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Pulpal disease > Principles of treatment of diseases of the vital pulp > Flashcards

Principles of treatment of diseases of the vital pulp Flashcards

1
Q

Endodontics definition

A

Scientific/study

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2
Q

Endodontology definition

A

Therapeutic procedure

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3
Q

Interceptive endodontics

A

Pulp capping

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4
Q

Preventive endodontics

A 
Good restorative and operative practice
Maintenance of pulpal health
Prevention of pulpal damage
Minimising negative impact of therapeutic interventions on pulpal health
'keeping pulp alive'
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5
Q

Corrective RCT

A

Repeat RCT

Re-treatment

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6
Q

Vital pulp

A

Living tissue with blood supply
May or may not be innervated
Non-innervated tissue insensitive
Key-critical component of tooth and without it tooth is irreversibly compromised, with very negative effect on durability

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7
Q

Contrast between vitality and sensitivity

A

Vitality - blood supply

Sensitivity - nerve supply

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8
Q

Apical foramen

A

Opening at the apex of the root of a tooth, through which the nerve and blood vessels that supply the dental pulp pass

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9
Q

What does pulpal tissue contain

A 
Blood supply
Nutrients
Immune factors
Nerve supply
Controls dentine fluid flow
Important in mineralisation
Essential for proper physiological functioning of dentine and enamel
Proprioception - regulates max loads
Resides inside pulp chamber that provides structural integrity to tooth
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10
Q

Preservation of pulp vitality - why?

A 
To keep the tooth (avoid extraction)
To avoid root-canal treatment
To preserve structural integrity of tooth
To maintain proprioception of pulp
To minimise operative treatment
-->To prolong durability of tooth
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11
Q

Consequences of loss of pulp vitality to the individual

A

Inflammation & infection of pulp and local and systemic consequences of this
Pain, in different grades and of unpredictable nature

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12
Q

Consequences of loss of pulp vitality to the tooth

A
  1. Necrotic pulp
    - loss of proprioception
    - breakdown of pulp into dentine: dark tooth
    - need for RCT or XLA
  2. RCT: significant loss of structural integrity
  3. Restoration of root filled tooth
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13
Q

Consequences of RCT: significant loss of structural integrity

A

Loss of roof of pulp chamber (mechanical prep)
Effects of RCT mechanical prep
-NaOCl - dissolution of superficial (canal wall) collagen - makes dentine more brittle
-EDTA - dissolution of superficial (canal wall) calciumHAP
-Effect of eugenol - makes dentine more brittle

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14
Q

Consequences of necrotic pulp

A
  • loss of proprioception
  • breakdown of pulp into dentine: dark tooth
  • need for RCT or XLA
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15
Q

Consequences of restoration of root filled tooth

A

Always more compromised
At best = occlusal adhesive restoration
At worst= retained root that needs post-core and crown restoration
Durability and overall prognosis very poor

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16
Q

Why avoid extraction?

A

Loss of tooth
Functional and aesthetic problems
Avoid compromising other teeth
Avoid other treatment modalities with > morbidity and unpredictable outcomes

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17
Q

Why avoid RCT

A

To avoid irreversible and catastrophic structural degradation
To maintain proprioception
To avoid periapical and periradicular infection - with local and systemic complications

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18
Q

How compromised is a root-filled tooth?

A

Loss of roof of pulp chamber significantly reduces fracture strength
Direct relationship between amount of remaining tooth structure and ability to resist occlusal loads
Minimal access cavity in intact tooth reduces cuspal stiffness by 5%

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19
Q

Upper 6

A

4 canals, 3 roots

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20
Q

What makes a root-filled tooth different?

A

Compromised architecture
Changes in physical properties
Changes in loading

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21
Q

If lesion at bottom of root (periapical)

A

Do a sensitivity test
If asymptomatic, monitor
If symptomatic, RCT
Should do something about it

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22
Q

Reduction in fracture strength due to

A

Loss of structural integrity
Tubular sclerosis, secondary and reparative dentine
< in amount of mature collagen in dentine matrix
Eugenol > dentine microhardness
NOT due to < in moisture content

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23
Q

Darker tooth

A

Something wrong with pulpal tissue
Sensibility test - vital or non-vital
Then radiograph

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24
Q

Challenges to the pulp

A

Mechanical prep e.g. trauma, cavity prep
Thermal damage e.g. pulp testing, cavity prep
Chemical substances e.g. dietary acids, eugenol
Microorganisms e.g. caries, periodontal disease, cracks

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25
Q

Change in what temp can pulp not tolerate

A

5 degrees C

26
Q

Factors affecting tooth

A 
Bacterial biofilm
Variable pH
Constantly wet
Changes in T
Tooth-materials interactions
27
Q

Environmental damage

A 
Temp cycling
Permanentlywet
pH changes
Functional loads
Parafunctional loads
28
Q

Total or partial caries removal?

A

A lot more pulpal exposures from total (50 vs 219)
No evidence of diff. restoration longevity
Insufficient evidence to determine whether diff. in signs and symptoms of PD between partial and total

29
Q

Partial caries removal advantages

A
  1. Partial caries removal < incidence of pulpal exposure in symptomless, vital, carious primary as well as permanent teeth
  2. PCR technique shows clinical advantage over complete caries removal in management of dentinal caries
    Reduces cavity size - preserve tooth structure
30
Q

Effect of operative damage

A 
Overheating
Inappropriate cavity prep
Over cutting during caries removal
Mismatch of material properties
Inappropriate use of materials
Lack of attention to detail
31
Q

Spray coolant

A

Irreversible structural damage to dentine occurs at temp over 70 degrees
All cavity prep under effective spray coolant
Once damaged thermally, dentine cannot recover
-visco-elastic properties ruined for life

32
Q

Pulpal protection

A
  1. Prevention of bio-film contamination
  2. Cleaning surface
    - oil-free prophylactic paste or pumice
    - prophylactic slow-speed cup (500rpm)
  3. Disinfecting surface and adjoining teeth/ surfaces
    - 2% chlorhexidine
    - 2.5 mins (impregnated cotton wooil)
33
Q

Remaining dentine thickness

A

Remaining odontoblasts were reduced
-13.6% beneath RDT of 2.5-0.5mm
-33.7% beneath RDT 0.5-0.01mm
-By 99% beneath pulp exposed cavities
Reparative dentine observed following pulp exposure and reactionary dentine was observed with mean RDT of 0.77mm (2.5-0.01mm)
Cavity RDT mediates powerful influence on underlying pulp tissue vitality
Cavity RDT has little effect on reactionary dentine secretion and inflammatory activity
Gross tissue injury explains poor pulp capping prognosis following exposure and underlies need to avoid this type of injury
Following restoration, RDT of 0.5mm or greater necessary to avoid evidence of pulp injury

34
Q

Pulpal death following crown preps

A 
Aggressive insult to tooth, dentine, and odontoblasts
Thermal damage
LA
Dessication
Bacterial contamination
~10% pulpal death
35
Q

Minimum of dentine thickness recommended for pulpal protection

A

0.7mm

Shoulder prep of 1.2mm leaves remaining dentine width of 0.7mm only in 50% of maxillary molars

36
Q

Natural course of ‘untreated’ pulpal inflammation

A
  1. Pulpitis - symptomatic or asymptomatic
  2. Pulp necrosis
  3. Root canal infection, leading to periapical inflammatory lesion (periapical peiodontitis)
37
Q

Pumice with which bur

A

Intracoronal brush for proximal box

Cup for rest of cavity

38
Q

Cavity disinfection

A

Avoiding infection
Effective isolation - with rubber dam
Cavity and prep disinfection with chlorhexidine (conc.not so important)
Sealing dentine with adhesive should be considered for crown preps.

39
Q

Cavity disinfection - effect of chlorhexidine on dentine

A

Dentine contains matrix metalloproteinases (MMPs), a group of neutral zinc- and calcium-dependent enzymes that regulate physiologic and pathologic metabolism of collagen-based tissues
CHX preserves hybrid layer by preventing release of MMPs from incompletely infiltrated collagen fibrils, thus preventing that will breakdown collagen
Does not improve bond strength, but preserves its durability

40
Q

Posterior tooth composite shade

A

Lighter cures better

Aesthetic not as important

41
Q

Conservative approach

A

Preserves pulp, re-establish healthy longterm conditions

‘Biological’ caries excavation to remove dentine but retaining dentine, so avoiding pulpal exposure

42
Q

Radical approach

A

Remove pulpal tissue (pulpectomy) and replace with RCT

Total and uncompromising removal of caries and if pulpal exposure occurs it is then managed biologically

43
Q

Vital pulp therapy

A

Clinical procedures aimed at

  • relieving painful symptoms of pulpitis
  • preventing development of destructive course of inflammation, pulp death and subsequent infection of root canal space
44
Q

The pulpal wound

A

Has little self-healing capacity unless properly treated, in contrast to skin and mucosal tissues
Has no epithelia with which to bridge the defect

45
Q

Vital pulp treatments

A 
Partial caries removal
Indirect pulp capping
Direct pulp capping
Partial pulpotomy
Coronal pulpotomy
Pulpectomy and RCT
46
Q

Indirect pulp capping

A

Residual caries - affected dentine retained in close proximity to pulp without a breach (exposure)
Restore permanently with:
-GIC and/ or DBAs composite resin
-GIC and amalgam alloy
Review pulp status in time by signs and symptoms, and sensibility testing

47
Q

Direct pulp capping

A

Managing exposed surface of pulp using suitable material to try and stimulate dentine bridge formation to close over exposure so repairing the breach

48
Q

Pulp capping

A 
Place rubber dam
Remove any blood clot with sharp excavator
Establish haemostasis
-chlorhexidine
-sodium hyperchloride
-saline
Gently apply capping agent without firm pressure (MTA)
Cover wound dressing with hard setting cement e.g. GIC
Restore and seal with permanent restoration
Review at 1 week to check on symptoms
Review at 6 months to evaulate
-symptoms
-reaction to thermal stimuli
-sensitive to electric pulp testing
Radiographic changes
-periapical 
-dentine 'bridge' formation
49
Q

Pulpal exposure damage

A

Calcium hydroxide pulp capping material pushed into exposure causing major bleed

50
Q

Barthel 2000 method

A

123 pulp cappings
Teeth checked for sensitivity, percussion and palpation
Radiographs were taken to assess periapical status
Contributing factors considered
5 and 10 years

51
Q

Barthel 2000 results

A 
At 5 years
-44.5% failures
-18.5% questionable
-27% successful cases
At 10 years
-79.7% failing
-7.3% questionable
-13% successful cases
Main factor of survival influence: placement of definitive restoration within first 2 days after pulp exposure
All questionable and successful cases showed radiographic evidence of calcific reactionary dentine in pulp space when compared with adjacent teeth that had no pulp exposure
52
Q

Barthel 2000 conclusions

A

Pulp capping of carious exposures has poor outcome
Definitive restoration (immediately) > survival
Consideration given to likely need to undertake RCT in tooth with > reactionary calcifications in pulp space

53
Q

Al-Hiyasat 2006 method and results

A

Treatment outcomes of 193 pxs with 204 pulp exposures with direct pulp capping
Radiographic review
3 years
Success rate of pulp capping 59.3%
Mechanical exposure 92.2%
Carious exposure 33.3%
Permanent restoration 80.8%
Temporary 47.3%
Class I restoration 83.8%
Proximal multiple surface restorations 56.1% MO to 28.6% MOD
Pxs’ age, sex, tooth location and position no significant effect on outcome

54
Q

Al-Hiyasat 2006 conclusions

A

Carious pulp caps have very low success rate, worse if temporary restoration and large cavity

  • direct pulp capping recommended after mechanical exposure with immediate placement of permanent restoration
  • RCT would be choice of treatment if exposure was due to caries, large cavity and not able to place permanent restoration
55
Q

Effect of infected dentine

A

Following carious exposures outcomes (pulp likely to be compromised) are poor
Avoidance of carious pulpal exposures critical to long term outcome of tooth
Management using direct pulp capping technique associated with poor prognosis for maintaining vital pulp
Extirpation of damaged pulp and RCT would then be required

56
Q

Factors of importance in successful outcome to direct pulp capping

A

Type of injury - caries, trauma or iatrogenic
Age of px: pulp survival after 5 years was
-70% for 50-80 year olds
-85% for 30-50 years olds
-92% for 10-30 year olds

57
Q

Partial pulpotomy

A

Invasive surgical procedure
Involves removal of inflamed coronal portion of pulp tissue
Amputate diseased tissue with diamond bur until healthy tissue exposed and haemostasis achieved

58
Q

Coronal pulpotomy

A

Invasive surgical procedure
Removal of all coronal pulp
Amputate diseased tissue with high speed diamond bur until healthy tissue exposed and haemostasis acheived
In mature teeth, pulpotomy often carried out as temporary measure on emergency basis until time available for pulpectomy

59
Q

Effect of trauma on teeth. Survival compromised if:

A
  1. Exposure of dentine and or pulp to the mouth
  2. Disruption of blood supply
  3. Unpredictable pulp responses, precipitating unnecessary pulpectomy (of a recovering pulp)
  4. Obliteration of pulp space by mineralised tissue (accelerated following trauma)
60
Q

Determination of successful pulp management

A
  1. Accurate diagnosis
  2. Careful and appropriate planning
  3. Effective isolation - avoid further contamination
  4. Appropriate operative dentistry
  5. Effective disinfection
  6. Effective restoration with quality marginal seal
  7. Review and reassess diagnosis and prognosis

Pulpal disease (11 decks)

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