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Advanced Restorative > Vital Pulp Therapy > Flashcards

Vital Pulp Therapy Flashcards

1
Q

Bond strength to perpendic
Enamel (ENDS of rods)=

Bond strength to parallel
enamel (SIDES of rods)=

A

25MPa
7-10MPa

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2
Q

BOND STRENGTH HIGHEST TO — THIRD OF
TOOTH
* BOND STRENGTH LOWEST TO — THIRD OF
TOOTH

A

OCCLUSAL
CERVICAL

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3
Q
  • BOND STRENGTH LOWEST TO CERVICAL THIRD OF
    TOOTH
    (3)
A
  • Fewer enamel tags
  • Shorter enamel tags
  • Prismless enamel found here
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4
Q

Review- WHY BEVEL?
(2)

A
  • Reduce microleakage
    -Particularly at cervical of box in Class II resin
  • Better results from etching
    -Exposes underlying prismatic enamel
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5
Q

REVIEW- When to NOT bevel

A
  • When a bevel would remove all enamel
  • Attempting to bond to dentin only= microleakage, weak bond
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6
Q

Review/Disclaimer- Dentin Bonding
* BOND TO ENAMEL IS SUPERIOR TO BOND TO
DENTIN
(3)

A
  • Enamel interlocking with enamel rods
  • Dentin interlocking with dentin collagen
  • Dentin collagen is very touchy
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7
Q

Enamel Bonding, summarized
* — surface
* Increased surface — and surface —
* Allows wetting by —
* Remember- enamel has MINIMAL —
* — interlock
* Macro and micro tags into surface —
* — bonding!
* Enamel- Adhesive- Composite Bond!
* — MPa
* Clinically Acceptable!

Etch

A

Etch
area,energy
hydrophobic adhesive resin
water (3%)
Resin tags
irregularities
Micromechanical
20-25

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8
Q

Review- Dentin Bonding
* Dentin composition- —
* Less —, more —
* Dentin tubules
* Intertubular dentin
* Less —
* Hybrid layer is (2)
intermingled
* — etching dentin
* Partial or total — layer removal AND — collagen
Intertubular

A

heterogenous
mineral,water
mineralized
collagen fibrils and resin
Acid
smear
demineralizes

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9
Q

Review- Dentin Bonding
* Depth of cavity
* LESS INTERTUBULAR DENTIN CLOSER TO —
* Deeper cavity= — bond
* Rubber Dam
* Helps counteract some issues with dentin bonding

A

PULP
worse

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10
Q

Review- Dentin Bonding
* Crucial to get — formation
* Many factors working against you in deep preparations.

A

hybrid layer

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11
Q

Review- Dentin Bonding
* Potential problems with forming hybrid layer
(3)

A
  • Overdrying
  • Overetching
  • Underdrying
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12
Q
  • Overdrying-
  • Overetching-
  • Underdrying-
A

collapses collagen
demineralized zone is too thick and primer cannot
fully penetrate
excess water leads to poor hybrid layer formation

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13
Q

Total Etch
* You TOTALLY have to etch first!
* Advantages
(2)

A
  • Hybrid layer thicker
  • Larger Resin Tags
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14
Q

Total Etch
* Disadvantages
(4)

A
  • More steps
  • Possibility of collagen collapse
  • If done incorrectly
  • Can etch too deeply
  • If done incorrectly
  • Possibility of post-op sensitivity
  • If done incorrectly
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15
Q

Self Etch
* The bond agent claims to

A

etch the prep
* Not as good of an etch

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16
Q

Self Etch
Advantages
(3)

A
  • Takes less time
  • No problems with overdried, collapsed collagen
  • Low post-op sensitivity
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17
Q

Self Etch
Disadvantages
(3)

A
  • Not compatible with some composites
  • Does not efficiently etch prepared enamel
  • Questionable long term bond strength
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18
Q

Universal Adhesive

A
  • Works as Total OR Self- Etch
  • MDP monomers
  • Can acid etch then use universal adhesive
  • Option to SELECTIVE etch (enamel only)
  • I’m leaning toward this option most frequently
    OR
  • Can skip acid etching step
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19
Q

Chlorhexidine in bonding
Chlorhexidine gluconate has been found to increase long term bond
strengths
* How?
(3)
* Found in Consepsis antibacterial agent
(2)

A
  • Hybrid layer can degrade over time
  • CHX INHIBITS MMP COLLAGENOLYTIC ACTIVITY
  • Place 2% chlorhexidine solution after etching, rinse thoroughly
  • Indicated for endo procedures
  • Can place after etch prior to bonding
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20
Q

CAMBRA Risk Assessment
* Low Risk:
* Moderate Risk:
* High Risk:

A
  • no disease indicators, <2 risk factors, has
    protective factors
  • no disease indicators, > 2 risk factors (but no
    caries)
  • Cavitated lesions/disease indicators OR >3 risk
    factors
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21
Q
  1. For all ideal depth cavity preparations that use amalgam as
    the restorative material,
A

no sealer or liner is necessary.

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22
Q
    1. For preparations deeper than normal with at least 1.0 mm of
      dentin between the pulp and the restorative material,
A

no sealer
or liner is necessary.

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23
Q
    1. For preparations deeper than normal with less than 1.0 mm
      of dentin between the pulp and the amalgam,
A

a liner using a
resin modified glass ionomer is recommended as a thermal
insulator.

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24
Q
    1. For preparations with less than 0.5 mm of dentin between
      the pulp and the amalgam,
A

a thin calcium hydroxide liner is
recommended followed by a thermal insulator of resin modified
glass ionomer.

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25
Q
    1. For preparations with a direct pulp exposure on a vital pulp a
A

calcium hydroxide liner ~ 0.5 mm in thickness is recommended
followed by a thermal insulator of resin modified glass ionomer

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26
Q

TLDR;
* If you’re close to the pulp, place —
* If you’re REALLY close to the pulp, place —
* If pulp is exposed, place —

A

Vitrebond
Dycal then Vitrebond
Dycal then Vitrebond

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27
Q

DIAGNOSE
Two red flags:
(2)

A

Deep Caries
-may be symptomatic or asymptomatic
-must be aware caries could approach pulp

  • make patient aware of this BEFORE prep
    Patient Presents with Pain
    -Compare Objective vs. Subjective findings
    -Rule out other possibilities
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28
Q

**— TEST FIRST!
(before anesthesia!)

A

VITALITY

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29
Q

Any time you even suspect that you may get a pulp exposure, — test first!

A

vitality

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30
Q

DIAGNOSE
SCENARIO: Patient comes to your office in pain
Rule out other possible causes
* Differential diagnoses
(3)

A
  • Sinus pain
  • Periapical Abscess
  • Periodontal Origin
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31
Q

Differential Diagnosis: Maxillary Sinus Pain
* FLAG: patient presents with pain
* 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 of maxillary arch on one or both sides?
* Lack of radiographic/clinical evidence of decay?
DO NOT TREAT DENTALLY! May need to refer to —

A

ENT

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32
Q

Differential Diagnosis: Periodontitis
* Flag: patient presents with pain
* Pain more —
* —, can’t isolate to single tooth
* Pulp —
* — main symptom
* Deeper — depths usually
* Pain —

A

vague
Regional
VITAL
Percussion
Pocketing
episodic

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33
Q

Differential Diagnosis: PDL

A
  • Restoration left in hyperocclusion
  • Reduce occlusion
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34
Q

Differential Diagnosis: Acute Periapical Abscess
* Flag: (2)
* NOT Reversible Pulpitis
* May be painful
* To (3)
* To cold-> — as tooth is dying
* May have (2)
* Radiographic periapical lesion may or may not be present
* May be too early
* Caused by —
* Non-vital, necrotic pulp=
* NOT painful to —

A

potentially pain and/or radiographic caries
percussion, palpation, chewing
hot
swelling, fever
bacteria
right to endo (after consult, of
course)
cold/hot

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35
Q

DIAGNOSE
SCENARIO: PA radiolucency
Rule out other possible causes
* Differential diagnoses
(2)

A
  • Periapical Abscess
  • Cementoma
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36
Q

Differential Diagnosis: Chronic Periapical
Abscess
* Flag: (2)
* NOT Reversible Pulpitis
* Radiographic — lesion
* Non-vital, necrotic pulp=
* No response to —
* No response to —

A

radiolucency, previous trauma
periapical
right to endo (after consult, of
course)
endo ice
EPT

37
Q

Differential Diagnosis: Cementoma
* No flags, but the radiographs sure are suspicious!
* Not —!
* Rule out cementoma in radiograph presenting similar to —
* Most commonly in — region
* — test prior to tx
* Vitality:
* Be very suspicious if no caries present

A

Abscess
abscess
lower anterior/premolar
Pulp
VITAL

38
Q

Ruled those out?
* Next step:
* Determine if — in origin
* Subjective and Objective tests
* Subjective needs to match objective findings

A

pulpal

39
Q

skipped
Subjective Data
Gather from patient
(7)

A
  • WHERE is the pain?
  • How intense (1-10 scale)?
  • How long has it hurt?
  • How long does pain last?
  • What causes it to hurt?
  • Does anything make it feel better?
  • “What have you been taking for the pain?”
40
Q

Objective Tests
(7)

A
  • Percussion
  • Palpation
  • Thermal tests
  • Transillumination
  • Periodontal probing
  • Clinical exam
  • Radiographs
41
Q
  • Percussion
    (3)
A
  • Remember to begin on asymptomatic tooth to get baseline
  • Mirror handle
  • Tooth Slooth
42
Q

Alternate Ending- pain is pulpal BUT
* Reversible

A
  • Discuss options with patient
  • Including cost of ENTIRE procedure
  • Stop looking at Operative III lecture notes, refer to
    Endodontics lecture notes!
  • Endodontic Consultation in our clinic
  • Not too alarming because you already discussed this
    possibility with your patient before the procedure
  • AND you already have a rubber dam placed!
43
Q

Reversible Pulpitis

A
  • Mild- moderate pain
  • Cold response
  • Occasional response to sugar or heat
  • Occasional response to biting pressure
    Pulp is still vital
44
Q

Reversible Pulpitis, continued
* Causes:
(5)
* Possible Treatment:
(1)

A
  • Bacteria (caries)
  • Trauma
  • Exposed dentin
  • New restoration
  • Deep restoration or occlusion left high
  • Remove caries and or restoration and attempt to restore
45
Q

Irreversible Pulpitis

A

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

46
Q

What factors must be present to perform vital pulp therapy?
(4)

A
  • A VITAL tooth
    -Pulpitis optional (reversible only)
  • A RUBBER DAM
  • Clean walls of prep
  • Pulp capping materia
47
Q

Pulp Capping Materials
(5)

A
  • Calcium Hydroxide
  • Glass Ionomer/Resin Modified GI
  • Mineral Trioxide Aggregate
  • BC Putty
  • Zinc Oxide Eugenol
48
Q

Pulp Capping Materials
Newer liners:
(3)

A
  • Theracal™
  • Biodentine™
  • Limelight™
49
Q

Calcium Hydroxide (CaOH)
(2)

A
  • Dycal™ or Life™
  • Gold standard for direct pulp cap
50
Q

Calcium Hydroxide (CaOH)
* Gold standard for direct pulp cap

A
  • 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
51
Q

CaOH, continued
* Set up time: — minutes
* — minutes to resist condensation forces
* ~ 3 weeks=
* Cause — response in pulp
* Results in —
* Use CaOH with pH — ideally
* Leaves less pulp destruction
* Basic nature of CaOH=

A

2-3
5-7
formation of dentin bridge
inflammatory
dentin bridges
9-10
environment inhospitable to bacteria

52
Q

CaOH, continued
CONS:
(3)

A
  • No dentin bonding
  • Water soluble
  • Will eventually leak, may disappear
  • seal with GI overlayer to help reduce leakage
  • May lead to closure of pulp chamber and canals over time
53
Q

Glass Ionomer/Resin Modified GI
* Most are light cured
* The Good:
(3)

A
  • Seals well as indirect pulp cap
  • Good biocompatibility
  • Fluoride release
54
Q

Glass Ionomer/Resin Modified GI
* The not-so-good:
(2)

A
  • Moderate to intense inflammatory pulp response
  • No dentin bridge formation
55
Q

Mineral Trioxide Aggregate (MTA)
* — is the main reaction product of MTA
and water
* =causes reparative dentin formation=
* MTA provides some — to tooth structure

A

Calcium hydroxide
dentin bridges
seal

56
Q

MTA, continued
* Positives:
(7)

A
  • Antibacterial
  • Biocompatible
  • High pH
  • Radiopaque
  • Works well for perforations
  • Sharpey’s fibers attach to it
  • Better seal than CaOH
57
Q

MTA, continued
* Negatives:
(5)

A
  • Long setting time
  • High solubility
  • May discolor tooth
  • Expensive
    Cover with GI/RMGI
  • Protects MTA during long setting time
58
Q

ZOE
* Nope!
(5)

A
  • 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
59
Q

Managed to Avoid Exposure
* Ensure ALL — are removed
* May leave SMALL AMOUNT of — dentin to avoid pulp exposure
- Restorative and Endo disagree
* Place (2) to provide barrier against chemical and thermal
irritation
* Per Clinic Manual:
* CaOH when <— dentin remains
- Cover with —
* Vitrebond when >— dentin remains

A

CARIES
AFFECTED
CaOH or Vitrebond
0.5mm, Vitrebond
0.5mm

60
Q
  • Gold thermal conductivity= – times that of tooth
  • Amalgam thermal conductivity – times that of tooth
A

500
30-40

61
Q

When to Perform Vital Pulp Therapy-
Indirect (Indirect Pulp Cap)
(4)

A
  • VITAL TOOTH!!
  • Absolutely necessary
  • Rule out irreversible pulpitis or nonvitality prior to
    beginning procedure
  • Asymptomatic with deep caries
  • And/or
  • Reversible pulpitis
  • Caries free
62
Q

One Visit Vital Pulp Therapy-
Indirect Procedure
* Goal: avoid/prolong need for root canal

A
  • Remove all caries, place pulp capping material and final
    restoration
  • OPERATIVE: may leave AFFECTED dentin to avoid pulp exposure
  • Ideally, remaining caries remineralize, pulp not traumatized by exposure
  • ENDODONTICS: you can’t be 100% sure that affected dentin isn’t
    actually infected= REMOVE ALL CARIES
  • Better to get pulp exposure and leave no trace of caries
  • 1-2mm remaining dentinal thickness (including liner) is ideal
  • Restoration must rest on sound dentin
  • Reminder: Vitality Test first!
63
Q

Vital Pulp Therapy-Indirect Procedure:
Isolate
* No problem- we use — on all operative
procedures
* ESPECIALLY those with deeper lesions
* Keep bacteria far away from pulp in case of exposure

A

rubber dams

64
Q

Vital Pulp Therapy-Indirect Procedure:
Access
* Establish Outline Form
* Remove superficial caries at —
- Remember floor and cusp area

A

DEJ

65
Q

Vital Pulp Therapy-Indirect Procedure:
CAREFUL Debridement
* Outline form is established
* Continue caries removal at DEJ
* Ensure all non-pulpal walls are caries-free
(2)

A
  • Caries removed ENTIRELY from these walls
  • Remove enough tooth structure here that you can properly
    visualize the deeper areas
66
Q

Vital Pulp Therapy-Indirect Procedure:
CAREFUL Debridement Continued
* Carefully excavate across pulpal floor/wall
* Use new — bur
- Avoid cross contamination
* Use sharp — at final stage
* Strokes tangent to —
- Avoid forcing instrument/dentin chip into pulp

A

sterile
spoon excavator
pulp chamber

67
Q

Vital Pulp Therapy-Indirect Procedure:
CAREFUL Debridement Continued
* Place restoration
* WELL-SEALED (2) restoration

A

amalgam or composite

68
Q

If you’re planning crown/bridge:
* Proceed with

A

root canal therapy rather than vital pulp
therapy
* 95% success rate- better long term

69
Q

When to Perform Vital Pulp Therapy-
Direct (Direct Pulp Cap)
(4)

A
  • VITAL TOOTH!!
  • Asymptomatic with deep caries
  • And/or
  • Reversible pulpitis
  • AND exposed pulp
  • Yep, you used Endo Ice to vitality test before starting!
70
Q

Vital Pulp Therapy-Direct Procedure:
Access
(3)

A
  • Establish Outline Form
  • Remove superficial caries at DEJ
  • Remember floor and cusp area
71
Q

Vital Pulp Therapy- Direct Procedure:
CAREFUL Debridement
* Outline form is established
* Begin at DEJ
* Ensure all non-pulpal walls are —-free
- Caries removed ENTIRELY from these walls
- Remove enough tooth structure here that you can properly visualize the deeper areas
* Carefully excavate across —
- Use new — bur
- Avoid cross contamination
- Use sharp — at final stage
- Strokes tangent to —
- Avoid forcing instrument/dentin chip into pulp

A

caries
pulpal floor/wall
sterile
spoon excavator
pulp chamber

72
Q

Pulp is exposed
* Vital Pulp Therapy Time!
* MOST IMPORTANT DETERMINER OF SUCCESS:
* ACHIEVE —
* Once — is achieved,
* Cover exposure site with thin layer of —
* Begin at sound dentin, lead over exposure with instrument
* Cover with —
* Light cure
* Restore with amalgam or composite resin
material
If composite resin material used, etch and
bond — liner materials

A

HEMOSTASIS
hemostasis
CaOH
GI/RMGI
AFTER

73
Q

Pulp is exposed- hemostasis
* Controlling — is the most critical issue in
ensuring success of vital pulp therapy when pulp is
exposed
* Hemostasis achieved in – minutes is ideal
* Longer=
* Hold cotton soaked with — to exposure site for 30+
seconds to stop bleeding

A

hemorrhage
2-3
pulp already inflamed, will not respond well to therapy
NaOCl

74
Q

RECAP: Vital Pulp Therapy-
Exposed Pulp
* ONLY in VITAL tooth with pulp exposure
* Ideally <— exposure
* — hemostasis= better prognosis
- — minutes
* — exposure= better prognosis
- Minimal introduction of bacteria into site
- One reason we rubber dam!!!
* To attempt to avoid/delay —

A

0.5-0.75mm
Fast
2-3
MechanicalRCT

75
Q

Vital Pulp Therapy- Direct Procedure:
Final steps
(3)

A
  • Rinse with water
  • Gently dry with air, cotton pellets
  • Do not dessicate
76
Q

Vital Pulp Therapy:
Direct Restoration
* Ideally, place final restoration at same appointment
- Reduce —
* Check —
- Avoid — occlusion
- =pain caused by non-pulpal origin, confusing if vital pulp therapy is successful
* Restoration should be perfectly sealed
* Avoid placing etch near —
- Always etch — Vitrebond has been placed, focus on enamel

A

leakage
occlusion
premature
pulp
AFTER

77
Q

Vital Pulp Therapy: Convalescence
* “Sick” pulp will heal over next — weeks
- – days for reparative dentin to form
* Recommend healthy diet and guarded chewing on
affected side
* Inform patient that some soreness is normal
- It should begin to feel better after a couple days, not worse
- Root Canal may be indicated if pain does not go away or worsens
over time
- Ideally, you’ve set yourself up for success and already discussed
this with the patient before beginning procedure!

A

2-6
45

78
Q

Follow Up
* Look for pain that increases in severity=
- Post-operative discomfort is normal, but should decrease gradually
over the first — days
- — hypersensivity- normal part of healing process
- Recommend OTC analgesics
- Offer ibuprofen while patient is still in the chair
- Easier to ward off pain that try to play catch up
* You as provider do the following up
- Don’t wait for patient to call you
- Good practice builder

A

POOR prognosis
3-7
Cold

79
Q

Success!
(3)

Tooth may always become nonvital years later
-more success with patient under – years old
-historically, greatest success with —
restorations

A
  • Tooth asymptomatic
  • Tooth vital
  • PA radiograph is lesion-free

40
amalgam

80
Q

What if it’s not a success?
* This can be at the pulp exposure visit
- — cannot be achieved
- Pulp is exposed and gross caries remain
* This can after the —
- Soon after or a long time after
- Patient becomes symptomatic
- Subjective-
- Objective-
* TIME FOR ENDODONTICS
- Or extraction

A

Hemostasis
vital pulp therapy
feeling pain
radiographic evidence

81
Q

Evidence- Indirect Pulp Capping
-Lesion changes from —
-Lesion changes from —
-Significant reduction in (2)
-radiographs show no change or even reduction in
— zone
- — more important that type of
liner
-significant reduction of pulp exposure with partial
caries excavation

A

light to dark brown
soft, wet to hard, dry
s mutans and lactobacilli
radiolucent
well-sealed restoration

82
Q

Evidence- Indirect Pulp Cap
-Risk of failure similar for
(2)
excavated teeth
-Considerable reduction of post-
operative pulpal complications for
— excavation
-No evidence that partial caries
removal is detrimental in terms of
(4)
-Evidence that complete caries
removal is not necessary for
success when the restoration is
—

A

incompletely and completely
incomplete
signs, symptoms, pulpitis
occurrence, or restoration longevity
well-sealed

83
Q

Evidence- Indirect Pulp Cap
Approximately –% successful in first
year, –% success after 5 years,
–% after 9 years.
Definitive restoration played important
part in success, with — being
most successful, followed by
composite, then —.
— of tooth surfaces affected also
played a part in success, with fewer
affected surfaces being more
successful
No difference in gender of patient,
whether dental student under close
supervision or dentist placed cap, or
location of teeth on success of pulp
cap

A

80
68
58.7
amalgam
Glass Ionomer
Number

84
Q

Other caries control considerations:
Two Visit Caries Control
* To avoid restoring only one tooth to completion to later
discover that

A

multiple teeth need extractions due to gross
caries

85
Q

Other caries control considerations:
Two Visit Caries Control
* No —
* 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=
* Place —
- To stimulate — dentin formation
* Restore with —
* — weeks later, remove temporary restoration and
remaining caries
* Tooth may still require —
* Inform patient

A

anesthesia
stop
CaOH
tertiary
GI (NOT IRM)
6-8
endo

86
Q

Other caries control considerations:
Silver Diamine Fluoride
* Indications:
(4)

A
  • -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
87
Q

Other caries control considerations:
Silver Diamine Fluoride
* Contraindications:
(3)

A
  • -Patient desires esthetic treatment in the area
  • -Silver Allergy
  • -Ulcerative gingivitis, stomatitis
88
Q

Wrap Up
* Avoid exposing pulp if at all possible
* If pulp is exposed, control —
- Largest determining factor for success of pulp cap
* — is historic gold standard for direct pulp cap
- (2) close behind
* Provide a — restoration

A

hemorrhage
CaOH
MTA and Biodentine
WELL-SEALED

Advanced Restorative (14 decks)

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