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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
Non-vital pulp therapy for primary teeth
Pulpectomy or Extraction | LSTR potential
26
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
27
Objectives of Pulpectomy
Remove necrotic or irreversibly inflamed tissue Halt spread of inefction Maintain a healthy/asymptomatic tooth until exfoliation
28
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
29
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
30
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
31
Pulpectomy Root Filling Materials Desirable Properties
``` Resorbable Biocompatible Harmless to succedaneous teeth Easy to place Easy to remove ```
32
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
33
Indications for Extraction rather than Pulpectomy
Severe odontogenic infection If tooth is not restorable If infection envelops developing premolar Space maintenance often required
34
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
35
Deep caries lesions in permanent teeth
Present when penetration depth is in range of 3/4 of dentin thickness or more on BW radiograph
36
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
37
Conservative Treatment Approaches for Young Permanent Teeth with Deep Carious Lesions
``` Protective Base Indirect Pulp Treatment Stepwise Caries Removal Direct Pulp Cap Partial Pulpotomy ```
38
Aggressive Treatment Approaches for Young Permanent Teeth with Deep Carious Lesions
Coronal Pulpotomy | Partial Pulpectomy
39
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
40
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
41
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 ```
42
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
43
Advantages of Indirect Pulp Treatment
One visit | Lower cost
44
Disadvantages of Indirect Pulp Treatment
More tooth structure removed Sclerosis of dentinal tubules and dentin formation not promoted Greater risk of pulp exposure
45
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%)
46
Stepwise Caries Removal Indications
Active/soft/rapidly progressing carious lesion Primary carious lesion or recurrent caries under shallow restoration Reversible pulpitis No periradicular pathosis
47
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
48
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
49
Disadvantages of Stepwise Caries Removal
Time - 2 visits Patient compliance Higher cost
50
Direct Pulp Cap Indications
Permanent teeth with normal pulp status with small mechanical or traumatic exposure
51
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
52
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%
53
Partial Pulpotomy Definition
Procedure in which inflamed pulp tissue beneath an exposure is removed to reach healthy pulp tissue
54
Partial Pulpotomy Indications
Young Permanent tooth with carious pulp exposure | Vital tooth with diagnosis of normal pulp or reversible pulpitis
55
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
56
Partial Pulpotomy Technique
Pulp bleeding controlled by bactericidal agent (NaOCl, CHX) before site is covered by Ca(OH)2, or MTA
57
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%
58
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
59
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
60
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
61
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
62
Treatment of Necrotic Immature Permanent Teeth Objectives
Promote continued apical tooth development Achieve apical closure Alleviate pain Maintain a functional tooth
63
Definition of success in treatment of necrotic immature permanent teeth
Asymptomatic Radiographic absence of pathology Continued root development (sometimes) Hard tissue barrier at apex
64
Root Canal Therapy Indications
Restorable permanent tooth Irreversible pulpitis or pulp necrosis Root that has been apexified
65
RCT Objectives
Eliminate pulp or periradicular infection Successful obturation No adverse clinical or radiographic signs/symptoms Resolution of pre-treatment pathology
66
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
67
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
68
Actions of Calcium Hydroxide
Bactericidal Low grade irritation induces hard tissue formation Dissolves necrotic debris
69
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
70
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
71
Indication for regenerative endodontics
Necrotic immature permanent tooth (regardless of etiology)
72
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 ```
73
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
74
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
75
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
76
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
77
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
78
Materials used as permanent tooth pulp capping agents
``` Calcium Hydroxide Biodentine MTA Emdogain Propolis GI/RMGI Lasers Stem Cells Growth Factors ```
79
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 ```
80
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
81
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
82
Disadvantages of Biodentine
More long term clinical trials needed to evaluate success rate
83
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
84
Disadvantages of MTA
``` More expensive Poor handling properties Long setting time Tooth discoloration Two step procedure ```
85
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
86
Disadvantages of Emdogain
Clinical advantages of Emdogain are unproven
87
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
88
Disadvantages of Emdogain
Showed mild/moderate inflammation after 2-4 weeks with partial dentinal bridge
89
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
90
Disadvantages of GI/RMGI
Causes chronic inflammation Lack of dentin bridge formation Cytotoxic when in direct contact Poor physical properties
91
Advantages of lasers
Formation of secondary dentin Sterilization of targeted tissue Bactericidal effect
92
Disadvantages of lasers
Technique sensitive | Causes thermal damage to pulp in high doses
93
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)
94
Disadvantages of Stem Cells
Less economic | Technique sensitive
95
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
96
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
97
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
98
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
99
Characteristics of Facial Cellulitis of Odontogenic Origin
Diffuse, erythematous, facial swelling Rapid onset Possible fever Potentially life threatening (cavernous sinus thrombosis, Ludwig's angina)
100
Treatment for facial cellulitis
Identify causative tooth and extract ASAP Extract offending tooth ASAP (decreased length of stay) Oral antibiotic therapy
101
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)
102
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)

Pediatric Dentistry Handbook (9 decks)

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