CSA Management of deep caries Flashcards
What is caries?
• disease of hard tissue of teeth characterised by demineralisation and proteolytic destruction of tissues by acids produced by bacteria in dental plaque feeding on dietary carbohydrates
How does an early lesion present itself?
- lesion may just reach ADJ
- clinical appearance may be brown (if stain) or white
- beginnings of a pulpal response:
What is the beginning of a pulpal response>
increased blood flow to the odontoblasts connected to the affected dentinal tubules
What is the main pulpal response?
- increasing fluid flow in dentinal tubular fluid
• Toxins are flushed away from the pulp
What does fluid contain?
immunoglobulins
• fluid carries calcium & phosphate to form a barrier
What does Ca and Ph. do on walls of tubules?
settle and form barrier, then sclerose and close up
What happens when sclerosis occurs?
dead tract form
What is the dentine response to caries?
dentine under lesion made at higher rate >reactionary/secondary dentine
- pulp chambers changes shape
- area between lesion and pulp incr.
How can an advancing lesion spread?
laterally at ADJ, enamel prisms undermined
What happens if you don’t tackle problem of lesion?
• pulp keep trying to produce more dentine >reach point where pulp is inflamed
o Toxins moving down dentinal tubules faster than fluid flow can push them back out
What happens beyond a threshold of pulpal injury?
lesion becomes irreversible
what happens when pulp dies?
cells die, C fibres are last cells to die ahah
What are good for seeing if caries is deep?
x rays
How to check if tooth is alive or dead?
if sensitive - alive long lasting throbbing -dead o Pain history How long have the symptoms lasted? o Examination (clinical) o Special tests o Radiographs
What are vitality tests?
• Electric pulp tests and ethyl chloride (cold)
What is wrong with vitality tests?
• get false positives >patient waiting for something to hurt
How to reach a diagnosis?
must decide if a tooth is alive &
o Healthy
o If its reversible pulpitis
o If its irreversible pulpitis
What is reversible pulpitis?
- Short sharp pain with hot/cold,
- Pain by movement of fluid in dentinal tubules
- Pulp responding to stimulus
What happens during reverse pulpitis ?
dentinal tubules exposed odontoblastic processes being activated
What is irreversible pulpitis?
- Pulp inflamed
- Hot/Cold may initiate pain, once there can last for 30+ mins
- Pulp irreversibly damaged and not recover
What to decide for irreversible pulpitis ?
if it’s worth trying to save
o Should we carry out RCT?
o Should we extract?
is the tooth worth trying to save?
- How much tooth tissue is remaining?
- What does patient want to do with tooth?
- Financial
- Medical issues>Patient on anticoagulant
What is a basic treatment plan for irreversible pulpitis ?
- Emergency relief of pain & discomfort
- Establish healthy oral enviro > Remove cause of disease
- Corrective therapy
What is corrective therapy?
a. Permanent restorations
b. RSD
c. Endodontist treatment
How do pulp die?
ingress of bacteria
What does caries removal aim to do?
o remove bacterial threat
o W/o exposing pulp
o Provide restoration that seals cavity against further bacterial assault
What is the management of reversible pulpitis?
- Assess depth of cavity with radiographs
- Use LA to numb patient
- Place rubber dam
- then explore with high speed bur
How to see if caries has spread laterally?
drill laterally
How do we remove affected dentine?
slow speed bur and excavator
What to check before restoration placement during revers. pulpitis management?
removed all infected dentine
o take out affected dentine
o always check ADJ to see if clean
How to protect pulp?
• create seal before placing restoration with GIC liner (Fuji-liner)
o Do before placing composite/amalgam
What is Stepwise excavation technique ?
- Caries removed until feel we are near pulp
- fill cavity with GIC
- re evaluate 6 months later and replace restorations if still symptom free and vital
How to identify pulpal exposure ?
- Red ring
* May be mistaken by bleeding of gum/red coloured caries
for pulpal exposure management, what to do if tooth has symptoms before starting?
RCT
for pulpal exposure management, what to do if tooth asymptomatic before starting?
o Place rubber dam if not already placed
o Wash cavity
o Dry with cotton wool pledget this tries to stop bleeding
What if dentine around pulpal exposure is carious ?
RCT
What if size of pulpal exposure if >2mm?
RCT
What if size of pulpal exposure if NOT >2mm?
Place setting calcium hydroxide over exposure and dress with GIC
What calcium hydroxide is used in management of deep carious lesion ?
o Setting – Dycal, MTA (Mineral trioxide aggregate), Biodentine
o Non- setting – Hypocal or calsept
What are the properties of calcium hydroxide ?
o Very high pH
o Creates alkaline environment- bactericidal (high toxicity to bacteria)
What does calcium hydroxide stimulate?
- odontoblasts to lay down new reparative dentine in dentinal tubules
o stem cells in pulp tissue to create new odontoblast-like cells to create dentine bridges across pulpal exposure
What is direct pulp capping?
placing calcium hydroxide
when is direct pulp capping most successful?
o no symptoms of pulpitis before tooth opened
o Normal vitality responsef
Younger patients w/o previous history of restorative work about tooth in question
o rubber dam placed and no saliva contamination
o exposure is small (under 2mm)
o Exposure is not probed, or blown dry
o Haemorrhage ceases within short time 30-60s & minimal bleeding
What can pulp exposure being blown dry cause?
damages pulp tissue directly
