Diagnosing and Managing Dental pain or Infection

Question 1

What is Reversible pulpitits?

Answer 1

• Pain provoked by stimulus e.g. cold, sweet and relieves when stimulus removed
• Pain is intermittent, difficult for child to localise and does not affect childs sleep
• Pulp still vital and tooth not tender to percussion
• Management of carious lesion alone may be enough to resolve inflammation and allow pulpal healing

Question 2

What is irreversible pulpitis?

Answer 2

• Spontaneous pain but when provoked by stimulus is not relieved when stimulus removed
• Pain may last several hours and hard to localise
• Keep child up at night
• Pain dull and throbbing and worsened by heat
• No signs and symptoms of infection like sinuses/ abscesses/ periradicular pathology
• Pulp vital but inflammed
• Usually not tender to percussion
• Management of carious lesion along unlikely to resolve inflammation
• Pulp therapy (Primary = pulpotomy and permanent = RCT) or extraction required

Question 3

Signs and symptoms Dental abscess/ Periradicular periodontitis (Acute)

Answer 3

• Pain likely to be spontaneous
• Keep child awake at night
• Easily localised by child
• Increased mobility of tooth
• Tender to percussion
• May be clinical evidence of sinus/ abscess/ swelling/ radiographically evidence of periradicular pathology

Question 4

Signs and symptoms dental abscess/periradicular periodontitis (Chronic)

Answer 4

• Child may not report pain but other signs and symptoms present
• Infected necrotic remnants of dental pulp continue to cause problems unless managed by pulp therapy (both primary and permanent a pulpectomy/RCT where instrumentation also includes root canal system) or extraction

Question 5

Signs and symptoms of multi-rooted teeth

Answer 5

• Not uncommon for different pathology to be present in individual roots
• Root canal with most advanced pathology dictates management strategy

Question 6

What to do if child has reversible pulpitis symptoms?

Answer 6

• If pain to cold/sweet
• If tooth not tender to percussion
• If resolves on removal of stimulus
• If tooth difficult to localise
• Restore or place a dressing and restore later

Question 7

What to do if child has irreversible pulpitis and they are pre-cooperative child?

Answer 7

• If spontaneous pain wakens child at night
• Does not resolve on removal of stimulus
• Pain to hot/cold
• Does not resolve with placement of temporary dressing
• Patient pre-cooperative
• Try to dress with sub lining of corticosteroid antibiotic paste and prescribe pain relief

Primary tooth - Refer for treatment/extraction with sedation or GA
Permanent - RCT or extraction. If child remains uncooperative refer for specialist care

Question 8

What to do if child has irreversible pulpitis and is cooperative?

Answer 8

• If spontaneous pain wakens child at night
• Does not resolve on removal of stimulus
• Pain to hot/cold
• Does not resolve with placement of temporary dressing

Patient cooperative

Primary tooth - Carry out extraction or appropriate pulp therapy
Permanent - Carry out RCT or extraction

Question 9

What to do if child has dental abscess/periradicular periodontitis and is pre-cooperative child or has multiple abscessed teeth?

Answer 9

• If spontaneous pain awakens child at night
• Tooth mobile and tender to percussion
• Swelling
• Malaise

Consider local measure to control infection
- Prescribe antibiotics if indicated (swelling, cellulitis, lymph node involvement) and pain relief

Primary - Refer for extraction with sedation of GA
Permanent - RCT or extraction. May require referral for specialist care

Question 10

What to do if child has dental abscess/periradicular periodontitis and is cooperative child or has multiple abscessed teeth?

Answer 10

• If spontaneous pain awakens child at night
• Tooth mobile and tender to percussion
• Swelling
• Malaise

Patient cooperative

Primary - Extraction or appropriate pulp therapy
Permanent - RCT or extraction

Question 11

When should antibiotics be prescribed?

Answer 11

• If evidence of spreading infection
• Swelling, cellulitis, lymph node involvement or systemic involvement (fever, malaise)