Root Canal Therapy Indications

A

Restorable permanent tooth
Irreversible pulpitis or pulp necrosis
Root that has been apexified

65
Q

RCT Objectives

A

Eliminate pulp or periradicular infection
Successful obturation
No adverse clinical or radiographic signs/symptoms
Resolution of pre-treatment pathology

66
Q

Apexification

A

Method of inducing root end closure of incompletely formed non-vital permanent tooth by removing coronal and non-vital radicular tissue just short of the root end and placing a biocompatible agent such as Ca(OH)2 for 2-4 weeks

Should be used as last resort in immature permanent tooth

67
Q

Apexification Technique

A

Root end closure can be achieved by MTA barrier with or without collagen wound dressing followed by gutta percha filling
Apexification with Ca(OH)2: Frank technique

68
Q

Actions of Calcium Hydroxide

A

Bactericidal
Low grade irritation induces hard tissue formation
Dissolves necrotic debris

69
Q

MTA Apical Plug

A

Objective: induce root end closure at apices of immature roots and result in apical barrier
Technique: place MTA in apical 1/3 of canal, bonded core to fill canal, permanent restoration
Success: no post-op issues, no resorption radiographically, tooth continues to erupt

70
Q

Regenerative Endodontics

A

Biologically based procedures designed to predictably replace damaged, diseased or missing structures including dentin, with live viable tissues that restore the normal physiologic functions of the tooth

Emerging technique for immature necrotic teeth that enables continued root length formation, radicular secondary dentin formation and apical closure

Includes revascularization, partial pulpotomy, and apexogenesis

71
Q

Indication for regenerative endodontics

A

Necrotic immature permanent tooth (regardless of etiology)

72
Q

Key elements in tissue engineering

A 
Adult stem cells: capable of self-replication and differentiation into specialized cells
Growth factors (BMPs): regulate stem cells to form desirable cell type
Scaffolds: provide biocompatible 3D structures for cell adhesion and migration
73
Q

Additional information about regenerative endodontics

A

Antibiotic enables the establishment of infection-free canal
Blood clot forms scaffld for ingrowth of progenitor cells
Growth factors required for differentiation of cells into odontoblasts to deposit dentin

74
Q

Revascularization Technique Overview

A

Revasc via blood clot is one of several techniques in tissue engineering and most commonly used in pediatric population
Simple technique
Cost effective
Low immune response and low potential for infection

75
Q

Revascularization Technique

A

Evoke bleeding into root canal, which delivers mesenchymal stem cells
Should only be attempted if tooth is not suitable for RCT and after apexogeneis, apexification or partial pulpotomy have already been attempted
Survival of cells and regeneration of tissues is sensitive to conditions in intracanal environment

76
Q

Requirements for regeneration in revascularization

A

Traumatized tooth must be non-vital
Tooth should have at least 1.1mm open apex
Patient age between 7-16 years, in good health

77
Q

Revascularization Process (2 step)

A

Stage 1: disinfection of root canal system
-Tri- or bi-antibiotic paste (ciprofloxacin, metronidazole, minocycline) for 8-12 weeks
-Ca(OH)2 for 8-12 weeks
-5% sodium hypochlorite (slowly) as disinfectant
Stage 2: promotion of bleeding by filing through apex to fill root canal with blood and placing “double seal” of MTA and restorative material
-local anesthetic withOUT vasoconstrictor used
-further research needed to reliably predict success rate

78
Q

Materials used as permanent tooth pulp capping agents

A 
Calcium Hydroxide
Biodentine
MTA
Emdogain
Propolis
GI/RMGI
Lasers
Stem Cells 
Growth Factors
79
Q

Advantages of Calcium Hydroxide

A 
Biocompatible - gold standard
Superficial necrosis 
Deeply staining zone: basophilic Ca(OH)2 elements
Coarse fibrous tissue
Induction of calcified dentin bridge at 4-8 weeks
Vital pulp tissue
Antibacterial
Good results reported with MTA
80
Q

Disadvantages of Calcium Hydroxide

A

Highly soluble in oral fluids
Reported cases of root fractures due to thin root walls and weakening of root related to changes in organic matrix
Subject to dissolution with time
Lack of adhesion

81
Q

Biodentine Advantages

A

Contemporary tricalcium silicate based dentine replacement
Favorable physical and clinical aspects compared to Ca(OH)2 and MTA
Biocompatible
Easily handled
Shorter setting time than MTA
Bioactive properties encouraging hard tissue formation
Does not provoke pulp inflammation
Good marginal integrity
Stronger mechanically, less soluble than Ca(OH)2
Not as much tooth discoloration as MTA

82
Q

Disadvantages of Biodentine

A

More long term clinical trials needed to evaluate success rate

83
Q

Advantages of MTA

A

Good biocompatibility
Less pulp inflammation
More predictable hard tissue barrier formation compared to Ca(OH)2
Antibacterial properties
Radiopacity
Releases bioactive dentin matrix proteins

84
Q

Disadvantages of MTA

A 
More expensive
Poor handling properties 
Long setting time
Tooth discoloration 
Two step procedure
85
Q

Advantages of Emdogain

A

Promote odontoblast differentiation and reparative dentin formaiton
Suppresses inflammatory cytokine prodution and promote healing
More hard tissue formation than Ca(OH)2
Less post-op symptoms

86
Q

Disadvantages of Emdogain

A

Clinical advantages of Emdogain are unproven

87
Q

Advantages of Propolis

A

Antioxidant, antibacterial, antifungal, anti-inflammatory properties
Superior bridge formation compared to Dycal
Forms dental pulp collagen, reduces pulp inflammation
Stimulation of reparative dentin

88
Q

Disadvantages of Emdogain

A

Showed mild/moderate inflammation after 2-4 weeks with partial dentinal bridge

89
Q

Advantages of Glass Ionomer/RMGI

A

Excellent bacterial seal
Fluoride release, coefficient of thermal expansion and modulus of elasticity similar to dentin
Bond to enamel and dentin
Biocompatible

90
Q

Disadvantages of GI/RMGI

A

Causes chronic inflammation
Lack of dentin bridge formation
Cytotoxic when in direct contact
Poor physical properties

91
Q

Advantages of lasers

A

Formation of secondary dentin
Sterilization of targeted tissue
Bactericidal effect

92
Q

Disadvantages of lasers

A

Technique sensitive

Causes thermal damage to pulp in high doses

93
Q

Advantages of Stem Cells

A

Regeneration of dentin-pulp complex

Stem cells from human exfoliated deciduous teeth (SHED) are superior to dental papilla stem cells (DPSC)

94
Q

Disadvantages of Stem Cells

A

Less economic

Technique sensitive

95
Q

Advantages of Growth Factors

A

Formation of osteodentin and tubular dentin
Superior to Ca(OH)2 in mineralization inducing properties
Dentin bridge formation equal to Dycal after 28 days

96
Q

Disadvantages of Growth Factors

A

Possibility of unexpected side effects
Cost can be an obstacle
Fail to stimulate reparative dentin in inflamed pulp
Appropriate dose response is required to avoid uncontrolled obliteration of pulp chamber
Possibility of immunological problems due to repeated due to repeated implantation of active molecules

97
Q

Pulp Therapy Prior to Periods of Immunosuppression - Primary Teeth

A

Dearth of literature in this subject
Teeth with previous pulp therapy can be left if sound, but should be monitored closely
Teeth presenting with failed pulp therapy during periods of immunosuppression can have significant negative effects on overall health
Consider extraction of teeth with uncertain pulp status to prevent life-threatening infection

98
Q

Pulp Therapy Prior to Periods of Immunosuppression - Permanent Teeth

A

Symptomatic teeth requiring root canal therapy should be addressed at least 1 week prior to periods of immunosuppression or should be extracted
Root canal therapy for teeth that are asymptomatic can be delayed until patient is stable and immunocompetent

99
Q

Characteristics of Facial Cellulitis of Odontogenic Origin

A

Diffuse, erythematous, facial swelling
Rapid onset
Possible fever
Potentially life threatening (cavernous sinus thrombosis, Ludwig’s angina)

100
Q

Treatment for facial cellulitis

A

Identify causative tooth and extract ASAP
Extract offending tooth ASAP (decreased length of stay)
Oral antibiotic therapy

101
Q

When to consider hospital admission for facial cellulitis

A

Unmanageable child, unable to treat in office setting
Dehydrated or medically compromised child
Swelling that extends to orbit (cavernous sinus thrombosis risk) or extends beneath the mandible (airway compromise, Ludwig’s angina risk)

102
Q

Hospital admission procedures for facial cellulitis

A

Routine dental radiographs sufficient most cases (CBCT/CT scans not indicated unless medical issue is present)
Extract offending tooth ASAP (decreased length of stay)
IV antibiotic therapy
With multiple dental needs, consider treatment of all treatment at time of admission (reduced cost when compared to two GA procedures)

Pediatric Dentistry Handbook (9 decks)

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