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Pulp Therapy Flashcards

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1
Q

Accessory Canals

A
  • One or more extra canals near the furcation
  • May not be primary cause of infection transmission
  • Impossible to get all pulp tissue out of the tooth
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2
Q

Apexification technique: Short term vs. long term

A
  • Short term: MTA barrier w/ or w/o collagen wound dressing followed by gutta percha.
  • Long term: w/ Ca(OH)2 = Frank technique
    • Allows for formation of hard tissue barrier
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3
Q

Apexification w/ MTA

A
  • MTA reduces the time needed for completion of the RCT and restoration of the tooth.
  • Apical barrier achieved in one visit.
  • If re-treatment is needed, apical surgery is done.
  • MTA placed in apical ⅓ of canal; 4-5mm
  • Bonded core to fill canal
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4
Q

Apexification w/ MTA: Advantages

A
  • Patient compliance is less crucial than w/ Ca(OH)2
  • The dentin will not lose its physical properties
  • Allows for earlier restoration of the tooth, minimizing the likelihood of root fracture
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5
Q

Apexogenesis in permanent teeth: What is it?

A
  • Root formation
  • Histological term used to describe the continued physiologic development and formation of the root’s apex by IPT, direct pulp capping, partial pulpotomy for carious exposures and traumatic exposures.
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6
Q

Ca(OH)2 as a pulpectomy medicament

A
  • Resorbs very quickly
  • Can be applied with a syringe or lentulo spiral
  • Biocompatible
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7
Q

Ca(OH)2 as permanent tooth pulp capping agent: Advantages, Disadvantages

A
  • Advantages
    • BIocompatible – gold standard
    • Superficial necrosis
    • Deeply staining zone: Basophilic Ca(OH)2 elements
    • Coarse fibrous tissue: fibroblasts odontoblasts orient to periphery
    • Induction of calcified bridge at 4-8 wks
    • Vital pulp tissue
    • Antibacterial
  • Disadvantages
    • Highly soluble in oral fluids
    • Reported cases of root fractures due to thin root walls and weakening of root related to changes in organic matrix after placement of Ca(OH)2
    • Subject to dissolution w/ time
    • Lack of adhesion
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8
Q

Biodentine as permanent tooth pulp capping agent: Advantages, Disadvantages

A
  • Advantages
    • Contemporary tricalcium silicate based dentine replacement and repair material.
    • Has favorable physical and clinical aspects compared to Ca(OH)2 and MTA
    • Biocompatible
    • Easily handled w/ short setting time compared to MTA
    • Bioactive properties that encourage hard tissue regeneration (tertiary dentin)
    • Does not provoke pulp inflammation
    • Good marginal integrity due to formation of hydroxyapatite crystals at tooth surface
    • Upon application to exposed pulp, biodentine can significantly increase TGF-beta 1 secretion from pulp cells and induce an early form of reparative dentin synthesis.
    • Stronger mechanically, less soluble and produces tighter seals compared to Ca(OH)2
    • Early studies do not show tooth discoloration that is common w/ MTA
  • Disadvantages
    • More long term clinical trials are needed to evaluate success rates
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9
Q

MTA as permanent tooth pulp capping agent: Advantages, Disadvantages

A
  • Advantages
    • Good biocompatibility
    • Less pulp inflammation
    • More predictable hard tissue barrier formation compared to Ca(OH)2
    • Antibacterial properties
    • Radiopacity
    • Releases bioactive dentin matrix proteins
  • Disadvantages
    • $$$
    • Poor handling properties
    • Long setting time
    • Tooth discoloration
    • Two step procedure
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10
Q

Ca(OH)2 w/ pulpotomy in permanent teeth

A
  • Superficial necrosis
  • Deeply staining zone: basophilic Ca(OH)2 elements
  • Coarse fibrous tissue: fibroblasts odontoblasts orient to periphery
  • Calcified dentin bridge @4-8 weeks (dentin bridge forms w/ tunnel defects)
  • Vital pulp tissue
  • Antibacterial
  • Quick setting time
  • No effect on PDL
  • Unlikely to cause coronal discoloration
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11
Q

Calcium silicate as a pulpotomy medicament: MOA, success rates, additional information

A
  • MOA: Calcific barrier formation
  • Success rates: Comparable to MTA
  • Additional information: Less discoloration than MTA, less evidence
  • Components: tricalcium silicate, dicalcium silicate, calcium carbonate, oxide filler, iron oxide shade and zirconium oxide

**AAPD: conditional with very low evidence, not as many studies**

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12
Q

Cellulitis of odontogenic origin: Treatment

A
  • Identify offending tooth and EXT ASAP
  • Oral abx therapy per guidelines
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13
Q

Characteristics of cellulitis of odonotgenic origin

A
  • Diffuse, erythematous facial swelling
  • Rapid onset
  • Possible fever
  • Potentially life threatening (cavernous sinus thrombosis, Ludwig’s angina)
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14
Q

Components of Buckley’s full-strength formocresol

A

19% formaldehyde + 35% cresol + 15% glycerin

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15
Q

Concerns with FC pulpotomies

A
  • Accelerated primary teeth exfoliation
  • Mutagenic and carcinogenic potential
  • Humoral and cell-mediated response
  • Systemic distribution of FC
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16
Q

Concerns with FS as a pulpotomy medicament

A
  • Potential to mask diagnosis if used prior to evaluation of bleeding.
  • Reports of internal resorption
  • Concern related to iron and risk of non tuberculosis mycobacterium infection due to waterline contamination - iron feeds bacteria
    • CA and GA had an outbreak of mycobacterium in the water
  • Lower success than FMC or MTA
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17
Q

Conditions favoring extraction

A
  • Irreversible pulpitis or pulpal necrosis w/ advanced root resorption
  • Odontogenic infection resulting in compromised systemic health
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18
Q

Conditions favoring non-vital pulp therapy

A
  • Irreversible pulpitis or pulpal necrosis
  • Pulp exposure that reveals hyperemic pulp tissue or pulp necrosis
  • Proper isolation with rubber dam or equivalent
  • Restorable tooth that is desirable to maintain
  • Radiograph that clearly shows the tooth’s support structure
  • Minimal or no physiologic root resorption
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19
Q

Conditions favoring vital pulp therapy

A
  • Deep caries approximating pulp
  • Traumatic, mechanical or carious pulp exposure
  • Dependable diagnosis of reversible pulpitis
  • Proper isolation w/ rubber dam or equivalent
  • Restorable tooth that is desirable to maintain
  • Radiograph that clearly shows tooth’s support structure
  • Intact PDL
  • Intact bone (absence of furcal or PA radiolucency)
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20
Q

Coronal pulpotomy in permanent teeth: Objectives

A
  • Encourage root development
  • Emergency procedure for RCT if needed
  • Promote tertiary dentin formation
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21
Q

Coronal pulpotomy in permanent teeth: Success rates

A
  • Ca(OH)2 is higher for traumatic exposures (72-96%) than carious exposures (50-92%)
  • 2yr success rate
    • Ca(OH)2: 87.5-100%
    • MTA: 90-100%
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22
Q

Coronal pulpotomy: Indications

A
  • Pulp exposure (carious, traumatic, mechanical)
  • Restorable tooth
  • Coronal pulp inflamed
  • Radicular pulp judged to be healthy by controlled bleeding
  • No evidence of furcal or periradicular pathology on radiograph
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23
Q

Coronal pulpotomy: Objectives

A
  • Maintain symptom-free tooth that holds space for successor
  • No radiographic signs of infection
  • Normal resorption occurs
  • Succedaneous tooth undamaged
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24
Q

Decision to maintain pulp vitality whenever feasible is important for:

A
  • Development of favorable crown-root ratio
  • Apical closure
  • Formation of secondary radicular dentin
  • Long term tooth survival is 7x better if pulp vitality is maintained compared to a de-vitalized tooth (hazard ratio 7:1)
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25
Q

Dentin

A

inorganic hydroxyapatite, organic type I collagen

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26
Q

Dentin-Pulp Complex

A

Pulp originates from mesenchymal tissues, odontoblast synthesize dentin, cytoplasmic processes extend into the dentin tubules

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27
Q

Different types of nerve fibers in the pulp

A
  • Myelinated: A fibers, rapid sharp pain
    • Innervate dentinal tubules and are stimulated by fluid
    • Increase in number over time, few during eruption
    • Associated with odontoblasts
  • Unmyelinated: C fibers, dull aching pain
    • More frequent, around pulp tissues and blood vessels
    • Pulpitis pain is likely from this nerve
  • Nerve plexus of Raschkow: Myelinated fibers in cell rich zone
    • Monitors painful sensations
    • Mediates inflammatory events and tissue repair
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28
Q

DPC: Indications

A
  • Small traumatic or mechanical pulp exposure – not recommended for carious exposures
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29
Q

DPC: Objectives

A
  • Maintain vitality and allow for pulpal healing
  • Reparative dentin
  • Immature permanent teeth continue to develop (apexogenesis)
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30
Q

Electrosurgery as a pulp therapy technique: MOA, success rates, additional information

A
  • MOA: Cauterization
  • Success rates: Comparable to FC (62-97%)
  • Additional information: Collateral damage due to heat production; few human RCTs
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31
Q

Emdogain

A

Made from enamel matrix proteins (EMPs) from the tooth germ of swine and propylene glycol alginate (PGA) as a matrix. The function of EMD is known to differentiate cells of the dental follicle into cementoblasts.

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32
Q

Emdogain as permanent tooth pulp capping agent: Advantages, Disadvantages

A
  • Advantages
    • Promote odontoblast differentiation and reparative dentin formation
    • Suppresses inflammatory cytokine production and promotes healing
    • More hard tissue formation compared to Ca(OH)2
    • Less post-op symptoms
  • Disadvantages
    • Clinical advantages are unproven
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33
Q

Ferric sulfate as a pulpotomy medicament: MOA, success rates, additional information

A
  • MOA: Causes coagulation of blood where blood vessels have been severed
    • Hemostatic agent
  • Success rates: 77-93%
  • Additional information: Reports of internal resorption
  • Antibacterial
  • pH < 1
  • Must have healthy radicular pulp to obtain hemostasis
  • Concern related to iron and risk of non tuberculosis mycobacterium infection due to waterline contamination - iron feeds bacteria
    • CA and GA had an outbreak of mycobacterium in the water
  • Lower success than FMC or MTA
  • Studies have shown internal resorption

**AAPD: conditional recommendation with low evidence**

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34
Q

Formocresol as a pulpotomy medicament: MOA, success rates, additional information

A
  • MOA: Tissue fixation
  • Success rates: 62-97%
  • Additional information: Concerns w/ toxicity; other medicaments produce equivalent results
    • No reports on toxicity found
      • When used judiciously for pulpotomies, it is unlikely to be genotoxic, immunotoxic, or carcinogenic in children
  • Did not find sufficient evidence on adverse events that could influence the quality of evidence****
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35
Q

Findings consistent w/ irreversible pulpitis?

A
  • Spontaneous tooth pain
  • Nocturnal tooth pain
  • Constant or persistent thermal or chemical pain

Diagnosis of irreversible pulpitis cannot be based solely on pulpal bleeding that cannot be controlled within five minutes.

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36
Q

Findings consistent with reversible pulpitis?

A
  • Transient/intermittent tooth pain associated w/ chemical or thermal stimulus.
  • Lack of nocturnal and spontaneous tooth pain
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37
Q

Follow up interval for apexification w/ Ca(OH)2

A

Clinically and radiographically at 3-month intervals to examine the formation of an apical hard tissue barrier and to confirm the absence of pathology such as root resorption and apical periodontitis.

If calcified barrier is not evident and Ca(OH)2 has washed out, it should be replaced. When barrier is seen on the radiograph, the tooth is reopened and Ca(OH)2 is removed by copious irrigation. The apical area should be gently examined using a GP point to determine the completeness of the apical barrier.

Repeat until a complete barrier is established.

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38
Q

NaOCl as a pulpotomy medicament: MOA, success rates, additional information

A
  • MOA: Antimicrobial irrigant
  • Success rates: Equivalent to FC (62-97%) and FS (77-93%)
  • Additional information: Limited evidence
  • Usually at 5%
  • Antimicrobial, biocompatible, non irritating to pulp, surface effects, similar success to FC at 12 months

**AAPD: conditional with low evidence**

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39
Q

Formocresol MOA

A
  • Bactericidal
  • Tissue fixation at most coronal level of vital radicular pulp (acidophilic zone)
  • Causes persistent inflammation of radicular pulp
    • Dilute FC shown to cause less inflammation than full strength
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40
Q

GI/RMGI: Advantages, Disadvantages w/ permanent tooth pulp capping

A
  • Advantages
    • Excellent bacterial seal
    • Fl- release, coefficient of thermal expansion and modulus of elasticity similar to dentin
    • Bond to both enamel and dentin
    • Good biocompatibility
  • Disadvantages
    • Causes chronic inflammation
    • Lack of dentin bridge formation
    • Cytotoxic when in direct cell contact
    • Poor physical properties for GI
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41
Q

Glutaraldehyde when used as a pulpotomy medicament (fixative)?

A
  • Dialdehyde compound, mild fixatives, antibacterial
  • 2-5% concentration
  • Does not penetrate into periapical tissues
  • Antibacterial at pH of 7.5-8.5
  • Not as commonly used, short shelf life
  • Lower success, low antigenicity, and low toxicity
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42
Q

How long is application for formocresol?

A

5 minutes. Evidence suggests that 1 minute application of FC has equivalent success

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43
Q

Hydrodynamic Theory

A
  • Fluid movement in dentinal tubules is translated into electric signals in axons that innervate dentinal tubules
  • Increased pressure = increased nerve activity
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44
Q

Indications for apexification

A

Pulp necrosis following trauma, after carious exposures, and in teeth w/ anatomic variations (like dens invaginatus) w/ an immature root

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45
Q

Interim Therapeutic Restorations (ITR): When can they be removed?

A

ITR w/ glass ionomer cements for caries control for reversible pulpitis - can be removed once the pulp’s vitality determined, an indirect pulp cap can be performed (no conclusive evidence that it is necessary to reenter the tooth to remove the residual caries)

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46
Q

IPT in permanent teeth

A

Deep caries that exhibits no reversible pulpitis when the deepest carious dentin is not removed to avoid a pulp exposure of vital pulp

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47
Q

IPT in permanent teeth: Indications

A
  • Reversible pulpitis, deep caries that might otherwise need endo if the decay was completely removed.
  • When there is concern for pulp exposure
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48
Q

IPT in permanent teeth: Objectives

A
  • Change the cariogenic environment in order to decrease the number of bacteria
  • Close the remaining caries from the biofilm of the oral cavity, and slow or arrest the caries development.
    • Interim restoration should be retained for up to 12mo.
    • Intermediate and/or final restoration should seal, vitality, immature roots should show continued root development and apexogenesis
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49
Q

IPT in permanent teeth: Process

A
  • Remove caries along DEJ and only outermost infected dentin, leaving carious mass over the pulp.
  • Remove remaining caries and place final restoration
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50
Q

IPT rate of success in permanent teeth

A

Long term success rates are equivalent for partial caries removal or stepwise caries removal with >96% of teeth treated remaining vital after 2yr.

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51
Q

IPT survival rates

A
  • High survival rate
    • >90% OR 74-99% w/o adverse clinical symptoms or pathologic signs
  • MTA has higher success than Ca(OH)2
    • Ca(OH)2 = 60-100%
    • MTA = 98%
  • Higher success rate than direct pulp cap (DPC) and pulpotomy in long term studies

Long term success rates are equivalent for partial caries removal or stepwise caries removal with >96% of permanent teeth treated remaining vital after two years.

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52
Q

IPT: Advantages + Disadvantages

A
  • Advantages:
    • One visit
    • Lower cost
  • Disadvantages:
    • More tooth structure removed
    • Does not promote sclerosis of dentinal tubules and dentin formation
    • Greater risk of pulp exposure
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53
Q

IPT: Indications

A
  • Normal pulp
  • Asymptomatic tooth w/ deep caries approximating pulp
  • Clinically and radiographically sound tooth
  • Chronic/arrested/inactive/slowly progressing lesion
  • Well-defined radiopaque dentinal bridge between pulp chamber and carious lesion
  • No h/o pain/may have no lingering cold sensitivity
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54
Q

IPT: Objectives

A
  • Avoid pulp exposure
  • Seal and arrest deep decay
  • Maintain tooth vitality
  • Promote healing and repair
  • Remove all soft demineralized dentin
  • Biocompatible and radiopaque liner
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55
Q

IPT: Technique

A
  • Remove soft infected dentin, leave affected dentin
  • Clean periphery + DEJ
  • GI or Ca(OH)2 is placed to stimulate odontoblasts to form reactionary dentin and promote remineralization of existing dentin
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56
Q

Laser as a pulp therapy technique: MOA, success rates, additional information

A
  • MOA: Tissue ablation
  • Success rates: Lower than conventional techniques
  • Additional information: Many different types
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57
Q

Lasers in permanent tooth capping: Advantages, Disadvantages

A
  • Advantages
    • Formation of secondary dentin
    • Sterilization of targeted tissues
    • Bactericidal effect
  • Disadvantages
    • Technique sensitive
    • Causes thermal damage to pulp in high doses
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58
Q

LSTR: Advantages, Disadvantages

A
  • Advantages:
    • One visit
    • Simple
    • Painless
    • Less burdensome for patients
  • Disadvantages:
    • Tooth staining with minocycline
    • Radiolucent appearance of triple antibiotic paste
    • Allergic reaction
    • Potential antibiotic resistance
    • Risk for developmental anomalies in permanent teeth

Need more research - need the right case

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59
Q

LSTR: Indications

A
  • Primary tooth with irreversible pulpitis or necrosis or a tooth treatment planned for pulpotomy in which the radicular pulp exhibits clinical signs of irreversible pulpitis or pulp necrosis (suppuration, purulence)
  • ** When a tooth is to be maintained for less than twelve months and exhibits root resorption, LSTR is preferred to pulpectomy. **
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60
Q

LSTR: Objectives

A

Objectives: radiographic infectious process and pretreatment clinical signs and symptoms should resolve

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61
Q

LSTR: Process

A

No instrumentation of the root canals, antibiotic mixture is placed in the pulp chamber to disinfect the root canals, canal orifices are enlarged using a large round bur to create medication receptacles, walls of the chamber are cleaned with phosphoric acid and then rinsed and dried.

3 antibiotic mixture of clindamycin, metronidazole, and ciprofloxacin is combined with a liquid vector of polyethylene glycol and macrogol to form a paste placed directly into the medication receptables and over the pulpal floor, covered with a glass-ionomer cement and restored with a stainless steel crown

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62
Q

LSTR: Traditional 3Mix abx vs. Alternate 3Mix

A
  • Traditional
    • Tetracycline/minocycline
    • Ciprofloxacin
    • Metronidazole
  • Alternate
    • Clindamycin
    • Ciprofloxacin
    • Metronidazole
  • Blended w/ a prophylene glycol** base and **macrogol

** Statistically significant less success using a tetracycline mix (minocycline) versus a mix without tetracycline - recommend antibiotic mixtures should not include tetracycline. **

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63
Q

LSTR: What is it? Goals? What is used in this technique?

A
  • Lesion sterilization and tissue repair (LSTR)
    • Goal is to sterilize lesion and avoid instrumentation of canals
  • Similar to a pulpotomy except putting in triple antibiotic in the chamber
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64
Q

Materials used w/ IPT

A

Ca(OH)2, zinc oxide, or glass ionomer

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65
Q

Mild damage to dentin

A

Odontoblasts survive and secrete reactionary dentin (i.e. cavity prep, caries present)

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66
Q

MTA as a pulpotomy medicament: MOA, success rates, additional information

A
  • MOA: Calcific barrier formation
  • Success rates: Highest of any medicament
  • Additional information: Concerns with gray discoloration, $$$
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67
Q

MTA w/ pulpotomy in permanent teeth

A
  • Minimal inflammation histologically
  • Biocompatible
  • Normal dentin formation
  • Consistent dentin bridge formation
  • Favorable PDL architecture
  • Higher success rate than Ca(OH)2
  • Prolonged setting time (-)
    • Hydrophilic particles set in presence of moisture, biologically active for cell attachment
  • Likely to cause coronal discoloration (-)
  • More effective than Ca(OH)2 for maintaining long-term pulp vitality after IPT and DPC
    • Success rate for both materials is similar in partial pulpotomy and pulpotomy
    • Minimal pulp necrosis and inflammation
  • Compressive strength like IRM,
  • pH of 12.5 after setting - reaction product is CaOH2
  • Better seal than amalgam
  • Stimulates reparative dentin, makes a dentin bridge
    • Faster than CaOH2

**AAPD: strong recommendation with moderate evidence**

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68
Q

MTA: Pros, Cons

A
  • Pros:
    • High biocompatibility
    • Alkaline pH (12)
    • Induces hard tissue formation – dentin bridging
    • Success rates are very high, surpassing FC
  • Cons:
    • Technique sensitive to mix
    • Causes discoloration (not to be used in esthetic zone)
    • $$$
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69
Q

NaOCl: Pros, Cons

A
  • Pros:
    • Biocompatible and non-irritating to pulp tissue
    • Antimicrobial
  • Cons:
    • Injection into soft tissue through apex or through perforation → “sodium hypochlorite accidents” (severe pain, edema, and bruising)
      • Avoid this by determining working length, avoiding binding syringe tip, using side-venting needles, slowly extrude liquid
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70
Q

Partial (CVEK) pulpotomy: Indications

A

Vital, traumatically-exposed, young permanent tooth, especially one with an incompletely formed apex.

71
Q

Partial pulpectomy

A
  • Partial extirpation of radicular pulp
  • Indicated for persistent hemorrhage from pulp stumps
  • Ca(OH)2 is medicament of choice
    • Good results have been reported w/ MTA
72
Q

Partial pulpotomy for carious exposures: Indications

A
  • Young permanent tooth for a carious pulp exposure
  • Pulpal bleeding
73
Q

Partial pulpotomy for carious exposures: Objectives

A
  • Remaining pulp vital
  • Normal root development
  • Apexogenesis
74
Q

Partial pulpotomy for carious exposures: What is it?

A
  • Inflamed pulp tissue beneath an exposure is removed to a depth of 1-3mm or deeper to reach healthy pulp tissue. Pulpal bleeding controlled by irrigation with a bacteriocidal agent such as sodium hypochlorite or chlorhexidine, covered with calcium hydroxide or MTA.
    • Calcium hydroxide = long-term success
    • MTA = more predictable dentin bridging and pulp health
  • MTA (at least 1.5mm thick) over the exposure and surrounding dentin then a layer of light cured RMGI.
75
Q

Partial pulpotomy in young permanent teeth: Indications

A
  • Carious pulp exposure
  • Vital tooth w/ dx of normal pulp or reversible pulpitis
76
Q

Partial pulpotomy in young permanent teeth: Success rates

A
  • Very high: 91-96%
    • Ca(OH)2: 91-100% after 2yr
    • MTA: 95-100%
77
Q

Permanent teeth: Pulp therapy prior to periods of immunosuppression

A
  • Symptomatic teeth requiring RCT should be addressed at least 1 wk prior to period of immunosuppression or should be extracted.
  • RCT for teeth that are asymptomatic can be delayed until patient is stable and immunocompetent
78
Q

pH of RMGI?

A
  • pH is 4 to 5.5
  • Demineralizes dentin, may release bioactive materials
  • Irritating to the pulp
79
Q

Primary teeth: Pulp therapy prior to periods of immunosuppression

A
  • Lack of literature
  • Teeth w/ previous pulp therapy can be left if sound, but should be monitored closely
  • Teeth presenting w/ failed pulp therapy during periods of immunosuppression can have significant negative effects on overall health
  • Consider extraction of teeth w/ uncertain pulpal status to prevent life-threatening infection
80
Q

Prognosis of DPC w/ primary teeth

A
  • Questionable. Coronal pulpotomy has more predictable outcomes.
  • Hemostasis is important - 80-90% when bleeding is well-controlled
81
Q

Prognosis of DPC w/ young permanent teeth

A

5yr success rates:

  • Ca(OH)2: 59-69%
  • MTA: 78-98%
82
Q

Propolis used as a permanent tooth pulp capping agent?? Advantages, Disadvantages

A
  • Propolis (bee glue) is a byproduct of honeybees that is widely used in traditional medicine.
  • Advantages:
    • Antioxidant, antibacterial, antifungal, antiviral and anti-inflammatory
    • Superior bridge formation compared to Dycal, similar results to MTA
      • Stimulates reparative dentin formation
    • Forms dental pulp collagen, reduces both pulp inflammation and degeneration
  • Disadvantages:
    • Showed mild/moderate inflammation after 2-4 wks w/ partial dentinal bridge
83
Q

Protective base: Indications

A
  • Deep caries
  • Normal pulp after caries removal
84
Q

Protective base: Indications

A

Normal pulp w/ deep, complete caries removal

85
Q

Protective base: Objectives

A
  • Preserve vitality
  • Minimize pulp injury
  • Promote pulp tissue healing
  • Facilitate tertiary dentin formation
  • Minimize post-op sensitivity
86
Q

Protective base: Objectives

A
  • Preserve vitality
  • Prevent sensitivity
  • Promote pulpal healing
  • Minimize microleakage
87
Q

Protective liner in vital pulp therapy of permanent teeth

A

Thinly-applied material placed on the dentin in proximity to the underlying pulpal surface of a deep cavity preparation, covering exposed dentin tubules to act as a protective barrier between the restorative material or cement and the pulp.

Materials: MTA, trisilicate cements, calcium hydroxide, or other biocompatible material.

88
Q

Protective liner in vital pulp therapy of permanent teeth: Indications

A
  • Deep areas of the preparation to minimize injury to the pulp
  • Promote pulp tissue healing
  • Minimize post-operative sensitivity
89
Q

Protective liner in vital pulp therapy of permanent teeth: Objectives

A
  • Preserve the tooth’s vitality
  • Promote pulp tissue healing and tertiary dentin formation
  • Minimize bacterial microleakage
90
Q

Pulp

A
  • Fibroblasts (most frequent), macrophages, dendritic cells, t-cells, lymphocytes, mast, plasma.
  • Collagen Type I and III are the subtypes
  • Neuropeptides: CGRP, substance P, neuropeptide
  • Tideglusib stimulates stem cells in the pulp for teeth
  • Used in Alzheimers
  • Nerve fibers
91
Q

Pulp therapy in primary incisors

A
  • No significant difference between tx of pulpotomy vs pulpectomy
  • Used vitapex (73%) or formocresol (89%)
92
Q

Pulpectomy steps

A
  • Remove coronal and radicular pulp tissue and/or necrotic debris
  • Debride canal w/ hand file or rotary file
  • Irrigate w/ NaOCl or other antimicrobial
  • Dry and fill canal spaces w/ resorbable material
  • Place definitive restoration
93
Q

Pulpectomy: Indications

A
  • Necrotic or irreversible pulpitis
  • Good option for restorable teeth with normal root resorption
  • Good option for “key teeth” for arch development

** Recommended over LSTR when there is no root resorption present **

94
Q

Pulpectomy: Objectives

A
  • Remove necrotic or irreversibly inflamed coronal and radicular tissue
  • Stop spread of infection
  • Maintain a healthy, asymptomatic tooth until normal exfoliation
95
Q

Regenerative Endodontics: Definition

A
  • Biologically based procedures designed to predictable replace damaged, diseased, or missing structures, including dentin or root structures and the pulp-dentin complex, w/ live viable tissues, preferably from the same origin, that restore the normal physiologic functions of the original tooth.
  • Emerging technique for immature necrotic teeth that enables continued root length formation, radicular secondary dentin formation and apical closure.
  • Includes:
    • Revascularization
    • Partial pulpotomy
    • Apexogenesis
96
Q

Remaining dentin thickness (RDT)

A
  • Remaining Dentin Thickness: importance of a good seal on restorations to minimize microleakage and bacterial invasion
    • Bacteria in cavities with RDT <0.25mm will have much more pulp inflammation, best to have 0.5mm
    • If >0.5mm, more likely to get reactionary dentin
97
Q

Revascularization via blood clot

A
  • One of several techniques in tissue engineering and the most commonly used one in the pediatric population.
  • Evokes bleeding into the root canal, which delivers undifferentiated mesenchymal stem cells in the root canal space.
  • Can be completed using current instruments and materials
  • Cost effective
  • Low immune response and low potential for infection
  • Should only be attempted if the tooth is not suitable for RCT, and after apexogenesis, apexification, or partial pulpotomy have already been attempted and have a poor prognosis.
98
Q

Revascularization: Process

A
  • Two stages:
    • Stage 1: Disinfection of the root canal system, there are several options:
      • Tri- or bi-antibiotic 3Mix (ciprofloxacin, metronidazole, and minocycline OR cefaclor, metronidazole, and ciprofloxacin) or 2Mix (w/o minocycline) for 8-12 wks.
      • Ca(OH)2 for 8-12 wks.
      • Note: Use 5% NaOCl (slowly) as a disinfectant.
    • Stage 2: Promotion of bleeding by filing through apex into apical tissues to fill the root canal space w/ blood and placing “double seal” of MTA and an additional restorative material.
      • LA w/o vasoconstrictor should be used when attempting to induce bleeding in the canal system.
      • Thin layer of MTA/Ca(OH)2 placed over the blood clot.
      • Tooth restored w/ adhesive material to prevent microleakage.
      • Wait for revascularization of pulp space and continued root development.
      • Further research is needed and more reports to reliably predict the success rate and develop solid guidelines.
99
Q

Severe damage to dentin

A
  • May lead to death of odontoblasts, reparative dentin
    • Chronic pulpal inflammation due to deep caries, dry cutting, endotoxins from bacteria in deep caries, mechanical exposure to the pulp, presence of bacteria increases extent of pulpal inflammation
100
Q

Stem Cells in permanent tooth capping: Advantages, Disadvantages

A
  • Advantages
    • Formation of osteodentin + tubular dentin
    • Superior to Ca(OH)2 in the mineralization-inducing properties
    • Dentin bridge formation was equal to Dycal after 28 days
    • Only TGF-beta 1 induced reparative dentin
  • Disadvantages
    • Possibility of unexpected side effects
    • Cost can be an obstacle
    • Fail to stimulate reparative dentin in inflamed pulp
    • Appropriate dose response is required to avoid uncontrolled obliteration of the pulp chamber
    • Possibility of immunological problems due to repeated implantation of active molecules
101
Q

Stepwise caries removal: Advantages vs. Disadvantages

A
  • Advantages:
    • Preserves tooth structure/minimally invasive
    • Promotes formation of secondary/sclerotic dentin
    • Allows/maintains thicker remaining dentin
    • Clarifies pulp dx and px
  • Disadvantages
    • Time
      • 2 visits
        • 1st appointment: Transitional restoration
        • 2nd appointment: Re-evaluate after 6-12mo before the final restoration
    • Requires patient compliance
    • $$$
102
Q

Stepwise caries removal: Objective

A
  • Maintain pulp vitality
  • Promote remineralization + tubule sclerosis (biological treatment approach)
  • Well defined radiopaque dental bridge between pulp chamber and caries
  • No h/o pain/no lingering cold sensitivity
103
Q

Vitapex as a pulpectomy medicament

A
  • Slower resorption than Ca(OH)2 alone
  • Radiopaque
  • Overfill will resorb in 8 weeks
  • Friendly to permanent successor
104
Q

What are the key elements in tissue engineering w/ regenerative endodontic therapy?

A
  • Adult stem cells: Capable of self-replication and differentiation into specialized cells.
  • Growth factors (BMPs): Regulate stem cells to form desirable cell type
    • Required for differentiation of cells into odontoblasts to deposit dentin.
  • Scaffolds (biological or artificial): Provide biocompatible 3D structures for cell adhesion and migration.
    • Blood clot forms a scaffold for the ingrowth of progenitor cells.
105
Q

What are the requirements for regeneration to work?

A
  • Traumatized tooth must be non-vital
  • Tooth should have at least 1.1mm open apex
  • 1.2mm per month of periapical bone regeneration
  • 12 month follow up to see a result
  • Patient age between 7-16yo, in good health
106
Q

What are the three different types of dentin?

A
  • Primary: tubular dentin formed before eruption
  • Secondary: regular, circumferential after tooth eruption
    • Dentin forms at a slower rate
    • Continuous
  • Tertiary: response to irritation
    • Reactionary: formed by original odontoblasts, continuous with secondary dentin
    • Reparative: original odontoblasts died, dentin formed by odontoblast-like cells, not continuous
107
Q

What are the three zones when formocresol is used?

A
  • Acidophilic zone of fixation
  • Pale staining zone of atrophy- fewer cells and fibers
  • Broad zone of inflammatory cells extend apically
108
Q

What component of MTA causes discoloration?

A

Bismuth oxide

109
Q

What diagnostic data should be collected in determining pulpal status?

A
  • Patient and parent’s description of subjective symptoms
  • Pulpal sensibility testing
  • Clinical exam
110
Q

What do you do if you have a sodium hypochlorite accident?

A

Supportive care: Close monitoring, analgesics, prophylactic antibiotics.

More severe cases should be referred to medical professionals for evaluation.

111
Q

What factors should you consider when forming your clinical diagnosis/assessing status of pulpal health?

A
  • Comprehensive medical history
  • Review of past and present dental history and treatment, including current symptoms and chief complaint
  • Subjective evaluation of the area of current symptoms/chief complaint by questioning the patient/parent on the location, intensity, duration, stimulus, relief, and spontaneity
  • Objective extraoral examination and intraoral soft and hard tissues
  • Radiograph(s) to diagnose periapical or periradicular changes
  • Clinical tests such - palpation, percussion, and mobility (electric pulp and thermal tests are unreliable in immature permanent and primary teeth)

You should also consider the value of the involved tooth/teeth in relation to the patient’s overall development, alternatives to pulp treatment, and restorability of the tooth.

112
Q

What helps Ca(OH)2 maintain its antimicrobial effect for a long period of time?

A

High pH low solubility

113
Q

What is a common outcome with MTA use?

A

Pulp canal obliteration

114
Q

What is apexification?

A
  • AKA root end closure
  • Inducing root end closure of an incompletely formed non-vital permanent tooth by removing coronal and non-vital radicular tissue just short of the root end and placing a biocompatible agent like Ca(OH)2 for 2-4 weeks to disinfect canal space.
  • Growth and development has stopped due to pulpal necrosis.
  • Should be reserved as a last resort in immature permanent teeth.
115
Q

What is Buckley’s formocresol diluted to?

A

1 : 5

Comparable success to full-strength FC!

Diluted causes less radicular inflammation that full strength

116
Q

What is considered a successful outcome for pulpectomy?

A
  • No signs/symptoms of pathology (duh)
  • Radiographic success: good fill w/o gross over-extension, bone deposition in radiolucent areas, normal root resorption
  • Protect developing succedaneous tooth
  • Success rates are high (80%) when a quality definitive restoration is placed
117
Q

What is the purpose of apexification?

A

Induce root end closure

118
Q

What is the purpose of vital pulp therapy for primary teeth?

A
  • Maintain vitality, prevent pain and infection
  • Allow for normal exfoliation, prevent need for space maintenance
119
Q

What is the rate of success w/ development of apical barrier using Ca(OH)2 in apexification? What is the most common complication?

A
  • Apical barrier will be formed in 74-100% of cases.
  • Most common complication: Cervical root fracture due to thin walls of the cervical part of the tooth, which fractures easily.
120
Q

What is the recommended post-op follow up after vital/nonvital pulp therapy in permanent teeth?

A
  • Post-operative clinical assessment every six months (periodic oral examination) - comparative baseline for future films (the type and frequency with discretion)
  • Radiographic evaluation of primary tooth pulpotomies - annually (success rate of pulpotomies diminishes over time)
121
Q

What is vitally important for success of IPT?

A

Proper diagnosis, ensuring a good seal

122
Q

What is Vitapex composed of?

A

Ca(OH)2 and iodoform

123
Q

What materials are used for pulpectomy?

A
  • ZOE
  • Ca(OH)2
  • Vitapex
  • Other less common options:
    • Endoflas
    • Maisto’s paste
    • Ledermix
124
Q

What stimulates release of TGF-beta 1?

A
  • TGF-Beta is released when there is caries or acid etchant - growth factor
    • Leads to reparative dentin
    • Ca(OH)2 also has a similar effect
125
Q

What type of nerve fiber is stimulated w/ cold test?

A

Excites A fibers, C fibers not activated

126
Q

What type of nerve fibers does EPT stimulate?

A
  • Sensory A fibers, C fibers do not respond
  • On anterior teeth, incisal edge has lowest response threshold
  • Not very useful on young children
127
Q

When do you consider hospital admission for cellulitis of odontogenic origin?

A
  • Unmanageable child, unable to treat in office setting
  • Dehydrated or medically compromised child
  • Swelling that extends to the orbit (cavernous sinus thrombosis risk) OR extends beneath the mandible (airway compromise and Ludwig’s angina)
128
Q

When is a child admitted for cellulitis of odontogenic origin?

A
  • Routine radiographs are sufficient for most cases; CBCT or CT scans not indicated unless a medical issue is present
  • EXT offending tooth ASAP
  • IV abx
  • W/ multiple dental needs, consider completion of all treatment at time of admission (reduced cost when compared to two GA procedures)
129
Q

ZOE

A
  • Biocompatible
  • Antibacterial,
  • Resorbs more slowly than deciduous roots
130
Q

ZOE as a pulpectomy medicament

A
  • Commonly used in US
  • Under-filling produces better results than overfilling
  • Overfill = inflammatory reaction
  • ZOE performed better long term than iodoform-based pastes.
131
Q

Iodoform paste

A
  • Vitapex (CaOH with iodoform, silicone oil), kri paste, maisto paste)
  • Antibacterial, resorbs faster than the primary tooth roots
  • Vitapex disappears overtime with radiopacity
  • Vitapex and ZOE with Iodoform have the best success
132
Q

Partial (CVEK) pulpotomy: What is it?

A
  • For traumatic pulp exposures in permanent teeth.
  • Inflamed pulp tissue beneath an exposure that is 4mm or less in size is removed to a depth of 1-3mm or more to reach the deeper healthy tissue.
  • No evidence on tooth outcomes with longer periods of waiting time (may be completed up to 9 days following an exposure), pulpal bleeding is controlled using irrigants such as sodium hypochlorite or chlorhexidine, covered with calcium hydroxide or MTA (may cause tooth discoloration - light and gray).
    • Calcium hydroxide = long-term success.
    • MTA = more predictable dentin bridging and pulp health, at least 1.5mm thick over the exposure and surrounding dentin, then a layer of light-cured RMGI.
133
Q

How many days following a traumatic pulp exposure can a Cvek pulpotomy be completed?

A

9 days!!!!!!!!!!!!!

134
Q

Partial (CVEK) pulpotomy: Objectives

A

Remaining pulp vital, normal root development and apexogenesis.

135
Q

What are the goals of regenerative endodontics?

A
  • Elimination of clinical symptoms/signs and resolution of apical periodontitis in teeth with a necrotic pulp and immature apex.
  • Thickening of canal walls and/or continued root maturation.
136
Q

What is the difference between regenerative endodontic therapy (RET) and non-surgical conventional root canal therapy?

A

Disinfected root canal space in RET filled with the host’s own vital tissue and the canal space in the RCT filled
with biocompatible foreign materials.

137
Q

Regenerative endodontics: Indications

A

Nonvital permanent teeth with incompletely formed roots

138
Q

Regenerative endodontics: Objectives

A

Increased width of the root walls and may lead to increase in root length (confirmed by radiographic evaluation).

139
Q

In vital primary teeth with deep caries lesions treated with direct pulp cap due to pulp exposure (one mm or less) encountered during carious dentin removal, does the choice of medicament affect success?

A
  • Recommendation:
    • Success of DPC was independent of the type of medicament [dentin bonding agents, MTA, and formocresol] → therefore recommends clinicians choose the medicament based on preference
  • Summary of Findings:
    • Quality of evidence → very low
140
Q

In vital primary teeth with deep caries lesions treated with pulpotomy due to pulp exposure during caries removal, does the choice of medicament or technique affect success*?

A
  • Recommendation:
    • MTA OR FC
      • [Strong rec, mod quality evidence]
    • FS OR Laser
      • [Conditional rec, low quality evidence]
    • Use of NaOCl OR Tricalcium silicate
      • [Conditional rec, very low-quality evidence]
    • AGAINST use of Ca(OH)2
      • [Conditional rec, low quality evidence]
  • Summary of Findings:
    • Overall success rate at 24 M for MTA, formocresol, FS, NaOCl, calcium hydroxide and laser → 82.6%
    • Highest success rate at 24M → MTA and formocresol [not sig dif]
      • MTA success rate: 89.6%
      • Formocresol success rate: 85.0%
    • MTA, FC, and FS success rate at 24M → significantly better than Ca(OH)2 [don’t use Ca(OH)2)]
    • NaOCl success rate significantly less than FC success rate at 18M.
141
Q

Pulpotomy: FC vs. MTA

A
  • 8 studies, follow up of 24 months
  • Favored neither type of pulpotomy medicament
  • High evidence
142
Q

Pulpotomy: FC vs. FS

A
  • 4 studies, follow up of 24 months
  • Favored neither type of pulpotomy medicament
  • Moderate evidence
143
Q

Pulpotomy: FC vs. CaOH

A
  • 4 studies, follow up of 24 months
  • FC significantly better than CaOH
  • Moderate evidence
  • NNT: number needed to treat (On doing 3 pulpotomies, one failure could be prevented if FC was used instead of CaOH)
144
Q

Pulpotomy: FS vs. CaOH

A
  • 2 studies, follow up of 24 months
  • FS (ferric sulfate) was significantly better than calcium hydroxide
  • NNT: 4 pulps:1 failure avoided
  • Low evidence
145
Q

Pulpotomy: MTA vs. CaOH

A
  • 3 studies, follow up of 24 months
  • MTA significantly better than calcium hydroxide
  • Moderate evidence
  • NNT: out of 3 pulps: one failure could be avoided if MTA used over CaOH
146
Q

Pulpotomy: MTA vs. FS

A
  • 4 studies, follow up of 24 months
  • MTA was favored
  • NNT: 9 pulps: 1 failure avoided
  • Moderate evidence
147
Q

Pulpotomy: FC vs. NaOCl

A
  • 2 studies, follow up of 18 months
  • Formocresol was significantly better than NaOCl
  • NNT: 6:1
  • Moderate evidence
148
Q

Pulpotomy: FC vs. laser

A
  • 2 studies, follow up of 18 months
  • Favored neither type of pulpotomy technique
  • Quality of evidence was low due to small sample sizes
149
Q

Pulpotomy: FS vs. NaOCl

A
  • 2 studies, follow up of 18 months
  • Favored neither type of pulpotomy medicament
  • Low evidence
150
Q

Pulpotomy: CaOH vs. Laser

A
  • 2 studies, follow up of 18 months
  • Favored neither type of pulpotomy technique
  • Low evidence
151
Q

Pulpotomy: FS vs. laser

A
  • 2 studies, follow up of 12 months
  • Favored neither type of pulpotomy technique
  • Moderate evidence
152
Q

Pulpotomy: MTA vs. tricalcium silicate

A
  • 2 studies, follow up of 12 months
  • Favored neither type of pulpotomy medicament
  • Very low evidence
153
Q

Pulpectomy: Indications

A
  • Can be used for the treatment of dead, dying or abscessed primary teeth with no evident root resorption.
  • In teeth with no root resorption, pulpectomy should be chosen over LSTR.
  • Follow-up X-rays should be taken at least every 12 months to monitor the treatment
154
Q

Pulpectomy fillers

A
  • ZOE
  • Iodoform (Vitapex or Metapex)
  • Zinc oxide/iodoform/CaOH (Endoflas)
  • ZO/iodoform, CH
155
Q

What pulpectomy filler performs best?

A

For teeth expected to be in the mouth for 18 months or longer, zinc oxide/iodoform/CH and ZOE fillers performed better than iodoform fillers.

156
Q

In non-vital primary teeth, when should a clinician choose extraction over non-vital pulp therapy?

A
  • Recommendation:
    • No direct evidence to make a recommendation on criteria
    • It is suggested that, for teeth deemed non-restorable or when the patient has one or more exceptions to the guideline recommendations stated previously in this guideline and Figure, the treatment of choice may be extraction.
    • The AAPD’s SR stated the RCT articles on pulpectomy and LSTR showed non-restorable teeth were extracted.
    • Teeth were not considered for pulpectomy or LSTR if they had an inadequate crown or extensive root structure resorption and were not restorable
157
Q

In non-vital primary teeth, does pulpectomy have better long-term success in teeth with or without root resorption?

A
  • Recommendation:
    • Pulpectomy is a viable long-term treatment for non-vital primary teeth without root resorption compared to those with root resorption.
    • Pulpectomy should be considered for non-vital primary teeth without preoperative root resorption.
      • (Conditional recommendation, very low quality of evidence—12 months; conditional recommendation, very low quality of evidence—24 months.)
  • Remarks:
    • For longer periods (24 to 60 months) from RCT and NRS articles, pulpectomy success in teeth without pre-operative root resorption from the SR had higher success (84 to 90%) versus teeth with preoperative root resorption (59 to 69%).
158
Q

In primary teeth with no root resorption needing non-vital pulp therapy, how does the success of LSTR compare to conventional pulpectomy?

A
  • Recommendation:
    • Pulpectomy success was higher than LSTR for teeth without preoperative root resorption, indicating it should be preferred over LSTR in these teeth.
    • (Conditional recommendation, low quality of evidence.)
159
Q

In primary teeth with significant root resorption (external greater than one mm and/or internal) needing nonvital pulp therapy, how does the success of LSTR compare to conventional pulpectomy?

A
  • Recommendation:
    • LSTR choice over pulpectomy to save teeth for up to 12 months
    • If longer than 12 months, monitor with exams/radiographs every 12 months are doing LSTR
  • Summary of findings:
    • LSTR success rate 76% compared to pulpectomy success rate 47%
    • Moderate quality of evidence
  • Remarks:
    • LSTR tx adversely affected the permanent tooth eruption due to interradicular bone loss and in one case caused OKC
    • Perhaps LSTR should be used ONLY to save primary molars for up to 12 mos to maintain space then be monitored periodically
160
Q

In primary teeth treated with pulpectomy, does the number of tx visits influence success?

A
  • Recommendation:
    • Primary teeth pulpectomies, overall success after 12 mos not impacted by number of visits (very low quality of evidence)
  • Summary of findings:
    • 1 visit vs 2 visits were not statistically significant
161
Q

In primary teeth tx with pulpectomy, does the method of root length determination influence success?

A
  • Recommendation:
    • Clinicians may choose any root length determination method (very low evidence)
      • Tactile
      • Radiographs
      • Apex locators
  • Summary of findings:
    • Apex locator vs radiographs: not significantly difference
      • Very low evidence
  • Remarks:
    • One in vivo study with single rooted primary anterior teeth used apex locator, radiographs and tactile
      • Apex locator and radiographs mean length deviation from actual mean length of 15 mm was insignificant
      • Tactile feel was 1 mm shorter in the same teeth
162
Q

In primary teeth tx with pulpectomy, does the instrumentation (hand instruments vs rotatory) technique influence time of tx, quality of fill, success?

A
  • Recommendation:
    • Rotary instrumentation time= significantly shorter than manual by 2 mins
    • Rotary and instrumentation= comparable success while the occurrence of flush fills (a root canal filled to the apex) favored rotary
    • Clinicians can choose either method of instrumentation (moderate evidence)
  • Summary of findings: manual vs rotary canal preparation time
    • Significant difference favoring rotary filling
      • High evidence according to GRADE
    • No significant difference in two groups pulpectomy success
    • No difference in bacterial reduction
  • Manual vs rotary optimum (flush) filling outcome
    • Favored use of rotary filling for achieving a flush apical fill
    • Moderate evidence according to GRADE
  • Remarks:
    • Rotary required less time and involved less dentin removal and more uniform root canal preparation
    • Many primary teeth are ribbon shaped and rotary instruments are centered in canals=> rotary may leave behind infected tissue in unclean areas in fins and isthmuses
      • Additional hand instrumentation and irrigation may be needed to remove remanent tissues
    • Factors to consider: high cost of rotary system & training to learn rotary technique
163
Q

In primary teeth tx with pulpectomy, does the removal of the smear layer influence success?

A
  • Recommendation:
    • No adequate evidence to make a recommendation
    • Did not seem to depend on whether smear lay was removed or not
    • Choose either way of managing smear layer
  • Summary of findings:
    • Smear layer removal does not alter its success
  • Remarks:
    • Smear layer: accumulation of dentin and pulpal debris formed on the root canal walls during instrumentation for a pulpectomy by rotary or manual filing
    • Its removal possibly allows the root canal filler to adapt better to the canal walls
    • Smear layer may occlude the dentin tubules and prevent bacteria and toxin penetration
164
Q

In primary teeth tx with pulpectomy, does the choice of irrigants influence success?

A
  • Recommendation:
    • Irrigants had no impact on success
      • Sodium hypochlorite 1-5%
      • Water/saline
      • Chlorhexidine
    • Choose any irrigation solution
    • Very low quality of evidence
  • Summary of findings:
    • Difference between NaOCl and saline and/or distilled water was not significant
    • Very low evidence according to GRADE
  • Remarks:
    • Investigated pulpectomy success after 12 months in terms of irrigation
    • Water/saline= success rate 81%
    • NaOCl= success rate 89%
    • Chlorhexidine= success rate 87%
165
Q

In primary teeth tx with pulpectomy, does the choice of obturation material influence success?

A
  • Recommendation:
    • Zinc oxide/iodoform/calcium hydroxide (ZO/iodoform/CH) and zinc oxide eugenol (ZOE) may be better choices for pulpectomy success compared to iodoform at 18 mos
    • Very quality of evidence
    • RANKING BEST TO “WORST”
      • ZO/Iodoform/CH
      • ZOE
      • Iodoform
  • Summary of findings:
    • pulpectomy root canal fillers-ZOE vs iodoform pulpectomy success after 18 mos
      • No significant difference
      • Very low quality of evidence according to GRADE
    • ZOE vs ZO/iodoform/CH success 18 mos
      • No significant difference
      • Low quality of evidence according to GRADE
    • ZO/iodoform/CH vs iodoform success 18 mos
      • No significant difference
      • Very low quality of evidence according to GRADE
  • Remarks:
    • No significant difference b/w success of ZO/iodoform/CH and Vitapex brand of iodoform
    • No significant difference b/w success ZO/iodoform/CH and Metapex brand of iodoform
  • Network analysis:
    • Objective of network analysis: to combine both the direct and indirect evidence across all studies
    • Ranks effectiveness
    • ZO/iodoform/CH and ZOE were markedly better than iodoform
  • ZOE and ZO/iodoform/CH vs calcium hydroxide success 12 and 18 mos
    • Nonsignificant difference between ZOE and CH at 12 mos
      • The other CH brand result was statistically different
      • Low quality of evidence at 12 mos according to GRADE
    • ZOE success 100%, CH success 85% after 18 mos
    • No valid comparison using success rates 12 mos vs 18 mos, therefore CH was not included in the network analysis
166
Q

In primary teeth tx with non-vital pulp therapy, does the timing and/or type of final restoration influence success?

A
  • Recommendation:
    • SSC vs filling= comparable success unaffected by timing of when restoration was placed
    • SSC better success than composites
    • May choose type and timing
    • Very low quality evidence
  • Summary of findings: type of final restoration:
    • Pulpectomy success b/w SSC or composite/amalgam= no significant difference
    • Very low according to GRADE
  • Timing of final restoration:
    • Pulpectomy success b/w same day vs later day final restoration=no significant difference
167
Q

In primary teeth tx with pulpectomy, does the obturation technique (syringe, Lentulo, hand pluggers) influence the quality of fill and success?

A
  • Recommendation:
    • Not statistically significant
    • Choose any of these obturation techniques
  • Summary of findings: quality of pulpectomy fill:
    • Lentulo vs hand plugger vs syringe= no significant difference in achieving flush fills
      • Flush fill: a root canal filled to the apex
  • Obturation method and pulpectomy success:
    • Lenutols vs hand pluggers vs syringes= no significant difference
    • Lentulos vs syringe fills= no significant difference
      • Both very low quality of evidence
  • Remarks:
    • Overfilling of canals=lower success for pulpectomy
    • Type of technique all produce voids, some techniques may cause more overfills (lentuolo)
      • not enough clinical studies to evaluate these
168
Q

In primary teeth tx with pulpectomy, does the tooth type (incisor, primary first molar, primary second molar) influence success?

A
  • Recommendation:
    • No adequate evidence
    • Do not seem to be altered if it was incisor vs molar
    • Pulpectomy success rates for primary first molars & second molars=comparable
  • Summary of findings:
    • Incisor 87% success, molar 89% success
    • First vs second molars= comparable (nearly the same)
    • No GRADE assessment was possible
  • Remarks:
    • Tooth type didn’t appear to affect success
169
Q

In incisors that are necrotic as a result of trauma, is pulpectomy successful?

A
  • Recommendations:
    • Did not find adequate evidence
    • Pulpectomy success rate incisors tx due to trauma or caries= comparable
    • Does not appear success was adversely affected if tx for trauma or caries UNLESS the tooth was retraumatized
      • If re traumatized, pulpectomy success rate decrease significantly to 41%
  • Summary of findings:
    • No statistical comparison b/w traumatized primary anterior tooth vs primary incisors with caries
    • No GRADE possible
  • Remarks:
    • Incisor pulpectomy success do not appear much different if treated due to trauma vs caries
170
Q

In primary teeth tx with pulpectomy, does the type of isolation technique influence success?

A
  • Recommendation:
    • No evidence to make a recommendation on isolation technique
    • Rubber dam= critical for non vital procedures in maintaining isolation from saliva, blood and other contaminants
  • Summary of findings:
    • 5 studies that didn’t use rubber dam didn’t have usable data to evaluate
  • Remarks:
    • Rubber dam= standard of care for non vital pulp therapy
    • May be unethical to perform a study comparing with and without rubber dam
171
Q

When doing LSTR, how does traditional 3Mix (with tetracycline) compare to alternate 3Mix (without tetracycline)

A
  • Recommendation:
    • Choose alternate 3Mix over traditional
      • Potential adverse effects of tetracycline in children
      • Significantly higher success rates of alternate 3Mix
  • Summary of findings:
    • Significantly less success statistically using traditional vs alternate
    • Quality of evidence very low according to GRADE
  • Remarks:
    • Combination of clindamycin, metronidazole and ciprofloxacin was as effective as the combination minocycline, metronidazole and ciprofloxacin with no significant difference in reducing mean bacterial colony counts
172
Q

When doing LSTR, should the root canals be filed or broached?

A
  • Recommendation:
    • Choose whether or not to file/broach since success rate=not significantly different
  • Summary of findings:
    • Not filed or broached before placing the paste vs filed and/or broached before placing the paste=no significant difference
    • Very low quality of evidence GRADE
173
Q

What are the adverse events associated with non vital pulp therapy in primary teeth?

A
  • Recommendation:
    • Did not find adequate evidence to make a recommendation of adverse events
    • Rare
      • Mod to severe pain after 24 hrs
      • Enamel defects in permanent tooth
    • Retained ZOE filler after pulpectomy exfoliation=not uncommon
    • One report- LSTR tx after 36 mos= interradicular bone loss affecting permanent tooth
    • Clinicians should evaluate non vital pulp tx for success and adverse events clinically and radiographically at least every 12 months
    • Summary of findings:
      • ZOE resorbs slower than the primary tooth root in some cases
        • May cause permanent tooths path of eruption to be deflected
        • May result in anterior cross bite for incisors
      • Iodoform fillers resort at a faster rate than root
        • Make pulpectomy look like pulpotomy after 12-18 mos
      • If filler is extruded beyond apex
        • Iodoform fillers seem to resorb
        • ZOE resorbs slowly (can take years)
    • Exfoliation after non vital pulp tx:
      • Grewal study= longest LSTR follow up (36 mos)
        • LSTR tx teeth did not resorb, unlike untreated contralateral teeth
      • Pulpectomy teeth had early exfoliation (76 out of 317)
      • Pulpectomy teeth were over retained compared to contralateral (29 out of 319)
    • Problems from non vital tx in primary teeth on the succedaneous teeth:
      • One study- enamel defect for succedaenous tooth
      • Others- no enamel defects
        • Enamel defects were related to age of the child (younger than 4.6 years) when the tooth became infected, excessive preoperative root resorption or trauma
      • Grewal- LSTR teeth after 36 mos- overretained compared to conventional pulpectomy tx
        • Some associated with interradicular bone loss surrounding crown of perm successor
    • Pain:
      • Postop pain after 24-48 hrs= associated when non vital tx failed
      • No pain: 80%
      • Mild pain: 12%
      • Moderate to severe pain: 8%
      • Severe pain=uncommon

* (22 decks)

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