Operative One -- Pulp Protection and Therapy: Feitosa

Why dental pulp must be protected?

Why selective caries removal?

Preserve pulp vitality (patients seek care)

Avoid thermal sensitivity (pain) to the patient after restorative procedures

Avoid removal of sound/affected structure

Keep pulp mechanisms of reaction

Endo-treated teeth are more prone to fractures

Dentin-pulp complex

If you have any issue in the dentin the fluid inside the tubules will be felt by the odontoblast and can

present as sensitivity to the patient

- 1st pulp reaction = Pain

2nd reaction is called

Sclerotic Dentin

- If there is an enemy the odontoblasts can block the tubule and make it harder for the enemy (bacteria etc) can come

Is sclerotic dentin hard or softer than other dentin

harder

if you are restoring and the bottom is full of sclerotic dentin do you need to put a liner

No

3rd reaction

Rapid formation of tertiary dentin

- a reactionary formation of dentin

Causes of dental pulpal inflammation

Active caries

Cavity preparations (mild/severe)

Dental materials (mild/transient)

Occlusal trauma

Pulpal pain

- intra-pulpal pressure on nerve endings secondary to an inflammation response

- Absence of inflammation - hydrodynamic inflammation

When does pulp need protection

After selective caries removal that have lead to deep cavity preparation

Full crown cavity preparations

Presence of mechanical pulp exposure

-- limited space for swelling

-- increase of pressure and cell death with severe inflammation

-- limited regeneration

Cervical dentin exposure due to erosion causing pain

How to protect the dental pulp

By proposing a preventive program to "eliminate" development and/or progression of carious lesions

By collecting appropriate information regarding pulp health prior to restorative procedures

By selecting/using appropriate cutting instruments, use water during preparation, no water during caries removal

By selecting/applying appropriate biological and mechanically resistant dental protective materials

Diagnosis of Pulpal Health:

Clinical Examination

- Anamnesis (spontaneuous pain?)

- Clinical inspection

- Palpation

- Percussion

Diagnosis of Pulpal Health:

Objective Tests

- Cold test

- Electric Pulp Test (EPT)

--- In case of lingering pain = endo

Decisions towards restoration

Diagnosis of vital pulp

Pulpitis is Reversible

No clinical or radiographic pulp exposure

Periapical radiolucency (lesion) in x-ray

(Need all four to = operative)

If a patient has spontaneous pain (Anamnesis)

Send them to endo don't even think twice bout that shit.

That shit is irreversible and send em packing to endo

Cavity Sealers

provide a protective coating to the walls of a prepared cavity and a barrier to leakage at the interface. All walls in their entirety are coated (Usual with Amalgam)

Cavity Liners

Cement coating of minimal thickness (less than 0.5mm) to provide a therapeutic effect (remineralization) or a physical barrier to bacteria (coat walls near the pulp only)

NOT TO BE PLACED ON ENAMEL/DEJ

SuperSeal (Cavity Varnish)

Acidic nature- demineralizes the smear layer and the peritubular dentin

Reacts with the calcium hydroxyapatite to form a fine granular calcium oxalate precipitate

This precipitate occludes the dentinal tubules

Cavity liner RMGI

Cement or resin coating of minimal thickness- physical barrier to bacteria and their products

1-2 mm thickness for base

Cavity liner Resin Modified Calcium Silicates

Provided therapeutic benefit

- Fluoride release, dentinal seal, and antibacterial action promoting pulpal health

Vitrebond liner

Apply after partial caries removal

- is a RMGI

- Chemical bond to tooth structure

- Fluoride release

- Good mechanical properties

- Favorable pulpal response due to F release, initial low pH, physical barrier to bacteria penetration

Superficial cavity what kind of pulp protection

none silly

Moderate cavity what kind of pulp protection

Use Vitrebond some of the time

- depends on age of patient/ how clsoe to the pulp

Deep cavity what kind of pulp protection

Closed exposure

Use vitrebond always

Pulp exposure what kind of pulp protection

No vitrebond

can't put vitrabond on the pulp instead use Resin Modified Calcium Silicates

if you have sclerotic dentin

you do not need liner

Indirect pulp capping

When you put vitrebond layer down without exposure

Step-wise technique

young patient with risk for pulp exposure even with selective caries removal

Deep lesions

Two appointments to wait for tertiary dentin formation

Direct pulp capping

- Direct pulp exposure

- Theracal onto pulp tissue

- vitrebond liner

- final restoration

Observe

- Extension of exposure

- Time until pulp capping done

- Bleeding control

TheraCal LC

Resin-modified Calcium Silicate Pulp Protectant/liner

- Placement of a Ca[OH]2 liner in the deepest part of the preparation covering the pulp exposure

- Place liner on dentin only (pulpal and axial walls, away from all margins and enamel)

- Establish a tight seal to prevent bacterial invasion

- Stimulates apatite formation and the formation of tertiary dentin

- Maintain an antibacterial alkaline-related biological environment. It is an alkaline calcium silicate based on the chemistry of MTA

- After placement and curing follow with layer of Vitrebond and/or normal bonding procedures

Incomplete caries removal

only for very deep cavities

- Step Wise Technique may result in pulp exposure in 2nd visit

- Direct pulp capping has lower success rate tha SWT