3 -- 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 _____

fracture

they dont have all of the cells/foundation making them weak

Dentin-pulp complex

tubular structure of dentin with water and odontoblast processes insude

cells can go from the dentin to the pulp and make changes

If you have any issue in the dentin the fluid inside the tubules will be felt by the odontoblast and can present as ____ to the patient

sensitivity

- 1st pulp reaction = ____

Pain

2nd pulp 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

is sclerotic dentin a new type of dentin?

no - it is a primary or seconday dentin but it is black and more resistant

3rd reaction

Rapid formation of tertiary dentin

- a reactionary formation of dentin done to keep the tooth alive (emergency when bacteria still making way through sclerotic dentin)

unlikley to form this type of dentin in elderly patients

it is unlikely to form ____ dentin in elderly patients

teritary

what is created in a last ditch effort to save the tooth

tertiary 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 a stimulus causes the slow fluid movement to become rapid, nerve ending in the pulp are deformed, creating a response that is felt as pain

what is hydrodynamic inflammation

the pulp needs protection after selective caries removal that leads to a ______ cavity preparation

deep

the pulp needs protection after ____ ____ cavity preparations

full crown

the pulp needs protection after cervical dentin exposure due to _____ that is causing pain

erosion

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?) - doesnt need ot be constant

- Clinical inspection

- Palpation

- Percussion

does pain in a palpation or percussion test mean RCT?

no but likely

Diagnosis of Pulpal Health:

What physical tests can we do

- Cold test

- Electric Pulp Test (EPT)

--- In case of lingering pain = endo

if pain is only felt for a few seconds with the cold test the inflammation is_____

reversible

if cold test has pain >15 seconds

irreversible = endo

Decisions towards restoration

Diagnosis of vital pulp - felt the cold

Pulpitis is Reversible

No clinical or radiographic pulp exposure

Periapical radiolucency (lesion) in x-ray

(Need all four to go forward with a restoration)

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

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 sealers

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

Cavity liner

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

superseal (cavity varnish) is most likely to be used with

amalgam

Cavity liner function

physical barrier to bacteria and their products

what is the optimal thickness for cavity liners

1-2 mm thickness for base

vitrebond is a ______ ____

cavity liner

Cavity liner Resin Modified Calcium Silicates provide a ______ benefit

Therapeutic

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

_____ _____ are the only thing you can place directly on top of the exposed pulp

calcium silicates (Theracal)

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

vitrebond liner is applies after ____ caries removal

partial

vitrebond is an _____

RMGI

Vitrebond has favorable pulpal response due to _____ release, initial ____ pH, physical barrier to _____ penetration

fluoride

low

bacterial

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 do you need a liner?

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

(deep lesion, pulp exposire risk → temp material placed → induces formation of tertiary dentin → complete actual restoration a few months down the road)

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

When Theracal is used for direct pulp capping, it stimulates _____ formation and the formation of ____ dentin

apetite

tertiary

after using theracal for direct pulp capping you should follow up with a layer of ____

liner

with pulp-capping the final restpration must be done ____ ___

same day (no stepwise)

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

direct pulp capping has (lower/higher) success rate than step wise technique

lower

____ ____ works better than both stepwise and non-selective removal

selective removal (to soft)

selective caries removal is the go-to