BOND STRENGTH LOWEST TO CERVICAL THIRD OF TOOTH (3)

Fewer enamel tags Shorter enamel tags Prismless enamel found here

Works as Total OR Self- Etch MDP monomers Can acid etch then use universal adhesive Option to SELECTIVE etch (enamel only) I’m leaning toward this option most frequently OR Can skip acid etching step

Vital Pulp Therapy Flashcards by sophie rosen

Bond strength to perpendic
Enamel (ENDS of rods)=

Bond strength to parallel
enamel (SIDES of rods)=

25MPa
7-10MPa

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BOND STRENGTH HIGHEST TO — THIRD OF
TOOTH
* BOND STRENGTH LOWEST TO — THIRD OF
TOOTH

OCCLUSAL
CERVICAL

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BOND STRENGTH LOWEST TO CERVICAL THIRD OF
TOOTH
(3)

Fewer enamel tags
Shorter enamel tags
Prismless enamel found here

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Review- WHY BEVEL?
(2)

Reduce microleakage
-Particularly at cervical of box in Class II resin
Better results from etching
-Exposes underlying prismatic enamel

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REVIEW- When to NOT bevel

When a bevel would remove all enamel
Attempting to bond to dentin only= microleakage, weak bond

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Review/Disclaimer- Dentin Bonding
* BOND TO ENAMEL IS SUPERIOR TO BOND TO
DENTIN
(3)

Enamel interlocking with enamel rods
Dentin interlocking with dentin collagen
Dentin collagen is very touchy

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Enamel Bonding, summarized
* — surface
* Increased surface — and surface —
* Allows wetting by —
* Remember- enamel has MINIMAL —
* — interlock
* Macro and micro tags into surface —
* — bonding!
* Enamel- Adhesive- Composite Bond!
* — MPa
* Clinically Acceptable!

Etch

Etch
area,energy
hydrophobic adhesive resin
water (3%)
Resin tags
irregularities
Micromechanical
20-25

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Review- Dentin Bonding
* Dentin composition- —
* Less —, more —
* Dentin tubules
* Intertubular dentin
* Less —
* Hybrid layer is (2)
intermingled
* — etching dentin
* Partial or total — layer removal AND — collagen
Intertubular

heterogenous
mineral,water
mineralized
collagen fibrils and resin
Acid
smear
demineralizes

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Review- Dentin Bonding
* Depth of cavity
* LESS INTERTUBULAR DENTIN CLOSER TO —
* Deeper cavity= — bond
* Rubber Dam
* Helps counteract some issues with dentin bonding

PULP
worse

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Review- Dentin Bonding
* Crucial to get — formation
* Many factors working against you in deep preparations.

hybrid layer

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Review- Dentin Bonding
* Potential problems with forming hybrid layer
(3)

Overdrying
Overetching
Underdrying

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Overdrying-
Overetching-
Underdrying-

collapses collagen
demineralized zone is too thick and primer cannot
fully penetrate
excess water leads to poor hybrid layer formation

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Total Etch
* You TOTALLY have to etch first!
* Advantages
(2)

Hybrid layer thicker
Larger Resin Tags

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Total Etch
* Disadvantages
(4)

More steps
Possibility of collagen collapse
If done incorrectly
Can etch too deeply
If done incorrectly
Possibility of post-op sensitivity
If done incorrectly

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Self Etch
* The bond agent claims to

etch the prep
* Not as good of an etch

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Self Etch
Advantages
(3)

Takes less time
No problems with overdried, collapsed collagen
Low post-op sensitivity

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Self Etch
Disadvantages
(3)

Not compatible with some composites
Does not efficiently etch prepared enamel
Questionable long term bond strength

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Universal Adhesive

Works as Total OR Self- Etch
MDP monomers
Can acid etch then use universal adhesive
Option to SELECTIVE etch (enamel only)
I’m leaning toward this option most frequently
OR
Can skip acid etching step

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Chlorhexidine in bonding
Chlorhexidine gluconate has been found to increase long term bond
strengths
* How?
(3)
* Found in Consepsis antibacterial agent
(2)

Hybrid layer can degrade over time
CHX INHIBITS MMP COLLAGENOLYTIC ACTIVITY
Place 2% chlorhexidine solution after etching, rinse thoroughly
Indicated for endo procedures
Can place after etch prior to bonding

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CAMBRA Risk Assessment
* Low Risk:
* Moderate Risk:
* High Risk:

no disease indicators, <2 risk factors, has
protective factors
no disease indicators, > 2 risk factors (but no
caries)
Cavitated lesions/disease indicators OR >3 risk
factors

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For all ideal depth cavity preparations that use amalgam as
the restorative material,

no sealer or liner is necessary.

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1. For preparations deeper than normal with at least 1.0 mm of
  dentin between the pulp and the restorative material,

no sealer
or liner is necessary.

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1. For preparations deeper than normal with less than 1.0 mm
  of dentin between the pulp and the amalgam,

a liner using a
resin modified glass ionomer is recommended as a thermal
insulator.

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1. For preparations with less than 0.5 mm of dentin between
  the pulp and the amalgam,

a thin calcium hydroxide liner is
recommended followed by a thermal insulator of resin modified
glass ionomer.

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* 5. For preparations with a direct pulp exposure on a vital pulp a

calcium hydroxide liner ~ 0.5 mm in thickness is recommended followed by a thermal insulator of resin modified glass ionomer

TLDR; * If you’re close to the pulp, place --- * If you’re REALLY close to the pulp, place --- * If pulp is exposed, place ---

Vitrebond Dycal then Vitrebond Dycal then Vitrebond

DIAGNOSE Two red flags: (2)

Deep Caries -may be symptomatic or asymptomatic -must be aware caries could approach pulp * make patient aware of this BEFORE prep Patient Presents with Pain -Compare Objective vs. Subjective findings -Rule out other possibilities

**--- TEST FIRST! (before anesthesia!)

VITALITY

Any time you even suspect that you may get a pulp exposure, --- test first!

vitality

DIAGNOSE SCENARIO: Patient comes to your office in pain Rule out other possible causes * Differential diagnoses (3)

* Sinus pain * Periapical Abscess * Periodontal Origin

Differential Diagnosis: Maxillary Sinus Pain * FLAG: patient presents with pain * Does your patient have a history of allergies and/or sinus infections? * Worse when they bend over/lie down/jump up and down? * Located in general area of maxillary arch on one or both sides? * Lack of radiographic/clinical evidence of decay? DO NOT TREAT DENTALLY! May need to refer to ---

ENT

Differential Diagnosis: Periodontitis * Flag: patient presents with pain * Pain more --- * ---, can’t isolate to single tooth * Pulp --- * --- main symptom * Deeper --- depths usually * Pain ---

vague Regional VITAL Percussion Pocketing episodic

Differential Diagnosis: PDL

* Restoration left in hyperocclusion * Reduce occlusion

Differential Diagnosis: Acute Periapical Abscess * Flag: (2) * NOT Reversible Pulpitis * May be painful * To (3) * To cold-> --- as tooth is dying * May have (2) * Radiographic periapical lesion may or may not be present * May be too early * Caused by --- * Non-vital, necrotic pulp= * NOT painful to ---

potentially pain and/or radiographic caries percussion, palpation, chewing hot swelling, fever bacteria right to endo (after consult, of course) cold/hot

DIAGNOSE SCENARIO: PA radiolucency Rule out other possible causes * Differential diagnoses (2)

* Periapical Abscess * Cementoma

Differential Diagnosis: Chronic Periapical Abscess * Flag: (2) * NOT Reversible Pulpitis * Radiographic --- lesion * Non-vital, necrotic pulp= * No response to --- * No response to ---

radiolucency, previous trauma periapical right to endo (after consult, of course) endo ice EPT

Differential Diagnosis: Cementoma * No flags, but the radiographs sure are suspicious! * Not ---! * Rule out cementoma in radiograph presenting similar to --- * Most commonly in --- region * --- test prior to tx * Vitality: * Be very suspicious if no caries present

Abscess abscess lower anterior/premolar Pulp VITAL

Ruled those out? * Next step: * Determine if --- in origin * Subjective and Objective tests * Subjective needs to match objective findings

pulpal

skipped Subjective Data Gather from patient (7)

* WHERE is the pain? * How intense (1-10 scale)? * How long has it hurt? * How long does pain last? * What causes it to hurt? * Does anything make it feel better? * “What have you been taking for the pain?”

Objective Tests (7)

* Percussion * Palpation * Thermal tests * Transillumination * Periodontal probing * Clinical exam * Radiographs

* Percussion (3)

* Remember to begin on asymptomatic tooth to get baseline * Mirror handle * Tooth Slooth

Alternate Ending- pain is pulpal BUT * Reversible

* Discuss options with patient * Including cost of ENTIRE procedure * Stop looking at Operative III lecture notes, refer to Endodontics lecture notes! * Endodontic Consultation in our clinic * Not too alarming because you already discussed this possibility with your patient before the procedure * AND you already have a rubber dam placed!

Reversible Pulpitis

* Mild- moderate pain * Cold response * Occasional response to sugar or heat * Occasional response to biting pressure Pulp is still vital

Reversible Pulpitis, continued * Causes: (5) * Possible Treatment: (1)

* Bacteria (caries) * Trauma * Exposed dentin * New restoration * Deep restoration or occlusion left high * Remove caries and or restoration and attempt to restore

Irreversible Pulpitis

-Longer Duration -pain lingers several minutes- hours -Heat Sensitivity -Cold -may have lingering cold sensitivity OR - cold may alleviate pain -Spontaneous

What factors must be present to perform vital pulp therapy? (4)

* A VITAL tooth -Pulpitis optional (reversible only) * A RUBBER DAM * Clean walls of prep * Pulp capping materia

Pulp Capping Materials (5)

* Calcium Hydroxide * Glass Ionomer/Resin Modified GI * Mineral Trioxide Aggregate * BC Putty * Zinc Oxide Eugenol

Pulp Capping Materials Newer liners: (3)

* Theracal™ * Biodentine™ * Limelight™

Calcium Hydroxide (CaOH) (2)

* Dycal™ or Life™ * Gold standard for direct pulp cap

Calcium Hydroxide (CaOH) * Gold standard for direct pulp cap

* Inexpensive * Antibacterial * Evidence-supported * Stimulates repair * Release of Bone Morphogenic Protein and Transforming Growth Factor- Beta One * Stimulates pulp to form odontoblasts which can produce reparative dentin

CaOH, continued * Set up time: --- minutes * --- minutes to resist condensation forces * ~ 3 weeks= * Cause --- response in pulp * Results in --- * Use CaOH with pH --- ideally * Leaves less pulp destruction * Basic nature of CaOH=

2-3 5-7 formation of dentin bridge inflammatory dentin bridges 9-10 environment inhospitable to bacteria

CaOH, continued CONS: (3)

* No dentin bonding * Water soluble - Will eventually leak, may disappear - seal with GI overlayer to help reduce leakage * May lead to closure of pulp chamber and canals over time

Glass Ionomer/Resin Modified GI * Most are light cured * The Good: (3)

* Seals well as indirect pulp cap * Good biocompatibility * Fluoride release

Glass Ionomer/Resin Modified GI * The not-so-good: (2)

* Moderate to intense inflammatory pulp response * No dentin bridge formation

Mineral Trioxide Aggregate (MTA) * --- is the main reaction product of MTA and water * =causes reparative dentin formation= * MTA provides some --- to tooth structure

Calcium hydroxide dentin bridges seal

MTA, continued * Positives: (7)

* Antibacterial * Biocompatible * High pH * Radiopaque * Works well for perforations * Sharpey’s fibers attach to it * Better seal than CaOH

MTA, continued * Negatives: (5)

* Long setting time * High solubility * May discolor tooth * Expensive Cover with GI/RMGI - Protects MTA during long setting time

ZOE * Nope! (5)

* Highly Cytotoxic * Leaks * Less eugenol released over time - Effectiveness reduced over time * No pulp healing, no dentinal bridge formation * Compromises bond strength if using bonded restoration

Managed to Avoid Exposure * Ensure ALL --- are removed * May leave SMALL AMOUNT of --- dentin to avoid pulp exposure - Restorative and Endo disagree * Place (2) to provide barrier against chemical and thermal irritation * Per Clinic Manual: * CaOH when <--- dentin remains - Cover with --- * Vitrebond when >--- dentin remains

CARIES AFFECTED CaOH or Vitrebond 0.5mm, Vitrebond 0.5mm

* Gold thermal conductivity= -- times that of tooth * Amalgam thermal conductivity -- times that of tooth

500 30-40

When to Perform Vital Pulp Therapy- Indirect (Indirect Pulp Cap) (4)

* VITAL TOOTH!! - Absolutely necessary - Rule out irreversible pulpitis or nonvitality prior to beginning procedure * Asymptomatic with deep caries - And/or * Reversible pulpitis * Caries free

One Visit Vital Pulp Therapy- Indirect Procedure * Goal: avoid/prolong need for root canal

* Remove all caries, place pulp capping material and final restoration * OPERATIVE: may leave AFFECTED dentin to avoid pulp exposure * Ideally, remaining caries remineralize, pulp not traumatized by exposure * ENDODONTICS: you can’t be 100% sure that affected dentin isn’t actually infected= REMOVE ALL CARIES * Better to get pulp exposure and leave no trace of caries * 1-2mm remaining dentinal thickness (including liner) is ideal * Restoration must rest on sound dentin * Reminder: Vitality Test first!

Vital Pulp Therapy-Indirect Procedure: Isolate * No problem- we use --- on all operative procedures * ESPECIALLY those with deeper lesions * Keep bacteria far away from pulp in case of exposure

rubber dams

Vital Pulp Therapy-Indirect Procedure: Access * Establish Outline Form * Remove superficial caries at --- - Remember floor and cusp area

DEJ

Vital Pulp Therapy-Indirect Procedure: CAREFUL Debridement * Outline form is established * Continue caries removal at DEJ * Ensure all non-pulpal walls are caries-free (2)

* Caries removed ENTIRELY from these walls * Remove enough tooth structure here that you can properly visualize the deeper areas

Vital Pulp Therapy-Indirect Procedure: CAREFUL Debridement Continued * Carefully excavate across pulpal floor/wall * Use new --- bur - Avoid cross contamination * Use sharp --- at final stage * Strokes tangent to --- - Avoid forcing instrument/dentin chip into pulp

sterile spoon excavator pulp chamber

Vital Pulp Therapy-Indirect Procedure: CAREFUL Debridement Continued * Place restoration * WELL-SEALED (2) restoration

amalgam or composite

If you’re planning crown/bridge: * Proceed with

root canal therapy rather than vital pulp therapy * 95% success rate- better long term

When to Perform Vital Pulp Therapy- Direct (Direct Pulp Cap) (4)

* VITAL TOOTH!! * Asymptomatic with deep caries - And/or * Reversible pulpitis * AND exposed pulp - Yep, you used Endo Ice to vitality test before starting!

Vital Pulp Therapy-Direct Procedure: Access (3)

* Establish Outline Form * Remove superficial caries at DEJ * Remember floor and cusp area

Vital Pulp Therapy- Direct Procedure: CAREFUL Debridement * Outline form is established * Begin at DEJ * Ensure all non-pulpal walls are ----free - Caries removed ENTIRELY from these walls - Remove enough tooth structure here that you can properly visualize the deeper areas * Carefully excavate across --- - Use new --- bur - Avoid cross contamination - Use sharp --- at final stage - Strokes tangent to --- - Avoid forcing instrument/dentin chip into pulp

caries pulpal floor/wall sterile spoon excavator pulp chamber

Pulp is exposed * Vital Pulp Therapy Time! * MOST IMPORTANT DETERMINER OF SUCCESS: * ACHIEVE --- * Once --- is achieved, * Cover exposure site with thin layer of --- * Begin at sound dentin, lead over exposure with instrument * Cover with --- * Light cure * Restore with amalgam or composite resin material If composite resin material used, etch and bond --- liner materials

HEMOSTASIS hemostasis CaOH GI/RMGI AFTER

Pulp is exposed- hemostasis * Controlling --- is the most critical issue in ensuring success of vital pulp therapy when pulp is exposed * Hemostasis achieved in -- minutes is ideal * Longer= * Hold cotton soaked with --- to exposure site for 30+ seconds to stop bleeding

hemorrhage 2-3 pulp already inflamed, will not respond well to therapy NaOCl

RECAP: Vital Pulp Therapy- Exposed Pulp * ONLY in VITAL tooth with pulp exposure * Ideally <--- exposure * --- hemostasis= better prognosis - --- minutes * --- exposure= better prognosis - Minimal introduction of bacteria into site - One reason we rubber dam!!! * To attempt to avoid/delay ---

0.5-0.75mm Fast 2-3 MechanicalRCT

Vital Pulp Therapy- Direct Procedure: Final steps (3)

* Rinse with water * Gently dry with air, cotton pellets * Do not dessicate

Vital Pulp Therapy: Direct Restoration * Ideally, place final restoration at same appointment - Reduce --- * Check --- - Avoid --- occlusion - =pain caused by non-pulpal origin, confusing if vital pulp therapy is successful * Restoration should be perfectly sealed * Avoid placing etch near --- - Always etch --- Vitrebond has been placed, focus on enamel

leakage occlusion premature pulp AFTER

Vital Pulp Therapy: Convalescence * “Sick” pulp will heal over next --- weeks - -- days for reparative dentin to form * Recommend healthy diet and guarded chewing on affected side * Inform patient that some soreness is normal - It should begin to feel better after a couple days, not worse - Root Canal may be indicated if pain does not go away or worsens over time - Ideally, you’ve set yourself up for success and already discussed this with the patient before beginning procedure!

2-6 45

Follow Up * Look for pain that increases in severity= - Post-operative discomfort is normal, but should decrease gradually over the first --- days - --- hypersensivity- normal part of healing process - Recommend OTC analgesics - Offer ibuprofen while patient is still in the chair - Easier to ward off pain that try to play catch up * You as provider do the following up - Don’t wait for patient to call you - Good practice builder

POOR prognosis 3-7 Cold

Success! (3) Tooth may always become nonvital years later -more success with patient under -- years old -historically, greatest success with --- restorations

* Tooth asymptomatic * Tooth vital * PA radiograph is lesion-free 40 amalgam

What if it’s not a success? * This can be at the pulp exposure visit - --- cannot be achieved - Pulp is exposed and gross caries remain * This can after the --- - Soon after or a long time after - Patient becomes symptomatic - Subjective- - Objective- * TIME FOR ENDODONTICS - Or extraction

Hemostasis vital pulp therapy feeling pain radiographic evidence

Evidence- Indirect Pulp Capping -Lesion changes from --- -Lesion changes from --- -Significant reduction in (2) -radiographs show no change or even reduction in --- zone - --- more important that type of liner -significant reduction of pulp exposure with partial caries excavation

light to dark brown soft, wet to hard, dry s mutans and lactobacilli radiolucent well-sealed restoration

Evidence- Indirect Pulp Cap -Risk of failure similar for (2) excavated teeth -Considerable reduction of post- operative pulpal complications for --- excavation -No evidence that partial caries removal is detrimental in terms of (4) -Evidence that complete caries removal is not necessary for success when the restoration is ---

incompletely and completely incomplete signs, symptoms, pulpitis occurrence, or restoration longevity well-sealed

Evidence- Indirect Pulp Cap Approximately --% successful in first year, --% success after 5 years, --% after 9 years. Definitive restoration played important part in success, with --- being most successful, followed by composite, then ---. --- of tooth surfaces affected also played a part in success, with fewer affected surfaces being more successful No difference in gender of patient, whether dental student under close supervision or dentist placed cap, or location of teeth on success of pulp cap

80 68 58.7 amalgam Glass Ionomer Number

Other caries control considerations: Two Visit Caries Control * To avoid restoring only one tooth to completion to later discover that

multiple teeth need extractions due to gross caries

Other caries control considerations: Two Visit Caries Control * No --- * Multiple carious lesions treated at once * Removal of superficial carious dentin - As well as loose enamel to insure good seal * When patient begins to feel pain= * Place --- - To stimulate --- dentin formation * Restore with --- * --- weeks later, remove temporary restoration and remaining caries * Tooth may still require --- * Inform patient

anesthesia stop CaOH tertiary GI (NOT IRM) 6-8 endo

Other caries control considerations: Silver Diamine Fluoride * Indications: (4)

* -Rampant Caries that cannot be definitively treated in a timely manner * -Patients with behavioral concerns * -Medically compromised patients * -Carious lesions determined un-restorable, or complicated to restore AND patient desires or requires to avoid conventional treatment as long as possible

Other caries control considerations: Silver Diamine Fluoride * Contraindications: (3)

* -Patient desires esthetic treatment in the area * -Silver Allergy * -Ulcerative gingivitis, stomatitis

Wrap Up * Avoid exposing pulp if at all possible * If pulp is exposed, control --- - Largest determining factor for success of pulp cap * --- is historic gold standard for direct pulp cap - (2) close behind * Provide a --- restoration

hemorrhage CaOH MTA and Biodentine WELL-SEALED

Vital Pulp Therapy Flashcards

(88 cards)