Pulp Therapy/Orofacial Trauma Flashcards
Dentin-Pulp Complex
- Pulp originates from mesenchymal tissue
- Odontoblasts synthesize dentin organic matrix and line the edge of the pulp space
- Cytoplasmic processes extend into dentin tubules
- Orbans (1980) stated that “The pulp lives for the dentin and the dentin lives by the grace of the pulp.”
Dentin components
- Inorganic - hydroxyapatite
- Organic - mostly type I collagen but odontoblasts also secrete type V collagen, dentin sialoprotein and phosphophoryn, acid phosphatase and alkaline phosphatase
Dentin types
- Primary - tubular dentin formed before eruption; includes mantle dentin
- Secondary - regular, circumferential dentin formed after tooth eruption; tubules are continuous with primary dentin
- Tertiary - in response to irritation
Primary dentin vs secondary dentin
- Bulk of dentin formed during primary dentinogenesis
* Secondary dentin forms at a slower rate over the life of the tooth
Tertiary dentin
• Forms in response to irritation:
- Previously called irregular, irritation, reparative and/or replacement dentin
- Reactionary dentin - formed by original odontoblasts; continuous with secondary dentin
- Reparative dentin - original odontoblasts died, dentin formed by new odontoblast-like cells; not continuous with secondary dentin
Dentin-pulp reaction to damage
• When there is damage to dentin-pulp complex due to disease, trauma, operative, odontoblasts react to defend the pulp • Stimulated to create tertiary dentin - Appears sclerotic histologically - Decreased dentin permeability - Depends on extent of injury
Mild insult consequence
Odontoblasts usually survive and secrete reactionary dentin in response to injury
Severe insult consequence
May cause death of odontoblasts
- May lead to generation of new odontoblast-like cells and secretion of reparative dentin matrix
• Tubular structure discontinuity and reduced permeability
Molecular basis for odontoblast stimulation
- TGF-b (transforming growth factor beta) is sequestered in dentin matrix during tooth development
- TGF-b may be released when caries or acid etchant causes dissolution of matrix
- Growth factors interact with pulp to cause proliferation and differentiation of mesenchymal cells to form reparative dentin
Odontoblast stimulation by calcium hydroxide
Calcium hydroxide has a similar effect – high pH causes slight demineralization and releases TGF-b leading to reparative dentin and apexification
Example of mild insult
- Cavity preparation (no pulp exposure)
* Caries lesion in dentin
Example of severe insult
- Chronic pulpal inflammation due to deep caries
- Dry cutting
- Endotoxins from bacteria in deep caries lesions
- Mechanical exposure of pulp
- Presence of bacteria increases extent of pulpal inflammation
Importance of seal on restorations
• Importance of a good seal on restorations to minimize microleakage and bacterial invasion
What is RDT?
Remaining dentin thickness
Values for remaining dentin thickness
- Bacteria in cavities with RDT < 0.25 mm results in more severe pulp inflammation than when RDT is greater
- Best to have > 0.50 mm
- When RDT is > 0.5 mm diffusion of irritants is delayed – odontoblasts secrete reactionary dentin - increases distance between pulp and restorative material
- When RDT is < 0.5 mm, reduction in odontoblasts – differentiation of odontoblast-like cells - secretion of reparative dentin - decreased permeability - protective barrier
Pulp cells
• Fibroblasts are most frequent cell type
- Capable of generating odontoblast-like cells
- Many are undifferentiated (stem cells)
• Macrophages - involved in signaling pathways, activated by inflammation
• Dendritic cells - induce T-cell dependent immunity
• T-lymphocyte
• Mast cells - rare in normal pulp, common in chronically inflamed pulp
Structural proteins of pulp
• Collagen - type I and III are main subtypes
- Comprises 26-32% of dry weight in premolars and molars
• Elastin - found in walls of arterioles
Cells in dental pulp
- Fibroblasts
- Odontoblasts
- Histiocytes
- Macrophages
- Granulocytes
- Mast cells
- Plasma cells
Neuropeptides
• Calcitonin gene-related peptide (CGRP) is most common
- Important in induction of neurogenic inflammation
• Substance P
• Neuropeptide Y
• Neurokinin A
• Vasoactive intestinal peptide (VIP)
Drug to regrow teeth?
• Tideglusib stimulates stem cells in the pulp of teeth.
• Functions as a Gycogen Synthase Kinase (GSK-3) enzyme antagonist
- GSK-3 is involved in dentin degradation
• From the lab of Paul Sharpe in the UK
Types of pain
• Spontaneous, nocturnal, constant
- Irreversible
• Thermal, chemical, intermittent
- Reversible
Subjective findings
- Young children are not good historians
- May not report pain
- May report pain when no evidence of disease
Objective findings
- Extraoral
- Intraoral
- Radiographically
- Percussion
- Palpating
- Cold testing
Nerve fibers in pulp
• Myelinated — A fibers
- A-beta and A-delta (90%) both innervate dentinal tubules and are stimulated by fluid movement in the tubules
- Increase in number over time; relatively few at time of eruption - may be why EPT is unreliable in young teeth
• Unmyelinated — C-fibers
- 3 to 8 times more frequent than A-delta fibers in pulp
Nerve fiber: A-fibers
Myelinated nerves that conduct rapid and sharp pain sensations:
• Mainly A-delta type
• Located in periphery of pulp
• In close association with odontoblasts; extend fibers to many dentinal tubules
Nerve fibers: C-fibers
Thinner, non-myelinated nerves involved in dull aching pain:
• Typically terminate in pulp tissue proper either as free nerve endings or as branches around blood vessels
Nerve plexus of Raschkow
- Myelinated nerve fibers located in cell rich zone
- Monitors painful sensations
- Mediates inflammatory events and tissue repair
Electric pulp testing
- Stimulates sensory A fibers
- C fibers do not respond
- On anterior teeth, incisal edge has lowest response threshold
- Generally not reliable in young children
Cold testing
- Excites intradental A fibers
- C fibers not usually activated unless stimulus causes injury to pulp
- 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 the pulp
- Outward fluid movements produce stronger nerve response than inward movement
- Primarily A fibers that are stimulated
Pulpitis pain
- Most likely due to C fiber activity resulting from pulpal tissue injury
- Prolonged or spontaneous pain indicates irreversible pulpitis
Prescribing radiographs recommendation: New Patient being evaluated for oral diseases
- Child with primary dentition (prior to eruption of first permanent tooth): individualized radiographic exam consisting of selected periapical/occlusal views and/or posterior bite wings if proximal surfaces cannot be visualized or probed. Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time.
- Child with transitional dentition (after eruption of first permanent tooth): individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images.
- Adolescent with permanent dentition (prior to eruption of third molars) + Adult, dentate, or partially edentulous: Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images. A full mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment.
Prescribing radiographs recommendations: Recall patient* with clinical caries or at increased risk for caries**
- Child with primary dentition (prior to eruption of first permanent tooth) + child with transitional dentition (after eruption of first permanent tooth) + adolescent with permanent dentition (prior to eruption of third molars): posterior bitewings exam at 6-12 month intervals if proximal surfaces cannot be examined visually or with a probe.
- Adult, dentate or partially edentulous: Posterior bitewing exam at 6-18 month intervals
Prescribing radiographs recommendations: Recall patient* with no clinical caries and not at increased risk for caries**
- Child with primary dentition + child with transitional dentition: posterior bitewing exam at 12-24 month intervals if proximal surfaces cannot be examined visually or with a probe
- Adolescent with permanent dentition: posterior bitewing exam at 18-36 month intervals
- Adult, dentate, or partially edentulous: posterior bitewing exam at 24-36 month intervals.
Prescribing radiographs recommendations: patient (new and recall) for monitoring of dentofacial growth and development, and/or assessment of dental/skeletal relationships
- Child with primary dentition + child with transitional dentition: clinical judgment as to need for and type of radiographic images for evaluation and/or monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
- Adolescent with permanent dentition: clinical judgment as to need for and type of radiographic images for evaluation and/or monitoring of dentofacial growth and development, or assessment of dental and skeletal relationships. Panoramic or periapical exam to assess developing third molars.
- Adult, dentate or partially edentulous: Usually not indicated for monitoring of growth and development. Clinical judgement as to the need for and type of radiographic image for evaluation of dental and skeletal relationships.
Prescribing radiographs recommendations: patient with other circumstances including, not not limited to proposed or existing implants, other dental and craniofacial pathoses, restorative/endodontic needs, treated periodontal disease and caries remineralization
For all categories: clinical judgement as to need for and type of radiographic images for evaluation and/or monitoring in these conditions.
Accessory canals
- Luglie PF et al. 2012. Found that 77% of the samples (both maxillary and mandibular primary molars) had one or more extra foramina near the furcation.
- May not be primary cause of infection transmission.
Radiolucent lesions
- Periapical radiolucencies can only be seen radiographically after cortical bone at the apex is destroyed and the infection has spread into cancellous bone.
- Lamina dura is cortical bone
Furcation radiolucency
- Furcation radiolucency in primary molars is a sign of pulp necrosis
- Recommended extraction when furcation lesion is present following pulpotomy
Myers study on furcation radiolucency
Myers et al (1987) is one of the few studies describing histopathology of furcation lesions in primary teeth:
- Granulomatous inflammation present in majority of specimens
- Chronic proliferating inflammation also seen
- Epithelium present in some specimens suggest cystic potential
Myers DR et al (1988) found greater percentage of specimens with granuloma + epithelium or furcation cyst than were found in the untreated teeth in previous study
Vital pulp therapy — primary teeth
- Indirect pulp cap
- Direct pulp cap
- Pulpotomy
Indirect pulp cap
• Partial caries removal decreased risk of pulp exposure by 98%; 3 studies with 24 month follow-up showed 94.4% success
• Independent of medicaments used
- Compared calcium hydroxide to bonding agent liners
• Most important factors for success:
- Accurate diagnosis of vitality
- Well sealed restoration - composite or SSC
Partial caries removal
Goal is to remove soft carious dentin and leave firm or leathery dentin over pulp. • Slow speed with large round bur • Hand excavation • Chemomechanical - Carisolv • Margins must be free of caries
Carisolv
• Carisolv is a gel based chemico-mechanical caries removal system:
- Consists of 0.95% sodium hypochlorite solution and a gel containing three amino acids (glutamic acid, Leucine, Lysine), sodium chloride, Na-CMC (carboxymethylcellulos)
• Sodium hydroxide provides a pH of 11 and purified water acts as a vehicle
• May lead to excess caries removal if IPT is the goal
• Not routinely taught in dental schools
Liners under restorations
• Ideal liner: (1) the ability of the material to kill bacteria, (2) induce mineralization, and (3) establish a tight bacterial seal
• Most common liners: CaOH, Glass ionomer, MTA
• Multisubstrate bonding ability - bonding to dentin and to composite restoration is a plus
- RMGI, dentin bonding agents, etc.
MTA facts
- Mineral trioxide aggregate
- Main soluble component is CaOH
- Alkaline pH contributes to antibacterial activity
- Hard-setting — minimizes microleakage
- Biocompatible — minimal inflammation
- Stimulates reparative dentin formation
- Induces dentin bridge formation
Calcium hydroxide [Ca(OH)2]
- Alkaline pH leads to antibacterial activity
- Causes superficial necrosis of pulp
- Stimulates reparative dentin
- Water soluble, so may not create good seal
Resin modified glass ionomer (RMGI)
- Initial pH is 4.0-5.5
- Demineralizes dentin
- May release bioactive materials in dentin matrix
- Irritating to pulp
Direct pulp cap
- Small mechanical or traumatic exposure
- Healthy pulp
- Goal: preserve vitality
- Tertiary dentin
- No harm to successors
- Continued root formation for permanent teeth
Recommendations for direct pulp cap
- Not recommended for carious exposure in primary teeth
- Hemostasis is important
- Success rate up to 80-90% when bleeding well controlled
- Ca(OH)2 or MTA in direct contact with pulp
Pulpotomy indications
- Carious exposure in vital primary tooth
* Restorable tooth
Pulpotomy contraindications
- Fistula or swelling
- Necrotic pulp
- Uncontrolled hemorrhage
- Radiolucent lesion
- Pathologically resorption
- Dystrophin calcification
- More than 1/3 root resorption
Pulp medications
- Fixatives: FMC, glutaraldehyde
- Mineralization/bacteriostatic: Ca(OH)2, iodoform
- Palliative sealers: ZOE
- Obturators: MTA
- Coagulants: Ferric sulfate
- Antibiotics/antimicrobial: NaOCl, erythromycin, 3X antibiotic
Composition of Formocresol
- Formula: 19% formaldehyde, 35% cresol in 15% glycerin and water
- Bactericidal
- Mutagenic and carcinogenic potential - humoral and cell mediated response
- No dentin bridging
Mechanism of formocresol
Fixation followed by degeneration
• Acidophilic zone of fixation
• Pale staining zone of atrophy - fewer cells & fibers
• Broad zone of inflammatory cells extend apically
Formocresol and cancer
• Systemic distribution of radio-isotope-labeled formaldehyde has been demonstrated following formocresol pulpotomy in dogs and rhesus monkeys (found in bone, urine, liver, kidney, lungs, skeletal muscle and cerebrospinal fluid within minutes of the pulpotomy)
• Mutagenicity in peripheral blood lymphocyte cultures following formocresol pulpotomy as been found
• A correlation between formocresol pulpotomies in primary teeth and enamel defects in the permanent successor has been suggested
• In June 2004 - The International Agency for Research on Cancer (IARC) classified formaldehyde as carcinogenic to human beings
• Work group of experts determined there is:
- sufficient evidence that formaldehyde causes nasopharyngeal cancer in humans
- limited evidence for cancer of the nasal cavity and paranassal sinuses
- strong but not sufficient evidence for a causal association between leukemia and occupational exposure to formaldehyde
Percentage of formaldehyde in Buckley’s Formocresol
Buckley’s Formocresol contains 19% formaldehyde in its full strength
AAPD guideline on vital pulp therapies in primary teeth with deep caries lesions
- Panel recommends use of MTA and formocresol - strong recommendations, moderate-quality evidence
- Success rates in multiple clinical trials between 77-91%
- Review of available data, FMC is unlikely to be genotoxic, immunotoxic, or carcinogenic when used judiciously for pulpotomies
Glutaraldehyde
• A dialdehyde compound • Large molecule - does not penetrate into periapical tissues • Mild fixative • Antibacterial: - Requires pH between 7.5 and 8.5 - Short shelf life • Concentration 2-5% • Overall success lower than FMC or FS • Low antigenicity and low toxicity • Lloyd et al recommended concentration of 2% with exposure time of 10 min • AAPD guidelines — not evaluated
Ferric sulfate
• Iron (III) sulfate
• Agglutination agent
- Acidic pH (<1.0)
- Produces hemostasis
• Forms a protein complex and concludes capillaries
• Antibacterial against numerous oral bacteria
• Must have healthy radicular pulp to obtain hemostasis
• Concern related to iron and risk of mycobacterium infection due to waterline contamination
• Lower success rate than FMC or MTA
• Studies have demonstrated internal resorption ***
• AAPD guidelines - conditional recommendation with low evidence
Ferric sulfate and mycobacterium
- Nontuberculosis mycobacterial infection linked to pulpotomy procedures and possible dental waterline contamination reported in California and Georgia
- ADA News September 21, 2016
- MMWR report stated the outbreak was caused by contaminated water used during pulpotomies. Improper treatment of waterlines.
Sodium hypochlorite
- Generally used at 5% concentration
- Anti-microbial
- Biocompatible, non-irritating to pulp
- Surface effects, minimal penetration
- Similar success to FC at 12 months
- AAPD Guidelines - Conditional recommendation with very low evidence
Calcium hydroxide
- AAPD guidelines - not recommended for vital tooth pulpotomies in primary teeth
- Very high pH
- Thought to initiate inflammatory cascade***
- Low success rate due to internal resorption***
Mineral trioxide aggregate composition
- Tricalcium silicate, dicalcium silicate, tricalcium aluminate, gypsum, tetracalcium aluminoferrite and bismuth oxide
- Hydrophilic particles set in presence of moisture
- High biocompatibility
- pH 12.5 after setting - reaction product is CaOH2
- Compressive strength similar to IRM
- Better seal than amalgam
- May turn tooth gray over time
Mineral trioxide aggregate mechanism
- Provides a biologically active substrate for cell attachment
- Stimulates reparative dentin
- Minimal pulp necrosis and inflammation
- Forms dentin bridge more quickly than Ca(OH)2
- AAPD guideline - strong recommendation with moderate evidence
Calcium silicate
- Contains tricalcium silicate, dicalcium silicate, calcium carbonate, oxide filler, iron oxide shade, and zirconium oxide
- Creates dentin bridge
- Bioactive properties
- Alkaline pH
- Setting time 9-12 minutes — enhanced by calcium carbonate and calcium chloride
- Less evidence than MTA
- Creates a good seal — prevents microleakage
- Induction of reparative dentin
- AAPD guidelines — conditional recommendation, very low evidence
**Less discoloration
Non-vital pulp therapy for primary teeth
Pulpectomies indications: • Necrotic/irreversible inflammation - Spontaneous pain - Pain on stimulation that lingers - Draining fistula • Abscesses (in limited instances)
Primary maxillary molar anatomy
- 3 roots is most common; may have 2 or 3 roots
- 1/3 of maxillary first molars have fusion of palatal and distobuccal roots
- 2nd maxillary molars have 3 canals (70%) or 4 canals (30%)
Primary mandibular molar anatomy
• 1st molars have 2 roots with 3 (80%) or 4 (20%) canals
- Mesial roots with 2 canals
- Distal root with 1 or 2 canals
• 2nd molars have 2 roots and 4 canals
Pulpectomy
- Radiographic findings documented
- Clinical findings documented
- Eliminate infection via adequate canal de ride net, irrigation, and filling material
- Maintain tooth until normal exfoliation
Pulpectomy indications
- Irreversible pulpitis or necrosis
- No root resorption
- Restorable tooth
Pulpectomy contraindications
- Non-restorable
- Perforation of pulpal floor
- Extreme tooth mobility
- Radiolucency involving permanent tooth follicle
- Children with medical compromise
- May be more “heroic” for 2nd primary molar prior to eruption of permanent molar
Zinc oxide and eugenol
- Most widely used for pulpectomy
- Biocompatibility
- Antibacterial
- Resorts more slowly than deciduous roots
- Resists resorption if extruded beyond apex