Pulp Therapy Flashcards

Question

Dentin

Answer 1

inorganic hydroxyapatite, organic type I collagen

Answer 2

Pulp originates from mesenchymal tissues, odontoblast synthesize dentin, cytoplasmic processes extend into the dentin tubules

Answer 3

* **Myelinated:** A fibers, rapid sharp pain * Innervate dentinal tubules and are stimulated by fluid * Increase in number over time, few during eruption * Associated with odontoblasts * **Unmyelinated:** C fibers, dull aching pain * More frequent, around pulp tissues and blood vessels * Pulpitis pain is likely from this nerve * **Nerve plexus of Raschkow:** Myelinated fibers in cell rich zone * Monitors painful sensations * Mediates inflammatory events and tissue repair

Answer 4

* Small traumatic or mechanical pulp exposure – **_not recommended for carious exposures_**

Answer 5

* Maintain vitality and allow for pulpal healing * Reparative dentin * Immature permanent teeth continue to develop (apexogenesis)

Answer 6

* MOA: **Cauterization** * Success rates: **Comparable to FC (62-97%)** * Additional information: **Collateral damage due to heat production; few human RCTs**

Answer 7

Made from **enamel matrix proteins (EMPs) from the tooth germ of swine and propylene glycol alginate (PGA)** as a matrix. The function of EMD is known to differentiate cells of the dental follicle into cementoblasts.

Answer 8

* Advantages * Promote odontoblast differentiation and reparative dentin formation * Suppresses inflammatory cytokine production and promotes healing * More hard tissue formation compared to Ca(OH)2 * Less post-op symptoms * Disadvantages * Clinical advantages are unproven

Answer 9

* MOA: Causes **coagulation** of blood where blood vessels have been severed * Hemostatic agent * Success rates: **77-93%** * Additional information: **Reports of internal resorption** * Antibacterial * **pH \< 1** * Must have healthy radicular pulp to obtain hemostasis * ***_Concern related to iron and risk of non tuberculosis mycobacterium infection due to waterline contamination - iron feeds bacteria_*** * CA and GA had an outbreak of mycobacterium in the water * Lower success than FMC or MTA * Studies have shown internal resorption ## Footnote **_\*\*AAPD: conditional recommendation with low evidence\*\*_**

Answer 10

* MOA: **Tissue fixation** * Success rates: **62-97%** * Additional information: **Concerns w/ toxicity; other medicaments produce equivalent results** * **No reports on toxicity found** * When used judiciously for pulpotomies, it is unlikely to be genotoxic, immunotoxic, or carcinogenic in children * **Did not find sufficient evidence on adverse events that could influence the quality of evidence\*\*\*\***

Answer 11

* **_Spontaneous_** tooth pain * **_Nocturnal_** tooth pain * **_Constant or persistent_ thermal or chemical pain** ## Footnote **_Diagnosis of irreversible pulpitis cannot be based solely on pulpal bleeding that cannot be controlled within five minutes._**

Answer 12

* **_Transient/intermittent_** tooth pain associated w/ **chemical or thermal stimulus**. * **_Lack_** of nocturnal and spontaneous tooth pain

Answer 13

**Clinically and radiographically at 3-month intervals** to examine the formation of an apical hard tissue barrier and to confirm the absence of pathology such as root resorption and apical periodontitis. If calcified barrier is not evident and Ca(OH)2 has washed out, it should be replaced. When barrier is seen on the radiograph, the tooth is reopened and Ca(OH)2 is removed by copious irrigation. The apical area should be gently examined using a GP point to determine the completeness of the apical barrier. Repeat until a complete barrier is established.

Answer 14

* MOA: **Antimicrobial irrigant** * Success rates: Equivalent to **FC (62-97%)** and **FS (77-93%)** * Additional information: **Limited evidence** * Usually at 5% * Antimicrobial, biocompatible, non irritating to pulp, surface effects, similar success to FC at 12 months ## Footnote **_\*\*AAPD: conditional with low evidence\*\*_**

Answer 15

* Bactericidal * Tissue fixation at most coronal level of vital radicular pulp (acidophilic zone) * Causes persistent inflammation of radicular pulp * Dilute FC shown to cause less inflammation than full strength

Answer 16

* Advantages * Excellent bacterial seal * Fl- release, **coefficient of thermal expansion and modulus of elasticity similar to dentin** * Bond to both enamel and dentin * Good biocompatibility * Disadvantages * Causes chronic inflammation * Lack of dentin bridge formation * Cytotoxic when in direct cell contact * Poor physical properties for GI

Answer 17

* Dialdehyde compound, mild fixatives, antibacterial * 2-5% concentration * Does not penetrate into periapical tissues * **Antibacterial at pH of 7.5-8.5** * Not as commonly used, short shelf life * Lower success, low antigenicity, and low toxicity

Answer 18

5 minutes. Evidence suggests that 1 minute application of FC has equivalent success

Answer 19

* Fluid movement in dentinal tubules is translated into electric signals in axons that innervate dentinal tubules * Increased pressure = increased nerve activity

Answer 20

Pulp necrosis following trauma, after carious exposures, and in teeth w/ anatomic variations (like dens invaginatus) w/ an **_immature_** root

Answer 21

ITR w/ glass ionomer cements for caries control for reversible pulpitis - can be removed once the pulp’s vitality determined, an indirect pulp cap can be performed (no conclusive evidence that it is necessary to reenter the tooth to remove the residual caries)

Answer 22

Deep caries that exhibits no reversible pulpitis when the deepest carious dentin is not removed to avoid a pulp exposure of vital pulp

Answer 23

* Reversible pulpitis, deep caries that might otherwise need endo if the decay was completely removed. * When there is concern for pulp exposure

Answer 24

* **Change the cariogenic environment** in order to decrease the number of bacteria * Close the remaining caries from the biofilm of the oral cavity, and slow or arrest the caries development. * Interim restoration should be retained for up to **12mo.** * Intermediate and/or final restoration should seal, vitality, immature roots should show continued root development and apexogenesis

Answer 25

* Remove caries along DEJ and only outermost infected dentin, leaving carious mass over the pulp. * Remove remaining caries and place final restoration

Answer 26

Long term success rates are equivalent for partial caries removal or stepwise caries removal with **\>96% of teeth treated remaining vital after 2yr.**

Answer 27

* High survival rate * **\>90%** *_OR_* **74-99%** w/o adverse clinical symptoms or pathologic signs * MTA has higher success than Ca(OH)₂ * **Ca(OH)₂ = 60-100%** * **MTA = 98%** * **_Higher success rate than direct pulp cap (DPC) and pulpotomy in long term studies_** ## Footnote **_Long term success rates are equivalent for partial caries removal or stepwise caries removal with \>96% of permanent teeth treated remaining vital after two years._**

Answer 28

* Advantages: * One visit * Lower cost * Disadvantages: * More tooth structure removed * **Does not promote sclerosis of dentinal tubules and dentin formation** * Greater risk of pulp exposure

Answer 29

* Normal pulp * Asymptomatic tooth w/ deep caries approximating pulp * Clinically and radiographically sound tooth * Chronic/arrested/inactive/slowly progressing lesion * Well-defined radiopaque dentinal bridge between pulp chamber and carious lesion * No h/o pain/may have no lingering cold sensitivity

Answer 30

* Avoid pulp exposure * Seal and arrest deep decay * Maintain tooth vitality * Promote healing and repair * Remove all soft demineralized dentin * Biocompatible and radiopaque liner

Answer 31

* Remove soft **infected** dentin, leave **affected** dentin * Clean periphery + DEJ * GI or Ca(OH)₂ is placed to stimulate odontoblasts to form reactionary dentin and promote remineralization of existing dentin

Answer 32

* MOA: **Tissue ablation** * Success rates: **Lower than conventional techniques** * Additional information: Many different types

Answer 33

* Advantages * **Formation of secondary dentin** * Sterilization of targeted tissues * Bactericidal effect * Disadvantages * Technique sensitive * Causes thermal damage to pulp in high doses

Answer 34

* Advantages: * One visit * Simple * Painless * Less burdensome for patients * Disadvantages: * Tooth staining with minocycline * Radiolucent appearance of triple antibiotic paste * Allergic reaction * Potential antibiotic resistance * Risk for developmental anomalies in permanent teeth Need more research - need the right case

Answer 35

* Primary tooth with irreversible pulpitis or necrosis or a tooth treatment planned for pulpotomy in which the radicular pulp exhibits clinical signs of irreversible pulpitis or pulp necrosis (suppuration, purulence) * **_\*\* When a tooth is to be maintained for less than twelve months and exhibits root resorption, LSTR is preferred to pulpectomy. \*\*_**

Answer 36

Objectives: radiographic infectious process and pretreatment clinical signs and symptoms should resolve

Answer 37

No instrumentation of the root canals, antibiotic mixture is placed in the pulp chamber to disinfect the root canals, canal orifices are enlarged using a large round bur to create medication receptacles, walls of the chamber are cleaned with phosphoric acid and then rinsed and dried. 3 antibiotic mixture of clindamycin, metronidazole, and ciprofloxacin is combined with a liquid vector of polyethylene glycol and macrogol to form a paste placed directly into the medication receptables and over the pulpal floor, covered with a glass-ionomer cement and restored with a stainless steel crown

Answer 38

* Traditional * Tetracycline/minocycline * Ciprofloxacin * Metronidazole * Alternate * Clindamycin * Ciprofloxacin * Metronidazole * Blended w/ a **_prophylene glycol**_ base and _**macrogol_** \*\* **_Statistically significant less success_** using a tetracycline mix (minocycline) versus a mix without tetracycline - recommend antibiotic mixtures should not include tetracycline. \*\*

Answer 39

* Lesion sterilization and tissue repair (LSTR) * **Goal is to sterilize lesion and avoid instrumentation of canals** * Similar to a pulpotomy except putting in triple antibiotic in the chamber

Answer 40

Ca(OH)₂, zinc oxide, or glass ionomer

Answer 41

Odontoblasts survive and secrete reactionary dentin (i.e. cavity prep, caries present)

Answer 42

* MOA: **Calcific barrier formation** * Success rates: **Highest** of any medicament * Additional information: **Concerns with gray discoloration, $$$**

Answer 43

* Minimal inflammation histologically * Biocompatible * **Normal dentin formation** * **Consistent dentin bridge formation** * Favorable PDL architecture * **Higher success rate than Ca(OH)2** * Prolonged setting time (-) * Hydrophilic particles set in presence of moisture, biologically active for cell attachment * Likely to cause coronal discoloration (-) * **More effective than Ca(OH)2 for maintaining long-term pulp vitality after IPT and DPC** * **Success rate for both materials is similar in partial pulpotomy and pulpotomy** * Minimal pulp necrosis and inflammation * **Compressive strength like IRM,** * **pH of 12.5 after setting - reaction product is CaOH2** * Better seal than amalgam * Stimulates reparative dentin, makes a dentin bridge * Faster than CaOH2 ## Footnote **_\*\*AAPD: strong recommendation with moderate evidence\*\*_**

Answer 44

* Pros: * High biocompatibility * Alkaline pH (12) * Induces hard tissue formation – dentin bridging * Success rates are very high, surpassing FC * Cons: * Technique sensitive to mix * Causes discoloration (not to be used in esthetic zone) * $$$

Answer 45

* Pros: * Biocompatible and non-irritating to pulp tissue * Antimicrobial * Cons: * Injection into soft tissue through apex or through perforation → **“sodium hypochlorite accidents”** (severe pain, edema, and bruising) * Avoid this by determining working length, avoiding binding syringe tip, using side-venting needles, slowly extrude liquid

Answer 46

Vital, traumatically-exposed, young permanent tooth, especially one with an incompletely formed apex.

Answer 47

* Partial extirpation of radicular pulp * Indicated for persistent hemorrhage from pulp stumps * Ca(OH)2 is medicament of choice * Good results *have* been reported w/ MTA

Answer 48

* Young permanent tooth for a carious pulp exposure * Pulpal bleeding

Answer 49

* Remaining pulp vital * Normal root development * Apexogenesis

Answer 50

* Inflamed pulp tissue beneath an exposure is **_removed to a depth of 1-3mm or deeper_** to reach healthy pulp tissue. Pulpal bleeding controlled by irrigation with a bacteriocidal agent such as sodium hypochlorite or chlorhexidine, covered with calcium hydroxide or MTA. * Calcium hydroxide = long-term success * MTA = more predictable dentin bridging and pulp health * **_MTA (at least 1.5mm thick)_** over the exposure and surrounding dentin then a layer of light cured RMGI.

Answer 51

* Carious pulp exposure * Vital tooth w/ dx of normal pulp or reversible pulpitis

Answer 52

* Very high: **91-96%** * Ca(OH)₂: **91-100%** after 2yr * MTA: **95-100%**

Answer 53

* Symptomatic teeth requiring RCT should be addressed **at least 1 wk prior** to period of immunosuppression or should be extracted. * RCT for teeth that are asymptomatic can be delayed until patient is stable and immunocompetent

Answer 54

* **pH is 4 to 5.5** * Demineralizes dentin, may release bioactive materials * Irritating to the pulp

Answer 55

* Lack of literature * Teeth w/ previous pulp therapy can be left if sound, but should be monitored closely * Teeth presenting w/ failed pulp therapy during periods of immunosuppression can have significant negative effects on overall health * Consider extraction of teeth w/ uncertain pulpal status to prevent life-threatening infection

Answer 56

* Questionable. Coronal pulpotomy has more predictable outcomes. * Hemostasis is important - **80-90% when bleeding is well-controlled**

Answer 57

5yr success rates: * Ca(OH)₂: **59-69%** * MTA: **78-98%**

Answer 58

* Propolis (bee glue) is a byproduct of honeybees that is widely used in traditional medicine. * Advantages: * Antioxidant, antibacterial, antifungal, antiviral and anti-inflammatory * Superior bridge formation compared to Dycal, similar results to MTA * Stimulates reparative dentin formation * Forms dental pulp collagen, reduces both pulp inflammation and degeneration * Disadvantages: * Showed mild/moderate inflammation after 2-4 wks w/ partial dentinal bridge

Answer 59

* Deep caries * Normal pulp after caries removal

Answer 60

Normal pulp w/ deep, complete caries removal

Answer 61

* Preserve vitality * Minimize pulp injury * Promote pulp tissue healing * Facilitate tertiary dentin formation * Minimize post-op sensitivity

Answer 62

* Preserve vitality * Prevent sensitivity * Promote pulpal healing * Minimize microleakage

Answer 63

Thinly-applied material placed on the dentin in proximity to the underlying pulpal surface of a deep cavity preparation, covering exposed dentin tubules to act as a protective barrier between the restorative material or cement and the pulp. Materials: MTA, trisilicate cements, calcium hydroxide, or other biocompatible material.

Answer 64

* Deep areas of the preparation to minimize injury to the pulp * Promote pulp tissue healing * Minimize post-operative sensitivity

Answer 65

* Preserve the tooth’s vitality * Promote pulp tissue healing and tertiary dentin formation * Minimize bacterial microleakage

Answer 66

* Fibroblasts (most frequent), macrophages, dendritic cells, t-cells, lymphocytes, mast, plasma. * Collagen Type I and III are the subtypes * Neuropeptides: CGRP, substance P, neuropeptide * Tideglusib stimulates stem cells in the pulp for teeth * Used in Alzheimers * Nerve fibers

Answer 67

* No significant difference between tx of pulpotomy vs pulpectomy * Used **vitapex (73%) or formocresol (89%)**

Answer 68

* Remove coronal and radicular pulp tissue and/or necrotic debris * Debride canal w/ hand file or rotary file * Irrigate w/ NaOCl or other antimicrobial * Dry and fill canal spaces w/ resorbable material * Place definitive restoration

Answer 69

* Necrotic or irreversible pulpitis * Good option for restorable teeth with **normal root resorption** * Good option for “key teeth” for arch development **_\*\* Recommended over LSTR when there is_** ***_no root resorption present \*\*_***

Answer 70

* Remove necrotic or irreversibly inflamed coronal and radicular tissue * Stop spread of infection * Maintain a healthy, asymptomatic tooth until normal exfoliation

Answer 71

* Biologically based procedures designed to predictable replace damaged, diseased, or missing structures, including dentin or root structures and the pulp-dentin complex, w/ live viable tissues, preferably from the same origin, that restore the normal physiologic functions of the original tooth. * Emerging technique for immature necrotic teeth that enables continued root length formation, radicular secondary dentin formation and apical closure. * Includes: * **Revascularization** * **Partial pulpotomy** * **Apexogenesis**

Answer 72

* Remaining Dentin Thickness: importance of a good seal on restorations to minimize microleakage and bacterial invasion * **_Bacteria in cavities with RDT \<0.25mm will have much more pulp inflammation, best to have 0.5mm_** * **_If \>0.5mm, more likely to get reactionary dentin_**

Answer 73

* One of several techniques in tissue engineering and the most commonly used one in the pediatric population. * **Evokes bleeding into the root canal, which delivers undifferentiated mesenchymal stem cells in the root canal space.** * Can be completed using current instruments and materials * Cost effective * Low immune response and low potential for infection * **Should only be attempted if the tooth is not suitable for RCT, and after apexogenesis, apexification, or partial pulpotomy have already been attempted and have a poor prognosis.**

Answer 74

* Two stages: * Stage 1: Disinfection of the root canal system, there are several options: * Tri- or bi-antibiotic 3Mix **(ciprofloxacin, metronidazole, and minocycline** ***_OR_*** **cefaclor, metronidazole, and ciprofloxacin)** or 2Mix **(w/o minocycline)** for **8-12 wks**. * Ca(OH)2 for 8-12 wks. * Note: Use 5% NaOCl (slowly) as a disinfectant. * Stage 2: Promotion of bleeding by filing through apex into apical tissues to fill the root canal space w/ blood and placing “double seal” of MTA and an additional restorative material. * **LA w/o vasoconstrictor** should be used when attempting to induce bleeding in the canal system. * Thin layer of MTA/Ca(OH)2 placed over the blood clot. * Tooth restored w/ adhesive material to prevent microleakage. * Wait for revascularization of pulp space and continued root development. * Further research is needed and more reports to reliably predict the success rate and develop solid guidelines.

Answer 75

* May lead to death of odontoblasts, reparative dentin * Chronic pulpal inflammation due to deep caries, dry cutting, endotoxins from bacteria in deep caries, mechanical exposure to the pulp, presence of bacteria increases extent of pulpal inflammation

Answer 76

* Advantages * Formation of osteodentin + tubular dentin * Superior to Ca(OH)2 in the mineralization-inducing properties * Dentin bridge formation was **equal to Dycal after 28 days** * **_Only TGF-beta 1 induced reparative dentin_** * Disadvantages * Possibility of unexpected side effects * Cost can be an obstacle * Fail to stimulate reparative dentin in inflamed pulp * Appropriate dose response is required to avoid uncontrolled obliteration of the pulp chamber * Possibility of immunological problems due to repeated implantation of active molecules

Answer 77

* Advantages: * Preserves tooth structure/minimally invasive * Promotes formation of secondary/sclerotic dentin * Allows/maintains thicker remaining dentin * Clarifies pulp dx and px * Disadvantages * Time * 2 visits * 1st appointment: Transitional restoration * 2nd appointment: **Re-evaluate after 6-12mo** before the final restoration * Requires patient compliance * $$$

Answer 78

* Maintain pulp vitality * Promote remineralization + tubule sclerosis (biological treatment approach) * Well defined radiopaque dental bridge between pulp chamber and caries * No h/o pain/no lingering cold sensitivity

Answer 79

* Slower resorption than Ca(OH)₂ alone * Radiopaque * Overfill will resorb in **8 weeks** * Friendly to permanent successor

Answer 80

* **Adult stem cells:** Capable of self-replication and differentiation into specialized cells. * **Growth factors (BMPs):** Regulate stem cells to form desirable cell type * Required for differentiation of cells into odontoblasts to deposit dentin. * **Scaffolds (biological or artificial):** Provide biocompatible 3D structures for cell adhesion and migration. * Blood clot forms a scaffold for the ingrowth of progenitor cells.

Answer 81

* Traumatized tooth must be non-vital * Tooth should have **at least 1.1mm open apex** * **1.2mm per month of periapical bone regeneration** * **12 month follow up** to see a result * Patient age **between 7-16yo, in good health**

Answer 82

* **Primary:** tubular dentin formed before eruption * **Secondary:** regular, circumferential after tooth eruption * Dentin forms at a slower rate * Continuous * **Tertiary:** response to irritation * **Reactionary:** formed by original odontoblasts, continuous with secondary dentin * **Reparative:** original odontoblasts died, dentin formed by odontoblast-like cells, not continuous

Answer 83

* Acidophilic zone of fixation * Pale staining zone of atrophy- fewer cells and fibers * Broad zone of inflammatory cells extend apically

Answer 84

Bismuth oxide

Answer 85

* Patient and parent's description of subjective symptoms * Pulpal sensibility testing * Clinical exam

Answer 86

Supportive care: Close monitoring, analgesics, prophylactic antibiotics. More severe cases should be referred to medical professionals for evaluation.

Answer 87

* Comprehensive medical history * Review of past and present dental history and treatment, including current symptoms and chief complaint * Subjective evaluation of the area of current symptoms/chief complaint by questioning the patient/parent on the location, intensity, duration, stimulus, relief, and spontaneity * Objective extraoral examination and intraoral soft and hard tissues * Radiograph(s) to diagnose periapical or periradicular changes * Clinical tests such - palpation, percussion, and mobility (electric pulp and thermal tests are unreliable in immature permanent and primary teeth) You should also consider the value of the involved tooth/teeth in relation to the patient's overall development, alternatives to pulp treatment, and restorability of the tooth.

Answer 88

High pH low solubility

Answer 89

Pulp canal obliteration

Answer 90

* **AKA root end closure** * Inducing root end closure of an incompletely formed non-vital permanent tooth by removing coronal and non-vital radicular tissue just short of the root end and placing a biocompatible agent like Ca(OH)2 for **2-4 weeks** to disinfect canal space. * Growth and development has stopped due to pulpal necrosis. * **Should be reserved as a _last_ resort in immature permanent teeth.**

Answer 91

1 : 5 Comparable success to full-strength FC! Diluted causes less radicular inflammation that full strength

Answer 92

* No signs/symptoms of pathology (duh) * Radiographic success: good fill w/o gross over-extension, bone deposition in radiolucent areas, normal root resorption * Protect developing succedaneous tooth * Success rates are high **(80%)** when a quality definitive restoration is placed

Answer 93

Induce root end closure

Answer 94

* Maintain vitality, prevent pain and infection * Allow for normal exfoliation, prevent need for space maintenance

Answer 95

* Apical barrier will be formed in **74-100%** of cases. * Most common complication: **Cervical root fracture** due to thin walls of the cervical part of the tooth, which fractures easily.

Answer 96

* Post-operative clinical assessment every six months (periodic oral examination) - comparative baseline for future films (the type and frequency with discretion) * Radiographic evaluation of primary tooth pulpotomies - annually (success rate of pulpotomies diminishes over time)

Answer 97

Proper diagnosis, ensuring a good seal

Answer 98

Ca(OH)₂ and iodoform

Answer 99

* ZOE * Ca(OH)₂ * Vitapex * Other less common options: * Endoflas * Maisto's paste * Ledermix

Answer 100

* TGF-Beta is released when there is **caries or acid etchant** - growth factor * **Leads to reparative dentin** * **Ca(OH)₂ also has a similar effect**

Answer 101

**Excites A fibers**, C fibers not activated

Answer 102

* **Sensory A fibers**, C fibers do not respond * On anterior teeth, incisal edge has lowest response threshold * Not very useful on young children

Answer 103

* Unmanageable child, unable to treat in office setting * Dehydrated or medically compromised child * **Swelling that extends to the orbit (cavernous sinus thrombosis risk) OR extends beneath the mandible (airway compromise and Ludwig's angina)**

Answer 104

* Routine radiographs are sufficient for most cases; CBCT or CT scans not indicated unless a medical issue is present * EXT offending tooth ASAP * IV abx * W/ multiple dental needs, consider completion of all treatment at time of admission (reduced cost when compared to two GA procedures)

Answer 105

* Biocompatible * Antibacterial, * Resorbs more slowly than deciduous roots

Answer 106

* Commonly used in US * Under-filling produces better results than overfilling * Overfill = inflammatory reaction * ZOE performed better long term than iodoform-based pastes.

Answer 107

* Vitapex (CaOH with iodoform, silicone oil), kri paste, maisto paste) * Antibacterial, resorbs faster than the primary tooth roots * Vitapex disappears overtime with radiopacity * Vitapex and ZOE with Iodoform have the best success

Answer 108

* For traumatic pulp exposures in permanent teeth. * **Inflamed pulp tissue beneath an exposure that is 4mm or less in size is removed to a depth of 1-3mm or more to reach the deeper healthy tissue.** * No evidence on tooth outcomes with longer periods of waiting time **(may be completed up to 9 days following an exposure),** pulpal bleeding is controlled using irrigants such as sodium hypochlorite or chlorhexidine, covered with calcium hydroxide or MTA (may cause tooth discoloration - light and gray). * Calcium hydroxide = long-term success. * MTA = more predictable dentin bridging and pulp health, a**_t least 1.5mm thick over the exposure and surrounding dentin, then a layer of light-cured RMGI._**

Answer 109

9 days!!!!!!!!!!!!!

Answer 110

Remaining pulp vital, normal root development and apexogenesis.

Answer 111

* Elimination of clinical symptoms/signs and resolution of apical periodontitis in teeth with a necrotic pulp and immature apex. * Thickening of canal walls and/or continued root maturation.

Answer 112

Disinfected root canal space in RET filled with the host’s own vital tissue and the canal space in the RCT filled with biocompatible foreign materials.

Answer 113

Nonvital permanent teeth with incompletely formed roots

Answer 114

Increased width of the root walls and may lead to increase in root length (confirmed by radiographic evaluation).

Answer 115

* Recommendation: * Success of DPC was **independent** of the type of medicament [dentin bonding agents, MTA, and formocresol] → therefore recommends **clinicians choose the medicament based on preference** * Summary of Findings: * Quality of evidence → **very low**

Answer 116

* Recommendation: * **MTA OR FC** * [Strong rec, mod quality evidence] * **FS OR Laser** * [Conditional rec, low quality evidence] * **Use of NaOCl OR Tricalcium silicate** * [Conditional rec, very low-quality evidence] * ***_AGAINST_*** use of Ca(OH)2 * [Conditional rec, low quality evidence] * Summary of Findings: * Overall success rate at 24 M for MTA, formocresol, FS, NaOCl, calcium hydroxide and laser → **82.6%** * Highest success rate at 24M → **MTA and formocresol** [not sig dif] * **MTA success rate: 89.6%** * **Formocresol success rate: 85.0%** * MTA, FC, and FS success rate at 24M → significantly better than Ca(OH)2 [don’t use Ca(OH)2)] * **NaOCl success rate significantly less than FC success rate at 18M.**

Answer 117

* 8 studies, follow up of 24 months * Favored neither type of pulpotomy medicament * **High** evidence

Answer 118

* 4 studies, follow up of 24 months * Favored neither type of pulpotomy medicament * **Moderate** evidence

Answer 119

* 4 studies, follow up of 24 months * **FC significantly better than CaOH** * **Moderate** evidence * NNT: number needed to treat (On doing 3 pulpotomies, one failure could be prevented if FC was used instead of CaOH)

Answer 120

* 2 studies, follow up of 24 months * FS (ferric sulfate) was significantly better than calcium hydroxide * NNT: 4 pulps:1 failure avoided * **Low evidence**

Answer 121

* 3 studies, follow up of 24 months * **MTA significantly better than calcium hydroxide** * **Moderate evidence** * NNT: out of 3 pulps: one failure could be avoided if MTA used over CaOH

Answer 122

* 4 studies, follow up of 24 months * **MTA was favored** * NNT: 9 pulps: 1 failure avoided * **Moderate evidence**

Answer 123

* 2 studies, follow up of 18 months * **Formocresol was significantly better than NaOCl** * NNT: 6:1 * **Moderate evidence**

Answer 124

* 2 studies, follow up of 18 months * **Favored neither type of pulpotomy technique** * **Quality of evidence was low** due to small sample sizes

Answer 125

* 2 studies, follow up of 18 months * **Favored neither type of pulpotomy medicament** * **Low evidence**

Answer 126

* 2 studies, follow up of 18 months * **Favored neither type of pulpotomy technique** * **Low evidence**

Answer 127

* 2 studies, follow up of 12 months * **Favored neither type of pulpotomy technique** * **Moderate evidence**

Answer 128

* 2 studies, follow up of 12 months * **Favored neither type of pulpotomy medicament** * **Very low evidence**

Answer 129

* Can be used for the treatment of dead, dying or abscessed primary teeth with no evident root resorption. * **In teeth with no root resorption, pulpectomy should be chosen over LSTR**. * Follow-up X-rays should be taken at least **_every 12 months_** to monitor the treatment

Answer 130

* ZOE * Iodoform (Vitapex or Metapex) * Zinc oxide/iodoform/CaOH (Endoflas) * ZO/iodoform, CH

Answer 131

**For teeth expected to be in the mouth for 18 months or longer, zinc oxide/iodoform/CH and ZOE fillers performed better than iodoform fillers.**

Answer 132

* Recommendation: * No direct evidence to make a recommendation on criteria * It is suggested that, for teeth deemed non-restorable or when the patient has one or more exceptions to the guideline recommendations stated previously in this guideline and Figure, the treatment of choice may be extraction. * The AAPD’s SR stated the RCT articles on pulpectomy and LSTR showed non-restorable teeth were extracted. * Teeth were not considered for pulpectomy or LSTR if they had an inadequate crown or extensive root structure resorption and were not restorable

Answer 133

* Recommendation: * Pulpectomy is a viable long-term treatment for non-vital primary teeth **without root resorption compared to those with root resorption.** * Pulpectomy should be considered for non-vital primary teeth without preoperative root resorption. * (Conditional recommendation, very low quality of evidence—12 months; conditional recommendation, very low quality of evidence—24 months.) * Remarks: * For longer periods (24 to 60 months) from RCT and NRS articles, pulpectomy success in teeth without pre-operative root resorption from the SR had higher success **(84 to 90%)** versus teeth with preoperative root resorption **(59 to 69%)**.

Answer 134

* Recommendation: * **Pulpectomy success was higher than LSTR for teeth without preoperative root resorption, indicating it should be preferred over LSTR in these teeth.** * (Conditional recommendation, low quality of evidence.)

Answer 135

* Recommendation: * **LSTR choice over pulpectomy to save teeth for up to 12 months** * **If longer than 12 months, monitor with exams/radiographs every 12 months are doing LSTR** * Summary of findings: * **LSTR success rate 76% compared to pulpectomy success rate 47%** * **Moderate quality of evidence** * Remarks: * LSTR tx adversely affected the permanent tooth eruption due to interradicular bone loss and in one case caused OKC * Perhaps LSTR should be used ONLY to save primary molars for up to 12 mos to maintain space then be monitored periodically

Answer 136

* Recommendation: * **Primary teeth pulpectomies, overall success after 12 mos not impacted by number of visits (very low quality of evidence)** * Summary of findings: * 1 visit vs 2 visits were not statistically significant

Answer 137

* *Recommendation*: * Clinicians may **choose any root length determination method** (very low evidence) * Tactile * Radiographs * Apex locators * *Summary of findings*: * Apex locator vs radiographs: not significantly difference * Very low evidence * *Remarks:* * One in vivo study with single rooted primary anterior teeth used apex locator, radiographs and tactile * Apex locator and radiographs mean length deviation from actual mean length of 15 mm was insignificant * Tactile feel was 1 mm shorter in the same teeth

Answer 138

* *Recommendation*: * Rotary instrumentation time= significantly shorter than manual by 2 mins * Rotary and instrumentation= comparable success while the occurrence of flush fills (a root canal filled to the apex) favored rotary * **Clinicians can choose either method of instrumentation** (moderate evidence) * *Summary of findings: manual vs rotary canal preparation time* * Significant difference **favoring rotary filling** * High evidence according to GRADE * No significant difference in two groups pulpectomy success * No difference in bacterial reduction * *Manual vs rotary optimum (flush) filling outcome* * **Favored use of rotary filling** for achieving a flush apical fill * Moderate evidence according to GRADE * *Remarks*: * **Rotary required less time and involved less dentin removal and more uniform root canal preparation** * Many primary teeth are ribbon shaped and rotary instruments are centered in canals=\> rotary may leave behind infected tissue in unclean areas in fins and isthmuses * Additional hand instrumentation and irrigation may be needed to remove remanent tissues * Factors to consider: high cost of rotary system & training to learn rotary technique

Answer 139

* *Recommendation:* * No adequate evidence to make a recommendation * Did not seem to depend on whether smear lay was removed or not * **Choose either way of managing smear layer** * *Summary of findings:* * **Smear layer removal does not alter its success** * *Remarks:* * **Smear layer:** accumulation of dentin and pulpal debris formed on the root canal walls during instrumentation for a pulpectomy by rotary or manual filing * Its removal possibly allows the root canal filler to adapt better to the canal walls * Smear layer may occlude the dentin tubules and prevent bacteria and toxin penetration

Answer 140

* *Recommendation:* * **Irrigants had no impact on success** * Sodium hypochlorite 1-5% * Water/saline * Chlorhexidine * Choose any irrigation solution * Very low quality of evidence * *Summary of findings:* * Difference between NaOCl and saline and/or distilled water was **not significant** * Very low evidence according to GRADE * *Remarks:* * Investigated pulpectomy success after 12 months in terms of irrigation * Water/saline= success rate 81% * NaOCl= success rate 89% * Chlorhexidine= success rate 87%

Answer 141

* *Recommendation:* * Zinc oxide/iodoform/calcium hydroxide (ZO/iodoform/CH) and zinc oxide eugenol (ZOE) may be better choices for pulpectomy success compared to iodoform at 18 mos * Very quality of evidence * **RANKING BEST TO “WORST”** * ZO/Iodoform/CH * ZOE * Iodoform * *Summary of findings:* * *pulpectomy root canal fillers-ZOE vs iodoform pulpectomy success after 18 mos* * No significant difference * Very low quality of evidence according to GRADE * *ZOE vs ZO/iodoform/CH success 18 mos* * No significant difference * Low quality of evidence according to GRADE * *ZO/iodoform/CH vs iodoform success 18 mos* * No significant difference * Very low quality of evidence according to GRADE * *Remarks*: * No significant difference b/w success of ZO/iodoform/CH and Vitapex brand of iodoform * No significant difference b/w success ZO/iodoform/CH and Metapex brand of iodoform * *Network analysis:* * **Objective of network analysis**: to combine both the direct and indirect evidence across all studies * Ranks effectiveness * ZO/iodoform/CH and ZOE were markedly better than iodoform * *ZOE and ZO/iodoform/CH vs calcium hydroxide success 12 and 18 mos* * **Nonsignificant** difference between ZOE and CH at 12 mos * The other CH brand result was statistically different * Low quality of evidence at 12 mos according to GRADE * ZOE success 100%, CH success 85% after 18 mos * No valid comparison using success rates 12 mos vs 18 mos, therefore CH was not included in the network analysis

Answer 142

* *Recommendation*: * SSC vs filling= comparable success unaffected by timing of when restoration was placed * SSC better success than composites * May choose type and timing * Very low quality evidence * *Summary of findings: type of final restoration:* * Pulpectomy success b/w SSC or composite/amalgam= no significant difference * Very low according to GRADE * *Timing of final restoration:* * Pulpectomy success b/w same day vs later day final restoration=no significant difference

Answer 143

* *Recommendation*: * Not statistically significant * Choose any of these obturation techniques * *Summary of findings: quality of pulpectomy fill:* * Lentulo vs hand plugger vs syringe= no significant difference in achieving flush fills * Flush fill: a root canal filled to the apex * *Obturation method and pulpectomy success:* * Lenutols vs hand pluggers vs syringes= no significant difference * Lentulos vs syringe fills= no significant difference * Both very low quality of evidence * *Remarks:* * Overfilling of canals=lower success for pulpectomy * Type of technique all produce voids, some techniques may cause more overfills (lentuolo) * not enough clinical studies to evaluate these

Answer 144

* *Recommendation*: * No adequate evidence * Do not seem to be altered if it was incisor vs molar * Pulpectomy success rates for primary first molars & second molars=comparable * *Summary of findings:* * Incisor 87% success, molar 89% success * First vs second molars= comparable (nearly the same) * No GRADE assessment was possible * *Remarks:* * Tooth type didn’t appear to affect success

Answer 145

* *Recommendations*: * Did not find adequate evidence * Pulpectomy success rate incisors tx due to trauma or caries= comparable * Does not appear success was adversely affected if tx for trauma or caries UNLESS the tooth was retraumatized * If re traumatized, pulpectomy success rate decrease significantly to 41% * *Summary of findings:* * No statistical comparison b/w traumatized primary anterior tooth vs primary incisors with caries * No GRADE possible * *Remarks:* * Incisor pulpectomy success do not appear much different if treated due to trauma vs caries

Answer 146

* *Recommendation*: * No evidence to make a recommendation on isolation technique * Rubber dam= critical for non vital procedures in maintaining isolation from saliva, blood and other contaminants * *Summary of findings:* * 5 studies that didn’t use rubber dam didn’t have usable data to evaluate * *Remarks*: * Rubber dam= standard of care for non vital pulp therapy * May be unethical to perform a study comparing with and without rubber dam

Answer 147

* *Recommendation*: * Choose alternate 3Mix over traditional * Potential adverse effects of tetracycline in children * Significantly higher success rates of alternate 3Mix * *Summary of findings:* * Significantly less success statistically using traditional vs alternate * Quality of evidence very low according to GRADE * *Remarks*: * Combination of clindamycin, metronidazole and ciprofloxacin was as effective as the combination minocycline, metronidazole and ciprofloxacin with no significant difference in reducing mean bacterial colony counts

Answer 148

* *Recommendation*: * Choose whether or not to file/broach since success rate=not significantly different * *Summary of findings:* * Not filed or broached before placing the paste vs filed and/or broached before placing the paste=no significant difference * Very low quality of evidence GRADE

Answer 149

* *Recommendation:* * Did not find adequate evidence to make a recommendation of adverse events * Rare * Mod to severe pain after 24 hrs * Enamel defects in permanent tooth * Retained ZOE filler after pulpectomy exfoliation=not uncommon * One report- LSTR tx after 36 mos= interradicular bone loss affecting permanent tooth * **Clinicians should evaluate non vital pulp tx for success and adverse events clinically and radiographically at least every 12 months** * Summary of findings: * ZOE resorbs slower than the primary tooth root in some cases * May cause permanent tooths path of eruption to be deflected * May result in anterior cross bite for incisors * Iodoform fillers resort at a faster rate than root * Make pulpectomy look like pulpotomy after 12-18 mos * If filler is extruded beyond apex * Iodoform fillers seem to resorb * ZOE resorbs slowly (can take years) * *Exfoliation after non vital pulp tx:* * *Grewal study= longest LSTR follow up (36 mos)* * LSTR tx teeth did not resorb, unlike untreated contralateral teeth * Pulpectomy teeth had early exfoliation (76 out of 317) * Pulpectomy teeth were over retained compared to contralateral (29 out of 319) * *Problems from non vital tx in primary teeth on the succedaneous teeth:* * One study- enamel defect for succedaenous tooth * Others- no enamel defects * Enamel defects were related to age of the child **(younger than 4.6 years)** when the tooth became infected, excessive preoperative root resorption or trauma * Grewal- LSTR teeth after 36 mos- overretained compared to conventional pulpectomy tx * Some associated with interradicular bone loss surrounding crown of perm successor * *Pain*: * Postop pain after 24-48 hrs= associated when non vital tx failed * No pain: 80% * Mild pain: 12% * Moderate to severe pain: 8% * Severe pain=uncommon

Pulp Therapy Flashcards

(173 cards)