pulp diagnosis and pulp therapy introduction Flashcards
when is pulp therapy indicated?
When pulpal involvement or exposure of tooth occurs.

what are the two types of pulp therapy?
Vital Pulp Therapy Pulp cap (indirect and direct) Cvek pulpotomy (partial pulpotomy) Coronal Pulpotomy Apexogenesis Non-vital Pulp Therapy Pulpectomy and root canal Extraction
Why should we save primary teeth?
Function/mastication
Allow for normal growth and development of dentition and oral structures
Speech (minor degree)
Esthetics and Self-Esteem
why are primary teeth susceptible to pulpal involvement?
Primary teeth susceptible to pulpal involvement due to:
a) Dentin and enamel is 1/2 the thickness
b) Dentin is less dense
c) Pulp horns are higher
• Mechanical exposures occur easier.
• Caries can progress through less tooth structure to involve pulp.
what do you need to know to diagnose pulpal disease?
Successful pulp therapy depends on the vitality status of the pulp.
Need to know if the pulp is vital or non-vital.
Or does it have reversible or irreversible pulpitis?
This determines if you will attempt vital pulp therapy or non-vital pulp therapy.
what is the diagnosis for reversible pulpitis?
Reversible pulpitis:
History:
provoked or stimulated pain that ends when stimulus stops.
No history of swelling, fever, spontaneous pain.
Pain associated with eating:
May not mean pulpal inflammation
May be momentary and disappear with removal of the stimulus (may indicate only a thin amount of dentin remains between the pulp and carious lesion)
Can be due to pressure, chemical irritation, or thermal irritation
Probably a reversible state exists if all other signs and symptoms negative
Clinical Exam: no mobility no swelling/parulis/fistula not percussion not palpation tender no sig. probing depths
Periapical radiograph
No internal resorption/pathology
No external periapical/furcation resorption/pathology
No resorption/pathology or permanent tooth follicle
No PDL widening.
What is the diagnosis for irreversible pulpitis?
History: spontaneous pain (unprovoked). child waking up at night. history of severe toothache, swelling, fever. aching pain (necrotic)
Clinical Exam: Mobile or non-mobile +/- swelling/parulis/exudate from sulcus +/- probing depth >3mm +/- percussion tenderness +/- palpation tenderness
periapical radiograph:
Irreversible:
+/- widened PDL
+/- pathologic internal/external resorption
+/- pulp calcifications
Necrotic:
Widened PDL
+/- pathologic root or furcation resorption
+/- aveolar bone destruction
+/- perforation of permanent tooth follicle
+/- pulp calcifications
is diagnosis of pulpal disease difficult?
Diagnosis of pulp disease is difficult:
Clinical symptoms Histology of pulp
(not always a positive correlation)
When gathering history of symptoms, do not rely solely on parent‟s information. Involve the child also; may get different response.
what are some diagnostic tips?
Pain: not as reliable in primary teeth as it is in permanent teeth. Children often are unable to recall experiences of pain. Type of pain is important.
Radiographs: Carious exposures of pulp cannot be solely diagnosed with radiographs. Root sheath of immature permanent teeth can be mistaken as teeth with apical lesions.
Pulp Test: Questionable value in primary teeth. May get a vital response but poor assessment of degree of pulpal inflammation.
Mobility: Pathologic or physiologic? Abnormal mobility may be a sign of severely diseased pulp with periapical involvement.
Percussion: Sensitivity to percussion in teeth with deep carious lesions is most likely from pulp disease and possible involvement of the PDL.
What should you do with treatment planning?
Based on history and exam, able to guess if teeth vital or non-vital.
What other factors are important to decide what treatment is appropriate?
Patient Factors
Restorability of tooth
Other factors
Size/Type of exposure and pulpal hemorrhage.
how does physical condition of the patient come in to play in your treatment planning?
In chronically ill children: extraction of pulpally involved teeth is the treatment of choice. Antibiotic coverage may be needed.
Due to the canal morphology of primary teeth, successful pulp therapy is not assured. Such teeth can act as a source of infection in compromised patients and cause acute infections.
Such patients include ones with: Susceptibility for subacute bacterial endocarditis Leukemia Solid tumors Cyclic neutropenia Depressed granulocyte or PMN leukocyte counts (transplants, immunosuppressed)
How should you evaluate treatment prognosis before pulp therapy?
Is the crown restorable?
Are the periodontal structures irreversibly involved?
Pulp therapy vs. extraction and space management
Age of patient (4 years vs. 8 years)
what are some other factors in your decision of what treatment to use?
Patient and parent cooperation Oral hygiene and motivation Caries activity
Stage of dental development
Difficulty in performing the pulp therapy
Space management considerations:
- Previous extractions
- existing malocclusions
- M-D space loss due to caries
Extrusion of pulpally involved teeth resulting from missing opposing teeth
when there is a pulp exposure and pulpal hemorrhage what are your most valuable observations?
Mechanical exposure Carious exposure Size of exposure Appearance of the pulp Amount of bleeding
For cariology what happens with non-cavitated enamel caries or slow progressing dentinal caries? deep caries?
Odontoblasts may or may not survive (dead tracts). If odontoblasts survive create reactionary dentin. Appears as if pulp recedes.
odontoblasts die. Undifferentiated cells recruited to act as odontoblast- like cells and produce reparative dentin. Appears as if pulp recedes.
What else do we need to know about size of exposure and pulpal hemorrhage?
No irreversible pathologic change in pulp occurs until caries is within 1 mm of pulp. But the pulp can be reversibly inflamed as soon as caries enters dentin.
Bleeding from exposures in healthy pulp indicates exposure may be greater than pinpoint in size.
Excessive bleeding is generally associated with hyperemia and generalized inflammation.
Exposures which produce a watery exudate or pus = indicate that vital pulp therapy is not indicated
what is the most conservative approach to treating deep carious lesions?
indirect pulp therapy
Most conservative approach to treating deep carious lesions.
Acceptable for teeth with reversible pulpitis.
Requires accurate diagnosis based on history, proper clinical and radiographic exam.
Requires a leakage free restoration.
what’s the definition of indirect pulp therapy?
“Technique to prevent an accidental or mechanical exposure of the pulp during the treatment of a tooth with a deep carious lesion closely approximating the pulp, but which does not cariously involve it.”
How do you perform an indirect pulp therapy?
Removal of all caries on axial walls approaching
cavosurface margin.
Gross caries removal towards pulp, but not
exposing pulp, carious dentin left should be firm, not soft.
Placement of glass ionomer over Ca(OH)2 to arrest the carious process and placement of a permanent restoration, preferably a stainless steel crown, to eliminate the bacterial substrate.
All of the caries except that which would be likely to expose the pulp is removed.
After IPT for 60 days, will see bacteria counts decrease in „carious dentin‟ left is now drier.
By removing outer caries, and sealing, the internal caries arrests.
Success rate >90%.
What is the case selection criteria for indirect pulp therapy?
No history of spontaneous pain (may have pain with eating; should disappear with stimulus removal)
No mobility
No swelling in area
Normal adjacent soft tissues
No widening of PDL
No rarefaction
No periapical changes (or root resorption)
Only asymptomatic teeth (primary or permanent) with deep carious lesions should be selected.
CASE SELECTION IS VERY IMPORTANT FOR SUCCESS OF IPT!!!
What do you do with the residual carious dentin?
Residual carious dentin, which might result in a mechanical exposure if removed, is allowed to remain and is covered with Ca(OH)2 and GI.
How is the carious process arrested?
The carious process is arrested in two ways:
- Number of micro-organisms is reduced
- Substrate is unable to lodge in tooth
What happens to the repair of dentin?
Reparative process; (reparative dentin) is allowed to occur after caries process decreased
Pulp involvement occurs at a late stage of the carious process
Only when < 0.3 mm of dentin remains does pulp involvement occur.
Bulk of reparative dentin is laid down in the first month
Also have sclerosis of the sound dentin after treatment
What is the clinical technique for IPT?
- Accurate Diagnosis and consent.
- Anesthesia
- Rubber dam should be used
- Caries removal:
Grossly carious dentin is removed until firmer dentin is reached (may get an exposure if attempt to remove it all)
Clinical experience determines when to stop
All carious dentin is removed laterally to establish sound margins (remove grossly unsupported enamel) - Ca(OH)2 is placed over the remaining caries
- Glass Ionomer is used to restore the preparation and cover the Ca(OH)2.
- Place permanent restoration, preferably a stainless steel crown on primary molar.
Indirect pulp therapy is a valuable tool in controlling caries in children with rampant decay.
what are rampant caries?
Another pattern of decay is “rampant caries”, which signifies advanced or severe decay on multiple surfaces of many teeth.[67] Rampant caries may be seen in individuals with xerostomia, poor oral hygiene, stimulant use (due to drug-induced dry mouth[68]), and/or large sugar intake.
what are direct pulp therapies for?
Limited to small exposures that have been accidentally produced by trauma or during cavity preparation (mechanical pulp exposures NOT CARIOUS EXPOSURES).
What is the case selection for direct pulp therapy?
Asymptomatic
No history of unprovoked pain
No caries at site of exposure
Small exposure (pinpoint)
Sound dentin around periphery
Little or no hemorrhage (should stop immediately. If not, probably means pulpal inflammation or larger exposure)
DPT is less successful in primary teeth as compared to permanent teeth
what’s the technique and follow up for direct pulp therapy?
Ca(OH)2 placed over exposure site
Tooth restored with permanent restoration
Remember that all treatment must be followed-up, especially if there was deep caries.
Reassess patient in 6 months and then at 1 yr.