Deep Caries & Pulp Therapy for primary dentition-Dr. Tucker

Question 1

Pulp Therapy Objectives

Answer 1

• maintain:
  
  • integrity and health of the teeth and supporting tissues
  • vitality of the pulp affected by caries, traumatic injury, other causes

Question 2

Pulp Preservation

Answer 2

• Primary goal for tx of young permanent dentition
• continues apexogenesis

Question 3

Long term retention of a permanent tooth requires:

Answer 3

• root w/a favorable crown/root ratio
• thick dentin walls to withstand normal function

Question 4

Pulp therapy Progression: Label each line

Answer 4

Question 5

Things to consider before starting pulp therapy

Answer 5

• Medical Hx
• Dental Hx
• Clinical eval
• Radiograph exam
• Value of involved teeth in relation to child’s overall dental developement
• alternatives to pulp therapy
• restorability of tooth

Question 6

Medical Hx

Answer 6

• Serious illness-contraindicated for endo
  
  • bc of risk of acute infection if pulp therapy fails
• High SBE risk patients
• immunosuppressed patients
• poor healing potention
  
  • uncontrolled diabetes

Question 7

Radiographic Assessment

Answer 7

Primary molars

• BW
  
  • evaluate
    
    • depth of decay
    • furcation area
      
      • furcation radiolucency occurs in primary teeth first
• PA
  
  • internal root resorption
  • external root resorption
• compare lamina dura w/adjacent and contralateral teeth

Question 8

In primary teeth, where are most accessory canals located?

Answer 8

• Furcation

Question 9

In permanent teeth, where are most accessory canals located?

Answer 9

apex

Question 10

Value of involved teeth

Answer 10

• how long before expected exfoliation
• position in arch
• Overall health of dentition
  
  • previous space loss from extractions or caries
  • health of remaining teeth
• Level of parents desire and motivation in maintaining oral health

Question 11

Signs of reversibe pulpitis

Answer 11

• Pain provoked by a stimulus
  
  • hot, cold, or sweets
  • NOT spontaneous
  • relieved by removing stimulus or covering exposed dentin
• soft tissue
  
  • within normal limits
  • free of abscess or fistula
• not sensitive to percussion
• No:
  
  • lymphadenapthy and fever
  • internal or external root resorption
  • furcation radiolucency
• Pain relieved by OTC analgesics

Question 12

Signs of irreversible pulpitis or necrosis

Answer 12

• Pain is spontaneous
  
  • especially at night and persists
• Soft tissue:
  
  • inflammation or swelling
    
    • not related to perio condition
• Sensitive to percussion or mobile
  
  • not related to trauma or exfoliation
• Lymphadenapathy and/or fever
• Abcess or fistula
• Internal/external resorption
• furcation radiolucency

Question 13

Vital Therapy Techniques is used to treat what?

Answer 13

• Tx reversible pulpitis
  
  • to retain tooth
  • maintain function

Question 14

Vital therapy techniques goal in primary teeth is to

Answer 14

• preserve tooth until it naturally exfoliates

Question 15

What are the Vital Therapy Techniques:

Answer 15

• Protective liner
• caries control
• indirect pulp treatment (“Cap”)
• Direct pulp cap
• Pulpotomy

Question 16

Protective Liner

Answer 16

• thin liqued on pulpal surface of deep cavity prep
• covers exposed dental tubules
• acts as a protective barrier b/w restorative material/cement and the pulp

Question 17

Protective liner examples

Answer 17

• calcium hydroxide
• Glass ionomer
• dentin bonding agent

Question 18

Cavity Liners

Answer 18

• suspensions of calcium hydroxide in water or organic liquid
• barrier
• neutralizes acids

Question 19

Protective Liners Indications

Answer 19

• minimize injury to pulp
• promote pulp tissue healing
• minimize post-op sensitivity

Question 20

Objectives for use of a protective liner

Answer 20

• Preserve vitality
• promote pulp tissue healing and tertiary dentin formation
• Minimize bacterial microleakage
• No adverse post-op signs or symptoms
  
  • sensitivity
  • swelling
  • pain

Question 21

Caries control procedure is indicated when

Answer 21

• extensive caries-adverse pulpal consequences are likely to occur soon
• goal of tx is to remove the focus of the infection
• extensive caries that cannot or should not be permanently restored due to inadequate time or questionoable pulp prognosis

Question 22

caries control

Answer 22

• urgent/emergency procedure
• slows the progression of the decay process
• minimizes sensitivity to hot, cold and sweets
• prevents food impaction
• Only for
  
  • reversible pulpitis
  • asympmtomatic vital teeth

Question 23

Caries control procedure

Answer 23

• rapid removal of caries
• placement of temporary restoration
• reschedule for permanent restoration
  
  • gives pulp time to recover
  • better assessment of pulp status

1. no local anesthetic
2. Superficial decay removed
3. Seal lesion w/temporary material (IRM or glass ionomer cement)

Question 24

Indirect Pulp Treatment indications

Answer 24

• no pulpitis or reversible pulpitis or asyptomatic
  
  • when deepest carious (hard) dentin is not removed to avoid pulp exposure
  • no decay left on walls
• Deep decay that approaches the pulp
• no evidence of pathology
• Pulp evaled by clinical and radiograph criteria to be vital and able to heal

Question 25

Indirect Pulp Treatment: Objectives

Answer 25

• Restoration should seal the dentin from oral enviroment complement
• Preserve tooth vitality
• No post-op signs or symptoms
  
  • sensitivity
  • pain
  • swelling
• No radiographihc evidence of:
  
  • external or interal resorption
  • other pathologic changes
• No harm to succedaneous tooth

Question 26

Silver Diamine Fluoride: Indications vs contraindications

Answer 26

• indications:
  
  • High caries risk
  • behavior management challenges
  • multiple caries
  • limited access to care
• Contraindications:
  
  • symptomatic
  • pulpal involvement

Question 27

What is the purpose of indirect pulp cap?

Answer 27

• Arrest caries process
• promote dentin sclerosis
• formation of tertiary dentin
• Remineralize carirous dentin

Question 28

Indirect Pulp Cap materials used:

Answer 28

• Calcium hydroxxide
• Zink Oxide Eugenol
• Glass Ionomer
• Resin-modified calcium cilicate

Question 29

Direct Pulp cap indications

Answer 29

• Small mechanical exposure
• Asymptomatic immature permenent teeth
• limited to:
  
  • small exsposures produced by trauma
  • pinpoint carious exposure w/sound dentin around it and no bleeding at site

Question 30

Direct Pulp Cap Materails

Answer 30

• Hard setting calcium hydroxide or MTA (mineral Trioxide aggregate)

Question 31

Primary Tooth Pulpotomy

Answer 31

• most frequent technique used for asymptomatic primary teeth w/deep caries
• Remove coronal pulp
• Remaining pulp is treated w/a medicament to preserve health
• Tooth restored with SSC
  
  • protects from microleakage

Question 32

Primary Tooth Pulpotomy: indications

Answer 32

• extensive caries
  
  • w/no evidence of radicular pathology
  • caries removal causes a carious or mechanical pulp exposure
• Asymptomatic or reversible pulpitis
  
  • inflammation limited to coronal pulp
• Radicular pulp
  
  • vital

Question 33

Primary Tooth Pulpotomy: Contraindications

Answer 33

• Spontaneous pain
• Fistula or swelling
• Necrosis
• Periapical or furcal pathosis
• uncontrolled pulpal bleeding
• Internal/external root resorption
• non-restorable tooth
• tooth near exfoliation or no bone over succedaneous tooth

Question 34

Clinical Criteria for Pulpotomy

Answer 34

• Asymptomatic pulp or reversible pulpitis
  
  • Radiographic
    
    • no furcal or PA radiolucency
    • no internal/external resorption
  • No soft tissue swelling or mobility
  • Direct pulp assessment
    
    • red (not purple) bleeding
    • Hemostasis obtained in 5 mins w/cotton pressure

Question 35

Ideal characteristics of Pulpotomy medicament

Answer 35

• Bactericidal
• Harmless to pulp and surrounding structures
• promotes healing of radicular pulp
• does not interfere w/physiologic root resorption
• inexpensive

Question 36

Medicaments of Pulpotomy

Answer 36

• Formocresol
• Ferric Sulfate
• Calcium Hydroxide
• MTA (mineral Trioxide Aggregate)
• Sodium Hypochlorite
• Glutaraldehyde

Question 37

Filling canals of Primary teeth

Answer 37

• material must be resorbable
  
  • no resistance to eruption of permanent teeth
• gutta percha contraindicated

Question 38

Pulpectomy: Indications

Answer 38

• Can’t obtain hemostasis during pulpotomy
  
  • inflammation has extended to radicular pulp
• Irreversible inflamed or necrotic pulp
• Root canals

Question 39

What is the purpose of pulpectomy

Answer 39

• Primary Dentition space maintenance
  
  • don’t lose tooth

Question 40

Pulpectomy: Contraindications

Answer 40

• PA or interradicular infection involving the crypt of succedaneous tooth
• can’t debride canals thoroughly
• unrestorable or nonstrategic tooth
• Mechanical or carious perforations of pulp chamber floor
• Excessive pathologic root resorption more than a 1/3 of root or advanced internal/external resorption
• Excessive pathologic loss of bone support
  
  • lost PDL
• Dentigerous or follicular cyst
• medical contraindications

Question 41

Ideal characteristics of primary root canal filling material

Answer 41

• Resorb at similar rates as primary root
• readily resorb if pressed beyond apex
• Harmless to periapical tissues and permanent tooth germ
• antiseptic
• fill canals easily
• adhere to walls
• no shrink
• easily removed
• radiopaque
• no discoloration of tooth

Question 42

Materials for pulpectomy

Answer 42

• ZOE
  
  • most common
  • does not resorb at same rate as tooth
• Iodoform
  
  • resorbs rapidly if extruded
• Calcium hydroxide
  
  • rarely used by itself
  • good when mixed with iodoform (Vitapex)