Pulpal Diagnosis Flashcards
How can pulp be damaged?
Caries Trauma Cavity prep Orthodontic Tx Radiation therapy Restorative material - toxicity, pH, heat
What are the stages of pulpal pathologies?
Healthy pulp Reversible pulpitis Irreversible pulpitis (symptomatic/asymptomatic) Necrotic pulp Infected pulp
What are the symptoms of reversible pulpitis?
Discomfort from cold/sweet stimulus Pain resolves with removal of stimulus No change in pulp blood flow Inflamed pulp No significant changes in periapical region
What are the symptoms of symptomatic irreversible pulpitis?
Vital inflamed pulp is incapable of healing
Sharp pain upon thermal stimulus that lingers
Negative to cold, pain to hot (C fibres)
Spontaneous, unprovoked pain
Increase in pulpal blood flow
No pain or discomfort to percussion
What is the Tx for irreversible pulpitis?
Pulpectomy then RCT
Extraction if tooth unrestorable or patient preference
What is the treatment for necrotic pulp?
Mature teeth (closed apices): RCT or extraction Immature teeth (open apices): Pulpotomy Pulpectomy then full RCT Extraction
What are the signs of a non-vital tooth?
Discolouration - yellow, grey, pink Sinus Gross caries Large restoration Radiographic evidence - periapical radiolucency, periradicular radiolucency
How would you treat infected pulp?
Root canal treatment
Extraction
How can you test pulp vitality?
Electric pulp tests (EPT) Thermal tests - cold tests (ethyl chloride) - heat tests (hot gutta percha) Test drilling *These tests stimulate nerve fibres & do not indicate state of blood supply Laser doppler - assesses blood flow
What nerve fibres dose an EPT stimulate?
A delta
Unmyelinated C-fibres may or may not respond
How would you conduct an EPT?
Dry teeth thoroughly
Isolate tooth/teeth
Apply conducting medium (toothpaste/fluoride gel) on tip of EPT probe
Place EPT probe on incisal edge/cusp tip adjacent to pulp horn (where most sensory fibres are found)
Pt holds hand of EPT to complete the circuit
Slowly increase current
Pt indicates when a tingling/heat sensation is felt
What do the responses of an EPT indicate?
Positive response:
- vital pulp tissue in coronal aspect of pulp chamber
- no indication of reversibility of inflammation
Negative response:
- indicator for pulpectomy
EPT of young pulps is unreliable
How would you conduct a cold test?
Cotton pellet/roll sprayed with ethyl chloride or difluorodichloromethane (-500). Frozen sticks of CO2 or ice can be used but they are not very reliable.
Carefully dry teeth and isolate. Place cold object close to pulp horn.
Negative response highly indicative of pulpal necrosis.
How would you conduct a heat test?
Coat tooth with vaseline
Apply hot gutta percha/green stick to tooth
Stimulates A delta (sharp pain) and C fibres (dull, radiating pain)
*Caution as too much heat may cause irreversible pulpitis
Negative response indicative of necrotic pulp
When would you use test drilling as a pulp vitality test?
When full coverage restorations are present - renders other forms of testing impossible.
How would you conduct test drilling?
No LA given
Cut into tooth
Pt will report severe pain or no pain felt when cutting into dentine
If there is a sensitivity like response to dentine prep, then the tooth is vital
How would you treat carious pulp exposure?
RCT in mature teeth
Pulpotomy in immature teeth with open apices
How does age affect pulp?
Decreased number of blood vessels and nerves.
Pulp less likely to reverse an inflammatory response.
What is the effect of periodontal disease on pulp?
Prematurely aged pulp
Less resistant to inflammation than healthy pulp
How can you prevent pulpal damage?
Know tooth anatomy - size, location, pre-assessment with radiographs
Avoid drilling into pulp
Use of cavity sealers/indirect pulp caps in cavities close to pulp
Use of direct pulp cap in pulpal exposure during cavity prep
What is the purpose of cavity sealers?
Protect pulp from bacteria & their products and the toxic effects of the setting reaction of restorative materials.
What is a liner?
A varnish containing fillers and additives
Applied as a thin layer
What is a cavity base?
A thicker sealant
Thermal protection
e.g. zinc phosphate, ZOE, CaOH, RMGIC
What are the effects of CaOH?
Bacteriocidal/bacteriostatic
High pH
- stimulates fibroblasts to form reparative dentine
- stimulates recalcification of demineralised dentine
- neutralises low pH from acidic restorative materials
BUT - cytotoxic, weak cement, very soluble if not protected
What are the treatment options for pulpal damage?
Indirect pulp cap or stepwise excavation
Direct pulp cap
Partial pulpal removal (pulpotomy)
Full pulpal removal (pulpectomy) - progress to RCT
What are the functions of the pulp?
Nutrition
Sensory - temp, pain, pressure
Protective - tertiary dentine formation
Formative - secondary dentine formation
What would you expect from normal pulp?
Symptom free
Responsive to pulp testing
Mild/transient response to thermal cold testing (lingers no longer than 2 seconds)
What are the symptoms of asymptomatic irreversible pulpitis?
Vital inflamed pulp incapable of healing
No clinical symptoms
Normal response to thermal testing
What are the typical causes of reversible pulpitis?
Exposed dentine
Caries
Deep restoration
What are the typical causes of symptomatic irreversible pulpitis?
Deep caries
Extensive restoration
Fractures exposing pulpal tissue
What are the typical causes of asymptomatic irreversible pulpitis?
Trauma or deep caries that would likely result in exposure following removal
What are the symptoms of pulp necrosis?
Pulp non-responsive to pulp testing
Asymptomatic
No TTP or Radiographic evidence of osseous breakdown unless the canal is infected
How would you diagnose a previously treated tooth?
Radiograph - Canals are obturated with filling materials
The tooth typically does not respond to thermal or electrical pulp testing
How would a previously initiated tooth respond to pulpal testing?
Tooth has been treated by partial endo therapy.
Depending on the level of treatment the tooth may or may not respond to tests.
