vital pulp therapy Flashcards
definition of indirect pulp capping
ADA current dental terminology 2020:
procedure in which the nearly exposed pulp is covered with a protective dressing to protect the pulp from additional injury and to promote healing and repair via formation of secondary dentine
definition of stepwise excavation
application of a biomaterial in an indirect 2 stage selective carious tissue removal technique whereby a temporary restoration is placed in between visits
first stage: selective carious soft dentine removal, to an extent that facilitates TD placement. the carious dentine left behind will become arrested and the margins free of soft dentine can facilitate a good seal for the TD
second stage: after 6-12 months, we can re enter and remove to firm dentine. place permanent resto after
defn of direct pulp capping and what is the classification
application of a biomaterial directly onto exposed pulp, before placement of a permanent restoration
class I: underlying pulp tissue is healthy
class II: presence of deep carious lesion, with an expectation that the underlying pulp is inflamed
defn of pulpotomy (partial and full)
partial is the removal of a small portion of coronal pulp tissue after exposure, followed by the application of a biomaterial directly onto the remaining pulp tissue, before placement of a permanent restoration
full is the removal of coronal pulp, followed by the application of a biomaterial directly onto the pulp tissue at the level of the root canal orifice, before placement of a permanent restoration
how do the objectives of VPT in mature permanent teeth differ from that in immature permanent teeth and primary teeth?
goal in mature permanent teeth
- preservation of pulp vitality
- dentin bridge formation
- long term health
goal in immature permanent teeth
- continuation of root development (apexogenesis) is the primary objective, and need to preserve pulp vitality to allow for the natural closure of the root apex
- growth promotion: ensure that the tooth continues to mature and root canals develop fully to avoid future complications
goal in primary teeth
- mainly is to maintain pulp vitality until the natural exfoliation of the tooth, because premature loss can affect the alignment of permanent teeth
- prevent infection and pain
what are the types of selective caries removal and why is it done over complete caries removal
selective removal to soft dentine VS selective removal to firm dentine
done over complete caries removal because
- Maltz et al 2012: predictable outcomes have been achieved with selective caries removal
- Ricketts et al 2013: clinical studies have consequently not found detrimental effects to the pulp by sealing in bacteria
- Paddick et al 2015: number of viable long term remaining bacteria in proximity to the pulp does not seem to be increased in sealed lesions
hence we should embrace selective caries removal because
- reduced risk of pulpal exposure: Ricketts 2013: stepwise caries removal resulted in a 56% reduction in incidence of pulp exposure compared to complete caries removal
- dentine conservation
whats the incidence of pulp exposure in complete caries removal vs stepwise
Ricketts 2013
incidence of pulp exposure in complete caries = 34.7%
incidence of pulp exposure in stepwise = 15.4%
why is dentine conservation important when we remove caries
- dentine is an excellent thermal insulator when >0.5mm (Stanley 1981)
- remaining dentine thickness of >0.5mm is necessary to avoid causing any evidence of pulp injury, so we should maximize the RDT to limit pulp tissue destruction (Murray 2003)
describe how selective caries removal is performed and the rationale for each step
technique is completed in 2 visits. re entry after 6-12 months
1st visit:
- selective removal of carious dentine until soft dentine is left over pulp
- peripheral dentine is prepped to hard dentine, to allow for tight and durable coronal seal
- rationale is to change the cariogenic environment and allow the carious dentine to change to arrested carious dentine, and to allow for formation of tertiary (reparative) dentine formation
- MTA/ biodentine/ GIC is placed over deep dentine when pulp is not exposed
2nd visit
- remova of firm dentine
- rationale is that it is now easier to remove the dentine as the consistency of retained dentine is different, going in a second time also serves as an opporutnity to reevaluate changes in intralesion color and hardness
why is dycal used for indirect pulp cap
- to promote remineralisation of affected dentine
- bactericidal
- promotes tertiary dentine formation
factors that can affect tx success of selective caries removal
split into patient related factors and operator dependent factors
patient related:
- extensive caries causing pulp exposure
- presence of multi surface restorations that increase the chances of leakage and technique sensitivity
- poor OH
- age of patients: pulp in older patients have less cells and poorer perfusion so less likely to react well to microbial insult
operator dependent
- lack of asepsis
- iatrogenic pulp exposure
- choice of material and restoration technique (eg if got lack of coronal seal allowing for bacterial ingess)
- technique sensitivity (fine line between soft and hard dentine for different operators)
defn of pulpotomy and the rationale behind it
it is the removal of the coronal portion of the vital pulp, and is a minimally invasive vital pulp treatment to manage deep caries when there is pulpal exposure
rationale:
- preserve vitality of remaining radicular pulp
- manage bacterial contamination, arrest caries progression and promote pulpal repair
- quicker, less technically complex and invasive than pulpect and RCT
- reduce unwanted effects like fracture
moa of caoh2 and what is its limitation
forms zone of liquefaction necrosis subjacent to it and deeper zone of coagulation necrosis next to vital pulp tissue
limitation is that there is dissolution leading to loss of antibacterial effect, allowing bacteria to use these vascular channels to enter pulp, can lead to pulpitis
moa of mta, what are its pros and cons
moa:
- apparently exact MOA is only partially understood
- but chatgpt says MTA releases calcium hydroxide during setting, leading to high pH of approx 12.5 and the alkaline envt has antimicrobial properties, reducing bacterial survival
- calcium ions released interact with surrounding tissues, stimulating the formation of HAP, whcih aids in dentin regeneration
- also promotes odontoblast differentiation, facilitating dentin bridge formation in pulp capping procedures
pros
- very biocompatible
- able to form a very tight seal where it contacts dentin walls (excellent sealing properties due to its expansion upon setting), hence reduce microleakage and prevent bacterial ingress
con:
- can cause staining and discoloration
what materials used to achieve hemostasis in pulpotomy, and what to avoid?
use cotton pellets soaked in sodium hypochlorite (0.5-5%) or CHX (0.2-2%) [Mente et al 2014, Kundzina 2017]
not preferred
- saline: acceptable in class I pulp capping (not carious exposure) but is limited in efficacy bc of lack of disinfection properties
- ferric sulphate (Astringedent 15.5%) is an effective hemostatic agent but will distort the assessment of pulpal bleeding because it will just stop the bleeding
factors affecting tx success of PULPOTOMY
1) patient factors
-patient age
- size of exposure: if very large
2) intraoperative factors
- asepsis: need to do RDI
- magnification and illumination to ensure removal of all soft dentine and inspect pulp tissue
- seal, integrity and quality of restoration
indications for direct pulp cap
- teeth with no hx of lingering pain to external stimuli (first thing is to make sure its not symptoms of irreversible pulpitis which will indicate need for RCT)
- small mechanical or traumatic pulp exposure of vital, asymptomatic pulp
- exposure occurs under RDI
- bleeding controlled at exposure site
- carious exposure of teeth in young patients with incompletely developed root (should be ok bc large pulp volume, pulp more cellular)
contraindications of DPC
- large pulp exposure in a non aseptic environment
- teeth with clinical signs and symptoms of irreversible pulpitis/ necrotic pulp
- teeth that present with periradicular pathosis
indications for pulpotomy in both primary and permanent teeth
primary teeth
- pulp exposure and radicular pulp is still healthy (main thing must make sure that radicular pulp is healthy)
- irreversible pulpitis (because clinical signs of irreversible pulpitis does not necessarily mean that the radicular pulp is affected)
permanent teeth
- carious exposure
- teeth with immature root formation, because we want continued root development (apexogenesis) prior to RCT
- as an emergency procedure until RCT can be performed
contraindications of pulpotomy
- when pulpal pathology involves radicular pulp
- teeth with irreversible pulpitis/ necrotic pulp in PERMANENT teeth
- teeth that present with periradicular pathosis
