Pulp Flashcards
Which pulp tissue becomes inflamed first, middle and last?
first: pulp horn
second: coronal pulp
third: radicular pulp
T/F
Pulp regeneration is similar in the deciduous dentition compared to the permanent dentition? Reference
T
Rodd 2009
Which feature of enamel breakdown indicates the degree to which the pulp is inflamed?
marginal ridge breakdown.
with increase in marginal ridge breakdown the pulpal inflammation is more widepsread
Which caries, proximal or occlusal, shows the greatest amount of pulp inflammation? Reference
proximal
Kassa et al 2009
What are the four potential pulp statuses?
Healthy
Reversible pulpitis
Irreversible pulpitis
Pulp Necrosis
What is the pulp response to caries?
initially tertiary dentine is laid down
following this, if the lesion is allowed to progress this leads to irreversible pulpitis and necrosis
What is the most reliable method for diagnosing pulp status?
Histological analysis
Why do we need to determine the pulp status correctly?
To determine the most appropriate treatment option
What are the challenges with regards to diagnosing pulp statuses in children?
lack of correlation between clinical signs and symptoms
unreliable tests
What to we use to diagnose the pulp status?
symptoms
clinical findings
special investigations
What are the symptoms of irreversible pulpitis?
Spontaneous pain constant long duration not always relived by analgesics dull throbbing ache sleep disruption
What are the symptoms of reversible pulpitis?
provoked pain disappears on removal of stimulus shorter duration relieved with analgesia sharp pain
What clinical findings suggest pulp involvement?
sinus
swelling
clinical extent of caries
Which features on the radiographs can be use to assess pulp status?
extent of caries
radiolucency interadicular
Resorption (internal/external, physiological)
Which special investigations can be performed to investigate pain?
Mobility (normal vs abnormal)
TTP (distinguish between food impaction and peri-radicular resorption)
Which 4 factors about the patient will indicate whether or not the tooth should be extracted or restored?
medical factors
social
dental
pulp
Which medical factors would make you more inclined to retain the tooth?
bleeding disorders
patients at risk from GA
Which medical factors would make you more inclined to extract the tooth?
Immune compromised
cardiac disorders
Which social factors would you consider when considering treatment options?
attendance motivated dental awareness co-operation and compliance age of the child
Which dental factors would affect treatment decisions?
gross dental neglect restorability acute infection/pathology time to exfoliation: if due to exfoliate within one year/advanced root resporption: provisional restoration or extract If more than one year: retain hypodontia value of the tooth? effect on developing dentition?
What are the two treatment options for vital pulp therapy?
Pulp cap (direct or indirect) Pulpotomy (vital or desensitising)
What are the two treatment options for non-vital pulp therapy?
Pulpectomy
Extraction
What are the requirements for a vital pulp therapy?
Restorable Crown
Vital Pulp (no history of spon pain, reversible pulpitis, no sinus)
No radiographic pathology (resorption)
What is a pulp cap?
a method of maintaining pulp vitality by placing a dressing directly or indirectly over the exposed pulp or onto residual dentine left over a nearly exposed pulp
What is the purpose of a pulp cap?
To promote pulp healing
When is an indirect pulp cap indicated?
symptom free tooth with deep caries where full caries removal would lead to pulp exposure
What is the process of indirect caries removal?
All margins free from caries
remove as much of the softened caries from the margins as possible
place CaOH ontop (setting)
What can be used to help locate where the infected dentine is?
dyes
eg 0.5% fuschin dye
According to Welbury 2012 which type caries, proximal or occlusal should indirect pulp cap be avoided?
proximal since Kassa 2009 showed that caries proximally causes much more wide spread inflammation than occlusal. deep proximal lesions should be restpred with a pulpotomy first.
How effective are direct pulp caps in deciduous teeth? and why?
not very (welbury 2012) this is because the medicament is less likely to stimulate reparative dentine in the inflamed area
What is a pulpotomy?
removal of inflamed coronal pulp tissue leaving the intact radicular pulp, medicament then placed on top
When the coronal pulp is removed in a pulptomy how should you stop the bleeding of the radicular pulp?
direct pressure with sterile saline soaked cotton wool pledget
What is the potential problem if bleeding of the radicular pulp fails to halt following application of cotton wool and sterile saline? What are the options following this?
the radicular pulp is likely to be irreversible inflamed
vital pulpectomy or XLA/GA
What will happen if a pulpotomy is carried out on an inflamed radicular pulp?
internal resorption will occur
Which two things would indicate the need for pulpectomy or extraction following opening up of the pulp chamber?
no pulp in the canal and unable to get haemostasis
Which medicatments can you use for a pulpotomy?
ferric sulphate (15.5%) formocresol used to be used no longer now
How do you perform a ferric sulphate pulpotomy?
Apply ferric sulphate on cotton wool to the pulp and obtain haemostasis
apply once for 15 seconds and then again for 15 seconds, if bleeding not controlled with this then need to perform pulpectomy or XLA
By what method does formocreosol work?
It works by fixing the pulp tissue
What is the success rate for ferric sulphate pulpotomy?
Coll et al 2008
70-95% success
Which material should be used to fill then pulp chamber?
Doyle et al 2010
Zn O Eugenol
CaOH (high failure rate)
MTA shows the best outcome with 2 year survival median value. DOyle et al 2010
What should be placed over the crown following the Zn O Eugenol?
SSC
Waterhouse et al 2000
What is essential after pulpotomy and SSC placement?
follow up
absence of signs and symptoms
radiograph shows no evidence of bone loss in the furcation
no evidence of internal resorption
When should you do further treatment on a tooth which has had a pulpotomy and internal resorption is now present radiologically?
If the resorption extends on to the external root surface
if the patient is experiencing any signs and symptoms
What is a desensitising pulpotomy?
hyperalgesic pulp
poor compliance
What is the rationale behind a desensitising pulpotomy?
Reduce pulpal inflammation symptoms to facilitate pulp therapy later on
How do you perform a desensitising pulpotomy?
ledermix and GIC temp
How do you perform a pulpectomy? When is it indicated?
extirpate the soft tissue contents from the coronal pulp chamber and root canal
indicated when there is evidence of irreversible pulpitis or necrosis
hyperaemic pulp
What material is placed in the root canals following pulpectomy?
resorbable dressing
Pure ZOE
Iodoform
CaOH
Ledermix
What is the success rate for pulpectomy?
86% at 36months
Casas et al 2004
What is a potential complication following pulpectomy?
Savage et al 1986
well recognised complication is that a radicular cyst can develop therfore need radiographic monitoring
What is the success rate for an indirect pulp cap?
CaOH 94% Al Zayer at al 2003
How far from the radiographic apex do you instrument in a pulpectomy?
2mm
Welbury 2012
What is the evidence behind the toxicity of formocreosol? paper?
IACR (international agency for cancer reserach) 2004 showed a causal relationship between creosol and nasophryngel cancer
generally accepted that formaldehyde is toxic at the site of contact
What are the two options for performing a pulpectomy?
Carrotte and waterhouse 2008
one stage: if the root canals are irreversibly inflamed but no evidence of peri-radicular inflammation then one stage
two stage: if the root canals are necrotic and evidence of peri-radicular root resorption, then need to do a two stage
