Chapter 7: Pulp Therapy Flashcards
Findings consistent with reversible pulpitis - primary teeth
Transient tooth pain associated with thermal or chemical stimulus
Lack of nocturnal and spontaneous tooth pain
Findings consistent with irreversible pulpitis - primary teeth
Spontaneous tooth pain
Nocturnal tooth pain
Constant or persistent thermal or chemical pain
Purpose of vital pulp therapy in primary teeth
Maintain vitality of tooth and prevent pain and infection
Allow for normal exfoliation and prevent need for space maintenance
Protective bases
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
Indirect Pulp Treatment (IPT) indications and objectives
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
IPT Technique
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
Conditions Favoring Vital Pulp Therapy
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)
Conditions Favoring Non-Vital Pulp Therapy
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
Conditions Favoring Extraction
Diagnosis of irreversible pulpitis or necrotic pulp with advanced root resorption
Odontogenic infection resulting in compromised systemic health
Direct Pulp Cap Indications and Objectives
Indications: small traumatic or mechanical pulp exposure; not recommended for carious exposure
Objectives: to maintain vitality and allow pulpal healing
Direct Pulp Cap Technique (primary teeth)
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
Coronal pulpotomy indications and objectives
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
Pulpotomy Technique
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
Best long-term restoration after pulpotomy?
SSC
Amalgam and composite is acceptable if sufficient tooth structure remains
Pulpotomy Medicaments
Formocresol Ferric sulfate Sodium hypochlorite MTA Calcium silicate (biodentine)
Formocresol
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
Ferric Sulfate
Hemostatic agent
Potential to mask diagnosis if used prior to evaluation of bleeding
Causes coagulation of blood
Reports of internal resorption
Sodium Hypochlorite
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
How to avoid sodium hypochlorite accidents
Determine working length
Avoid binding syringe tip
Use side-venting needle
Extrude liquid slowly
Mineral Trioxide Aggregate (MTA)
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
Negatives of MTA
Technique sensitive to mix and handle
Can cause discoloration due to presence of bismuth oxide
Cost is high
Calcium Silicate (Biodentine)
Bioactive properties
Faster setting time than MTA
Alkaline pH
Early studies do not show discoloration
Lasers and Pulpotomy
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
Electrosurgery
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
Non-vital pulp therapy for primary teeth
Pulpectomy or Extraction
LSTR potential
Indications for Pulpectomy
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
Objectives of Pulpectomy
Remove necrotic or irreversibly inflamed tissue
Halt spread of inefction
Maintain a healthy/asymptomatic tooth until exfoliation
Pulpectomy Technique
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
Treatment of sodium hypochlorite accident
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
Success of Pulpectomies
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
Pulpectomy Root Filling Materials Desirable Properties
Resorbable Biocompatible Harmless to succedaneous teeth Easy to place Easy to remove
Pulpectomy Materials
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
Indications for Extraction rather than Pulpectomy
Severe odontogenic infection
If tooth is not restorable
If infection envelops developing premolar
Space maintenance often required
Assessing Pulp Status for Young Permanent Teeth
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
Deep caries lesions in permanent teeth
Present when penetration depth is in range of 3/4 of dentin thickness or more on BW radiograph
Young Permanent Teeth - Reasons to Maintain Pulp Vitality if Possible
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
Conservative Treatment Approaches for Young Permanent Teeth with Deep Carious Lesions
Protective Base Indirect Pulp Treatment Stepwise Caries Removal Direct Pulp Cap Partial Pulpotomy
Aggressive Treatment Approaches for Young Permanent Teeth with Deep Carious Lesions
Coronal Pulpotomy
Partial Pulpectomy
Protective Base
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
Indirect Pulp Treatment Indications
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
Objectives of Indirect Pulp Treatment
Maintain pulp vitality Avoid pulp exposure Remove soft demineralized dentin Biocompatible and radiopaque liner Placement of definitive leakage-free restoration
Indirect Pulp Treatment Technique
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
Advantages of Indirect Pulp Treatment
One visit
Lower cost
Disadvantages of Indirect Pulp Treatment
More tooth structure removed
Sclerosis of dentinal tubules and dentin formation not promoted
Greater risk of pulp exposure
Success of Indirect Pulp Treatment
High survival rate (>90%) without adverse clinical symptoms or pathology
MTA has higher success rate than calcium hydroxide (98% vs 60-100%)
Stepwise Caries Removal Indications
Active/soft/rapidly progressing carious lesion
Primary carious lesion or recurrent caries under shallow restoration
Reversible pulpitis
No periradicular pathosis
Stepwise Caries Removal Objectives
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
Advantages of Stepwise Caries Removal
Preserve tooth structure/minimally invasive
Promotes formation of secondary/sclerotic dentin
Allows/maintains thicker remaining dentin
Clarifies pulpal diagnosis and prognosis
Disadvantages of Stepwise Caries Removal
Time - 2 visits
Patient compliance
Higher cost
Direct Pulp Cap Indications
Permanent teeth with normal pulp status with small mechanical or traumatic exposure
Direct Pulp Cap Objectives
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
Direct Pulp Cap Technique
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%
Partial Pulpotomy Definition
Procedure in which inflamed pulp tissue beneath an exposure is removed to reach healthy pulp tissue
Partial Pulpotomy Indications
Young Permanent tooth with carious pulp exposure
Vital tooth with diagnosis of normal pulp or reversible pulpitis
Partial Pulpotomy Objectives
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
Partial Pulpotomy Technique
Pulp bleeding controlled by bactericidal agent (NaOCl, CHX) before site is covered by Ca(OH)2, or MTA
Success of partial pulpotomy
High rates of success (91-96%)
Ca(OH)2 in permanent teeth: 91-200% after 2 years
MTA in permanent teeth 95-100%
Coronal Pulpotomy in Permanent Teeth
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
Partial Pulpectomy
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
Pulp Therapy for Traumatized Young Permanent Teeth (Cvek Pulpotomy)
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
Cvek Pulpotomy Additional Information
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
Treatment of Necrotic Immature Permanent Teeth Objectives
Promote continued apical tooth development
Achieve apical closure
Alleviate pain
Maintain a functional tooth
Definition of success in treatment of necrotic immature permanent teeth
Asymptomatic
Radiographic absence of pathology
Continued root development (sometimes)
Hard tissue barrier at apex
Root Canal Therapy Indications
Restorable permanent tooth
Irreversible pulpitis or pulp necrosis
Root that has been apexified
RCT Objectives
Eliminate pulp or periradicular infection
Successful obturation
No adverse clinical or radiographic signs/symptoms
Resolution of pre-treatment pathology
Apexification
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
Apexification Technique
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
Actions of Calcium Hydroxide
Bactericidal
Low grade irritation induces hard tissue formation
Dissolves necrotic debris
MTA Apical Plug
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
Regenerative Endodontics
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
Indication for regenerative endodontics
Necrotic immature permanent tooth (regardless of etiology)
Key elements in tissue engineering
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
Additional information about regenerative endodontics
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
Revascularization Technique Overview
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
Revascularization Technique
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
Requirements for regeneration in revascularization
Traumatized tooth must be non-vital
Tooth should have at least 1.1mm open apex
Patient age between 7-16 years, in good health
Revascularization Process (2 step)
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
Materials used as permanent tooth pulp capping agents
Calcium Hydroxide Biodentine MTA Emdogain Propolis GI/RMGI Lasers Stem Cells Growth Factors
Advantages of Calcium Hydroxide
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
Disadvantages of Calcium Hydroxide
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
Biodentine Advantages
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
Disadvantages of Biodentine
More long term clinical trials needed to evaluate success rate
Advantages of MTA
Good biocompatibility
Less pulp inflammation
More predictable hard tissue barrier formation compared to Ca(OH)2
Antibacterial properties
Radiopacity
Releases bioactive dentin matrix proteins
Disadvantages of MTA
More expensive Poor handling properties Long setting time Tooth discoloration Two step procedure
Advantages of Emdogain
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
Disadvantages of Emdogain
Clinical advantages of Emdogain are unproven
Advantages of Propolis
Antioxidant, antibacterial, antifungal, anti-inflammatory properties
Superior bridge formation compared to Dycal
Forms dental pulp collagen, reduces pulp inflammation
Stimulation of reparative dentin
Disadvantages of Emdogain
Showed mild/moderate inflammation after 2-4 weeks with partial dentinal bridge
Advantages of Glass Ionomer/RMGI
Excellent bacterial seal
Fluoride release, coefficient of thermal expansion and modulus of elasticity similar to dentin
Bond to enamel and dentin
Biocompatible
Disadvantages of GI/RMGI
Causes chronic inflammation
Lack of dentin bridge formation
Cytotoxic when in direct contact
Poor physical properties
Advantages of lasers
Formation of secondary dentin
Sterilization of targeted tissue
Bactericidal effect
Disadvantages of lasers
Technique sensitive
Causes thermal damage to pulp in high doses
Advantages of Stem Cells
Regeneration of dentin-pulp complex
Stem cells from human exfoliated deciduous teeth (SHED) are superior to dental papilla stem cells (DPSC)
Disadvantages of Stem Cells
Less economic
Technique sensitive
Advantages of Growth Factors
Formation of osteodentin and tubular dentin
Superior to Ca(OH)2 in mineralization inducing properties
Dentin bridge formation equal to Dycal after 28 days
Disadvantages of Growth Factors
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
Pulp Therapy Prior to Periods of Immunosuppression - Primary Teeth
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
Pulp Therapy Prior to Periods of Immunosuppression - Permanent Teeth
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
Characteristics of Facial Cellulitis of Odontogenic Origin
Diffuse, erythematous, facial swelling
Rapid onset
Possible fever
Potentially life threatening (cavernous sinus thrombosis, Ludwig’s angina)
Treatment for facial cellulitis
Identify causative tooth and extract ASAP
Extract offending tooth ASAP (decreased length of stay)
Oral antibiotic therapy
When to consider hospital admission for facial cellulitis
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)
Hospital admission procedures for facial cellulitis
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)
