Pathway 14-9 Pulp reaction to Bleaching, Ortho, Perio, Occlusal Trauma, Surgery

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Questions and Answers

What is the role of hydroxyl radicals in vital bleaching techniques?

They facilitate the whitening process. (correct)

They decrease bleaching effectiveness.

They stabilize the dental pulp.

They cause pulp irritation.

Which bleaching agent concentration is associated with no changes in pulp vitality according to clinical reports?

10% carbamide peroxide (correct)

5% hydrogen peroxide

16% carbamide peroxide

38% hydrogen peroxide

What complication can arise from the use of light activation in bleaching techniques?

Permanent discoloration of teeth

Increased pulp tissue temperature (correct)

Decrease in neuropeptides in the pulp

Restorative deficiencies in preoperative treatment

What type of response was observed histologically in the pulp following bleaching procedures?

Minor inflammatory changes that are reversible Signup and view all the answers

How can postoperative symptoms following bleaching procedures be addressed?

By treating teeth with fluorides and correcting deficiencies Signup and view all the answers

What is the primary reason for the transient effects on dental pulp tissue during orthodontic force application?

Circulatory changes due to applied force Signup and view all the answers

Which inflammatory mediators are noted to have only minor increases in the dental pulp during orthodontic movement?

IL-1a and TNF-a Signup and view all the answers

What factor is suggested to significantly increase pulp necrosis during orthodontic treatment?

Previous trauma to the tooth Signup and view all the answers

What surgical technique is modified to minimize disruption to the descending palatine artery during a Le Fort I osteotomy?

Horseshoe palatal osteotomy Signup and view all the answers

How does the magnitude of pulp response vary in relation to occlusal loading?

It is dictated by the degree and chronicity of dentinal deformation Signup and view all the answers

What is one potential source of pulp pain related to cusp flexure during occlusal loading?

Development of bacterial microleakage at the restoration interface Signup and view all the answers

Regarding blood supply to teeth undergoing maxillary osteotomies, which is NOT CORRECT?

Disruption only occurs if segmental osteotomy is used Signup and view all the answers

What was found to be effective in reducing postoperative sensitivity after light-activated bleaching?

A desensitizing gel of 5% nitrate potassium/2% sodium fluoride Signup and view all the answers

What is the most commonly observed pulp condition related to periodontal disease?

Mild inflammatory effect but often does not cause pulpitis or necrosis. Signup and view all the answers

What percentage of teeth in a study exhibited mild chronic inflammatory changes related to pulp due to periodontal disease?

29% Signup and view all the answers

What was concluded about the relationship between prosthodontic treatment and pulp complications in periodontitis patients?

It is associated with more frequent pulp involvement than periodontal disease. Signup and view all the answers

What mechanism is primarily affected by orthodontic forces, leading to pulp changes?

Hemodynamic changes Signup and view all the answers

What can occur if orthodontic forces are extreme during treatment?

Circulatory interruptions leading to pulp necrosis Signup and view all the answers

What did studies indicate about the flow of dentinal fluid in vital pulp situations?

It provides resistance against bacterial ingress in sufficient amounts. Signup and view all the answers

Study Notes

Vital Bleaching

Vital bleaching techniques use strong oxidizing agents like 10% carbamide peroxide and hydrogen peroxide to bleach the enamel of teeth with vital pulp.
Concerns exist regarding potential pulp irritation due to prolonged contact with the chemicals, especially in teeth with open tubules or cracks.
Minor reversible inflammatory changes in the pulp were observed after 2 weeks of bleaching, according to histologic and histochemical analysis.
Gingival irritation was found with 16% carbamide peroxide but no changes in pulp vitality or symptoms were observed.
Postoperative symptoms are generally reversible and can be prevented by fluoride treatment and correcting restorative deficiencies before bleaching.
Increased neuropeptides, such as SP, in the pulp are likely responsible for clinical symptoms.
Vital bleaching with 10% carbamide peroxide in a custom tray for 6 weeks was deemed safe for pulp health for up to 10 years postoperatively, though bleaching effectiveness may decline over time.
A clinical study found no histologic effects on the dental pulp at 2 to 15 days after bleaching with 38% H2O2 gel with or without a halogen light source.
When the same treatment was applied to incisors for 45 minutes, areas of coagulation necrosis were observed in the pulp.

Light-activated Bleaching

Light activation of bleaching agents is widely used to speed up the process.
Light sources, like halogen light or diode lasers, accelerate the release of hydroxyl radicals, facilitating the whitening process.
Light activation has been associated with higher incidence of tooth sensitivity compared to non-light activated bleaching.
Pretreatment with a desensitizing gel containing 5% potassium nitrate and 2% sodium fluoride has proven effective in reducing postoperative sensitivity after light-activated bleaching.

Pulp Reactions to Periodontal Procedures

The pulp is typically protected from microbial irritation in the oral cavity.
Periodontal disease exposes the root surface, leading to attachment loss and potential pulp inflammation in severe cases.
Some reports describe bacterial infiltration through dentinal tubules of exposed root surfaces causing mild inflammatory changes in the pulp.
Pulp necrosis is more commonly associated with periodontal disease than the other way around.
Microbial irritants are more likely to move outward from a necrotic pulp causing periodontal breakdown than inward from a periodontal pocket.
Periodontal scaling and root planning can expose dentin, often resulting in dentin hypersensitivity.
An older study in primates found mild inflammatory changes in the pulp in 29% of teeth with periodontal disease, and one tooth out of 40 developed pulp necrosis.
Scaling was associated with similar inflammatory changes but no pulp necrosis.
A clinical study showed a higher chance of pulp complications in teeth that were bridge abutments compared to non-abutment teeth, suggesting a connection between prosthodontic treatment and pulp involvement.
Two comprehensive reviews concluded that while periodontal disease and its treatment have the potential to cause pulp pathosis, this is a rare occurrence.

Mechanical Irritants: Orthodontic Movement

Orthodontic forces can cause hemodynamic changes in the pulp, increasing blood flow in both the moving tooth and adjacent teeth.
Extreme orthodontic forces can lead to circulatory interruptions and pulp necrosis.
Orthodontic movement can also cause metabolic and inflammatory changes in the pulp, including decreased tissue respiration rate, increased apoptosis and necrosis of pulp cells.
While inflammatory mediators like IL-1a and TNF-a increase during orthodontic movement, their levels are lower in the pulp compared to periodontal tissues.
Most of these effects are transient, but pulp necrosis is more common in traumatized teeth undergoing orthodontic treatment, especially in lateral incisors with pulp canal obliteration.
Increased SP and CGRP levels in the dental pulp are associated with occlusal trauma and orthodontic forces, respectively.
Orthodontic treatment is a potential etiological factor for cervical invasive root resorption (CIRR).

Pulp Reactions to Orthodontic Surgery

Osteotomies in the maxilla or mandible can disrupt blood supply to nearby teeth, leading to inflammation or necrosis.
Postoperative manifestations, such as pulp canal obliteration, are occasionally observed.
Maintaining a safe distance of 5-10 mm between the surgery site and teeth minimizes disruption.
Laser Doppler flowmetry has shown a reduction in pulp blood flow (PBF) immediately after maxillary Le Fort I osteotomy, particularly with segmental osteotomy.
Blood flow usually recovers within months of surgery.
A modified Le Fort I technique that spares the descending palatine artery appears to minimize PBF disruption in the anterior teeth.
A recent systematic review concluded that there is a decrease in pulpal vascularity and neurosensory response in the early postoperative period (1 to 10 days) following a Le Fort I osteotomy, but this effect is likely temporary.

Biomechanical Irritation: Parafunctional Habits

Occlusal loading can cause tooth deformation, especially in dentin.
Defects in enamel can lead to cusp flexure, which can trigger pulp responses due to dentinal fluid flow and microleakage.
The degree of pulp response depends on the severity and duration of dentin deformation.
Preparation geometry, width of the occlusal isthmus, and ablation of marginal ridges can influence cusp flexure.
Polymerization shrinkage of certain resin composites can induce inward deflection of cusps, placing stress on tooth structure.
Two main sources of pulp pain from cusp flexure are:
- Dentin deformation leading to dentinal fluid flow, activating nerve endings in the odontoblast layer.
- Bacterial microleakage at the restoration/dentin interface due to repeated cycles of occlusal loading.
These factors can work together to create inflammation, leading to thermal and biting sensitivity.
Chronic occlusal trauma can induce acute periradicular periodontitis, mobility, and radiographic changes.
Increased SP levels in the dental pulp are observed after experimentally induced occlusal trauma.
SP can disrupt the pain response and stimulate prostaglandin E2 production.
Dentinal cracks expose tubules, allowing bacterial access to the subjacent pulp.
Dentinal fluid flow and subsequent coagulation can form a temporary protective barrier for the pulp.
Dentinal sclerosis and tertiary dentin formation provide long-term protection.
Cracks can harbor bacterial biofilms, contributing to pulp irritation and inflammation, and potentially inducing periodontal pocket formation.

Pulp Reactions to Implant Placement and Function

Preoperative radiographic techniques are necessary for accurate implant placement to avoid damage to neighboring structures.
Implant placement may inadvertently perforate the root and devitalize the pulp if the three-dimensional anatomy is not carefully considered.
It is generally recommended to avoid placing implants directly at the site of periradicular lesions.
Immediate implant placement in adequately debrided sites with appropriate antimicrobial measures may be successful.
Case reports suggest that teeth with periradicular lesions could reduce the success of neighboring implants even after endodontic treatment.
A study in dogs found that treated or untreated periradicular lesions did not affect the long-term osseointegration of implants.
Clinical cases with complete resolution of periapical lesions involving implants have been reported after adequate endodontic treatment.

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