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Dent 430-week 4-1 Seghi Todays Topics Deep caries and tooth response to it Diagnosing the status of the

pulp Theory of tooth pain response Removing deep caries Functions of Dentin/Pulp Complex Functions of the pulp formative (1 and 2 dentin) week 1 nutritive (nutrients to vital cells) blood supply defensive (ability to self repair) week 3 sensory or protective (provides sensory nerve fibers within the pulp to mediate sensation of pain; pulp usually does not differentiate between heat, touch, pressure, or chemicals) - today Defensive : discussed in week 3 the ability of the pulp to protect the tooth from various insults Cellular response : reparative (secondary) dentin Physical/chemical response : sclerotic dentin Sensory role: Sensitivity Pain from pulpal Inflammation Sensitivity Causes of Tooth Sensitivity (Pain) physical stimuli (probing with explorer) thermal stimuli (cold air, hot and cold liquids) chemical stimuli (bleaching teeth) bacterial stimuli (eating sweets) traumatic stimuli (tooth preparation) Although the precise mechanism of the pain transmission have not been established conclusively, the most accepted theory is the hydrodynamic theory

Hydrodynamic Theory of Pain Transmission


Mechanoreceptors associated with odontoblast cell bodies and processes small, rapid movements of fluid in tubules occur from cutting drying pressure changes osmotic shifts changes in temperature stimuli induces fluid movements in dentinal tubules, distorting odontoblasts and afferent nerves - which leads to trigger of nerve conduction, which is interpreted as pain.

Dent 430-week 4-1 Seghi Pain from pulpal Inflammation (pulpitis) Pain is often associated with deep caries- not all caries When caries and bacteria are in proximity to pulp -toxins and even bacteria may enter pulp resulting in inflammation. Dentin is permeable so agents can diffuse through the tubular fluids. Inflammation is the way the body removes damaged tissue and begins the healing process. Inflammation can be triggered by Infection Trauma Physical and chemical agents Tissue necrosis Foreign materials Immune reactions Goal of inflammatory process Move defense mechanisms from vascular system out to tissue Simple inflammatory process: The bacteria present in a carious lesion cause pulpal effects long before they physically invade the pulp proper. Bacterial byproducts, diffusing through the dentinal tubules into the pulp, cause the local infiltration of chronic inflammatory cells (such as macrophages, lymphocytes and plasma cells). As bacteria actually invade the pulp, pulpal inflammation becomes acute with polymorphonuclear leukocytes the dominant inflammatory cell. Depending upon the severity of the pulpal insult, the pulp may exhibit a transient inflammation (reversible pulpitis). The most common cause of pulpitis is tooth decay; the second most common cause is injury. Mild inflammation, if relieved, may not damage the tooth permanently. Severe inflammation may cause the pulp to die. Symptoms and Diagnosis Pulpitis can cause intense tooth pain. To determine if the pulp is healthy enough to save, a dentist can perform certain tests. For example, a dentist can apply a hot or cold stimulus. If pain persists after the stimulus is removed or if pain occurs spontaneously, the pulp may not be healthy enough to save. A dentist may also use an electric pulp tester, which indicates whether the pulp is alive but not whether it is healthy. If the person feels the small electrical charge delivered to the tooth, the pulp is alive. Sensitivity to tapping (percussion) on a tooth often means that inflammation has spread to the surrounding tissues.

Dent 430-week 4-1 Seghi

Diagnosing the status of the pulp? Wanted Dead or Alive


Status of the Pulp - 4 possible states the pulp can be in 1) Normal, healthy vital pulp Pulpitis (inflammation of pulp) 2) alive and reversible (hyperemia and inflammation) 3) alive and irreversible (leads to pulp necrosis) 4) Necrotic (dead) pulp Characteristics of tooth pain help us determine the state or condition the pulp is in. Location: where does it hurt? Intensity: sharp or dull?-ususlly pulp pain is sharp Duration: long lasting or short duration? Cause of initiation: spontaneous, pressure, cold, hot

DIAGNOSING PULPAL STATUS


Common Clinical Tests to determine pulpal status (Tools we use) Cold stimulus (tests pulp vitality) Hot stimulus (tests pulp vitality) EPT (electric pulp test) (tests pulp vitality) Percussion or bite pressure - (tests ligament space)

TYPICAL CLINICAL SYMTOMS AND TEST RESPONSES


Normal healthy pulp Clinical Symptoms(chief complaint) - None Response to tests Cold/Hot causes momentary pain and stops when removed- this can vary from patient to patient because of dentin structure and amount. EPT (electric pulp test) elicits pain at some level increase electric current gradually record arbitrary number related to amount of current. This can vary due to dentine structure and amount. May not be effective with large or full coverage restorations. It is placed on tooth and not restorations (conduct) Percussion does not elicit any pain- people respond different to percussion percussion is used to tell you something about injury to the periodontal ligament. All tests can give false positives so no test is decisive alone Often test contralateral or adjacent tooth to assess relative response Reversible Pulpitis (mild) Clinical Symptoms may not have any Response to tests Cold/Hot causes momentary pain and stops when removed- may be slightly more intense compared to contralateral or adjacent teeth. Hyperemic or inflamed pulps usually hypersensitive

Dent 430-week 4-1 Seghi EPT (electric pulp test) elicits pain at some level may be slightly more intense compared to contralateral or adjacent teeth. Hyperemic or inflamed pulps usually hypersensitive Percussion does not elicit any pain in normal patients Reversible Pulpitis (moderate) Clinical Symptoms patient complains of pain when eating sweets or drinking cold Cold sensitivity alone may indicate root sensitivity and no disease Sweet sensitivity usually associated with caries Response to tests (same as above case) Cold/Hot causes momentary pain and stops when removed- may be slightly more intense compared to contralateral or adjacent teeth. Hyperemic or inflamed pulps usually hypersensive EPT (electric pulp test) elicits pain at some level may be slightly more intense compared to contralateral or adjacent teeth. Hyperemic or inflamed pulps usually hypersensive Percussion does not elicit any pain in normal patients Irreversible Pulpitis Clinical Symptoms patient may complain of spontaneous pain (just starts hurting randomly) or pain could be brought on by cold drinks and lingers for some time. Could be dull ache or sharp spontaneous pain cold and hot elicits pain that continues (lingers) for >15 sec pain elicited by heat that continues until cold applied Response to tests Cold/Hot causes pain but pain lingers for at least 15 seconds or more after stimulus removed EPT (electric pulp test) elicits pain at some level Percussion does not elicit any pain Pulpal Necrosis Clinical Symptoms vary from none to significant swelling and pain. This depends on whether the infection is confined or draining (fistula tact) Some typical complaints it hurts to bite on spontaneous and continuous pain no response to cold or hot localized (abscess) or generalized swelling (cellulitis) periodic bad taste in mouth (draining fistula) Response to tests Cold/Hot no vital pulp no response EPT no vital pulp no response Percussion can cause pain if infection confined to apex area may cause no pain if infection has a drainage site (fistula tract)

Dent 430-week 4-1 Seghi Combinations of these symptoms can occur anatomical considerations-multi rooted teeth rate of inflammatory processstage of pulpal necrosisSUMMARY Clinical Indications of pulpal inflammation Inflammation is evidenced by the patient as a sharp pain elicited by cold and/or sweet. The pain last only a few seconds. Cold test used in diagnosis: pulpal hyperemia or reversible pulpitis will be painful to cold stimuli for a few seconds (<10sec duration) When the pulp becomes more severely inflamed it elicits a spontaneous pain or lingering pain to cold stimuli (>15 sec duration) indicates irreversible pulpitis Percussion or biting pressure indicates some inflammation of the periodontal ligament space around the apex of the tooth. Pulpal inflammation has worked its way outside the chamber and is irreversible and/or partially necrotic

Treatment The inflammation stops when the cause is treated. When pulpitis is detected early, a temporary filling containing a sedative can eliminate the pain. This filling can be left in place for 6 to 8 weeks or more and then replaced with a permanent filling. Other times a base can be placed to protect the pulp and a permanent filling can be put in immediately. When pulp damage is extensive and cannot be reversed, the only way a dentist can stop the pain is by removing the pulp by root canal treatment or tooth extraction. CLINICAL CARIES REMOVAL: The recognized control of cavitated carious lesions occurs predominantly by clinical removal of the infected area from the tooth, and the restoration of the tooth to optimal form, function, and esthetics. Specific clinical treatment depends on the extent of the destruction that has occurred. Clinical terms- we need to determine clinically the difference between dentine types Non-affected dentin (zone 1) normal dentin Affected dentin (zones 2 and 3) no bacteria present, dentin demineralized but not denatured, can be remineralized, need not be removed. Infected dentin (zones 4 and 5) presence of bacteria, dentin (collagen) is irreversibly denatured, unable to remineralize, must be removed. Methods of clinically detecting infected vs. affected dentin (difficult) degree of discoloration not all discoloration is caries hardness (explorer detection) most common method caries detect solutions (stains infected dentin) probably most discriminating but not widely used by dentists

Dent 430-week 4-1 Seghi Clinical Strategy for Caries Removal dentin that appears leathery, peels off in small flakes, or can be penetrated by sharp explorer should be removed Strategy aggressive removal of staining at DEJ less aggressive over pulpal wall Method largest round bur that fits slow speed light pressure spoon excavator and explorer as we get closer to pulp after softened dentin removed, carefully evaluate excavated area with explorer (or caries detect solutions) to determine if remaining dentin is hard and sound