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ABPD 2021 > Pulp Therapy and Trauma > Flashcards

Pulp Therapy and Trauma Flashcards

1
Q

What is the origin of pulp?

A

Mesenchymal tissue

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2
Q

Dentin components

A

Inorganic: hydroxyapatite
Organic: mostly type I collagen, also type V collagen, dentin sialoprotein

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3
Q

Primary dentin

A

Tubular dentin formed before eruption

Includes mantle dentin

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4
Q

Secondary dentin

A

Regular circumferential dentin formed after tooth eruption

Tubules continuous with primary dentin

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5
Q

Tertiary dentin

A

Dentin in response to irritation

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6
Q

Reactionary versus Reparative Dentin

A

Reactionary: formed by original odontoblasts, continuous with secondary dentin
Reparative: original odontoblasts died, dentin formed by new odontoblast-like cells and is not continuous with secondary dentin

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7
Q

Molecular basis for odontoblast stimulation

A

TGF-B: sequestered into dentin matrix during tooth development

Growth factors interact with pulp to cause proliferation of mesenchymal cells and making of dentin

Calcium hydroxide has a similar effect - high pH causes demin and releases TGF-B to make reparative dentin

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8
Q

Mild insult to dentin

A

Cavity preparation without pulp exposure

Caries lesion into dentin

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9
Q

Severe insult to dentin

A

Chronic pulp inflammation due to deep caries
Dry cutting
Endotoxins from bacteria in deep caries
Mechanical exposure of pulp
Presence of bacteria increases extent of pulp inflammation

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10
Q

Remaining Dentin Thickness (RDT)

A

<0.25mm results in more severe pulp inflammation

Best to have more than 0.5mm

  • when greater than 0.5mm, reactionary dentin
  • when less than 0.5mm, reparative dentin
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11
Q

What is the most frequent cell type of the pulp?

A

Fibroblasts

Capable of generating odontoblast-like cells

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12
Q

What cells are in the pulp?

A 
Fibroblasts
Odontoblasts
Histiocytes
Macrophages
Granulocytes
Dendritic cells 
T-lymphocytes
Plasma cells
Mast cells (rare in healthy pulp)
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13
Q

Structural proteins of pulp

A

Collagen (type I and III main subtypes)

Elastin (arterioles)

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14
Q

Neuropeptides of the pulp

A

Calcitonin gene related peptide (CGRP) is most common - involved in induction of neurogenic inflammation

Substance P
Neuropeptide Y
Neurokinin A
Vasoactive intestinal peptide

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15
Q

Correlation between clinical findings and histology of pulp?

A

“Currently very little or no correlation exists between clinical diagnostic findings and the histopathologic status of the pulp” Fuks et al. 2018

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16
Q

Diagnosis of pulp status

A 
Medical history
Dental history
History of pain (and type)
Clinical Exam
Radiographs
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17
Q

Types of nerve fibers in pulp

A 
A fibers (myelinated)
C fibers (unmyelinated)
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18
Q

A fibers of pulp

A

90% are A-delta (10% A-beta)
Innervate dentin tubules and stimulated by fluid movement
Rapid, sharp pain
Increase in number over time after eruption

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19
Q

C fibers of pulp

A

3-8X more common than A-delta
Thinner
Dull, aching pain

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20
Q

Nerve Plexus of Raschkos

A

Myelinated nerve fibers located in cell rich zone
Monitors painful sensation
Mediates inflammatory events and tissue repair

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21
Q

EPT

A

Not reliable in young children

Stimulates A fibers

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22
Q

Cold Testing

A

Excites A fibers (not C)

No evidence that cold testing injures pulp

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23
Q

Hydrodynamic theory

A

Fluid movement in dentinal tubules is translated into electric signals in axons that innervate dentinal tubules

Increased pressure = increased nerve impulses from pulp

A fibers mainly

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24
Q

Pulpitis Pain

A

C fiber activation from pulp tissue injury

Prolonged pain indicative of irreversible pulpitis

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25
Q

Pulp necrosis in primary teeth

A

Furcational radiolucency is sign of pulp necrosis

77% of primary molars have at least one accessory foramina in furcation

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26
Q

Indirect Pulp Cap - Primary Teeth

A

94.4% success independent of medicament

Most important factors are accurate diagnosis of vitality and sealed restoration

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27
Q

What is Carisolv?

A

Gel-based chemical-mechanical caries removal system

Sodium hypochlorite and amino acids

Not routinely taught; may lead to excessive caries removal

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28
Q

Ideal properties of a liner

A

Kill bacteria
Induce mineralization
Establish bacterial seal
Multisubstrate bonding ability (ex: RMGI, dentin bonding agents)

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29
Q

Most common liners

A

CaOH
GI
MTA
Tricalcium silicate

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30
Q

Properties of MTA

A

Main soluble component is CaOH
Alkaline pH contributes to antibacterial activity
Hard setting minimizes microleakage
Biocompatible
Stimulates reparative dentin formation, induces dentin bridge formation

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31
Q

Properties of CaOH2

A

Alkaline pH leads to antibacterial activity
Causes superficial necrosis of pulp
Stimulates reparative dentin
Water-soluble

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32
Q

Properties of RMGI Liner

A

Initial pH is 4.0-5.5
Demineralizes dentin
May release bioactive materials in dentin
Irritating to pulp

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33
Q

Direct Pulp Cap Indications

A

Healthy pulp

Small mechanical or traumatic exposure

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34
Q

Direct pulp cap in primary teeth?

A

Not recommended

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35
Q

Indications for pulpotomy of primary tooth

A

Carious exposure in vital primary tooth that is restorable

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36
Q

Contraindications for pulpotomy of primary tooth

A 
Fistula or swelling
Necrotic pulp
Uncontrolled hemorrhage
Radiolucent lesions
Pathologic resorption
Dystrophic calcification
More than 1/3 root resorption
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37
Q

Medicaments for Pulpotomy

A 
Fixatives (formocresol, glutaraldehyde)
Mineralizing (CaOH, iodoform)
Palliative (ZOE)
Obturators (MTA)
Coagulants (ferric sulfate)
Antimicrobial (NaOCl, triple paste)
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38
Q

Formocresol formula

A

19% formaldehyde
35% cresol
15% glycerin
Water

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39
Q

Mechanism of action of formocresol

A

Fixation followed by degeneration

Bactericidal

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40
Q

Does formocresol result in dentin bridging?

A

No

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41
Q

Problems with formocresol

A

Mutagenic/carcinogenic potential (unlikely when used judiciously)

Enamel defects in permanent successor

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42
Q

AAPD and formocresol pulpotomy

A

Strong recommendation for Formocresol and MTA for pulpotomy

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43
Q

Glutaraldehyde pulpotomy

A

Dialdehyde compound
Mild fixative, some antibacterial properties
Lower success than formocresol and ferric sulfate
Not evaluated in AAPD guidelines

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44
Q

Ferric Sulfate Pulpotomy

A

Hemostasis from occluding capillaries
Antibacterial
Lower success than MTA or FMC
May lead to diagnosis confusion

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45
Q

AAPD and ferric sulfate pulpotomy

A

Conditional recommendation with low evidence

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46
Q

Concerns with ferric sulfate pulpotomy?

A

Must have clean water line!

Risk of mycobacterium contamination

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47
Q

Sodium hypochlorite pulpotomy

A

5% concentration
Antimicrobial
Biocompatible
Surface effects

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48
Q

AAPD and sodium hypochlorite pulpotomy

A

Conditional recommendation with very low evidence

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49
Q

Calcium hydroxide pulpotomy

A

High pH, initiates inflammatory cascade

Low success rate due to internal resorption

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50
Q

AAPD and CaOH pulpotomy

A

Not recommended for vital tooth pulpotomy in primary teeth

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51
Q

What is the reaction product of MTA?

A

Calcium hydroxide

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52
Q

AAPD and MTA pulpotomy

A

Strong recommendation with moderate evidence

53
Q

Calcium silicate pulpotomy

A

Tricalcium silicate, dicalcium silicate, calcium carbonate, oxide filler, iron oxide and zirconium oxide

Creates dentin bridge
Bioactive 
Sets faster (9-12 minutes)
Alkaline pH
Induction of reparative dentin
54
Q

AAPD and calcium silicate pulpotomy

A

Conditional recommendation with very low evidence

Not many studies; probably similar to MTA

55
Q

Indications for Pulpectomy

A

Necrotic/irreversible inflammation
No root resorption
Restorable tooth

56
Q

Contraindications for pulpectomy

A 
Non-restorable tooth
Perforation of pulp floor 
Extreme tooth mobility
Radiolucency involving permanent tooth follicle
Children with medical compromise
57
Q

Goals of pulpectomy

A

Eliminate infection via adequate canal debridement, irrigation and filling material
Maintain tooth until normal exfoliation

58
Q

Pulpectomy filling materials

A

ZOE

Iodoform pastes

59
Q

ZO and Eugenol Pulpectomy

A

Most widely used
Biocompatible
Antibacterial
Resorbs more slowly than deciduous roots and resists resorption if extruded beyond apex

60
Q

Iodoform paste pulpectomy

A

Vitapex, Kri paste, Maisto paste

Antibacterial
Resorbs faster than primary tooth roots

61
Q

LSTR

A

Sterilize lesion and avoid instrumentation of canal

62
Q

Triple paste in LSTR

A

Ciprofloxacin
Metronidazole
Minocycline

Ratio 1:3:3

63
Q

Advantages of LSTR

A

1 visit
Simple, painless
Less burdensome for patients

64
Q

Disadvantages of LSTR

A

Tooth staining with minocycline
Radiolucent appearance of triple antibiotic paste
Allergic reaction
Potential antibiotic resistance
Risk for developmental anomalies in permanent teeth

65
Q

Primary Incisor Pulp Therapy

A

Previous studies suggested pulpotomy not as successful as pulpectomy

66
Q

Primary maxillary molar pulp anatomy

A

3 roots most common
1/3 of maxillary first molars have fusion of palatal and distobuccal roots
3 canals in 2nd molars (70%) or 4 canals (30%)

67
Q

Primary mandibular molar pulp anatomy

A

1st molars 2 roots with 3 (80%) or 4 (20%) canals

2nd molars 2 roots and 4 canals

68
Q

Indications for pulpotomy in immature permanent tooth

A

Pulp exposure due to caries or trauma
Hemorrhage controlled with pressure
Tooth is vital
No spontaneous pain, necrosis or PA lesion

69
Q

Permanent tooth pulpotomy

A

Goal: maintain root canal vitality and complete apex formation
Entire coronal pulp tissue is removed

70
Q

Direct pulp cap in permanent teeth

A

Ca(OH)2 or MTA most common

Good seal important to promote pulp repair and dentin bridge

71
Q

Apexification versus Apexogenesis

A

Apexification: induce root development by forming calcific barrier
Apexogenesis: stimulating root development

72
Q

Requirements for pulp revascularization

A 
Disinfection of canal
Creation of scaffold for new tissue
Stem cells
Signaling molecules
Good seal of coronal access
73
Q

How open does an apex need to be for revascularization?

A

Minimum 1.1mm open

Patient between 7-16 years in good health

74
Q

What is the most common trauma to young children?

A

Luxation

75
Q

What is the most common trauma to older children?

A

Uncomplicated crown fracture

76
Q

Epidemiology of young children dental trauma

A

1/3 of children 5 years had trauma to primary teeth

Most occurred between 18-30 months

77
Q

Epidemiology of older children dental trauma

A

20-30% 12 year olds had had dental trauma

Peak incidence 9-10 years

78
Q

What tooth is most likely traumatized?

A

Maxillary central incisors (71% of trauma cases)

79
Q

What gender is most affected by dental trauma?

A

Boys 2:1

Especially boys 7-10 years

80
Q

Highest rate of dental trauma for female sports? Male sports?

A

Female: field hockey
Male: basketball

72% of injuries not wearing mouthguard

81
Q

What is a medical condition associated with higher risk for dental trauma?

A

ADHD

82
Q

Overjet over __mm is associated with higher risk of trauma

A

6mm

83
Q

Prevention of trauma

A

Home: childproof house
Sports: helmets, mouthguards, face masks
ADHD: medication?
Excessive overjet: ortho intervention

84
Q

Type I mouthguard

A

Custom

Impression, vacuum formed
Better protection, better retention

85
Q

Type II mouthguard

A

Mouth-formed

Boil and bite

86
Q

Type III mouthguard

A

Stock

Ready made

87
Q

Minimum thickness for mouthguard?

A

3mm

88
Q

Materials for mouthguards

A

Polymer, copolymer clear thermoplastic
Polyurethane
Laminated thermoplastic
Polyolefin

89
Q

Do mouthguards reduce traumatic dental injuries?

A

Yes
Athletes who wore mouthguards 82% and 93% less likely to suffer injury compared to those not wearing mouthguards

Not much significance in reducing concussion

90
Q

Sports that require mouthguards

A 
Field hockey 
Football
Ice hockey
Lacrosse 
Wrestling if wearing ortho
91
Q

Glasgow Coma Scale

A

Eye opening
Verbal Response
Motor response

Lower numbers are worse

92
Q

Fractures of what bone is most common of skull?

A

Mandible

93
Q

Most common midface fracture?

A

Nasal

94
Q

Trauma to chin concerns

A

Subcondylar/condylar fracture of TMJ

95
Q

Battles sign

A

Mastoid hematoma (posterior cranial fracture)

96
Q

Racoon sign

A

Orbital hematoma

97
Q

What is soft tissue radiograph reduction?

A

Reduce to 0.25 exposure

98
Q

Is pulp vitality testing reliable at the time of trauma?

A

No

Usually increases over time

99
Q

Primary tooth avulsion sequelae

A

Do not replant
Ensure tooth is not intruded with radiograph
May delay eruption of permanent tooth 1-2 years

100
Q

Primary tooth intrusive luxation

A

Most common in maxillary primary incisors
Dangerous to permanent tooth bud
Monitor for re-eruption unless it is interfering with permanent tooth (then extract)

101
Q

Primary tooth lateral luxation

A

Usually displaced toward palate

Reposition if occlusal interferences, extract if apex is displaced into permanent tooth

102
Q

Primary tooth extrusive luxation

A 
If minor (<3mm), resposition, if severe extract 
Likely to become discolored
103
Q

Crown fracture with pulp exposure primary tooth

A

Unusual in primary dentition

Pulpotomy with calcium hydroxide, GI and composite or extract

104
Q

Crown/Root fracture of primary tooth

A

Remove fragment and restore, extract if pulp exposed

105
Q

Root fracture of primary tooth

A

Assess location with radiograph
May reposition and monitor if minimally displaced
If displaced and mobile, extract coronal fragment and monitor root tip
Prognosis is better the closer to the apex

106
Q

Alveolar fracture

A

Entire segment is mobile

Reposition and splint segment 4 weeks

107
Q

Partial pulpotomy (Cvek)

A

Removes inflamed pulp
Preserves pulp
Increases healing potential
Goal is to avoid need for RCT

108
Q

Complications of trauma to primary teeth

A 
Discoloration (53%)
Pulp necrosis
Ankylosis
Resorption
Enamel hypoplasia of permanent successor
Delayed eruption of permanent tooth
109
Q

What is the most common injury that causes hypoplasia of permanent successor?

A

Intrusion of primary tooth

110
Q

Factors affecting prognosis of permanent tooth trauma

A 
Timely treatment
Appropriate treatment
Patient/parent compliance
Appropriate follow up
Prevention of subsequent trauma
111
Q

Avulsion prevalence

A

1-16% of all trauma to permanent dentition

112
Q

2 key factors in permanent tooth avulsion

A

Extra-oral dry time

Open or closed apex

113
Q

Transport media options for avulsed permanent teeth

A 
Tooth's socket is best
Hank's Balanced Salt (24 hours)
Cold milk (2-3 hours)
Saliva (max 30min)
Isotonic saline (1 hour)
Cold contact lens solution
Olive oil, soybean oil?
114
Q

Contraindications for replantation of permanent avulsed tooth

A 
Severe cardiac disease
Seizure disorder
Compromised healing
Severe mental disability
Poor alveolar support
115
Q

Antibiotics after avulsion?

A

Tetracycline is more effective in reducing inflammatory root resorption compared to PenVK

Antibiotics can prevent pulp necrosis and reduce root resorption

116
Q

Possible outcomes for permanent tooth avulsion?

A 
Revascularization (open apex)
Pulp necrosis (most likely)
Pulp obliteration
Ankylosis
Inflammatory root resorption
Tooth loss
117
Q

Intrusive luxation for immature teeth

A

If less than 7mm, spontaneous re-eruption

118
Q

Intrusive luxation for mature teeth

A

If less than 3mm, spontaneous re-eruption

If 3-7mm, surgical or ortho repositioning

119
Q

Lateral luxation in permanent teeth

A

Open apex - monitor for continued root formation
Closed apex - monitor for necrosis

Concomitant uncomplicated fracture significantly increases risk for pulp necrosis

120
Q

Where is prognosis the worse for root fractures of permanent teeth?

A

Cervical 1/3

121
Q

Uncomplicated crown fracture of permanent teeth

A

Pulp necrosis most likely to occur in first 3 months

Increased risk for necrosis with complete root formation and luxation injury

122
Q

Complicated fracture of permanent teeth

A

Open apex: preserve pulp vitality with pulp cap or partial pulpotomy
Closed apex: may need RCT but can try partial pulpotomy or pulp cap

123
Q

Decoronation

A

Alternative to extraction of traumatized tooth or ankylosed tooth
Goal is to preserve surrounding alveolar bone
Remove pulp and get blood into canal with goal of replacement resorption

124
Q

Laser Doppler Flowimetry

A

LDF measures pulp blood flow to assess revascularization

More reliable in children

More of research tool

125
Q

Oral electrical burn management

A

Consult/coordinate with plastic surgeon

Expect sloughing of eschar in 7-10 days

Appliance needed to minimize wound contracture -delivered 10-14 days after injury and worn 6-12 months

126
Q

Definition of Abuse

A

Any act or failure to act on part of parent or caretaker which results in death, serious physical or emotional harm, sexual abuse, or exploitation, that presents imminent risk of serious harm

127
Q

Definition of Neglect

A

Willful failure of following through with treatment necessary to ensure level of oral health essential for adequate function and freedom from pain and infection

128
Q

Orofacial signs of abuse

A

Lacerations in mucosa, tongue, gingiva
Damage to teeth
Bruises in pre-ambulatory children
Bruises to TEN4 (torso, ears and neck in children under 4)

129
Q

Munchausen syndrome by proxy

A

Medical child abuse
Parent fabricates illness of child
No typical presentation
Usually females and usually mother

ABPD 2021 (14 decks)

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