Root Camp Lecture 12 - Endo Management of Immature Permanent Tooth

Question 1

Loss of vitality in young permanent teeth creates 3 problems. Name them

Answer 1

Poor crown-root ratio
Thin root walls
Difficulty obturating canals

Question 2

What shape are immature roots?

Answer 2

Blunderbuss

Question 3

Immature permanent teeth have thin, fragile ____________ walls that are prone to fracture

Answer 3

dentinal

Question 4

T/F: Open apices do not allow for condensation of root canal filling - material is easily extruded into periradicular tissues

Answer 4

True

Question 5

When does apical closure occur?

Answer 5

~3 yrs after eruption

Question 6

It is difficult to assess the extent of apical closure _______________

Answer 6

radiographically

Question 7

_______ dimension is wider than MD dimension in immature permanent teeth

Answer 7

BL

Question 8

Historical term denoting incompletely formed root in which the apical diameter of the pulp canal is greater than the coronal diameter

Answer 8

Blunderbuss canal

Question 9

Pulp therapy for immature vital teeth

Answer 9

Apexogenesis

Question 10

Name the 4 types of pulp therapy for immature vital teeth

Answer 10

Indirect pulp therapy
Direct pulp therapy
Partial pulpotomy
Complete pulpotomy

Question 11

Pulp therapy for immature necrotic teeth

Answer 11

Apexification

Question 12

Name the 3 types of pulp therapy for immature necrotic teeth

Answer 12

Apexification w/ CaOH
Apexification w/ bioceramic barrier
Regenerative pulp therapy

Question 13

How do you decide which tx is indicated for an immature permanent tooth?

Answer 13

Cooperation
Age
PA diagnosis
Vitality of tooth
Stage of root development

Question 14

Vital pulp therapy procedure performed to encourage continued physiological development and formation of the root end. Frequently used to describe vital pulp therapy performed to encourage the continuation of this process.

Answer 14

Apexogenesis

Question 15

A dental material is placed on a thin
partition of remaining carious dentin that if removed might expose the pulp in immature permanent teeth

Answer 15

Indirect pulp therapy

Question 16

Technique for avoiding pulp exposures in teeth with deep carious lesions:

-Must be no clinical evidence of pulp degeneration or PA disease
-Allows tooth to use natural protective mechanisms of the pulp against caries

Answer 16

Indirect pulp therapy

Question 17

Removes outer layer of infected dentin so that inner layer of affected dentin can remineralize

Answer 17

Indirect pulp therapy

Question 18

Odontoblasts form reparative dentin thus avoiding a pulp exposure

Answer 18

Indirect pulp therapy

Question 19

Success rate is 74-99%

Answer 19

Indirect pulp therapy

Question 20

Indications include:

Absence of Irreversible Pulpitis Symptoms (mild pain, not spontaneous; cold sensitivity of short duration)
Normal lamina dura and PDL space on radiograph

Answer 20

Indirect pulp therapy

Question 21

Which procedure?

Careful diagnosis (widespread pulp
inflammation or PA pathosis is not indicated!)
Anesthesia
Rubber dam
All caries removed except that overlying pulp exposure
Large slow speed round bur in a brushing motion
Layer of CaOH or Bioceramic placed
ZOE or amalgam restoration
Remove restoration and all caries in 6-8 weeks (2nd appt)
Reparative dentin formation rate is 1.4 microns/day. Decreases after 48 days.
If no exposure at 2nd appt, place base and permanent restoration
With exposure, go to pulpotomy or pulpectomy

Answer 21

Indirect pulp therapy

Question 22

A dental material is placed directly on a
mechanical or traumatic vital pulp
exposure

Answer 22

Direct pulp therapy

Question 23

Which procedure in teeth with immature apices has the following indications?

Mechanical exposures
Small exposures surrounded by sound dentin
Slight hemmorhage that is easily controlled

Answer 23

Direct pulp therapy

Question 24

Which procedure?

Must have excellent seal to prevent bacterial microleakage

Answer 24

Direct pulp therapy

Question 25

Which procedure? Calcium hydroxide pH 11-12 MTA/Bioceramics Coagulation necrosis with underlying tissue differentiating into odontoblastic-like cells Reparative dentin bridge

Answer 25

Direct pulp therapy

Question 26

The surgical removal of a small portion of the coronal portion of a vital pulp as a means of preserving the remaining coronal and radicular pulp tissues

Answer 26

Partial pulpotomy

Question 27

AKA "Cvek pulpotomy"

Answer 27

Partial pulpotomy

Question 28

Which procedure for immature vital teeth has the following indications? Immature teeth with open apices Tooth may have symptomatic or asymptomatic irreversible pulpitis Pulp exposure may be carious, mechanical, or due to trauma

Answer 28

Partial pulpotomy

Question 29

Which procedure for immature vital teeth has the following disadvantage? Leaving damaged tissue that may break down

Answer 29

Partial pulpotomy

Question 30

What confirms pulp vitality after partial pulpotomies?

Answer 30

Continued root development

Question 31

Which procedure for immature vital teeth has the following indications? Immature teeth with open apices and thin dentinal walls Tooth may have symptomatic or asymptomatic irreversible pulpitis Exposed pulp usually due to carious exposure

Answer 31

Complete pulpotomy

Question 32

Which procedure for immature vital teeth has the following contraindications? Mature teeth (closed apices) due to limited vascular supply compared to immature teeth; dressing would be placed on an inflamed pulp that is less likely to heal

Answer 32

Complete pulpotomy

Question 33

Which procedure is only indicated for teeth with immature apices?

Answer 33

Pulpotomy

Question 34

Removes pulp tissue that has inflammatory or degenerative changes; cover remaining vital pulp tissue with pulp capping agent to promote healing

Answer 34

Pulpotomy

Question 35

Pulp tissue removed with diamond bur using high speed and water coolant; irrigate with sterile saline or distilled water

Answer 35

Pulpotomy

Question 36

Control bleeding with moist cotton pellets; if difficult to control, amputate pulp to a more apical level

Answer 36

Pulpotomy

Question 37

MTA (posterior teeth) or other Bioceramic placed over pulp stump and restoration placed; recall at 4-6 month intervals to check for root development

Answer 37

Pulpotomy

Question 38

Which procedure? Success measured by: Absence of clinical symptoms or radiographic signs of pathosis May see signs of dentin bridge forming over pulp stump Continued root development (can't pulp test!)

Answer 38

Pulpotomy

Question 39

The surgical removal of the entire coronal portion of a vital pulp may be performed as emergency procedure for temporary relief of symptoms in closed apex teeth with SIP; root canal is done at next available appt

Answer 39

Complete pulpotomy

Question 40

A method of inducing a calcified barrier in a root with an open apex or the continued apical development of an incompletely formed root in teeth with a necrotic pulp

Answer 40

Apexification w/ CaOH

Question 41

The canals are cleaned and filled with a temporary paste to stimulate formation of calcified tissue at the apex. The paste is later removed and the canal obturated with gutta percha

Answer 41

Apexification w/ CaOH

Question 42

A method to induce a calcified barrier in a root with an open apex; for necrotic teeth only

Answer 42

Apexification

Question 43

Defined as the continued apical development of an incompletely formed root in teeth with necrotic tissue

Answer 43

Apexification

Question 44

Outcome is establishment of an apical barrier against which an obturation material may be placed; for immature teeth or resorbed apices

Answer 44

Apexification

Question 45

Which procedure? Anesthesia Rubber Dam Access large enough to remove all necrotic tissue Use large hand files WL about 2 mm short of radiographic apex Clean canal with circumferential filing and copious irrigation Dry canal with inverted large paper points CaOH paste packed into canal with pluggers Follow-up in 4-6 wks. then 2-3 mo. interval Repack CaOH when material fades out on radiograph If PA lesion is healing, look for development of apical barrier Remove temp. and probe canal with size 40 file If still open, repack If barrier present, fill with gutta percha and sealer. Custom made master point may be necessary. Vertical condensation is best.

Answer 45

Apexification w/ CaOH

Question 46

Histology of calcified material at apex - very porous layer of cementum-like tissue (osteoid or cementoid); looks like “swiss cheese”

Answer 46

Apexification

Question 47

Which procedure has the following disadvantages? Long term CaOH treatment may reduce root strength Root fracture can follow this form of apexification, due to weak dentin walls Multiple treatment visits are required Patient compliance is an issue

Answer 47

Apexification w/ CaOH

Question 48

Hydraulic cement that sets in presence of water/blood

Answer 48

MTA

Question 49

50-75% calcium oxide 15-25% silicon dioxide

Answer 49

MTA

Question 50

Blended together tricalcium silicate, dicalcium silicate, tricalcium aluminate, tetracalcium aluminoferrite

Answer 50

MTA

Question 51

Made with Bismuth oxide for radiopacity

Answer 51

MTA

Question 52

Which color MTA is available now?

Answer 52

White

Question 53

T/F: Both white and gray MTA can stain the crown of a tooth

Answer 53

True

Question 54

Which color MTA lacks aluminoferrite?

Answer 54

White

Question 55

Which procedure? To avoid the challenges associated with long-term CaOH, a nonsurgical, one-step alternative barrier technique with a variety of materials has been used

Answer 55

Apexification w/ bioceramic

Question 56

Which procedure? Defined as the nonsurgical condensation of a biocompatible material into the apical end of the root canal in order to establish an apical stop that would enable the root canal to be immediately filled

Answer 56

Apexification w/ bioceramic

Question 57

Which procedure? 1 or 2 visit apexification

Answer 57

Apexification w/ bioceramic

Question 58

What is currently the material of choice for the apical barrier for apexification?

Answer 58

Bioceramic

Question 59

In a tooth with immature root formation, 4 different stem cell populations have been isolated. Name them.

Answer 59

Apical papilla stem cells Dental pulp stem cells PDL stem cells Bone marrow stem cells

Question 60

Which procedure? The canal is disinfected with copious irrigation and a combination of 3 antibiotics. After the disinfection protocol is complete, the apex is mechanically irritated to initiate bleeding into the canal to produce a blood clot to CEJ. The double seal of the coronal access is then made. In this case, the combo of a disinfected canal, a matrix into which new tissue could grow, and an effective coronal seal appears to have produced the environment necessary for successful revascularization.

Answer 60

Pulp revascularization

Question 61

Which procedure? Elimination of bacteria from canal system Creation of scaffold for ingrowth of new tissue Prevention of reinfection by creating a bacteria-tight seal

Answer 61

Pulp revascularization