Vital Pulp Therapy Flashcards
if you’re close to the pulp place:
vitrebond
if you’re really close to the pulp place:
dycal then vitrebond
if pulp is exposed, place:
dycal then vitrebond
what are the two red flags in diagnosis
- deep caries
- pt presents with pain
what are the considerations with deep caries
- may be symptomatic or asymptomatic
- must be aware caries could approach pulp
- make the pt aware of this before prep
what are the considerations with pt presenting with pain
- compare objectives vs subjective findings
- rule out other possibilities
when do you vitality test
before anesthesia
what is the DDX for pain
- sinus pain
- periapical abscess
- periodontal origin
what are the considerations with maxillary sinus pain
- does pt have hx 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
what are the considerations with periodontitis as a DDX for pain
- pain more vague- regional, cant isolate to one tooth
- pulp vital
- percussion main symptom
- deeper pocketing depths usually
- pain episodic
what do you do with a pain DDX of PDL
- restoration left in hyperocclusion
- reduce occlusion
what are the considerations with acute periapical abscess as a DDX for pain
- not reversible pulpitis
- may be painful to percussion, palpation, chewing, to cold - >hot as tooth is dying
- may have swelling, fever
- radiographic PA lesion may or may not be present
- caused by bacteria
what do you do when a tooth tests non vital, necrotic pulp
refer to endo
what are the DDXs for PA radiolucency
- periapical abscess
- cementoma
what are the considerations for chronic periapical abscess as a DDX for PA radiolucency
- NOT reversible pulpitis
- radiographic periapical lesion
what are the considerations with cementoma as a DDX for PA radiolucency
- 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
what are the possible causes of pulpal irritation
- mechanical: iatrogenic or pt
- heat: dentists handpiece
- chemical: some dental materials
- bacteria: caries
what subjective data do you gather from the pt
- where is the pain
- how intense is the pain (1-10 scale)?
- how long has it hurt
- how long does the pain last
- what causes it to hurt
- does anything make it feel better
- what have you been taking for the pain
what are the objective tests
- percussion: remember to begin on asymptomatic tooth to get to baseline, use mirror handle or tooth slooth
- palpation
- thermal tests
- transillumination
- periodontal probing
- clinical exam
- radiographs
once it is determined that pain is pulpal in origin:
determine the type of pulpitis
what is the response in reversible pulpitis
- mild to moderate pain
- cold response
- occasional response to sugar or heat
- occasional response to biting pressure
- pulp is still vital
what are the causes of reversible pulpitis
- bacteria - caries
- trauma
- exposed dentin
- new restoration- deep restoration or occlusion is left high
what is the possible tx for reversible pulpitis
remove caries and or restoration and attempt to restore
what are the symptoms of irreversible pulpitis
- longer duration: pain lingers several minutes- hours
- heat sensitivity
- cold: may have lingering cold sensitivity or cold may alleviate pain
- spontaneous
what factors must be present to perform vital pulp therapy
- a vital tooth: pulpitis optional - reversible only
- a rubber dam
- clean walls of prep
- pulp capping material
what are the vital pulp therapy materials
- calcium hydroxide
- glass ionomer/resin modified GI
- mineral trioxide aggregate
-BC putty - # zinc oxide eugenol
what are the names for calcium hydroxide
dycal or life
what is the gold standard for direct pulp cap and why
- calcium hydroxide
- inexpensive
- antibacterial
- evidence- supported
- stimulates repair
describe the timeline of CaOH
- 2-3 minutes set up time
- 5-7 minutes to resist condensation forces
- 3 weeks formation of dentin bridge
glass ionomer/resin modified GI are most ___ cure
light
what are the advantages and disadvantages to glass ionomer/resin modified GI
- advantages: seals well as indirect pulp cap, good biocompatibility, fluoride release
- disadvantages: moderate to intense inflammation, no dentin bridge formation
what are the newer liners
-theracal
-biodentine
- limelight
may leave a small amount of ____ dentin to avoid pulp exposure
affected
when to perform vital pulp therapy - indirect pulp cap
- vital tooth: absolutely necessary, rule out irreversible pulpitis or nonvitality prior to beginning procedure
- asymptomatic with deep caries
- reversible pulpitis
- caries free
what are the considerations with indirect pulp cap
- 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 cant be 100% sure that affected dentin isnt 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
what is are the steps in the indirect procedure
- isolate
- access
- carefule debridement
what do you need to do in the isolation step for an indirect pulp cap
- use rubber dam
- keep bacteria far away from pulp in case of exposure
when do you perform a direct pulp cap
- vital tooth
- asymptomatic with deep caries
- reversible pulpitis
- and exposed pulp
what is the most important determinant of success in direct pulp caps
hemostasis
what do you do in a direct pulp cap
- achieve hemostasis
- cover exposure site with thin layer of CaOH
- begin at sound dentin, lead over exposure with instrument
- cover with GI/RMGI
- light cure
- restore with amalgam or composite resin material
- if composite is used, etch and bond after liner materials
you do VPT on exposed pulp only when:
the tooth is vital
how do you finish and seal a direct pulp cap
- rinse with water
-gently dry with air, cotton pellets- do not dessicate - place final restoration at same appointment to reduce leakage
- check occlusion to avoid premature occlusion
- restoration should be perfectly sealed
- avoid placing etch near pulp - always etch after vitrebond has been placed, focus on enamel
what is the most crtitical issue in insuring success of VPT when pulp is exposed
controlling hemorrhage
hemostasis achieved in ____ minutes is ideal
2-3 minutes
why is hemostasis achieved in 2-3 minutes ideal
longer= pulp already inflamed- will not respond well to therapy
how can you stop hemostasis
hold cotton soaked with NaOCl to exposure site for 30 seconds to stop bleeding
why bevel
- reduce miroleakage - particularly at cervical box in class II resin
- better results from etching - exposes underlying prismatic enamel
where is bond strength the highest in enamel
occlusal third of tooth
where is bond strength the lowest in enamel and why
- lowest to cervical third of tooth
- fewer enamel tags
- shorter enamel tags
- prismless enamel found here
when would you not bevel
when a bevel would remove all enamel
describe the etch surface
- increased surface area and surface energy
- allows wetting by hydrophobic adhesive resin
- enamel has minimal water- 3%
describe enamel bonding
- resin tags interlock
- micromechanical bonding
- enamel- adhesive composite bond- 20-25mPA
describe dentin bonding
- dentin compositiion- heterogenous
- dentin tubules
- intertubular dentin- less mineralized, hybrid layer is collagen fibrils and resin intermingled
- acid etched dentin- partial or total smear layer removal and demineralizes collagen
less intertubular dentin where?
closer to pulp
rubber dam helps counteract some issues with:
dentin bonding
in dentin bonding it is crucial to get:
hybrid layer formation
what are potential problems with forming hybrid layer
- overdrying - collapses colalgen
- overetching- demineralized zone is too thick and primer cannot fully penetrate
- underdrying- excess water leads to poor hybrid layer formation
what are advantages to total etch
- hybrid layer thicker
- larger resin tags
what are the disadvantages to total etch
- more steps
- possibility of collagen collapse
- can etch too deeply
- possibility of post op sensitivity
what are sealants
- resin material placed on grooves of non carious teeth
sealants seal surfaces to prevent caries formation on:
grooves and fissures
what are the most common type of sealants
resin based sealnts
what is the sealant placement process
- tooth must be cleaned with pumice
- optional enameloplasty
- etch grooves 15-20 seconds rinse
- place sealant material
- light cure
- check occlusion
when is a PRR done
- when inital caries are present
what is the PRR process
- remove caries- anesthetic not needed
- etch for 15-20 sec and rinse
- bond
- place flowable resin
- check and adjust occlusion
what brand do we use for resin infiltration
ICON
what is resin infiltration used for
white spot lesions usually after ortho tx or initial lesions in interproximal surfaces
what is the process of resin infiltration
- etch surface
- infiltrate using icon resin
what are the indications for SDF
- rampant caries that cannot be definitively treated in a timely manner
- pt with behavioral concerns
- medically compromised patients
- carious lesions determined un restorable or complicated to restore and pt dsires or requires to avoid conventional tx
what are the contraindications to SDF
- pt desires esthetic tx in the area
- silver allergy
- ulcerative gingivitis, stomatitis
what is low risk in CAMBRA
- no disease indicators, less than 2 risk factors and has protectice factors
what is moderate risk in CAMBRA
no disease indicators, more than 2 risk factors but no caries
what is high risk in cambra
cavitated lesions/disease indicatros or more than 3 risk factors
