W8/9 Pulp pathology + deep caries management

Question 1

What can irritate the pulp/pa tissues?

Answer 1

Living irritants: microbial and viruses.

Non-living irritants:
Mechanical
Thermal
Chemical

Question 2

What could be microbial irritants?

Answer 2

Mainly from caries causing irritation to pulp and pa tissues; such a s.mutans, lactobacilli, actinomyces.

These produce toxins that penetrate the pulp. If the pulp is exposed, cannot eliminate bacteria gaining entry and pathway

Question 3

What are potential mechanical and thermal irritants?

Answer 3

Deep cavity preps
Handpieces without adequate cooling.
Occlusial trauma
Impact trauma
Periodontal curettage
Orthodontic movement

Question 4

What are potential chemical irritants?

Answer 4

Etch, acids, alcohol based products, hydrogen peroxide.

——-Excessive Eugenol

Question 5

What is an inflammatory response?

Answer 5

Non-specific inflammatory response. This is produced by response to antigens (bacteria) and their by products.
Immunoglobulins are sent to help, but necrosis may occur.

Question 6

How to diagnose pulp pathologies?

Answer 6

History!
EO
IO
Special tests
Radiographs

Question 7

What are defining features of ‘reversible pulpitis’?

Answer 7

Causes: caries, defective restorations exposing dentine, recent dental tx.
Symptoms: Can be asymptomatic, sharp, transient pain (h/c).

Removal of stimuli = immediate relief.

Question 8

What is the treatment in Reversible pulpitis?

Answer 8

Conservative elimination of causative agents, should reverse inflammation and pulp return to normal state.

Question 9

What is Irreversible pulpitis?

Answer 9

Severe inflammation in pulpal tissue. Usually a sequel to and progression of reversible pulpitis. If untreated = pulp necrosis

Question 10

What are the symptoms of Irreversible Pulpitis?

Answer 10

Can be spontaneous with no external stimuli.
Intermittient / continuous 
Sharp, dull, localised, diffuse.
May keep pt awake at night. 
May not be relieved by analgesics. 

When you place external stimulus h/c prolonged pain.

It can be asymptomatic.

Unless inflammation has extended into PDL, will response within normal limits to percussion and palpation.

Question 11

What is hyperplastic pulpitis?

Answer 11

Overgrowth of chronically inflamed young pulp outside of pulp chamber. Found in younger pts.

Question 12

What is pulpal necrosis?

Answer 12

Irreversible pulpitis = necrosis. Usually asymptomatic unless pain associated with PA area.

Question 13

What 4 types of deep caries management are their?

Answer 13

Complete caries removal: indirect pulp therapy, direct pulp cap.

Partial caries removal: indirect pulp therapy; stepwise caries removal.

Question 14

Describe complete caries removal?

Answer 14

Caries is completely removed. Small thickness of dentine remains over pulp or consequently pulp may become exposed.

Question 15

Describe Indirect pulp therapy after complete caries removal?

Answer 15

Once all caries is removed and no pulp exposure. <1mm of dentine remains over pulp. Calcium hydroxide is placed to increase dentine thickness.

Maintains pulp vitality through sclerosis of dentinal tubules and dentine formation.

Place final restoration immediately.

Question 16

How would you clinically do Indirect pulp therapy of complete caries removal?

Answer 16

1. Polyacrylic acid
2. Calcium hydroxide over deepest area
3. RMGIC (Fuji II).
4. Final restoration CR.
   “ Closed sandwhich”.

Question 17

When would a direct pulp cap be indicated?

Answer 17

All caries removed and small pulp exposure. No symptoms or symptoms associated with reversible pulpitis.

Question 18

How do you perform a direct pulp cap?

Answer 18

1. Apply slight pressure over exposure with sterile cotton pellet to stop bleeding x 3 1-2min
2. Calcium hydroxide

Question 19

When is direct pulp cap contraindicated?

Answer 19

Large mechanical exposure, exposure associated with infected dentine. Symptoms of irreversible pulpitis, necrotic pulp

Question 20

What are the steps involved in direct pulp cap?

Answer 20

1. Achieve haemostasis
2. Place calcium hydroxide
3. Place GI vitrebond liner
4. Conditioner
5. Place Fuji II (FMGI)
6. Place restoration CR etch, prime, bond.
7. Warn pt of possible outcomes
8. Review

Question 21

What are the disadvantages of complete caries removal?

Answer 21

High risk of pulp exposure. 
Invasion tx.
Extensive removal of tooth structure.
Follows mechanical approach as opposed to biological.
Cost.

Question 22

Describe partial caries - indirect pulp therapy

Answer 22

More caries is remove with spoon excavator, or large slow speed bur.

Leave small area of caries over pulpal/axial wall, that is high risk of exposure if removed.

Affective dentine remaining.
Pulp cap CaOH

Question 23

What are the clinical steps in the Stepwise technique

Answer 23

1. Polyacrylic acid
2. Calcium hydrox
3. GIC fuji II
4. Review 6 months

Question 24

What is the indication for indirect pulp therapy (partial removal)?

Answer 24

Chronic/arrested/ inactive/ slow progression.
Recurrent caries lesion under deep restoration with think remaining dentinal thickness.

Reversible pulpitis.
No PA pathology
No history of pain.

Question 25

What are the contraindication for indirect pulp therapy (partial removal).

Answer 25

Signs/symptoms of irreversible pulpitis, pa pathology, pulp exposure

Question 26

What are the contraindication for indirect pulp therapy (partial removal).

Answer 26

Signs/symptoms of irreversible pulpitis, pa pathology, pulp exposure

Question 27

What is step wise excavation?

Answer 27

Some caries removed with spoon excavator. Placement of temp resto over remaining caries. Promotes remineralisation and tubule sclerosis.

Question 28

What are the indication for step wise removal?

Answer 28

Active/soft, rapid lesion progression.
Reversible pulpitis.
No PA pathology

Question 29

What is the (5) steps of initial excavation (first stage of stepwise)?

Answer 29

1. Discuss procedure with pt.
2. Rubber dam isolation.
3. Remove peripheral superficial layers of carious lesion.
4. Remove peripheral superficial layers of carious lesion, resulting in atleast 1-1.5mm wise zone of sound dentin.
5. Leave discoloured, leathery dentin - remaining on pulpal and axial floors.

Question 30

What is the second stage in the (stepwise)?

Answer 30

1. New PA
2. Evaluate for symptoms or signs of pathology.
3. Remove provisional resto.
4. Remove remaining carious tissue.
5. Place final resto as indication.
6. FU in 6 months

Question 31

What are the advantages of Step Wise procedure?

Answer 31

Preserve tooth strucutre/minimall invasive procedure. Promotes sclerotic dentine. ALlows/maintains thicker remaining dentine. Claridies pulp vitality.