Management of deep caries

Question 1

What are the three diagnoses regarding deep caries?

Answer 1

Reversible pulpitis, irreversible pulpitis and necrotic pulp.

Question 2

What would you conduct on irreversible pulpitis and a necrotic tooth?

Answer 2

Irreversible pulpitis - RCT

Necrotic - RCT/extraction

Question 3

How is reversible pulpitis classified?

Answer 3

Pain comes with stimulus and resolved quickly, not spontaneous and controlled with analgesics.

Question 4

How is irreversible pulpitis diagnosed?

Answer 4

Severe, spontaneous pain, keeps patient up at night, not controlled with analgesics.

Question 5

How is necrosis diagnosed?

Answer 5

May be in just one canal so can lead to mixed symptoms patient may not even have any pain.

Question 6

How do we examine this?

Answer 6

Dry tooth, good light, palpate and percuss, probing, vitality tests.
All new patients need a bitewing but may need a periapical to see apex of the tooth

Question 7

Can a brown spot lesion be reversed?

Answer 7

Yes until it has cavitated

Question 8

How much of caries present can a radiograph show?

Answer 8

60-80% so caries will always be deeper and more extensive than on the X-ray.

Question 9

What is deep caries?

Answer 9

At least 3/4 of the way to the pulp from the ADJ, high risk of pulpal exposure so tell patient.

Question 10

How do we protect the pulp after removing caries?

Answer 10

Pulp capping with CaOH after a partial pulpotomy removing part of the pulp or just pulp capping.

Question 11

What is stepwise excavation?

Answer 11

Remove soft dentine until affected dentine, leave it place CaOH and temporary filling and leave for some months. Remove the filling make sure caries has stopped and place permanent restoration.
DO THIS WHEN NEAR EXPOSURE

Question 12

What is affected dentine?

Answer 12

not demineralised just discoloured

Question 13

What is sclerotic dentine?

Answer 13

Protective for the pulp, no invasion of pulp, increases mineral content, more resistant to attack.

Question 14

What is reactionary dentine?

Answer 14

Lays more dentine to be more resistant to attack

Question 15

What colours indicate progress of caries?

Answer 15

Light yellow - actively progressing
Light brown - slowly
Dark - slowly/arrested

Question 16

What do we place after pulp capping?

Answer 16

Biodentine - maintains pulpal vitality and stimulates formation of tertiary dentin

Question 17

What is a pulpotomy?

Answer 17

Removing a layer or two of to the full orifice level. Can be partial or full.

Question 18

What are the two types of direct pulp capping?

Answer 18

Class 1 - no preoperative presence of deep caries - iatrogenic/traumatic exposure
2 - preoperative presence of deep caries/pulp inflamed - has a worse prognosis

Question 19

What is the series of stages you should go through in managing deep caries?

Answer 19

Direct pulp capping - partial pulpotomy - full/more pulpotomy/ RCT - stop when bleeding stops, use sodium hypochloride to help stop bleeding

Question 20

What should the restoration be?

Answer 20

Seal the cavity, biocompatible and should have bioactive properties - induce pulp to repair

Question 21

What can you use as pulp capping materials?

Answer 21

CaOH - stimulates pulp to repair but is porous and not the best handling
Calcium silicate cements - bioactive - MTA, biodentine, bioceramics

Question 22

When do we review the restoration?

Answer 22

every 6-12 months up to 4 years, look or near to normal pulp, no pain and continuation of root formation.