Pedo Core 9: Jerrell's Pulp Ssc

Front 1

1) Your choice of primary tooth pulp therapy is based on the extent of _________
2) What are your choices if you have reversible inflammation?
3) Do we usually do direct pulp caps on primary teeth?
4) What are your choices if you have irreversible inflammation?

Back 1

1) Pulpal inflammation
2) Caries removal only (protective base or indirect/direct pulp therapy)
3) NO
4) Pulpotomy (coronal pulp only), pulpectomy (radicular inflammation - beyond the coronal pulp, or pulpal necrosis), ext and space maintenance (pulpal necrosis and non-restorable)

Front 2

What are the 3 initial diagnostic considerations to see which treatment you should pursue?

Back 2

1) Health of the patient (if they have a systemic disease, may want to use an alternative approach, like extraction vs. pulp therapy)

2) Time to be retained (age of patien)

3) Status of remaining dentition

Front 3

What are the 9 things you need to assess clinically on the tooth that you're addressing?

Back 3

1) Pain eval: elicited pain when provoked = normal restorative or pulpotomy, and unprovoked, spontaneous pain indicates pulpectomy or extraction
2) Soft tissue exam (swelling or fistula?)
3) Palpation
4) Temperature
5) Cellulitis
6) Percussion sensitivity
7) Mobility (pulpectomy/ext)
8) Pulp testing (unreliable due to secondary canals)
9) Restorability

Front 4

1) What does percussion sensitivity mean for the tooth and pulp? What do you need to help confirm your suspicion?
2) If the tooth is mobile: what cause it to be mobile? Status of the pulp? Tx options? What shouldn't you confuse this with?
3) What 5 things should you look for on a radiograph?
4) What is indicated if the depth of the carious lesion is: Minimal? Near pulp? Inflammation in the coronal part only?
5) What do pulp calcifications indicate, and what are your tx options?

Back 4

1) Indicates that supporting perio structures are inflamed, pulp usually non-vital. Need a current radiograph to help confirm.
2) Long term inflammation => pathologic resoprtion of bone, root, or both. Non-vital, pulpectomy or ext. Don't confuse with normal exfoliation (look at tooth bud relationship, and determine if pathologic or physiologic resorption)
3) Depth of carious lesion, pulp calcifications, bifurcation radiolucency, internal resorption, external resorption
4) Minimal - caries removal only. Near pulp - indirect pulp cap. Inflammation coronal part only - pulpotomy unless other symptoms
5) Chronic inflammation. Pulpotomy or pulpectomy

Front 5

Bifurcation radiolucency:

1) Can be seen on what kind of films?
2) Why is this spot important?
3) Why does bone break down here?
4) Tx options if you see a bifurcation radiolucency?
5) What teeth should you NOT do a pulpectomy on?

Back 5

1) PA and BW films
2) FIRST indication of extensive pathology - early radiolucencies show up here
3) Pulpal floors are porous, and secondary canals lead to breakdown of bone
4) Pulpectomy or ext
5) 1st primary molars

Front 6

1) Internal root resorption indicates?
2) Tx options if you see internal root resorption?
3) What is really important to do if you see external root resorption on a film?
4) What are your tx options if you see external root resorption?

Back 6

1) Extensive inflammation of vital pulp
2) Pulpectomy (unlikely - most don't work)/extraction
3) Get a RECENT radiograph - changes can occur quickly
4) Pulpectomy/extraction

Front 7

Other diagnostic considerations?

Back 7

1) Stage of dental development (proximity of permanent successor)
2) Space maintenance (locatin of tooth)
3) Restorability
4) How hard it will be to perform the procedure
5) Patient/parent cooperation

Front 8

1) What are 2 normal factors that may complicate radiographic interpretation? What is a better film to take if the tooth bud is superimposed?
2) What are the 2 most important difficult aspects of pulp diagnosis?
3) What is the best way to formulate a final diagnosis for the status of the pulp? How do you determine the status?
4) What should you NOT use during your pulpotomy - it'll get in the way of your pulpal diagnosis? What should you use instead?
5) What are your 3 treatment options for a vital pulp?
6) Types of diagnosis for deep caries?
7) 3 tx options for vital pulp?

Back 8

1) Superimposition of developing tooth buds, normal resorption patterns. BW > PA if tooth bud is superimposed
2) Determining health of the pulp, determining the extent of inflammation (coronal vs. radicular)
3) Evalutae it directly, during a pulptomy procedure and following coronal pulp amputation. Hemorrhage control - healthy pulp. No hemorrhage control - radicular pulp is inflamed
4) Medicament. Use cotton pellet with pressure only
5) Indirect pulp cap, direct pulp capping (don't do this a lot), pulpotomy
6) Deep caries => vital pulp/reversible pulpitis, irreversible pulpitis/non-vital
7) Indirect pulp cap, direct pulp cap, pulpotomy

Front 9

CARIES REMOVAL ONLY:

What are 2 things you can place?

Back 9

1) Protective base (Vitrebond, GI)
2) Indirect pulp cap (for a deep carious lesion with no signs or symptoms of pulpal degeneration, primary teeth and immature permanent teeth)

Front 10

Indirect pulp treatment:

1) What is the definition?
2) What is placed over the remaining affected dentin?
3) What happens if you put CaOH over inflamed pulp? Is it okay with healthy pulp?
4) Indications for an indirect pulp cap?
5) Are IPTs acceptable procedures for primary teeth with reversible pulp inflammation?
6) How many mm do you need between caries and pulp?
7) How do you do an IPT?
8) What is the thought (rationale) behind a IPT?
9) If you have any doubt as to whether an IPT would be successful, what should you do?

Back 10

1) Procedure performed on a deep carious lesion adjacent to the pulp. The caries near the pulp is left in place to avoid pulp tissue exposure and is covered with biocompatible material (ie Vitrebond).
2) A radiopaque material such as calcium hydroxide, ZOE, or GI cement is placed over the remaining affected dentin to stimulate healing and repair. The tooth is then restored with a material that seals the tooth from microleakage.
3) Internal resorption. Okay with healthy pulp
4) Primary tooth with no pulpitis or reversible pulpitis and when the deepest carious dentin is not removed to avoid a pulp exposure. The pulp is judged by CLINICAL AND RADIOGRAPHIC criteria to be vital and able to heal from the carious insult.
5) Yes, as long as this dx is based on a good history, a proper clinical and radiographic evaluation, and the tooth has been sealed with a leakage free restoration
6) 0.5 mm
7) Leave the deepest layers of carious dentin, remove soft/mushy dentin and leave hard, discolored dentin. Cover with Vitrebond (GI), be sure all caries are removed around the lateral edges of the lesion (DEJ)
8) Few viable bacteria remain, and when sealed properly the bacteria that remain are inactivated.
9) Pulpotomy

Front 11

Caries removal: Direct pulp cap

1) What are the only indications for doing this?
2) How do you do one?
3) What does the pulp status HAVE to be?
4) Can you do this on primary teeth with a carious exposure?
5) Can this be successful on immature permanent teeth?

Back 11

1) HEALTHY, asymptomatic pulp with MECHANICAL PINPOINT exposure only. Free of salivary contamination (use a rubber dam)
2) Put CaOH over exposure to stimulate reparative dentin formation.
3) It HAS to be on a healthy pulp, otherwise, do a pulpotomy
4) NO!
5) Maybe

Front 12

Treatment decision making:

1) Your treatment depends on the extent of ___ and how far ____ does the inflammation extend
2) The final determination is made once you're where?
3) What is the key?

Back 12

1) Irreversible pulpal inflammation and how far apically the inflammation extends
2) In the pulp
3) Hemorrhage control

Front 13

Pulpotomy:

1) Definition?
2) What is the goal?
3) Indications?
4) Clinically, what does the pulp need to be like, and where does the inflammation have to be restricted to?
5) Pain symptoms?
6) You have to see if it's restorable, and if so, what do you restore with?
7) What will your radiographic exam look like?
8) What 3 things will you need to perform a pulpotomy? (Radiographs, LA, rubber dam - why?)

Back 13

1) Involves the removal of inflamed coronal pulp tissue and placement of a medicament over the excised pulp stumps
2) To maintain radicular pulp vitality
3) Vital primary tooth with a probable carious exposure
4) A healthy radicular pulp - all inflammation must be restricted to coronal pulp
5) Elicited (provoked) pain only - cannot be spontaneous because this indicates inflammation beyond the coronal pulp
6) SSC or composite if there are intact walls
7) Probable carious exposure, normal periapical tissues, NORMAL FURCATION, and normal root development
8) CURRENT radiograph, maxillary infiltrations + palatal, or mandibular block + long buccal. Need rubber dam to prevent bacterial contamination by saliva, and formocresol is very caustic and can burn soft tissue

Front 14

Steps on how to do a pulpotomy?

Back 14

1. Access pulp w/ football diamond (wide, deep class 1 using a 245/330 bur)
2) Caries removal with large round slow speed - lateral wall wall first, pulpal floor last, remove all carious dentin before exposing pulp.
3) Remove all overhanging enamel.
4) Unroof chamber with high speed 245/330 bur, remove all overhanging dentin or enamel and don't perforate the floor
5) Excise pulp tissue with large round bur slow speed, sppon excavator, to the orifices of the canals
6) Wash out debris
7) Control + evaluate hemorrhage with damp cotton pellets over orifices, PRESSURE for 3-5 minutes. If not controlled, look for tissue tags and reapply pressure. If it continues, inflammation is beyond coronal pulp and is now a pulpectomy or ext.
8) Apply ferric sulfate to pulp stumps IF hemorrhage is controlled. Rub stumps for 15 seconds. Rinse with water, should have no heme. OR Formo on MOISTENED pellet for 2-5 minutes, remove and stumps should appear black, no hemorrhage. If bleeding continues, then look for tags, reapply.
9) Fill chamber with IRM, place SSC

Front 15

4 medicaments used for a pulpotomy?

Back 15

1) Ferric sulfate - 15.5%, ferric ion protein complex on contact w/ blood. Membrane of this complex seals the cut vessels mechanically, producing hemostasis. Complex forms plugs that occlude the capillary orifices.
2) Buckley's formocresol - active agents = 19% formaldehyde + 35% tricresol. Vehicle = 15% glycerirn, 31% water. Fixation/mummification of pulp stumps (don't use much)
3) Diluted formo 5:1. 3 parts glycerin, 1 part distilled water. 4 parts dilute to 1 part formocresol.
4) Glutaraldehyde

Front 16

1) Procedure for using ferric sulfate?
2) Procedure for using formo?
3) What should you do if minimal bleeding continues?
4) What 4 things remain in a completed pulpotomy?
5) What is the success rate for both ferric sulfate and formo?
6) What are the 3 keys to a successful pulpotomy?
4) Success rate of pulpotomy?
5) 4 reasons for failure?
6) 5 contraindications for pulpotomies?

Back 16

1) Apply to exposed pulp stumps if hemorrhage is controlled, apply medicament, rub pulp stumps for 15 seconds, rinse with water, should be no hemorrhage.
2) Apply with moistened pellet, not saturated, for 2-5 mins, then pulp should appear black and no hemorrhage.
3) Check for residual pulp tissue tags, reapply ferric sulfate/formo.
4) Remaining apical tissue vital, IRM, cement, SSC
5) 90%+
6) Diagnosis, access prep, pressure with cotton pellets, ferric sulfate or formo
4) Poor dx, pulpal degeneration continues, internal resorption, early exfoliation
5) Non-restorable, **SPONTANEOUS PAIN** ( most important clinical symptom), percussion sensitivity, non-vital (fistula, swelling, bifurcation/periapical radiolucency), necrotic (dry) pulp

Front 17

Contraindications for pulpotomies?

Back 17

1) Non-restorable
2) Spontaneous pain (**Most important clinical symptom**),
3) Percussion sensitivity
4) Non-vital - fistula/swelling, bifurcation or PA radiolucency
5) Necrotic (dry) pulp
6) Continued hemorrhage (uncontrollable or dark, unhealthy color)
7) Extensive root resorption INTERNAL or external
8) Extreme mobility - root resorption. Need 2/3 of root remaining
9) Major systemic illness

Front 18

1) Indications for pulpectomies?
2) What does the procedure involve
3) Teeth that are good candidates?
4) Poor candidates?
5) Clinical indications for a pulpectomy? (Hx of? Clinical presence of? Radiographic evidence of? Resorption? Timing? Necrosis?)
6) How do you know if a tooth is necrotic?
7) What exactly causes a bifurcation radiolucency?
8) Contraindications? (Supporting bone? Resorption? Succedaneous tooth? Restorability? Access? Disease?)

Back 18

1) Primary teeth show evidence of chronic inflammation or necrosis of the radicular pulp
2) Complete removal of the necrotic pulpal tissue from canals and coronal portion of primary tooth
3) Primary second molars, before the first permanent molar is erupted, and maxillary primary incisors in young kids
4) Primary first molars (tortuous root canals) and mandibular primary incisors
5) Hx spontaneous pain, fistula, radiographic evidence of bifurcation or PA involvement, MINIMAL root resorption (physiologically only 1/3rd of root, no pathologic), and you do it before the permanent first erupts, or if tooth is necrotic
6) Fistula, inflammation beyond the coronal pulp, percussion sensitive
7) Necrotic products pass into bifurcation through microscopic foramen - this is the FIRST place where bone resorption will show
8) Extensive loss of supporting bone, more than 1/3 root resorbed, internal/external resorption, physiologic resorption due to permanent tooth, 2/3 root development of the succedaneous tooth, non-restorable, can't gain access to canals, perforation, chronic illness like immune deficiency disorders or cyanotic heart disease)

Front 19

Pulpectomy technique?

Back 19

1) Recent radiograph to confirm dx. Delay could change the dx - you need to determine the extent of root/bone pathology, determine root length
2) Local anesthesia
3) Rubber dam
4) Pulpotomy procedure up to formocresol app
5) See uncontrollable hemorrhage (inflammation goes beyond the coronal pulp and into the radicular puplP)
6) Determine length of broach and file, and calculate root length RADIOGRAPHICALLY - 2 mm short of apex
7) Remove pulpal tissue w/ broach, measure to length or RESISTANCE POINT - do not force and do not instrument or enlarge canals
8) File canals: molars size 15-35, anteriors size 40-50, do not enlarge, only go until canals are fairly clean. Can't remove all tissue in tortuous root canals
9) Rinse w/ sterile water or saline, local anesthetic, or sodium hypochlorite (CAREFUL)
10) Dry w/ paper points
11) Fill canals with Vitapex - CaOH and iodoform (put in passively and backstep) or ZOE
12) Check fill radiograph
13) Full coverage crowns (SSC on molars, veneered stainless steel/composite strip crowns - labial access)
14) Place on recall

Front 20

1) What is Vitapex paste? What are its benefits?
2) How do you fill with ZOE? Is it resorbable?

Back 20

1) CaOH and iodoform paste. Resorbable, so okay to extrude. Bactericidal and bacteriostatic
2) Use pluggers, paper points, lentulo spiral, and use condensing pressure. NOT resorbable - IRM doesn't resorb due to fillers

Front 21

1) 4 reasons for pulpectomy failures?
2) Where should you stay regarding the apex? What is something you need to watch out for? What is a danger of overfilling?

Back 21

1) Overfill, underfill, perforation, continued inflammation/resorption
2) 2-4 mm short of apex, and the APEX may NOT be at root end! It can extrude into the follicle of the developing tooth and stop its development

Front 22

1) 4 advantages of SSCs?
2) Main disadvantage?
3) Indications for using it? (7)
4) What kind of developmental defects do you use it on?

Back 22

1) Durable, inexpensive, minimal technique sensitivity (takes one appt), full coronal coverage
2) Appearance
3) Where class 2 is likely to fail - 3+ carious surfaces, first primary molars w/ mesial caries, primary teeth w/ caries into line angles. Use after pulp therapy. Teeth with extensive wear, fractures, ankylosis (infraocclusion)
4) Hypoplastic enamel, AI, DI

Front 23

What are 5 caries risk factors that might indicate it's time for a more aggressive approach with a SSC?

Back 23

1) Relationship to maxillary anterior caries (subsequent development of proximal caries that may continue through mixed dentition)
2) DMFS greater than child's age
3) 2+ lesions in one year (poor OH, cervical demineralization)
4) Parents/siblings w/ high caries rate
5) High sugar diet

Front 24

1) 4 burs you need for SSC?
2) Other instruments?

Back 24

1) Tapered diamond, 169L bur, football diamond, 245 bur
2) Sharp scaler to mark SSC length, C&B scissors to trim, Howe pliers to adjust contours (ie flatten contacts), 114 contouring pliers (adjust contour of crown after trimming and if you're overcrimped), 800-417 crimping pliers (crimp gingival margins in and increase retention), heatless stone to trim, tapered green stone/rubber wheel to smooth crown margins, cleoid to remove crown

Front 25

SSC procedure?

Back 25

1) LA
2) Check occlusion before rubber dam, observe canines, opposing teeth, mesial drift, occlusal plane (supraeruption)?
3) Rubber dam - protect surrounding tissue, improve visibility/efficiency, manage behavior, prevents swallowing/aspiration
4) Caries removal
5) Reductions
6) Round all line angles

Front 26

1) How should you do your M/D slices? How to do it, what to avoid, margins? How to avoid hitting other teeth? What do you need to do on a second primary molar?
2) 3 proximal slice errors?
3) Occlusal reduction: what bur do you use? How much reduction? What should you compare to? Anatomy?
4) B/L reduction: what bur? Where do you bevel?
5) What should you round line angles with?
6) What should the contour of the crown prep conform to?
7) Buccal bulge - should you always reduce? What is the most common MB bulge issue?

Back 26

1) M/D slices - tapered diamond bur or 169L, contacts must be completely opened, extend to B/L line angles, depth is through contact and beyond and interproximal caries, margins are feather edge, taper from buccal to lingual and don't create ledges! Must be able to pass explorer tip through the subgingival contact area. Interproximal wedges/T bands on adjacent teeth. Distal slice on 2nd primary molar if they're <5, be sure to remove enough tooth structure so you don't block 6's!
2) Excessive taper (reduction of retention), no taper (crown may not seat), ledges (crown will not seat)
3) Football shaped diamond bur or 245 bur, 1.0-1.5 mm reduction. Compare adjacent marginal ridges, depth grooves w/ 330 bur, connect them, keep occlusal anatomy
4) Tapered diamond. Bevel occlusal 1/3rd only (most retentive preps maintain buccal and lingual tooth structure), use feather edge margins
5) Tapered diamond (169 L)
6) Internal contour of the SSC
7) No - aids in retention and only reduce if you really need to seat the crown and it's too prominent. MB bulge of the mandibular first molars

Front 27

SSC crown selection:

1) How many sizes are there?
2) Size number goes where on the tooth?
3) What are 3M's made out of?
4) M-D diameter - if it's too small, what will happen? Too big?
5) What size should you start with?
6) If you think the size is good, what should you do?
7) What do you do it proper size crown doesn't seat

Back 27

1) Six
2) Buccal
3) Stainless steel, nickel chrome, Pretrimmed and precrimped
4) Too small - open contact. Too large - rotated crown
5) Medium size 4
6) Try a smaller size
7) Check for ledges, check occlusal reduction (be sure it's beveled), round all line angles. Last resort - reduce buccal bulge. Recheck the crown size - look for a cookie cutter look on the gingiva

Front 28

SSC:

1) What direction should you seat?
2) What should you mark the gingival margin with and how far down should you trim?
3) Trimming (increases/decreases) crown size
4) Finished margins should be parallel to?
5) What is the contour of crown margins on buccal and lingual? Interproximal?
6) Margins should be subgingival just below the greatest _________
7) As the crown margin is shortened, what happens to the space between the inner crown surface and the tooth surface?

Back 28

1) Lingual to buccal. Seat with no mouth prop, look for gingival blanching and check margin length
2) Explorer, should extend 1 mm below FGM into sulcus
3) Increases
4) CEJ
5) B/L: smile. Interproximal: Frown
6) Diameter of the tooth
7) Becomes smaller - allows for close adaptation of the crown

Front 29

SSC:

1) Steps for checking occlusion?
2) What do you check for the final check?
3) When do you finish crown margins? What do you use?
4) What do you cement with? What is the ratio?
5) What do you have to do to the tooth before you cement? Which way to do you seat?
6) What do you do after cementation?

Back 29

1) Remove rubber dam, marginal ridges must be in line, check canine relationship, check contralateral side
2) Retention, all margins, occlusion
3) Only if you trimmed. Green stone to smooth margins, rubber wheel to smooth and polish
4) GI (Fuji 1) cement: 1 scoop powder to 2 drops liquid, and use 1 scoop more than # of crowns to be cemented
5) Clean and dry the tooth, seat lingual to buccal
6) Remove excess w/ wet 2x2 and forceful air and water spray, floss interproximal w/ knot, check gingival sulcus for retained cement with explorer + clean with rubber cup

Front 30

4 causes of SSC failures?

Back 30

1) Poor tooth prep
2) Poor crown adaptation/retention
3) Improper cementation
4) Induced ectopic eruption (crown too large, prevents perm tooth eruption, may lead to permanent tooth caries)

Front 31

1) How do you go about 2 back to back SSCs?
2) How do you do a SSC and class 2 restoration amalgam?
3) How do you do a SSC and class 2 composite?

Back 31

1) Prepare @ same time, slice each tooth individually and cement at same time
2) Prep SSC first, prep amalgam, cement crown, fill amalgam
3) Class 2 prep, SSC prep + fit (careful because may damage class 2 margins and cause heme), place matrix + wedge for class 2, restore, then cement crown

Front 32

1) What are some adaptation adjustments for space loss?

Back 32

1) Do normal crown prep but have additional buccal/lingual reduction. Flatten contact areas with Howe Pliers