9. Endodontic Emergency Flashcards
- “what is an endodontic emergency?”
- ____ patients: ones that you didn’t plan to see this morning
- they present with pain, discomfort, swelling and trauma
- photo shows a patient with a necrotic lower molar - typically seen in an emergency endo situation
unscheduled
What is an endodontic emergency?
____ inflammation or infection
- most of the problems are leading to pulpal and periaplical inflammation and infection
- Left side - fractured restoration and caries = discomfort for patient
- Right side - fractured cusp with recurrent decay = caries reaching pulp = significant pain for patient
- middle photos = premolar necrotic tooth & periapical radiolucency (infection)
- all of these = patients seeking emergency care
pulpal and periapical
What is an endodontic emergency?
An external injury of significant magnitude or
duration injures the pulp.
Low ____ environment. Damaged tissue degenerates.
• an injury to the pulp of significant magnitude and duration causes injury to the pulp tissue
• ____ tissue is low compliance environment: encased in ____ dentin structure, no room for inflammation
or expansion
• starts to break down and degenerate = patient presents with symptoms
• extensive restoration caused pulp to become necrotic and forms radiolucency = swelling ensues and patient
comes to emergency
compliance
pulp
rigid
study done by Iqbal (from Penn)
• 2000 patients from emergency
• most common reason that they pursue treatment = ____
◦ decay reaches pulp and causes significant pain • other reasons =
◦ ____ restorations: 18%
◦ post treatment ____: flare-up after root canal started
◦ ____ and fracture = 3%
caries
faulty
AP
trauma
3 different types of emergencies
• most common =____
◦ never had endo treatment before
• ____= cases that were started (sometimes they require multiple visits)
• ____ = rarest
◦ all of a sudden the patient gets swelling, biting / percussion sensitivity
pre-treatment
intra-treatment
post-obturation
Nonodontogenic pain
Orofacial pain can mimic ____pain.
Patient may interpret pain as a “____ ”.
• before we talk about any endodontic problem = want to talk about nonodontogenic pain
• sometimes the patients won’t have endodontic problems
• x-ray shows maxillary right area - multiple teeth treated endodontically
◦ ____ everything looks fairly normal
◦ no pathology noted
◦ but patient is experiencing extreme pain
◦ orofacial pain can mimic pulpal/periradicular pain
◦ patient may interpret this pain as a toothache
◦ but retreating these teeth will not solve the issue
pulpal/periradicular
toothache
radiographically
Nonodontogenic pain \_\_\_\_ Myocardial pain \_\_\_\_ Atypical facial pain \_\_\_\_ tooth pain Herpes zoster \_\_\_\_ disease
trigeminal neuralgia
maxillary sinusitis
phantom
neoplastic
Assessment of a patient in pain
Perceive all symptoms as ____.
Listen, express empathy, and do not judge.
Be ____.
Show a ____ attitude of the patient’s problem. Inform ____ during and after treatment.
real
calm and confident
positive
expectations
Pain perception and reaction
Varies greatly according to ____ and physical state.
Reduce ____.
Gain patient ____.
Provide ____.
psychologic
anxiety
confidence
empathy
• diagnostic data has to be collected
◦ ____ exam: questions regarding the patient’s pain
◦ ____ exam: clinical tests that we’ve learned to do
‣ percussion, palpation, thermal testing, electric pulp test
◦ ____ exam: X-rays, CBCT images
subjective
objective
radiographic
Subjective exam
____
Location of the complaint.
____ of symptoms. Clinical manifestations. ____ of the complaint. Intensity of the complaint. ____ factors.
chief complaint
inception
quality
affecting
Chief complaint
always in the patient’s own ____
words
Location of the chief complaint
• just because we can take an X-ray doesn’t mean that we can determine what the ____ tooth is
offending
Location of the chief complaint
Maxillary molars refer pain to the ____, parietal, and ____ regions.
Mandibular molars refer pain to the ____, angle of the jaw and ____ regions of the neck.
zygomatic
occipital
ear
posterior
Location of the chief complaint
Correctly localize pain: ____%
Periradicular pain: ____%
73
89
Inception of symptoms
History of ____.
History of ____.
Other events such as ____ surgery or infections.
• always ask for history of dental procedures: was the filling recently placed? did the pain start after the
restoration vs. after a long time (pulp becoming necrotic)
• always ask for history of trauma - especially ____ teeth that develop radiolucencies (maybe they had trauma when they were a kid many years ago and now it is becoming a periapical abscess)
• always ask about sinus surgery / infections: they have more ____ to maxillary teeth, more sensitive to temperature or percussion
* always ask what type of work was done to the teeth before
dental procedures
trauma
sinus
anterior
sensitivity
Clinical manifestations
Mode: is the onset or reduction of symptoms ____ or provoked? Sudden or gradual? ____ or delayed?
Period: are symptoms ____ or occasional?
Frequency: ____ or persistent?
Duration: how ____ do the symptoms last? Momentary or lingering?
spontaneous
immediate
sporadic
intermittent
long
Quality of the complaint
____ ● dull ● burning throbbing ● stabbing ● shooting aching ● spontaneous
sharp
Intensity of the complaint
____: on a scale of 0-10, how much pain are you experiencing now?
____ terms: mild, moderate, or severe.
quantity
descriptive
Affecting factors
• affecting factors that intensify or influence the pain that the patient is feeling
• these questions are important because we need to ____ patient’s pain in their own mouth to make our
accurate diagnosis
• reads slide
• sweets or acid = probably ____ problem
• head position - may indicate ____ infection vs. endodontic problem
• have to ask what makes the pain worse or better?
• there are situations where patient has large cup of cold water to constantly drink to keep pain away = ____
• could see diagnosis before examining patient
reproduce
restorative
sinus
partial necrosis
if patient drinks something cold and experiences sharp pain is different than dull pain = tells us about the pulp ____
degenerating
• biting and chewing are also important questions
• left photo = large spanning bridge - looks fairly normal but patient reports pain biting down - no missing canals, periodontally nothing wrong, but checking occlusion = patient only contacting on ____ spot of the bridge
• right photo: pulpal testing = normal, radiographically no radiolucency, checked occlusion and patient making contact with tooth
• if we didn’t ask about this then we might assume that the pulp needs to be treated and we would be
wrong
• if root canal done, and occlusion is off, patient would still experience these symptoms
one
Affecting factors
Head position may indicate ____ infection.
No ____ needed.
sinus
endodontics
Affecting factors
Is the discomfort more pronounced at certain times of the day or at night?
bruxism
• another affecting factor = clenching and grinding
• does it happen all day long or is it certain times of the day?
• patient might tell you that teeth are sore in the morning = clenching / grinding while sleeping = recommend
____
• can pulp test teeth, even though it looks normal it comes from clenching / grinding = endo tx not needed
• if pain comes at end of the day / nighttime = from ____ during the day
nightguard
clenching
Sequence of emergency treatment
- Locate ____ of the complaint.
- Make a ____ diagnosis.
- Make a ____ diagnosis.
Avoid the temptation to do something if the diagnosis is not cer tain or before a
____ can be made.
source
pulpal
periapical
definitive diagnosis
Making pulpal & periapical diagnosis \_\_\_\_ tests \_\_\_\_ test \_\_\_\_ test \_\_\_\_ analysis
thermal
percussion
palpation
x-ray
Making a pulpal diagnosis
Thermal test
Heat test
Electric pulp test
- ____ for anterior
• most common thing to use = thermal testing
• spray endo ice onto cotton pellet and place pellet on the ____ for anterior / ____ surface for
posterior
• if they have extreme symptoms to temperature and they’re scared - tell them that we need to make an accurate diagnosis / treating the right tooth / have to confirm what tooth they’re talking about - they will understand because they don’t want a root canal that is not necessary
• give instructions beforehand: tell patient going to place something cold on tooth to reproduce the pain that
you’re feeling - when you feel cold sensation on tooth raise hand - when raise hand will take cold away - but hold hand up until you can’t feel the cold any longer
incisal edge
incisal edge
occlusal
