pulp diagnosis and pulp therapy introduction

Question 1

when is pulp therapy indicated?

Answer 1

When pulpal involvement or exposure of tooth occurs.



Question 2

what are the two types of pulp therapy?

Answer 2

Vital Pulp Therapy
 Pulp cap (indirect and direct)
 Cvek pulpotomy (partial pulpotomy) 
 Coronal Pulpotomy
 Apexogenesis
Non-vital Pulp Therapy
 Pulpectomy and root canal 
 Extraction

Question 3

Why should we save primary teeth?

Answer 3

 Function/mastication
 Allow for normal growth and development of dentition and oral structures
 Speech (minor degree)
 Esthetics and Self-Esteem

Question 4

why are primary teeth susceptible to pulpal involvement?

Answer 4

 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.

Question 5

what do you need to know to diagnose pulpal disease?

Answer 5

 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.

Question 6

what is the diagnosis for reversible pulpitis?

Answer 6

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.

Question 7

What is the diagnosis for irreversible pulpitis?

Answer 7

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

Question 8

is diagnosis of pulpal disease difficult?

Answer 8

 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.

Question 9

what are some diagnostic tips?

Answer 9

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.

Question 10

What should you do with treatment planning?

Answer 10

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.

Question 11

how does physical condition of the patient come in to play in your treatment planning?

Answer 11

 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)

Question 12

How should you evaluate treatment prognosis before pulp therapy?

Answer 12

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)

Question 13

what are some other factors in your decision of what treatment to use?

Answer 13

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

Question 14

when there is a pulp exposure and pulpal hemorrhage what are your most valuable observations?

Answer 14

 Mechanical exposure
 Carious exposure
 Size of exposure
 Appearance of the pulp 
 Amount of bleeding

Question 15

For cariology what happens with non-cavitated enamel caries or slow progressing dentinal caries? deep caries?

Answer 15

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.

Question 16

What else do we need to know about size of exposure and pulpal hemorrhage?

Answer 16

 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

Question 17

what is the most conservative approach to treating deep carious lesions?

Answer 17

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.

Question 18

what’s the definition of indirect pulp therapy?

Answer 18

“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.”

Question 19

How do you perform an indirect pulp therapy?

Answer 19

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%.

Question 20

What is the case selection criteria for indirect pulp therapy?

Answer 20

 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!!!

Question 21

What do you do with the residual carious dentin?

Answer 21

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.

Question 22

How is the carious process arrested?

Answer 22

The carious process is arrested in two ways:

1. Number of micro-organisms is reduced
2. Substrate is unable to lodge in tooth

Question 23

What happens to the repair of dentin?

Answer 23

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

Question 24

What is the clinical technique for IPT?

Answer 24

1. Accurate Diagnosis and consent.
2. Anesthesia
3. Rubber dam should be used
4. 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)
5. Ca(OH)2 is placed over the remaining caries
6. Glass Ionomer is used to restore the preparation and cover the Ca(OH)2.
7. 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.

Question 25

what are rampant caries?

Answer 25

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.

Question 26

what are direct pulp therapies for?

Answer 26

Limited to small exposures that have been accidentally produced by trauma or during cavity preparation (mechanical pulp exposures NOT CARIOUS EXPOSURES).

Question 27

What is the case selection for direct pulp therapy?

Answer 27

 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

Question 28

what’s the technique and follow up for direct pulp therapy?

Answer 28

 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.