Large Carious Lesions

What two units seal tubules and cavomargins?

varnish

bond/adhesive

What are the benefits of Dycal?

reparative dentin formation

What are the benefits of GI/RMGI?

fluoride release

bonding capability

some moisture tolerance

Benefits of IRM:

eugenol is sedative

Most bases and liners are bound (directly to tooth/with an intermediate between them)

directly to teeth

All preparations require long-term sealing of the dentinal tubules and cavomargins for reduced ___ and ___

sensitivity

pulpal inflammation

Base and liner placement depends on the need for ___ or ___

medication

pulp protection

Base and liner placement also depends on the remaining ___

dentin thickness

All preparations, whether shallow, moderate, or deep, use ...

varnish, dentin sealer or bonding agent

why put base down?

tubule and cavomargin sealing

Moderate and deep preps may additionally use ...

bases, liners

why use something additional for deep restorations (eugenol, gi, dycal)

specific benefits

eugenol —> palliative, antimicrobial

GI —> bonding, F release, antimicrobial

Dycal —> reparative dentin

Amalgam is compatible with ___ materials

all

Composite is compatible with ___ materials

all, except for varnish or materials like ZOE/IRM

Why not compatible with ZOE/IRM?

they contain eugenol

Speaking of eugenol, what does palliative effect mean?

soothing

Which component of Dycal stimulates reparative dentin formation?

CaOH

In moderately deep preps, clinicians routinely place Dycal to protect the pulp from GI acids... is this necessary?

not really... but it is frequently done

the "overuse" Dr. Boberick was talking about... Dycal really should only be for exposures, not for protective/preventative purposes

Shallow Amalgam: Materials

varnish

bonding agent

Moderate Amalgam: Materials

varnish

bonding agent

GI

IRM

Deep Amalgam: Materials

varnish

bonding agent

Dycal (if exposure)

GI

IRM

Shallow Composite: Materials

bonding agent

Moderate Composite: Materials

bonding agent

GI

Deep Composite: Materials

bonding agent

Dycal (if exposure)

GI

Why are varnish and IRM not used for/with composite?

no comparability

___ weaken restoration

Bases

When adding bases, you want to minimize ___

thickness

What is generally better to be placed on axial wall decay: GI or Dycal?

GI

Dycal has questionable use in the absence of a pulp exposure

Should the entire floor of a prep be covered with a base?

no

Should base be placed onto the gingival floor?

no

not closer than 1 mm from cavosurface margin

The caries process requires ... in order to be started

cariogenic bacteria

susceptible tooth surface

nutrients for bacterial growth

Cariogenic bacteria include ___ as the initial, and ___ for post enamel cavitation

strep mutans

lactobacillus

Cariogenic bacteria does what?

adheres to enamel

produces and tolerates acid

thrives in sucrose rich environment

produces bacteriocins

At which pH does enamel demineralization occur?

5.5 or less

At which pH does dentin demineralization occur?

6.2-6.5

There is a fine balance between the speed of the ___ front and rest rate at which the ___ defenses can be laid down

advancing decay

(vs.)

pulp-dentine

What is the reaction to long-term, low-level acid demineralization associated with a slowly advancing lesion?

sclerotic dentin

What is the reaction to a moderate-intensity attack with bacterial invasion that involves odontoblasts dying and replacement odontoblasts forming?

reparative dentin

What is the reaction to a severe, rapidly advancing caries characterized by very high acid levels?

necrosis

Necrosis results in ...

infection, abscess and pulp death

Acute Decay

bacteria spreads quickly, with staining far away from the site of infection

Chronic Decay

bacteria spreads slowly, with staining close to the site of infection

What are a few general strategies for caries prevention?

limit substrate

modify microflora

disrupt plaque

modify tooth structure

stimulate saline flow/artificial saliva

restore defective tooth surfaces

When preventive measures fail, what directly occurs?

development of various lesions

What type of treatment is required for carious lesions?

surgical tx (operative dentistry)

What are the main goals of operative dentistry?

conservatively remove infected tooth structure

medication of the pulp (if necessary)

restore the defect in permanent or temporary fashion

Caries control: teeth with acute threatening caries are treated with the intent to make immediate, corrective intervention to prevent ___ and possibly avoid ___

pulpal disease

root canal therapy

Generally speaking, when beginning treatment of large carious lesions, you start by ....

asking the patient to describe their pain

What about their pain?

onset and duration

stimuli

spontaneity

intensity

factors that relieve pain

factors that intensify pain

These questions are all ___... what happens next?

subjective

the objective phase

Objective phase is conducted by performing a ___

clinical exam

Clinical exams may involve:

percussion testing

palpation

transillumination

electric pulp testing & thermal testing

periodontal probing

restoration integrity

radiographic information

Percussion testing invokes gauging ___ involvement

PDL

Palpation involves checking for ___ in the apical region

tenderness

Transillumination checks for ___ and ___

caries

cracks

Don't get fooled when using TI.... all teeth have ___

some natural cracks

An incomplete fracture is called ___

cracked tooth syndrome

You feel pain when ___ in CTS

masticatory pressure is released

Electric testing and thermal testing gauge the condition of the __

pulp

Pulp diagnosis is determined via sensitivity to ___ (or not)

cold

Periodontal probing gauges condition of the ___

gingiva

Radiographs provide us with information about ...

caries

widened PDL

fractures

Reversible Pulpitis

a limited inflammation of the pulp from which the tooth can recover if the caries producing the iteration is eliminated by operative treatment

RP is clinically evident by ___ pain in response to placement of a cold thermal stimulus

short (under 10 seconds), sharp

Irreversible Pulpitis

a severe inflammation of the pulp from which the tooth is unlikely to recover after removing the caries

IP is clinically evident by ___ pain following thermal (cold) stimulus

lingering (over 10 seconds)

Recommended treatment for IP is ___ or ___

extraction

endodontics

Pulpotomy

a short tern, quick treatment to relieve pain of IP for a few weeks

A pulpotomy gives the patient a few weeks to choose between ___ or ___ routes... may be a tough choice to make!

extraction

endodontics (root canal therapy)

If you have RP, and you choose to operate, what is placed on top of direct pulp exposures if they occur as you are clearing the bacteria away?

Dycal

Dycal is weak, very soluble, and does not produce a long term bacterial seal. It must thus be covered by a ___ material and a well sealed ___

stronger base

permanent restoration

Direct pulp capping is for ___

direct exposure

Indirect pulp capping is for ___

blush

T/F: direct and indirect pulp mappings have the same treatment

true, actually! just different classifications

treatment with CaOH, covered by IRM, placement of final restoration

The main goal of an indirect pulp cap is to ....

avoid pulp exposure

(and stimulate reparative dentin formation)

If there is no pulpal blushing or exposure, you ___

restore

If there is pulpal blushing, you ___

indirect pulp cap

If there is pulp exposure, you often also see ___

blood (hemostasis)

If there is pulp exposure, you ___

direct pulp cap

All of the previous cases have been reversible pulpitis... if it is irreversible, you can only really consider ___ or ___

endodontics

extraction

Before conducting a direct pulp cap, even on a tooth with reversible pulpitis, you need to make sure that ...

this will be successful

don't want to do DPC if the tooth will end up soon, likely, needing E/E anyway

basically, is DPC enough to save the tooth? or is this RP very bad and potentially even IP at this point?

When dealing with RP, it is possible to conduct ___ excavation

stepwise (multiple appointments)

1st Appointment

remove all periphery caries

soft, wet, pale dentin is left pulpally

2nd Appointment

re-enter and continue caries excavation

dentin is darker, harder, drier — easier to clear—or don't clear this dentin, just add Dycal to it

Using this staggered technique, caries pulp exposure rate drops from ___% to ___%

40 to 17.5

Is re-entry necessary?

we say yes, so as to get rid of all of the decay

When dealing with direct pulp capping, ___ of the exposure and health of the pulp are important factors in determining success of the DPC

cause

Cause: rapidly progressing caries with toxin infiltration and symptoms of potential IP — has ___ prognosis

poor

Cause: trauma exposing the fracture site to bacterial contamination — has ___ prognosis

poor

Cause: mechanical exposure in the absence of deep caries, due to a mistake made by the dentist — has ___ prognosis

better

In general, using a rubber dam to reduce the level of bacterial contamination following an exposure also gives you a ___ prognosis

better

It is favorable for prognosis (of DPC) if ___ to the pulp is maintained

blood supply

What may inadvertently decrease blood supply to the pulp?

reparative dentin formation

It is favorable for prognosis (of DPC) if there is elimination of ___

bacteria and again others toxins

How?

use of rubber dam

restorative materials with antibacterial properties and a tight seal

successful formation and maintenance of the dentin bridge

It is favorable for prognosis (of DPC) if the tooth is ___

asymptomatic

It is favorable for prognosis (of DPC) if there is normal response to ___ before operative treatment

pulp testing

It is favorable for prognosis (of DPC) if exposure is ___

small (<0.5 mm in diameter)

It is favorable for prognosis (of DPC) if ___ is easily controlled

hemorrhage

It is favorable for prognosis (of DPC) if, in a traumatic exposure, there is little ___ and no evidence of ___ of blood into the dentin

desiccation (drying)

aspiration (blushing)