What are the 3 cell types in the pulp?
1. Odontoblasts
2. Fibroblasts
3. Undifferentiated mesenchymal cells (secrete tertiary dentin)
Primary vs secondary dentin
Primary = before root formation is complete
Secondary = after root formation is complete
T/F: the pulp lacks collateral circulation
True - this is why it cannot cope well with infection
Sclerotic dentin is a response to what?
Slowly advancing caries
It is the calcification of tubules in response to slowly advancing caries
Reactionary dentin is a response to what?
Minor damage
Reparative dentin is a response to what?
Major damage
Pulpal necrosis is a response to what?
Rapidly advancing caries or other severe damage
What is another name for reactionary dentin?
Secondary dentin
What is another name for reparative dentin?
Tertiary dentin
Calcium hydroxide liner causes the production of what?
Either reactionary dentin or reparative dentin depending on how deep
What are the 5 layers of the pulp from outside to inside?
1. predentin
2. odontoblastic layer
3. cell-free zone of weil
4. cell rich zone
5. pulp core
look up image
Alpha Delta pulp fibers carry what type of pain?
Is it Afferent or Efferent?
Myelinated or not?
MUST KNOW FOR EXAM
1. Sharp transient first pain
2. Cold
Afferent
Myelinated
Which pain fiber in the pulp are myelinated?
Alpha delta
C fibers in the pulp carry what type of pain?
Full throbbing second pain
Heat
Where are alpha delta fibers?
Where are c fibers?
Alpha delta - course coronally
C fibers - centrally
What nerves are involed in the pulpal dental complex?
Implications?
Alpha delta fibers
They are on the outside so they will be the first and then the later pain will be transmitted by the C Axons
Definition of hyperalgesia?
Allodynia?
Hyperalgesia - Heightened response to pain. So something that is usually painful becomes more painful
Allodynia (Aloe-dynia) - REDUCED pain threshold - pain to things that normally don't prvoke pain (like sun burn, touching skin doesn't hurt normally, but
Preauricular pain often refers from which molars? maxillary or mandibular?
What is the area on the face?
Mandibular due to v3 branch and innervation
Jaw, ear, and forehead
What is endo ice? What tempurature?
Do we use it for pulpal or periodical diagnosis>
1. dichlorodifluoromethane
2. -30 celcius
Pulpal
Where do we apply the endo ice?
Middle third of facial surface of crown for 5 seconds
What is the least reliable pulp vitality testing?
What is the most reliable?
EPT
Temperature
What does the electric pulp test tell us? Doesn't tell us?
1. if there are vital sensory fibers - bascially just tells us if its vital, but nothing else
2. does not tell if there is vascular supply to the pulp
Electric pulp test in contraindicated in who?
Electric pace maker patients
True of False: Pulpal necrosis always includes the entire pulp?
False, it can be partial or total
What causes pulp necrosis?
Long-term interruption of blood supply to the pulp
What teeth can experience crown discoloration in pulp necrosis?
Anterior teeth
T/F Apical radiolucency can be a confirmation of pulpal necrosis?
True
Acute apical abscess is what type of necrosis?
Liquefaction necrosis - purulent exudate
How do you distinguish chronic apical abscess from acute?
Chronic apical abscess usually has no discomfort
What is the most important technical aspect of TCT?
Access preparation
Access preparation for incisors?
Triangular
Access preparation for canines?
Ovoid
Access preparation for premolars?
Oval
Which premolar is most likely to have 2 roots?
Maxillary 1st pre molar
Which root of maxillary molars can have 2 canals?
Mesial buccal
Access preparation for maxillary molars?
Blunted triangle or rhomboidal
Mandibular molars access preparation?
Trapazoidal shape
What is the taper for the SS hand files?
.02
K-file shape?
Hedstrom shape?
k = twisted square, watch winding
Hedstrom = spiral cone (tear drop shape), only cuts in retraction
Rotary instrument taper?
.04 or .06
The first white file starts at what file number?
15
What is the color for 6, 8, 10 file?
Pink, Grey, Purple
D1 diameter tip for, say, a 15 file is what?
D2 (or D16) is what diameter for, say, a 15 file with .02 taper?
1. .15 mm
2. .15+(.02*16mm) = .47 mm
What is the length of the endo file?
16 mm
Crown-down is beneficial for what 2 reasons?
More efficiency
less risk of instrument fracture
What is the ideal range to end an rct?
0-2 mm from the apex
1 mm idealy
Crown down is usually done by what instruments?
Step back is usually done by what instruments?
1. rotary
2. hand files
What 2 things does bleach do?
irrigant
dissolves organic material
What 3 things does edta do?
1. lubricant
2. dissolves inorganic material (like the smear layer)
What does chloroform do?
Dissolves GP in retreatment
Primary endo infection is what bacteria?
Bacteroides
Failed endo treatment is what bacteria?
Enterococcus faecalis
What do we use for the gutta percha sealer?
Zinc Oxide Eugenol (ZOE)
What is trephination?
Surgical opening in hard tissue to release exudate and pressure...basically the hard tissue version of incision and drainage
What is orthograde?
This is crown down filling of a canal (the opposite of a apicoectomy
How much of the root tip should you resect in apicoectomy?
3 mm
What angle should you cut off the root tip?
0-10 degrees. the steeper the degree the more chance of leakage
How much to you instrument into the canal in apicoectomy?
3 mm
What do you retrofill with in apicoectomy?
MTA
How do you work past a ledge in endo?
Use a smaller instrument to bypass ledge
What is canal transportation?
Tendency for a file to straighten out a canal
What instrument type are MORE likely to fracture?
NiTi files
How do you work past an instrument fracture?
Use a smaller instrument
What stage of the root canal results in a better prognosis is an instrument fractures?
Later in the treatment because more bacteria has been removed
What is furcal perforation?
Perforation through the pulpal floor
What is a strip perforation?
Perforation due to excessive coronal flaring
Where is the "danger zone" on mandibular molars as is pertains to perforations?
What should you do to avoid this?
The distal surface of the mesial root because there is a large concavity and you could remove all the dentin
Favor the mesial surface of the mesial root as there is extra dentin there
What part of the root has a better prognosis for root perforation?
The more apical the better
Immediate hemorrhage or sudden pain instrumentation is a sign of what?
Root perforation
What is the treatment for root perforation?
Internal repair with MTA
All problems with endo have a better prognosis if they happen when?
Later in treatment
What is the simple to remember the trauma protocol for a tooth trauma? (acronym)
TRAVMA
T - tetanus booster (avulsion only
R - radiograph
A - antibiotics (avulsions only
V - vitality testing
M - more
A - appointments
What are the 6 classifications in the ellis clasification system?
1 - enamel only
2 - enamel and dentin
3 - enamel, dentin, and pulp
4 - traumatized tooth that has become non vital
5 - luxation
6 - avulsion
Uncomplicated fracture:
1. what is involved?
2. How to treat is only enamel
3. how to treat is enamel and dentin?
1. NO pulpal involvement
2. smooth edges
3. restore
What is a complicated fracture?
Involved pulp
What are the 3 time frames and treatments for complicated fractures?
1. Less than 24 hours - direct pulp cap
2. More than or equal to 24 hours - Cvek
3. More than or equal to 72 hours - PPTY
A suspect horizontal root fracture should involve what 4 radiographs?
3 PAs and 1 occlusal
What is the name for the ideal healing of a horizontal root fracture?
Calcific metamorphosis (calcific healing)
If the horizontal root fracture tooth is vital, what is the treatment?
If its not vital?
1. splint ASAP
2. RCT
For a vital horizontal root fracture tooth, what are the 3 locations of fractures and their treatments?
1. Coronal fracture - rigid splint for 6-12 weeks
2. Midroot fracture - flexible splint for 3 weeks
3. Apical fracture - flexible splint for 2 weeks maximum to avoid ankylosis
The more apical the horizontal root fracture the better
True
If we RCT the horizontally fractured tooth, what portion of the tooth MOST likely needs the treatment?
The coronal segment has a 25% change of necrosis, the apical segment very rarely
What is the definition of tooth concussion?
No displacement, no mobility, pdl is sore
What is the treatment for concussed tooth?
Let the tooth rest
Definition of subluxation?
No displacement, increased mobility, PDL rips and bleeds
What is the treatment for subluxation?
Flexible splint for 1-2 weeks
Subluxation is better prognosis for what type of tooth?
Open apex tooth
Tooth extrusion:
1. What to do for open apex?
2. Closed apex?
1. reposition, flexible splint, monitor
2. reposition, flexible splint, rct if needed
What is the change of necrosis for extruded closed apex teeth?
65%
What is the definition of lateral luxation?
Displacement of tooth in any direction except axially
What are the treatment for laterl luxation?
Same as extrusion, splint and monitor for necrosis
What is the chance of necrosis for lateral luxation of a tooth?
80%
Tooth intrusion:
1. Treatment for open apex?
2. Treatment for closed apex?
1. allow to reerupt
2. reposition, flexible splint, RCT
What is the chance of necrosis for intrusion?
96% chance
What is the EADT?
Extraalveolar dry time
What is the treatment for avulsion?
reimplant asap, flexible splint for 1-2 weeks
Avulsion treatment for closed apex:
1. less than 60 minutes
2. greater than 60 minutes
1. reimplant, splint
2. reimplant, splint, rct
Avulsion treatment for open apex:
1. <60 minutes
2. >60 minutes
1. reimplant, splint, no RCT but apexification at first sign of infected pulp
2. may or may not reimplant, splint, rct, plan for implant
What is the least desirable solution to hold teeth in?
Water
External resorption initiates in the periodontium and is due to what?
Damage to the cementoblastic layer
What is replacement resorption?
Ankylosis, replaces PDL with bone
What is cervical resorption?
Subepithelial sulcular infection from trauma or nontival bleaching
What is inflammatory root resorption?
Bacteria and byproducts from necrotic pulp travel through dentinal tubules to affect periodontium
2 ways external resorption appears?
1. margins are ragged and poorly defined
2. moves with angled radiographs
Internal resorption results from damage to WHAT?
Odontoblastic layer
Internal resorption, better or worse prognosis than external?
Better
Treatment for internal resorption?
RCT
Compare the 2 appearances of internal resorption to external:
1. Margins are SHARP and WELL-DEFINED
2. Does NOT move with angled radiographs
The body's ideal response to trauma is calcific metamorphosis.
1. What is happening with this?
The odontoblasts are stimulated to rapidly form extensive amounts of reparative dentin with the pulp space
Calcific metamorphosis is more likely with what teeth?
Open apices, intrusions, and severe crown fractures
Calcific metamorphosis has what color?
Yellow-orange color
Calcium hydroxide does what?
What is the pH?
1. Stimnulates secondary odontoblasts to repair with dentinal bridge formation (form tertiary dentin)
2. HIGH pH of 12.5
What does MTA do?
Stimulates cementoblasts to produce hard tissue
What are the 3 materials in MTA?
Calcium, Silicon, Aluminum
What is the problem with mta?
Bismuth oxide - opacifier
What are the 3 benefits for MTA?
1. Sets in the presence of moisture
2. antimicrobial
3. Nonresorbable
What are the 3, 3things with MTA (3 letters)
1. 3 minerals
2. 3 hours set time
3. 3 benefits (moisture doesn't affect it, antimicrobial, nonresorbable)
Direct pulp cap can be used for a carious exposure that is what size?
Less than 2 mm
When does a direct pulp cap hard tissue barrier form?
Hopefully within 6 weeks
What is a Cvek pul
removal of small portion of coronal diseased pulp
Pulpotomy involves what part of the tooth?
ONLY the coronal pulp
Pulpotomy for pediatric teeth, what 3 things must be there in order to decide to do this treatment?
1. Vital
2. Tooth is restorable
3. Asymptomatic
When you do a pulpotomy, what material is placed 1st?
2nd?
1. Formocresol
2. ZOE
We use "Buckley's" formocresol for pulpotomies, what 2 things does it do?
1. Bactericidal
2. "Fixative" to the pulp
When would you do a pulpectomy on a pediatric tooth?
When the tooth is nonvital but the restorable with pulp exposure but asymptomatic pulp exposure
When do you put in the root of a pulpectomy?
Calcium hydroxide and ZOE in the crown
What primary tooth would you prefer to extract rather than perform pulpectomy (so this would be a non vital tooth and you are choosing between extraction or pulpectomy - non pulpotomy)
Primary first molars because there are lots of accessory canals
What is apexogenesis?
Maintaining pulp vitality in order to stimulate root development and allow the body to make a stronger root
Apexogenesis can be done on what type of pulp?
Healthy OR disease pulp in an immature tooth
What is apexification?
Disinfection of root canal followed by induction of an acceptable apical barrier
What type of pulp is apexification done on?
Dead or dying pulp
How do you tell the difference between a necrotic and an asymptomatic irreversible pulpits?
asymptomatic irreversible will be normal and lingering where as necrotic will be NOTHING
Asymptomatic and no pain on percussion and palpation?
What is the periapical diagnosis?
Normal
Painful percussion and intense throbbing pain.
What is the periapical diagnosis?
Symptomatic apical periodontitis
Asymptomatic tooth but apical radiolucency. What is the periodical diagnosis?
Asymptomatic apical periodontitis
Rapid swelling, purulent exudate and severe pain.
How does this different from symptomatic apical periodontitis?
Acute apical abscess
Symptomatic apical periodontitis is going to be painful to percussion and throbbing pain but NO swelling and exudate
How does chronic apical abscess differ from acute apical abscess?
sinus tract without discomfort = chronic apical abscess