Vital pulp therapy

Question 1

Deep caries?

Answer 1

inner 1/4 dentine affected

Zone of hard dentine over the pulp

Risk of pulpal exposure

Question 2

Extremely deep caries?

Answer 2

penetrates entire thickness of dentine

Pulpal exposure unavoidable

Question 3

Answer 3

Extremely deep caries

Question 4

Answer 4

Deep caries

Question 5

Caries activity?

Answer 5

Light yellow

Actively progressing

Scoop out with spoon excavator

Question 6

Caries activity?

Answer 6

Light brown

Slowly progressing

Scoop out with spoon excavator

Question 7

Caries activity?

Answer 7

Dark brown

Slowly progressing/arrested

Question 8

Reparative dentinogensis after pulpal exposure?

Answer 8

Question 9

What is vital pulp tx?

Answer 9

to maintain health of all or part of the pulp

Question 10

Indirect pulp cap?

Answer 10

single stage caries removal to hard dentine

Biomaterial placement over thin layer of remaining dentine

Question 11

Selective various tissue removal?

Answer 11

selective to soft of firm dentine on pulpal wall

Biomaterial placement on pulpal wall of cavity

Question 12

Direct pulp cap?

Answer 12

class I - no pre-operative deep caries I.e. pulpal exposure due to trauma or iatrogenic damage

Class II - carious exposure, disinfectant and calcium silicate cement used

Question 13

Partial pulpotomy?

Answer 13

removal of a small portion of coronal pulp

Placement of biomaterial and restoration

Question 14

Full pulpotomy?

Answer 14

removal of all coronal pulp Placement

Placement of biomaterial and restoration

Question 15

What to use for class I pulp cap?

Answer 15

calcium hydroxide

Question 16

Indications for class I pulp cap?

Answer 16

complicated traumatic fracture, which involves a superficial exposure of the pulp or after an accidental perforation

Clinically pulp considered vital

Small exposure - coronal third of pulp chamber

Question 17

Class II pulp cap?

Answer 17

Pre operative presence of deep carious lesion

Symptoms may be present but not indicative of irreversible pulpitis

Question 18

What is biodentine?

Answer 18

calcium trisilicate cement

Question 19

When is direct pulp capping most cost-effective?

Answer 19

younger patients (under 40)

Question 20

When is pulp calling unsuccessful?

Answer 20

haemostasis difficult to achieve

Question 21

Can you do a partial pulpotomy for management of irreversible pulpitis?

Answer 21

Controversial

Remember to clean peripheries before going deeper

Question 22

What do you irrigate with?

Answer 22

sodium hypochlorite

Use cotton pellets and apply pressure to achieve haemostasis

Question 23

Technique for a pulpotomy?

Answer 23

1. Informed consent - pros and cons
2. Local anaesthesia
3. Rubber dam
4. Remove damaged pulpal tissue
5. Microbial control 1-3% NaOCl
6. Haemostasis
7. Placement hydraulic calcium trisilicate cement (biodentine)
8. Temporise (GIC)
9. Definative coronal restoration
10. Follow-up for upto 4 years

Question 24

Case selection VPT?

Answer 24

pulp must be vital

Younger or

Occlusal lesions

Traumatic lesions

No/minimal symptoms

All associated with better results

Question 25

When is VPT controversial?

Answer 25

management of irreversible pulpitis

Question 26

Properties of calcium silicate cements?

Answer 26

- Hydraulic (requires water to set) / hydrophilic - Non-resorbable - Biocompatible - Bioactive Favours regeneration of the pulp, bone, cementum and PDL

Question 27

How long does biodentine take to set?

Answer 27

12 mins No light cure No etch

Question 28

What dentine do bioceramics encourage?

Answer 28

Stimulate ondontoblasts to form tertiary dentine

Question 29

Do bioceramics cause host response?

Answer 29

Little or no host response when touches vital tissues Similar but better than calcium hydroxide

Question 30

Advantages of bioceramics?

Answer 30

Hydraulic setting reactions mean that they are hydrophilic with excellent ability to seal in moist areas, uninhibited by blood * Little or no host response when touches vital tissues – similar but better than calcium hydroxide * Collagen fibres can integrate with the material * When used for pulp capping this stimulation of odontoblasts encourages the formation of tertiary dentine * Regeneration of cementum & PDL also possible * Useful in many endodontic situations incl. retrograde apical filling material, internal / external perforation repair, internal / external tooth resorption, pulp capping, apexification, apexogenesis, orthograde sealant with GP

Question 31

Example of hydraulic calcium silicate cements?

Answer 31

MTA Biodentine (septodont)

Question 32

Properties of MTA?

Answer 32

* pH 12.5 therefore antimicrobial * Good dimensional stability, non-absorbent when set * Compressive strength develops slowly over 28 days to reach approx. 50MPa (equivalent to zinc oxide eugenol cement, less than dentine at ~290MPa) * Required to be placed in at least 2mm thickness to enable adequate compressive strength * Little or no marginal leakage in dye leakage studies * Expands in moist environments - advantageous in adapting material to walls of the tooth apically and in perforations * Denatures collagen so increases brittleness of adjacent dentine

Question 33

Disadvantages of MTA?

Answer 33

* Difficult to manipulate * Takes time to set (when used in orthograde situations a future apt for definitive restoration necessary) * Can be washed out when rinsed * Difficult to take a check PA prior to closure (as advocated in RCS/BES Periradicular surgery guidelines 2020) * Causes increased brittleness of adjacent dentine * Bismuth oxide causes darkening of tooth structure, particularly of it comes into contact with sodium hypochlorite * Expensive

Question 34

Properties of biodentine?

Answer 34

* Automix – easier with assured composition * If placed incorrectly can be washed out prior to setting. * Insoluable once set. * Ability to seal similar to other calcium silicate materials, equivocal whether better or worse than GIC. * Compressive strength similar to dentine, micro hardness outperforms bioaggregate, IRM, GIC and RMGIC. * Push out bond strength as good as MTA, unaffected by blood contamination. * Like MTA - definitive restoration should only be placed after 2 weeks when the biodentine is fully set. * Biocompatible, studies to date show biocompatibility and bioactivity comparable to that of the gold standard MTA. Dentine bridge formation and hydroxyapetite crystals forming at interface.