emergency endo Flashcards
What are the types of endo emergency?
1. Pulpitis
2. Periapical infection
3. Cracked tooth
4. Mid and post-tx flare ups
5. Trauma inv pulp
6. Iatrogenic damage inv pulp
What is pulpitis?
Inflam of pulp
Clinical diagnosis
Reversible- pain (hot, cold, sweet), doesn’t linger, difficult to localise, exaggerated response, no PAP
- tx- remove causative factor, place temporary, monitor response
- pain will decrease w time, take analgesics, emphasise need to complete tx, return if more severe
Irreversible- spontaneous, persistent pain, triggered by heat relieved by cold, keeps pt up at night, can be TTP, can radiate
- tx- RCT (intervisit dressing/obturate, bacteria tight seal/definitive)
What analgesics can you prescribe?
1. Paracetamol 2x500mg up to QDS
2. Ibuprofen 2-400mg up to TDS
3. Co-codamol 2x30/500mg QDS
What is a barbed broach?
Removes pulp tissue
Short file, has sharp hooks
Used more for intact pulps
What are hot pulps?
Tooth w pulpitis v painful and difficult to anaesthetise
How should you manage hot pulps?
1. Regional anaesthesia
2. Additional sources of innervation
3. Multiple anaesthetics
4. Intraligamentary
5. Intra pulpal
6. Intra-osseous
7. Inhalation sedation
What should you do if pain/time doesn’t permit RCT in irreversible pulpitis?
Remove as much pulp tissue as possible
Place sedative dressing (eg. Ledermix, Odontopaste)
If not- advise analgesics
NO PLACE FOR ANTIBIOTICS
Continue ASAP
What is symptomatic apical periodontitis?
TTP and palpatiom
Swelling and reddening of mucosa
No vitality response
Severe pain
Constant and worsening pain
Present for several hours
TX-
-RCT/extract
-should dress and complete in few days
What do you do to dress the tooth?
Calcium hydroxide paste
Sponge pellet
Provisional/intermediate eg. IRM, GIC
What is an acute apical abscess?
Swelling
Severe pain
Feel of tooth being elevated in socket
Mobility
Fever, malaise, lymphadenopathy
TX-
- attempt drainage through tooth (regional LA, diamond bur to reduce vibration, may need to explore apex w file to encourage, palpate/push swelling, copious irrigation, dry, dress)
- if no/little drainage AND fluctuant swelling (regional LA/topical/ethylchloride, vertical incision, aspirate, irrigate, leave to drain and heal)
-THEN do RCT
Return/A&E if-
- swelling progresses
- trismus
- feel unwell
- difficultly swallowing/breathing
When are antibiotics required?
1. Spreading infection (diffuse swelling, trismus etc)
2. Systemic involvement (fever, malaise, lymphadenopathy)
3. Severely med compromised
What is cracked tooth syndrome?
20% patients w pain
Incomplete fracture
Due to masticatory incidents, bruxism, thermal, cycling etc
Second premolars/first molars most often
Symptoms- pain on chewing, sensitivity to hot/cold, pain difficult to locate
Fracture line mesial to distal
How do you diagnose cracked tooth syndrome?
1. Ask pt to bite on cotton wool roll, wood stick or fracture detector (tooth sleuth)
2. Pain on release of pressure is indicative
3. Visual detection of crack (fibre optic, staining)
4. Radiographs little value
4.
How do you treat cracked tooth syndrome?
If no signs of pulpitis- stabilise w restoration/crown
Risk of RCT/extract if crack opens up
Consider ortho band to stabilise, diagnose, immediate relief
If signs of irreversible pulpitis- RCT and crown
If fracture line below alv crest- extract/root section
How do you assess mid and post tx flare ups?
Define source of pain (restorative/endo)
RESTORATIVE- depth and amount is tooth structure removed/condition of pulp
-assess symptoms
-assess restoration (leakage, occlusion, exposed dentine etc)
-consider monitoring, analgesics, adjusting occlusion, sedative dressing, desensitising agent etc
ENDODONTIC- bacterial contamination/change in bacterial flora
-due to poor isolation, poor temp, inappropriate dressing, incomplete prep, missed canals, debris through apex, overfill material
What signs and symptoms can you get from mid and post tx flare ups?
TTP and palpation
Swelling and reddening of mucosa
Severe pain
Constant and worsening pain
Present for several hours
What is a Phoenix abscess?
Non vital tooth flares up when it was previously asymptot
Probably due to alteration in internal environment during instrumentation
Bacteria flora altered and causes symptoms
How do you manage a mid tx flare up?
Assess need to reopen canal (can pt tolerate, is there time)
If not- provide advice, analgesics etc
If reopen- conventional, ascertain reason for flare up, leave tooth w well condensed CaOH in situ
Advice- return if worsen, unlikely to affect outcome, analgesics, antibiotics not required
How do you manage a post tx flare up?
Often due to bacterial contamination at apex/overfill of material
Usually best to monitor and advise, analgesics, reassure that will resolve w time
How do you manage trauma involving pulp?
YOUNG PTS (open apices)
- pulp capping/partial pulpotomy to secure further root development (apexogenesis)
- also for older pts w closed apices
-pulp capping only if v recent due to contamination
-partial p preferred
-CaOH and MTA
OLD PTS (closed apices)
- + luxation injury w displacement=RCT
- signs of pulpal necrosis= RCT
How do you do pulp capping?
1. LA
2. Isolate w rubber dam
3. Clean w water/saline/CHX
4. Disinfect w NaOCl
5. Apply MTA/biodentine/CaOH
6. Seal exposed dentine w GIC/composite
7. Restore w composite
How do you do partial pulpotomy?
1. LA
2. Isolate w rubber dam
3. Clean w water/saline/CHX
4. Perform pulpotomy 2mm w round diamond bur w water
5. Place saline moistened cotton pellet over pulp to stop bleeding
6. Apply MTA/biodentine/CaOH
7. Seal dentine w GIC/composite
8. Restore w composite
How do you follow up pulp capping/pulpotomy?
Clinical and radiographic at 6-8weeks then a year
How do you manage iatrogenic damage inv. pulp?
Non carious/carious
-extent of bacterial contamination
If soft caries and symptoms of pulpitis= RCT
If all infected dentine removed and no symptoms=pulp cap or partial pulpotomy
If bleeding doesn’t stop= RCT
Should you direct cap w CaOH or mineral trioxide aggregate?
MTA- higher success rate, less inflam response, more predictable dentine bridge formation
