Vital Pulp Therapy

Question 1

• FLAG: patient presents with pain
• Rule this out before treating
• Does your patient have a history of allergies and/or sinus infections?
• Worse when they bend over/lie down/jump up and down?
• Located in general area or maxillary arch on one or both sides?
• Lack of radiographic/clinical evidence of decay?
• DO NOT TREAT DENTALLY! May need to refer to ENT

Answer 1

Max sinus pain

Question 2

• Flag: potentially pain and/or rg caries
• NOT Reversible Pulpitis
• May be painful
• To percussion, palpation, chewing
• To cold-> hot as tooth is dying
• May have swelling, fever
• Radiographic lesion may or may not be present
• May be too early
• Caused by bacteria
• Non-vital, necrotic pulp= right to endo (after consult, of
  course)
• NOT painful to cold/hot

Answer 2

Acute apical abscess

Question 3

• Flag: patient presents with pain
• Pain more vague
• Regional, can’t isolate to single tooth
• Pulp VITAL
• Percussion main symptom
• Deeper Pocketing depths usually

Answer 3

Periodontitis

Question 4

• No flags, but the radiographs sure are suspicious!
• Not Abscess!
• Rule out cementoma in radiograph presenting similar to
  abscess
• Most commonly in lower anterior/premolar region
• Pulp test prior to tx
• Be very suspicious if no caries present

Answer 4

Cementoma

Question 5

• Mild- moderate pain
• Cold response
• Occasional response to sugar or heat
• Occasional response to biting pressure
• Causes:
• New restoration
• Trauma
• Bacteria
• Exposed dentin
• Possible Treatment:
• Remove restoration and/or caries and attempt to restore again

Answer 5

Reversible pulpitis

Question 6

-Longer Duration
-pain lingers several minutes- hours
-Heat Sensitivity
-Cold
-may have lingering cold sensitivity
OR
- cold may alleviate pain
-Spontaneous

Answer 6

Irreversible pulpitis

Question 7

• Gold standard for direct pulp cap
• Inexpensive
• Antibacterial
• Evidence-supported
• Stimulates repair
• Release of Bone Morphogenic Protein and Transforming Growth Factor-
  Beta One
• Stimulates pulp to form odontoblasts which can produce reparative
  dentin

Answer 7

Calcium hydroxide

Question 8

• Most are light cured
• The Good:
• Seals well as indirect pulp cap
• Good biocompatibility
• The not-so-good:
• Moderate to intense inflammatory pulp response
• No dentin bridge formation

Answer 8

RMGI Vitrebond

Question 9

• Calcium hydroxide is the main reaction product of MTA
  and water
• =causes reparative dentin formation= dentin bridges
• MTA provides some seal to tooth structure

Answer 9

MTA

Question 10

• Positives:
• Antibacterial
• Biocompatible
• High pH
• Radiopaque
• Works well for perforations
• Sharpey’s fibers attach to it
• Better seal than CaOH
• Negatives:
• Long setting time
• High solubility
• May discolor tooth
• Expensive
  Cover with GI/RMGI
• Protects MTA during long setting time

Answer 10

MTA

Question 11

• “Calcium silicate restorative dentin
  substitute
• Similar efficacy to MTA
• Dentin bridge formed underneath
• Stimulates calcium hydroxide ion release
• Reports not causing inflammation
• More cost effective than MTA
• Good sealing ability with dentin
• Many uses, including both direct and
  indirect pulp capping
• WEAK in early setting phase
• Sets in 10-12 minutes
• Manufacturer recommends waiting 12 minutes to
  place restoration

Answer 11

Biodentine

Question 12

• Nope!
• Highly Cytotoxic
• Leaks
• Less eugenol released over time
• Effectiveness reduced over time
• No pulp healing, no dentinal bridge formation
• Compromises bond strength if using bonded restoration

Answer 12

ZOE

Question 13

How many days does it take for reparative dentin to form?

Answer 13

45 days

Question 14

• Indications:
• -Rampant Caries that cannot be definitively treated in a
  timely manner
• -Patients with behavioral concerns
• -Medically compromised patients
• -Carious lesions determined un-restorable, or
  complicated to restore AND patient desires or requires to
  avoid conventional treatment as long as possible
• Contraindications:
• -Patient desires esthetic treatment in the area
• -Silver Allergy
• -Ulcerative gingivitis, stomatitis

Answer 14

Silver diamine fluoride

Question 15

• To avoid restoring only one tooth to completion to later
  discover that multiple teeth need extractions due to gross
  caries
• No anesthesia
• Multiple carious lesions treated at once
• Removal of superficial carious dentin
• As well as loose enamel to insure good seal
• When patient begins to feel pain= stop
• Place CaOH
• To stimulate tertiary dentin formation
• Restore with GI (NOT IRM)
• 6-8 weeks later, remove temporary restoration and
  remaining caries
• Tooth may still require endo
• Inform patient

Answer 15

Two Visit Caries Control