Pulp Therapy and Trauma Flashcards
What is the origin of pulp?
Mesenchymal tissue
Dentin components
Inorganic: hydroxyapatite
Organic: mostly type I collagen, also type V collagen, dentin sialoprotein
Primary dentin
Tubular dentin formed before eruption
Includes mantle dentin
Secondary dentin
Regular circumferential dentin formed after tooth eruption
Tubules continuous with primary dentin
Tertiary dentin
Dentin in response to irritation
Reactionary versus Reparative Dentin
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
Molecular basis for odontoblast stimulation
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
Mild insult to dentin
Cavity preparation without pulp exposure
Caries lesion into dentin
Severe insult to dentin
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
Remaining Dentin Thickness (RDT)
<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
What is the most frequent cell type of the pulp?
Fibroblasts
Capable of generating odontoblast-like cells
What cells are in the pulp?
Fibroblasts Odontoblasts Histiocytes Macrophages Granulocytes Dendritic cells T-lymphocytes Plasma cells Mast cells (rare in healthy pulp)
Structural proteins of pulp
Collagen (type I and III main subtypes)
Elastin (arterioles)
Neuropeptides of the pulp
Calcitonin gene related peptide (CGRP) is most common - involved in induction of neurogenic inflammation
Substance P
Neuropeptide Y
Neurokinin A
Vasoactive intestinal peptide
Correlation between clinical findings and histology of pulp?
“Currently very little or no correlation exists between clinical diagnostic findings and the histopathologic status of the pulp” Fuks et al. 2018
Diagnosis of pulp status
Medical history Dental history History of pain (and type) Clinical Exam Radiographs
Types of nerve fibers in pulp
A fibers (myelinated) C fibers (unmyelinated)
A fibers of pulp
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
C fibers of pulp
3-8X more common than A-delta
Thinner
Dull, aching pain
Nerve Plexus of Raschkos
Myelinated nerve fibers located in cell rich zone
Monitors painful sensation
Mediates inflammatory events and tissue repair
EPT
Not reliable in young children
Stimulates A fibers
Cold Testing
Excites A fibers (not C)
No evidence that cold testing injures pulp
Hydrodynamic theory
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
Pulpitis Pain
C fiber activation from pulp tissue injury
Prolonged pain indicative of irreversible pulpitis
Pulp necrosis in primary teeth
Furcational radiolucency is sign of pulp necrosis
77% of primary molars have at least one accessory foramina in furcation
Indirect Pulp Cap - Primary Teeth
94.4% success independent of medicament
Most important factors are accurate diagnosis of vitality and sealed restoration
What is Carisolv?
Gel-based chemical-mechanical caries removal system
Sodium hypochlorite and amino acids
Not routinely taught; may lead to excessive caries removal
Ideal properties of a liner
Kill bacteria
Induce mineralization
Establish bacterial seal
Multisubstrate bonding ability (ex: RMGI, dentin bonding agents)
Most common liners
CaOH
GI
MTA
Tricalcium silicate
Properties of MTA
Main soluble component is CaOH
Alkaline pH contributes to antibacterial activity
Hard setting minimizes microleakage
Biocompatible
Stimulates reparative dentin formation, induces dentin bridge formation
Properties of CaOH2
Alkaline pH leads to antibacterial activity
Causes superficial necrosis of pulp
Stimulates reparative dentin
Water-soluble
Properties of RMGI Liner
Initial pH is 4.0-5.5
Demineralizes dentin
May release bioactive materials in dentin
Irritating to pulp
Direct Pulp Cap Indications
Healthy pulp
Small mechanical or traumatic exposure
Direct pulp cap in primary teeth?
Not recommended
Indications for pulpotomy of primary tooth
Carious exposure in vital primary tooth that is restorable
Contraindications for pulpotomy of primary tooth
Fistula or swelling Necrotic pulp Uncontrolled hemorrhage Radiolucent lesions Pathologic resorption Dystrophic calcification More than 1/3 root resorption
Medicaments for Pulpotomy
Fixatives (formocresol, glutaraldehyde) Mineralizing (CaOH, iodoform) Palliative (ZOE) Obturators (MTA) Coagulants (ferric sulfate) Antimicrobial (NaOCl, triple paste)
Formocresol formula
19% formaldehyde
35% cresol
15% glycerin
Water
Mechanism of action of formocresol
Fixation followed by degeneration
Bactericidal
Does formocresol result in dentin bridging?
No
Problems with formocresol
Mutagenic/carcinogenic potential (unlikely when used judiciously)
Enamel defects in permanent successor
AAPD and formocresol pulpotomy
Strong recommendation for Formocresol and MTA for pulpotomy
Glutaraldehyde pulpotomy
Dialdehyde compound
Mild fixative, some antibacterial properties
Lower success than formocresol and ferric sulfate
Not evaluated in AAPD guidelines
Ferric Sulfate Pulpotomy
Hemostasis from occluding capillaries
Antibacterial
Lower success than MTA or FMC
May lead to diagnosis confusion
AAPD and ferric sulfate pulpotomy
Conditional recommendation with low evidence
Concerns with ferric sulfate pulpotomy?
Must have clean water line!
Risk of mycobacterium contamination
Sodium hypochlorite pulpotomy
5% concentration
Antimicrobial
Biocompatible
Surface effects
AAPD and sodium hypochlorite pulpotomy
Conditional recommendation with very low evidence
Calcium hydroxide pulpotomy
High pH, initiates inflammatory cascade
Low success rate due to internal resorption
AAPD and CaOH pulpotomy
Not recommended for vital tooth pulpotomy in primary teeth
What is the reaction product of MTA?
Calcium hydroxide
AAPD and MTA pulpotomy
Strong recommendation with moderate evidence
Calcium silicate pulpotomy
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
AAPD and calcium silicate pulpotomy
Conditional recommendation with very low evidence
Not many studies; probably similar to MTA
Indications for Pulpectomy
Necrotic/irreversible inflammation
No root resorption
Restorable tooth
Contraindications for pulpectomy
Non-restorable tooth Perforation of pulp floor Extreme tooth mobility Radiolucency involving permanent tooth follicle Children with medical compromise
Goals of pulpectomy
Eliminate infection via adequate canal debridement, irrigation and filling material
Maintain tooth until normal exfoliation
Pulpectomy filling materials
ZOE
Iodoform pastes
ZO and Eugenol Pulpectomy
Most widely used
Biocompatible
Antibacterial
Resorbs more slowly than deciduous roots and resists resorption if extruded beyond apex
Iodoform paste pulpectomy
Vitapex, Kri paste, Maisto paste
Antibacterial
Resorbs faster than primary tooth roots
LSTR
Sterilize lesion and avoid instrumentation of canal
Triple paste in LSTR
Ciprofloxacin
Metronidazole
Minocycline
Ratio 1:3:3
Advantages of LSTR
1 visit
Simple, painless
Less burdensome for patients
Disadvantages of LSTR
Tooth staining with minocycline
Radiolucent appearance of triple antibiotic paste
Allergic reaction
Potential antibiotic resistance
Risk for developmental anomalies in permanent teeth
Primary Incisor Pulp Therapy
Previous studies suggested pulpotomy not as successful as pulpectomy
Primary maxillary molar pulp anatomy
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%)
Primary mandibular molar pulp anatomy
1st molars 2 roots with 3 (80%) or 4 (20%) canals
2nd molars 2 roots and 4 canals
Indications for pulpotomy in immature permanent tooth
Pulp exposure due to caries or trauma
Hemorrhage controlled with pressure
Tooth is vital
No spontaneous pain, necrosis or PA lesion
Permanent tooth pulpotomy
Goal: maintain root canal vitality and complete apex formation
Entire coronal pulp tissue is removed
Direct pulp cap in permanent teeth
Ca(OH)2 or MTA most common
Good seal important to promote pulp repair and dentin bridge
Apexification versus Apexogenesis
Apexification: induce root development by forming calcific barrier
Apexogenesis: stimulating root development
Requirements for pulp revascularization
Disinfection of canal Creation of scaffold for new tissue Stem cells Signaling molecules Good seal of coronal access
How open does an apex need to be for revascularization?
Minimum 1.1mm open
Patient between 7-16 years in good health
What is the most common trauma to young children?
Luxation
What is the most common trauma to older children?
Uncomplicated crown fracture
Epidemiology of young children dental trauma
1/3 of children 5 years had trauma to primary teeth
Most occurred between 18-30 months
Epidemiology of older children dental trauma
20-30% 12 year olds had had dental trauma
Peak incidence 9-10 years
What tooth is most likely traumatized?
Maxillary central incisors (71% of trauma cases)
What gender is most affected by dental trauma?
Boys 2:1
Especially boys 7-10 years
Highest rate of dental trauma for female sports? Male sports?
Female: field hockey
Male: basketball
72% of injuries not wearing mouthguard
What is a medical condition associated with higher risk for dental trauma?
ADHD
Overjet over __mm is associated with higher risk of trauma
6mm
Prevention of trauma
Home: childproof house
Sports: helmets, mouthguards, face masks
ADHD: medication?
Excessive overjet: ortho intervention
Type I mouthguard
Custom
Impression, vacuum formed
Better protection, better retention
Type II mouthguard
Mouth-formed
Boil and bite
Type III mouthguard
Stock
Ready made
Minimum thickness for mouthguard?
3mm
Materials for mouthguards
Polymer, copolymer clear thermoplastic
Polyurethane
Laminated thermoplastic
Polyolefin
Do mouthguards reduce traumatic dental injuries?
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
Sports that require mouthguards
Field hockey Football Ice hockey Lacrosse Wrestling if wearing ortho
Glasgow Coma Scale
Eye opening
Verbal Response
Motor response
Lower numbers are worse
Fractures of what bone is most common of skull?
Mandible
Most common midface fracture?
Nasal
Trauma to chin concerns
Subcondylar/condylar fracture of TMJ
Battles sign
Mastoid hematoma (posterior cranial fracture)
Racoon sign
Orbital hematoma
What is soft tissue radiograph reduction?
Reduce to 0.25 exposure
Is pulp vitality testing reliable at the time of trauma?
No
Usually increases over time
Primary tooth avulsion sequelae
Do not replant
Ensure tooth is not intruded with radiograph
May delay eruption of permanent tooth 1-2 years
Primary tooth intrusive luxation
Most common in maxillary primary incisors
Dangerous to permanent tooth bud
Monitor for re-eruption unless it is interfering with permanent tooth (then extract)
Primary tooth lateral luxation
Usually displaced toward palate
Reposition if occlusal interferences, extract if apex is displaced into permanent tooth
Primary tooth extrusive luxation
If minor (<3mm), resposition, if severe extract Likely to become discolored
Crown fracture with pulp exposure primary tooth
Unusual in primary dentition
Pulpotomy with calcium hydroxide, GI and composite or extract
Crown/Root fracture of primary tooth
Remove fragment and restore, extract if pulp exposed
Root fracture of primary tooth
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
Alveolar fracture
Entire segment is mobile
Reposition and splint segment 4 weeks
Partial pulpotomy (Cvek)
Removes inflamed pulp
Preserves pulp
Increases healing potential
Goal is to avoid need for RCT
Complications of trauma to primary teeth
Discoloration (53%) Pulp necrosis Ankylosis Resorption Enamel hypoplasia of permanent successor Delayed eruption of permanent tooth
What is the most common injury that causes hypoplasia of permanent successor?
Intrusion of primary tooth
Factors affecting prognosis of permanent tooth trauma
Timely treatment Appropriate treatment Patient/parent compliance Appropriate follow up Prevention of subsequent trauma
Avulsion prevalence
1-16% of all trauma to permanent dentition
2 key factors in permanent tooth avulsion
Extra-oral dry time
Open or closed apex
Transport media options for avulsed permanent teeth
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?
Contraindications for replantation of permanent avulsed tooth
Severe cardiac disease Seizure disorder Compromised healing Severe mental disability Poor alveolar support
Antibiotics after avulsion?
Tetracycline is more effective in reducing inflammatory root resorption compared to PenVK
Antibiotics can prevent pulp necrosis and reduce root resorption
Possible outcomes for permanent tooth avulsion?
Revascularization (open apex) Pulp necrosis (most likely) Pulp obliteration Ankylosis Inflammatory root resorption Tooth loss
Intrusive luxation for immature teeth
If less than 7mm, spontaneous re-eruption
Intrusive luxation for mature teeth
If less than 3mm, spontaneous re-eruption
If 3-7mm, surgical or ortho repositioning
Lateral luxation in permanent teeth
Open apex - monitor for continued root formation
Closed apex - monitor for necrosis
Concomitant uncomplicated fracture significantly increases risk for pulp necrosis
Where is prognosis the worse for root fractures of permanent teeth?
Cervical 1/3
Uncomplicated crown fracture of permanent teeth
Pulp necrosis most likely to occur in first 3 months
Increased risk for necrosis with complete root formation and luxation injury
Complicated fracture of permanent teeth
Open apex: preserve pulp vitality with pulp cap or partial pulpotomy
Closed apex: may need RCT but can try partial pulpotomy or pulp cap
Decoronation
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
Laser Doppler Flowimetry
LDF measures pulp blood flow to assess revascularization
More reliable in children
More of research tool
Oral electrical burn management
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
Definition of Abuse
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
Definition of Neglect
Willful failure of following through with treatment necessary to ensure level of oral health essential for adequate function and freedom from pain and infection
Orofacial signs of abuse
Lacerations in mucosa, tongue, gingiva
Damage to teeth
Bruises in pre-ambulatory children
Bruises to TEN4 (torso, ears and neck in children under 4)
Munchausen syndrome by proxy
Medical child abuse
Parent fabricates illness of child
No typical presentation
Usually females and usually mother
