1. Diagnosis II/Anesthesia Flashcards
• Resident took piece of broken file out (not easy thing)
• Used this tube device where you screw it down and catch this and pull it out. (??? sorry this is exactly what he said lol)
◦ You do this after ____ is completed
• We try to avoid this happening when doing a RCT bc its hard to remove a broken instrument
◦ If this happens in lab, we will not continue with this tooth. Throw it away and do a new one. Bc these tools (ultrasonic tips) that are used to take out the broken files are very expensive.
RCT
Debris accumulation leads to rapid increase in ____ stress on the file
Always wipe ____ to get debris out.
torsional
counterclockwise
• This year we will use a second system in the course 9first time doing it in the course)
◦ This file looks like a snake and has the ability to instrument canals in a cross section thats more ____. Not meant for canals that not perfectly are ____.
‣ Which is common for ____
‣ These files are more difficult to break so it’ll be
easier to do instrumentation of served canals and molars
oval
round
posterior teeth
• Anything thats kinked or distorted you have to ____ away! So always look at your files before you put the files into the canal. If its distorted then it has lost it’s ____ deformation and they are already in the ____ deformation state and it will fracture and break.
throw
elastic
plastic
In clinic, we use ____ for regular instrumentation and use ____ as part of the final rinses for RTC.
sodium hyperchlorite
CHX and EDTA
• What you will do is take an x-ray to gauge the length with visual inspection. Look at your tooth and after you do the initial instrumentation, take the 10 file and wiggle the file to the apical constriction. Make sure you can
see the file poking out. This is called ____. This ensures that the contraction is ____ and theres no
____. Theres no severe kink that will prevent us to put a file out at the very end.
apical potency
open
calcification
◦ Make sure you see the file come thru then pull the back until the file is flush with the surface of the root.
This is the end of the major (outer) foramen. This is not the constriction. Measure this length with a rubber stop and ruler. Then subtract ____mm from this measurement.
This is the working length we will use in the lab
1
PreClinic Working Length
After straight-line access and initial instrumentation place #____ ____-file in root canal and let it get over the foramen for ca. 1mm. Place rubber stop, record length and subtract 1mm. This is the preclinical Working Length
- Do not do ____. This means do 2 anteriors and 2 PM at the same time. Do not do that.
- Do the instrumentation to the very end for a specific tooth then discuss w/ your TA and move on to the next tooth to remedy what you did wrong the first time.
- Then after you do the instrumentation you will do the fillings then we will move on the the PM.
- Progressively this is getting more difficult when you go to molars bc the canals are have more curvature and the molars have a variations in rc for molars compared to ant. In additions, molars have higher likelihood to split.
- This is where you play with the slot rule and different files.
10
K
serial production
A 43 year-old asian female
• CC: “ M y tooth hurts whenever I drink something cold or have sweets”
• PMH: none contributory
• HPI: Pain has been started 3 weeks ago. History of new filling #30.
• Allergy:NKDA
• Thoughts?
◦ ____- causes sensitivity bc every time you place new filing bc the pulp doesnt like it and you need to wait for tertiary dentin to be laid down
• Next step? - Do testing
◦ Negative percussion and palpation for 29,30,31
◦ Cold for 29 and 31 is WNL, 30 is more sensitive to cold
◦ No deep probings
deep filling
A 43 year-old asian female
• CC: “ M y tooth hurts whenever I drink something cold or have sweets”
• PMH: none contributory
• HPI: Pain has been started 3 weeks ago. History of new filling #30.
• Allergy:NKDA
• What would be the endo diagnosis?
◦ Do you need more info?
‣ Dr. S response: You can ask pt if there’s pain on
heat. The ____ test is something we dont do regularly bc it’s not easy to do. Theres new adapter with heat machines. In addition, its not pleasant and its hot and you might touch the lip
‣ Best was is to do a ____ and isolate with a rubber damn and do this one by one. He says this is the best way to test heat sensitivity
‣ This is an additional test to do when we dont know 100% which tooth has the pulpits
• EX: when pt complains about sensitivity and pain and has ____ restorations. The crowns can insulate well from the ____ test (if its not a metal crown). But ____ will get temperate change through if you use the hot water method and this gives you a more accurate reply.
• I would ask the pt if they had any recent pain from ____.
heat warm water bath crown cold heat hot or cold
A 43 year-old asian female
• CC: “ M y tooth hurts whenever I drink something cold or have sweets”
• PMH: none contributory
• HPI: Pain has been started 3 weeks ago. History of new filling #30.
• Allergy:NKDA
◦ He says this pt doesnt have any pain to hot. What does this tell you?
‣ It tells you that inflammation is not that ____ inside the pulp and is at an ____ state.
‣ With all this info combined, he’d ask the pt if the pain from the cold is long, short, lingering or wakes them up at night.
• This would be a sign of ____ pain and a sign of ____.
‣ All info together: new filling, elevated pain to cold, only a little bit longer and a little intense
compared to a normal healthy pump. This all points to an ____ tissues.
deep
initial
spontaneous
irreversible pulpititis
irreversible pulpitis w/ normal
Diagnosis #30: Reversible pulpitis + Normal apical tissues Treatment plan: no ____, observe
Prognosis: ____
treatment
favorable
• This is a posterior tooth in the mandible that has inflammation.
• Local anesthesia is different when you have to tx pt in the posterior mandible with severe inflammation.
◦ Ex: when you do a restorative procedure like a filling, its very likely that the pt will get numb when you give the regular anesthesia
◦ For mandible, what is the typical amount of anesthesia you do? -A: Infraalveolar nerve block ‣ What do you expect get numb?- ____
◦ How likely is it for block to work on pt?- A: 80%
‣ What does it depend on if a pt gets numb- degree of ____
• this is why one of the most difficult things during a tx of the pt is to get the pt numb with a severe inflammation in a ____
◦ Typical scenario- Have a pt with an irreversible pulpits and very painful conditions and you have to do a RTC on the pt. You’d have to drill on the pulp thats vvvery inflamed
• What’s going on in the pulp when theres inflammation?
◦ A: its a ____ inflammation in the pulp that has inflammatory mediators such as ____
‣ subp and cgrp will induce nerve ____ etc, then have peripheral and central ____
‣ There’s different receptors that are responsible for nerve endings.
• Such as: ____ related, ____ resistant receptors (pufferr fish poison), you can isolate different nerve endings and receptors on these nerve fibers. Some of these will make it ____ to make a pt numb.
teeth, lip, tongue, gingiva inflammation posterior mandible neurogenic substance P, cgrp
sprouting sensitization capcasin tetrodotoxin difficult
• Someone with extreme severe stage of inflammation with extreme pain. They will have servere multiplication of ____ resistant receptions at the end of the nerve fibers.
◦ These are bad bc pt may not respond to LA
• When you have someone who is not in the stage of inflammation, you can get them numb easily. Even if there’s some
inflammation, you do not have that many crazy receptors so you can get over this bc you give a lot of LA
• But if they are at the stage right before the pulp dies completely aka ____. At this stage is
where pt has the strongest pain and anesthesia may not work.
• Rant: He had one pt this year and could not get him numb so you have to do other tricks that we will all about later.
Another pt resident couldn’t get a pt numb, pt came back another week and still couldn’t get numb. This is something that happens when you have severe inflammation. The worst thing he has seen is when pt has really bad anxiety. And anxiety this can enhance the pain reception for the pt. So these pts dont dare to go to dentist bc they’re so afraid therefore they avoid going to the dentist until the pain gets much worse. This will finally bring them into the dental chair. This makes it worse for them bc they’re in pain and you won’t be able to get them numb :(
• What we talk about this afternoon will be about numbing a pt with irreversible pulpits w/ strong pain sensitivity when they need tx in posterior mandible
◦ This is the hardest place to numb pt bc bone is so ____ near the root ends that a direct deposit w/ buccal infiltration may not diffuse through the bone and will not reach the root tips.
◦ He said its ____ when he had a real difficulty of getting a pt numb with a RTC in the posterior maxilla w/ severe ____.
TTX partial pulpitis & partial necrosis thick rare inflammation
According to patients,
MOST IMPORTANT & DESIRED SKILLS OF THEIR DENTIST:
1. Does not ____
2. Administers ____ injections
Q: It has been 3 weeks and the dentinal bridge can be formed 4-6 weeks so should we wait 3 more weeks?
◦ A: Everything depends on a case like this how the pt feels about it! If pt is pain ____ and they cannot tolerate the sensitivity or pain so you have to intervene. Then you do RTC to relieve pt of pain by removing the inflamed nerve tissues.
hurt
painless
sensitive
According to patients,
MOST IMPORTANT & DESIRED SKILLS OF THEIR DENTIST:
1. Does not ____
2. Administers ____ injections
• Theres a diff bw were testing the tooth and they’re reacting to the pain vs when the pt has constant pain from the tooth.
◦ “Its constantly hurting me and not only present when they drink something. That was been happening for 2-3 weeks after filling was placed. This type of sensitivity is expected and can overcome this situation by having anything cold at the left size of the jaw and I’m ok with it.”
◦ This is usually what you will discuss with the patient. You come with diagnosis and appears that its reversible stage of inflammation
◦ Will tell pt, based on recent filling this is a situation where it can go back to normal. Bc after a new filling, this sensitivity is expected and can last from ____ weeks.
◦ If you have a pt that cannot bare this. Note, everyone has a different ____ to pain. But typically you cannot diagnose this as a ____ if they come to you and complain about strong pain to the tooth.
◦ Even if there’s reversible pulpits based on your tests and pain intensity, you have to let pt know that there’s nothing they have to ____ through if it’s not bearable.
◦ No tx means at this moment I won’t do tx, but will bring patient back after ____ weeks and double check everything.
hurt
painless
4-6 threshold reversible pulpitis suffer 3
Local Anesthesia for Endodontics
Do you find it ____ to regionally anesthetize a painful tooth over a non painful tooth?
After successfully administering a mandibular block (obtaining lip numbness) on an acutely painful tooth and then opening it, does the ____ find it painful?
225 ____ 43 No
harder
patient
yes
Infra-alveolar Nerve Block
In clinical studies, overall failure rates of IANB for healthy lower molars have ranged from 15% to 35%
A 44 to 81% failure rate in ____ molars with ____).
mandibular
symptomatic irreversible pulpitis
Infra-alveolar Nerve Block
- Here are the failure rates of IAND and comparing teeth that present with healthy pulp vs tooth w/ symptomatic irreversible pulpits.
- Study 1: failure rate was 15-35% but if you have a symptomatic irreversible pulpitis the failure rate is 44-81% and there may only be ____ out of 5 patients that get numb if they have symptomatic irreversible pulpits.
- Unfortunately, the positive sign that the lip is getting numb is not a guarantee that the ____ itself is numb
• What he does is that for any tx he has to do endodontically (unless its a retreatment w/ root filling or has a diagnosis of pulp necrosis)
—◦ Anytime he expects a vital tissue inside the tooth, before he even ____ or puts a rubber dam he will do a____ after anesthesia and ask pt if they feel the cold. Bc this is much more harmless than drilling the tooth. If pt still feels cold wait a little longer or add more ____.
1 tooth drills cold cotton pellet anesthesia
Articaine v. Lidocaine
Anesthetic Efficacy of Articaine for Inferior Alveolar Nerve Blocks in Patients with Irreversible Pulpitis
There is no significant difference in obtaining pulpal anesthesia with ____ or ____
What type of anesthesia did they tell you to use for a IANB?
◦ class: lidocaine. Is there a reason why? ____ w articaine/septocaine
Typically for restorative you use lidocaine. Typically 2% w/ epi 1:100k In endo: we also have articaine. 4% w/ 1:100k epi so it’s stronger
Studies out of Canada showing higher incidence of paresthesia w/ articaine. This is apparently NOT an issue w/ BIs - you’re not hitting a nerve like you could in IANB. Can do ____ nerve block or ____ w/ septocaine + you would have no paresthesia issues.
So even if there are other studies out there that show that there’s better anesthesia in particularly the speed of onset in regards to BI (NOT IANBs!)
This study shows this: no significant difference in obtaining pulpal anesthesia w/ articaine or lidocaine. (Now im not really sure about what the previous bullet means but the slide says this one)
articaine
lidocaine
paresthesia
palatal
max BI
Articaine vs. Lidocaine -Paresthesia
Paraesthesia after dental procedures is uncommon & mechanism of nerve damage are unknown, however, lingual nerve damage could be caused by: direct ____ trauma, intraneural ____ formation, local ____ toxicity and the ____ pattern. (Pogrel 1995,2003)
Incidence of paraesthesia after IANB range from 1:26,762 to 1:785,000, (half of LA injections are IANB injections).(Haas 1995, Gaffen 2009,Pogrel 1995,2000)
____ was the LA most commonly associated with paraesthesia (34–60%), mostly the ____ nerve (71–93%). (Haas 1995)(Hillerup 2006)(Gaffen,Haas 2009)(Garisto, Gaffen 2010)
4% solutions of articaine and prilocaine were associated with a higher frequency of paraesthesia than LAs of a lower concentration. (Garisto, Gaffen 2010)
Articaine may have ____ potential. (Haas 1995)(Hillerup 2006)(Gaffen,Haas 2009)(Garisto, Gaffen 2010) (Haas, Lennon 1996) (Miller, Haas 2000)
needle
hematoma
anaesthetic
fascicular
articaine
lingual
neurotoxic
Influence of Local Inflammation
Responses to ____ were significantly higher in the inflamed side compared to the control.
Markedly more difficult to inhibit impulse transmission on the ____ teeth with local anesthesia in comparison to the control.
These studies show how inflammation makes it more difficult to get anesthesia w/ patients that on one side they have an inflamed tooth that they want to anesthetize and they compare it to non- inflamed control side and found could get significantly more stimulation in inflamed side vs non-inflamed.
stimulation
inflamed
Influence of Local Inflammation
Neuropeptides are elevated in inflamed pulpal tissue.
____
Inflamed nerve fibers may have an altered capacity for anesthesia
This is connected to neuropeptides that are starting the neurogenic inflammation in pulpal tissues - CGRP, substance P, neurokinin A
• Margaret Byers did alot of these studies
cgrp, substance P, neurokinin A
Oral Premedication
Systematic review - Efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) as oral premedications on the success of IANBs in irreversible pulpitis.
Methods: Three databases were searched to identify randomized clinical trials (RCTs).Thirteen RCTs(N = 1034) wereincluded.
Statistical analysis of good-quality RCTs showed a significant beneficial effect of any ____ in increasing the anesthetic success of IANBs compared with placebo (RR= 1.92; 95% CI,1.55–2.38).
Subgroup analyses showed a similar beneficial effect for ____, diclofenac, and ____. Dose-dependent ibuprofen >____ mg/d (RR = 1.85; 95% CI, 1.39–2.45) was shown to be effective; however, ibuprofen ____ showed no association (RR= 1.78; 95% CI, 0.90–3.55).
Oral pre- medication with NSAIDs and ibuprofen (>400 mg/d) increased the anesthetic success of IANBs in patients with irreversible pulpitis.
NSAID ibuprofen ketorolac 400 #400 mg/d
