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
A vital pulpal diagnosis
Normal
Reversible pulpitis Symptomatic irreversible
Asymptomatic irreversible
if the patient feels a positive response to cold = pulp is ____ to some degree
• different choices for pulp vitality
• could be normal pulp: feel cold when pellet is on and don’t feel it once it’s off - no ____
• reversible pulpitis: if you had a recent filling / OTC bleaching and ____
• symptomatic irreversible pulpitis: hand still remains up when you take pellet off = ____
• asymptomatic irreversible pulpitis: recurrent ____ seen in photo, if you test tooth it might test normal, caries has reached pulp and it has become irreversible
• irreversible = need to do ____, pulp not going back to normal
vital lingering sensitive lingering decay
A non-vital pulpal diagnosis
- ____
necrosis
Making a periapical diagnosis
Percussion: a painful response may indicate ____ inflammation or a ____ tooth.
periradicular
cracked
Making a periapical diagnosis
First use mild ____ pressure.
If there is no response, increase with ____ pressure or bite stick.
finger
mirror
Making a periapical diagnosis
____: the sense of touch to determine texture, rigidity, and tenderness.
palpation
Making a periapical diagnosis
No ____ response.
Periodontal ligament is intact ____.
percussion
radiographically
Making a periapical diagnosis
Apical ____. Loss of ____ space. Painful to ____.
symptomatic apical periodontitis
radiolucency
PDL
percussion
Necrotic tooth
percussion: ____
palpation: ____
cold response: ____
heat response: ____
electric pulp test: ____
\+ \+ - - -
Emergency: necrotic tooth
____ throughout the entire root canal system.
Objective: to clean, shape, and disinfect the entire canal system.
bacteria
Emergency: necrotic tooth
- Establish ____ length.
- ____ instrumentation
of the entire root canal. - Allow for any ____.
- Irrigation ____, EDTA, CHX.
working
biomechanical
drainage
NaOCl
Emergency: necrotic tooth
- ____ root canal system.
- Place intra-canal ____.
- ____ access.
- Schedule for next visit.
dry
medication
seal
Emergency: necrotic tooth
____
If we don’t have any drainage from the tooth, we might need to create an incision to relieve the pressure
Then we will suture a ____ in place, so it will keep draining for as long as we want
Q: how long after the appointment will it take for the patient to be out of pain? A: Symptomatic irreversible pulpits = right after the procedure
If it is percussion positive, it might take a few days
If there is swelling/necrotic tooth, it might take a few days too
incision and drainage
drain
Vital tooth
caries entering the pulp
percussion: ____
palpation: ____
cold response: ____
heat response: ____
electric pulp test: ____
- Palpation negative b/c we have no ____ infection
- Expect cold response to be positive and lingering
\+ - \+++ \+ \+
peri-apical
Emergency: vital tooth
Pulpotomy: removal of the inflamed ____ portion of vital pulp.
Used only for time ____.
coronal
constraints
Emergency: vital tooth
Bacteria and inflammation limited to ____ portion.
Objective: due to limited time, minimally remove the inflamed ____ portion.
coronal
coronal
Vital tooth: pulpotomy
- ____ tooth.
- ____ removal.
- Removed ____ portion. 4. Irrigate with ____.
- No ____.
- ____ is placed over the canal orifice.
- ____ restoration (Cavit) to seal access.
- Continue at next visit.
access caries inflamed NaOCl instrumentation calcium hydroxide temporary
Post-operative instructions
Allow for setting of temporary material. (Cavit takes ~____mins)
Allow of ____ to dissipate.
Expect no ____ from a vital case.
OTC analgesics, if needed. NSAIDs
45
anesthesia
thermal sensitivity
Anesthesia and irreversible pulpitis
The inflammatory process causes ____ and ____, hampering profound anesthesia.
Hyperalgesia: ____ sensitivity to pain. Allodynia: reaction to a stimulus which does
not ____ provoke pain.
hyperalgesia
allodynia
heightened
normally
Anesthesia and irreversible pulpitis
Sodium channels in nociceptors are 4x more ____ to local anesthetics.
Presence of ____ channels in symptomatic pulp.
____ can compromise the entire axon extension, reducing the efficacy of anesthesia blocks.
-Nav1.9 are resistant to anesthetics we use today, so they make these teeth
difficulty to numb
resistant
Nav1.9
inflammation
Does volume of anesthetic matter?
No ____ between the two groups.
significance
Does type of anesthetic matter?
No ____ between groups (lido v articaine)
significance
Do supplemental infiltrations help?
(IANB and then a BI)
Supplemental infiltration with ____ is ____ more successful.
articaine
significantly
Are antibiotics needed?
____ for localized swellings or if drainage is achieved.
Recommend for diffuse ____ or when drainage is not possible.
Systemic involvement, elevated temperature.
Amoxicillin ____mg
unnecessary
swellings
500
Inter-appointment emergencies Inadequate \_\_\_\_ Debris extrusion Over-\_\_\_\_ Overfilling \_\_\_\_ lesion Retreatment cases
debridement
instrumentation
periapical
Leaving teeth open
Drainage is usually achieved within a few ____.
Recommend ____ all teeth to prevent contamination from the oral cavity.
With rare exception all teeth should be closed.
minutes
closing
ou only feel discomfort when you drink something cold?
Yes, every time something cold touches it
- B/c it shows that the tooth is ____.
- B/c if the tooth is sensitive to cold, we can test it against ____ teeth to see which one really is infected
vital
neighboring
If water touches it, the pain stays for at least 5 minutes
That means the pain is ____. It’s not a short-lived pain
lingering
#30 percussion: \_\_\_\_ palpation: \_\_\_\_ cold response: \_\_\_\_ heat response: \_\_\_\_ EPT: \_\_\_\_
Pulpal diagnosis #30:
____
Periapical diagnosis #30:
____
B/c it is ____ positive, the peri-apical diagnosis is symptomatic apical periodontitis
\+ - \++ \+ \+ \+
symptomatic irreversible pulpitis
sympatomatic apical periodontitis
percussion
We had a limited amount of time, so just did a ____ to get the patient out of pain until we could schedule a full appointment to finish treatmen
pulpotomy
Do you feel discomfort when you drink something cold?
Yes, even cold air sets it off
This shows us that we most likely have a ____ pulp situation
vital
Clinical manifestations How long do the symptoms last?
- it’s just throbbing. i could not ____ at all last night
This is a sign of ____ pain
sleep
spontaneous
What makes it worse?
Just about everything: ____ water, hot coffee, and even putting my teeth together
This shows she has ____ and percussion sensitivity
cold
thermal
8
percussion: +
palpation: -
cold response: +++
heat response: ++
EPT: +
Pulpal diagnosis #8:
____
Periapical diagnosis #8:
____
sympatomatic irreversible pulpitis
sympatomatic apical periodontitis
Available time
- ____ the tooth.
- Complete caries removal.
- Determine ____
- Instrument to MAF.
- ____ irrigation.
- Dry root canal system.
- Place ____ medication.
- Seal access with temporary material (Cavit).
- ____ for next visit.
-Why do we medicate the tooth instead of just closing/finishing it? Because the
patient is still in ____! We don’t want to obdurate unless the patient is asymptomatic
access working length NaOCl intra-canal schedule pain
So she isn’t experiencing pain. She only noticed the ____
#10 percussion: + palpation: ++ cold: - heat: - EPT: -
Pulpal diagnosis #10: ____
Periapical diagnosis #10:
____
The peri-apical diagnosis is not acute apical abscess b/c she is not having any ____ or
pain. She’s ____. It’d be different if she was experiencing pain
Q: Why wouldn’t it be a chronic apical abscess?
A: A chronic apical abscess is when there is a ____ and the infection is draining from it
swelling
necrosis
symptomatic apical periodontitis
discomfort
asymptomatic
sinus tract
- ____ the tooth.
- Complete caries removal.
- Establish ____.
- BMI of the entire root canal.
- Allow for any ____.
- Irrigation with NaOCl, EDTA, CHX.
- ____ root canal system.
- Place intra-canal medication.
- Seal access with ____ material (Cavit).
- Schedule for next visit.
- We shouldn’t inject ____ above #10 b/c it is swollen there
- We’ll inject in ____ tissues and allow it spread into the area we want
- Don’t want to go into infected tissue and spread infection deeper
access working length drainage dry temporary
directly
adjacent
We’d expect to see that the ____ has all subsided by the time the patient comes in for the next visit
swelling
Emergency: vital tooth
Pulpotomy: if ____ amount of time. Complete BMI: if time is ____.
-With a vital tooth, we have 2 different options!
Pulpotomy (limited time) and complete BMI (more time)
-Complete BMI is the more ____ procedure to get the patient out of pain
limited
available
predictable
Emergency: necrotic tooth
Complete BMI: since bacteria has spread ____ the entire root canal system.
throughout
An emergency patient
Be prepared.
Take ___ x-rays.
Don’t assume a previous diagnosis is accurate.
Get as much ___ from the patient as possible
additional
information
An emergency patient
Complete diagnosis and review with faculty.
Explain the need for ___ visits for root canal treatment and final restoration.
Discuss what to expect ___ and after treatment.
-You need to tell patients they will have to come in for ___ appointments to finish the tooth canal -Need to also tell them they will need to come in after the root canal is finished for a ___ restoration -Root canal is scary, so make sure the patient is aware of what is going on and what problems to look out for in-between appointments
follow-up
during
multiple
final
