Pulp Therapy

Question 0

What are some tooth specific factors that will influence the decision to treat?

Answer 0

1) Stage of dental development (>2/3 root resorptioon means close to exfoliation)
2) Pulpal status
3) Restorable/ unrestorable
4) Space management

Question 1

What medical conditions would strongly suggest pulp therapy over extraction?

Answer 1

1)Bleeding disorders and coagulopathies such as
Haemmophilia, Von Willebrands, Platelet disorders
2) Congenital heart disease
3) Immunocompromised
4) Poor healing potential - poorly controlled diabetes

Question 2

What questions should be asked with the pain history?

Answer 2

1) What stimmullates the pain?
2) Is it spontaneuos? Yes means poorer prognosis
3) Gettting better or worse?
4) How long has it been hurintg?
- Longer duration poorer prognosis
5) Does it keep patient awake?

Question 3

What clinical investigations should be carried out for children when diagnosing pulpal pain?

Answer 3

Clinnical exam
1) extent of carious lesion
2) mobility
3) percussion
4) swelling/ fistulas
Radiographs are essential

Question 4

What are the histological features of reversible pulpitis?

Answer 4

1) Inflammatory cell infiltrate limited to oddontoblastic layer (which is now absent or neecrotic) and the pulp regioin adjacent to the carious lesion
2) Thin to thick discontinuous layer of reparitive dentine
3) Poorly defined cell-free zone

Question 5

What are the clinical symptoms of reversible pulpitis?

Answer 5

Heat, cold, sweets, air and chewing can provoke pain which dissapears when stimulus is removed.

Question 6

What are the histological features of reverssible pulpitis?

Answer 6

1) Infflammatory changes extend frrom coronal pulp to radicular pulp
2) Loss of coronal pulp vasculature and nervous system architecture
3) There is inflammatory changes and cell exudate

Question 7

What are the clinical symptoms of irreversible pulpitis?

Answer 7

Spontanous unnprovoked pain which keeps patient awake at night.
Persistant/ constant pain

Question 8

What are the histological features of a necrotic pulp?

Answer 8

1) Loss of coronal vasculature and nervous system arcchitecture (as in irreversible pulpitis)
2) Inflammatory changes in radicular pulp
3) Reparitive dentine
4) Absent or necrotic odontoblast cell layer

Question 9

What are the clinical signs of a necrotic pulp?

Answer 9

Abnormal tooth mobility and tenderness to percussion
Sensation of occlusal interferences
Pain resolves when dental abcess obtains drainage

Question 10

What are some clinical SIGNS that may indicate pulpal symptoms?

Answer 10

1) Fracture of the marginal ridge in contact point caries
2) Undermining of cusps in pit and fissure caries
3) Large shadowing over pulp outline
4) Sensitive to coold air syringge (maybe…)
5) Alveolar involvement: abcess, sinus, pyogenic granuloma, swelling in sulcus, facial swelling

Question 11

What should be assessed from a radiograph with regards to caries?

Answer 11

1) extent of lesion
2) Position and proximity of pulpal horns
3) Presence and position of permanent successor
4) Status of the roots and the surrounding bone:
- calcific degenration
- internal/external resorption
- furcation/ interradicular pathology

Question 12

What are contrainddications for primary pulp therapy?

Answer 12

1) Presence of radiolucency in the furcation
2) Internal/external root resorption
3) Furcation or periapical bone lesions
These signs would indicate EXO

Question 13

What are the main aims of pulpal treatment?

Answer 13

1) To remove diseased and bacterially contaminated tissue

2) Establish an environment that will prevent future bacterial contamination

Question 14

What are the indications for an indirect pulp cap?

Answer 14

Tooth with a deep carious lesion, incomplete caries removal and no pulp exposure.
HOwever, mostly for permanent teeth. NOT RECOMMENDED for primary teeth, better off aggresively remove caries and pulpotomy.

Question 15

What is rationale for a pulpotomy of a primary tooth?

Answer 15

To remove the portion of thhe pulp that has beecome inflamed withh degenerative change while the remaining pulp is treated to maintain vitality.
This is to maintain the tooth withoout symptoms permitting normmal exfoliation without causing harm to permanent successor.
To avoid internal resorption or canal calcification.

Question 16

What are the indications for a pulpotomy in the primary dentition?

Answer 16

1) Mechanical, traumatic or carious exposure.
2) Inflammation limited to coronal pulp.
3) Absence of spontaneous pain.
4) Absence of swelling or alveolar abcess formation.
5) Patient compliant and is not immunocompromsied.

Question 17

What are the contraindications for a pulpotomy?

Answer 17

1) unprovoked pain
2) Presence of fistula or swelling
3) Necrotic pulp
4) UNcontrolled pulpal haemorrhage
5) Periapical or bifucational radiolucency
6) Root resorption
7) extensive loss of coronal tooth structure
8) Immunocomporomiised, congenital heart dss, special nneeds

Question 18

What is the overall technique for a pulpotomy?

Answer 18

Coronal pulp amputated, medicament over the remaining vital pulp (ferric sulphate), coronal pulp chamber filled (IRM), restored with SSC.

Question 19

What are the 4 zones of pulpal histology on exposuure to Formeccresol and how does it provide a stable physiologic state?

Answer 19

1) Zone of fixation: formaldehyde is bactericidal. it also devitaliseds the pulp causing the coronal third of the pulp to become fixed
2) Zone of autolysis - pale staining with coagulation necrosis
3) Zone of inflammation
4) Zone of vital tissue

It is both bacttericidal and devitalising

Question 20

How does fferric sulphate work as a pulpotomy medicament and how does it compare to formeccresol in terms of clinical success?

Answer 20

“astringidnnet’. It is an excellent haemosatic agent but does not have a bactericidal effect.
It has been associated with internal resorption when used with ZOE. Clinical success rate of about 90 - 96 % at 36-48 months which is less than 97% success rate of Formeccresol.

Question 21

How does MTA work and is it a justifiable alternative to more traditional pulpotomy medicaments?

Answer 21

MTA offers a biologically active substrate for bone cells. Its alkalinity stimulates interleukin producction.
Releasess CaOH which induces coagulation necrosis and dystrophic calcification.
It also has a high resistance to bacterial penetration.
Clinical success rates higher than formocresol and ferric sulphate but expensive.

Question 22

What are the objectives of carrying out a pulpectomy?

Answer 22

1) Maintain tooth and supporting structures free of infection
2) Resolution of innfective process
3) Biomechanical cleansing and canal obturation
4) Adequate fill of root canal
5) Prommote physiologic resorption
6) Maintainn space and function

Question 23

What are the indications for carrying out a pulpectomy?

Answer 23

1) Strategically important tooth
2) Restorable tooth
3) Poor chance of survival with vital pulp treatment
4) Co-operative patient
5) Adequate roots remaining (no reosrption)

Question 24

What kind of materials are used for a pulpectomy?

Answer 24

1) ZOE (nnon-reinforced)
2) Iodophore paste. e.g. KRI paste
3) CaOH +/- Iodophore paste (Vitapex)