Emergency endodontics Flashcards
What are the different types of endodontic emergency?
pulpitis - reversible and irreversible Periapical infection - symptomatic (acute) apical periodontitis, acute apical abscess Cracked tooth Mid and post-treatment flare-ups Trauma involving the pulp Iatrogenic damage involving the pulp
What is pulpitis?
Inflammation of the pulp
What are the clinical diagnoses of pulpitis?
Irreversible and reversible
What are the signs and symptoms of reversible pulpitis?
Pain brought on by hot, cold, sweet
Short duration - does not linger for long after the removal of the stimulus
Can be difficult to localise
Tooth may give an exaggerated response to sensibility testing
Radiographs are generally of normal appearance (no PA radiolucency)
What is the treatment for reversible pulpitis?
Removal of the causative factor e.g. caries, failed restoration
Consider placing a temp restoration e.g. ZoE
Monitor response to treatment
What are the instructions to patient with reversible pulpitis?
Pain will gradually decrease
Take analgesics as required
Emphasise need to complete treatment (only temp placed)
Return if the symptoms become more severe
What are the signs and symptoms for irreversible pulpitis?
Spontaneous pain Pain persists for hours Pain triggered by heat and in the later stages relived by cold (when have hot pulp) Kept patient awake at night Tooth can be TTP
What is the treatment for irreversible pulpitis if have enough time?
Local anaesthetic Access cavity Removal of pulp tissue (barbed broach) - hooks on to the pulp then pull it out Coronal 2/3 opening Determine the WL Complete chemico-mechanical debridement Copious irrigation Dry the canal Place CaOH into the canal Place bacteria to get tight seal
What would it be ideal to do if have time to start treatment and have more time?
Ideal to complete the RCT at the same appointment
So after drying the canal; complete the obturation and place a bacteria tight seal
What treatment would you do if pt presents with irreversible pulpitis and time does not permit?
LA Access cavity Removal of pulp tissue (barbed brooch) Copious irrigation Dry the pulp chamber Place a sedative dressing (e.g leadermix/Odontopaste) Place bacterial tight seal Complete root canal instrumentation in next few days
What is the problem with having a hot pulp?
When a tooth with pulpitis can be incredibly painful and difficult to anaesthetise
What are the different methods of anaesthetising if have a hot pulp?
Regional anaesthesia
Consider additional sources of innervation e.g. long buccal
Multiple anaesthetics (lignocaine and articaine)
Intra-ligamentary anaesthesia
Intra-pulpal anaesthesia - when hit pulp after access, place LA into pulp
Intra-osseous anaesthesia
Consider inhalation sedation
if patient presents with irreversible pulpitis and and pain doesnt allow treatment what should you do?
Attempt to remove as much pulpal tissue as possible and place a sedative dressing
If this isn’t possible then advise analgesics
No antibiotics for pulpitis
Pt should return to treatment as soon as possible
What are the prescribed/advised analgesics to give?
Paracetamol 2x500mg up to QDS
Ibuprofen 2x400mg up to RDS
Prescribe co-codamol 2x30/500mg QDs only in very severer pain
What are the signs and symptoms for symptomatic (acute) apical periodontitis?
TTP Tender to palpation over the apices Swelling and reddening of the mucosa No response to vitality testing Pain can be severe in function or pressure Can be constant and worsening Can be present for several hours
What is the treatment for symptomatic apical periodontits if time permits?
LA Access cavity Coronal 2/3 opening Determine working length Complete chemo-mechanical debridement Copious irrigation Dry the canal Place CaOH into canal Place bacteria tight seal
What is the treatment for symptomatic apical periodontitis if time doesn’t permit?
LA Access cavity coronal 2/3 opening Copious irrigation Dry the canal Place CaOH into the canal Place bacteria tight seal Complete root canal instrumentation in next few days
How do you temporise the RC between appointment’s
Intermediate or provisional filling material - IRM, GIC
Either sponge pellet or soft temp material cavit or coltosol
Calcium hydroxide paste
What are the instructions to patient presenting with symptomatic apical periodontitis?
Pain will gradually decrease Take analgesics as required Paracetamol 2x500mg up to QDS Inruprofen 2x400mg up to TDS Prescribe co-codamol 2x30/500mg QDS - only if in severe pain
What are the signs and symptoms of acute apical abscess?
Swelling
Severe pain especially on pressure
Feeling of the tooth being elevated in the socket
Mobility may be present (bone loss because of apical infection)
The patient may experience fever, malaise and lymphadenopathy
What is the treatment for acute apical abscess, if attempting drainage through the tooth?
Attempt drainage through the tooth Local anaesthetic regional block Access cavity Drain the pus - if not pus immediately explore the canal/apex with small file to encourage discharge Copious irrigation Dry the canal Place CaOH into canal Place bacteria tight seal Complete root canal instrumentation when patient is able
What is the treatment for acute apical abscess if there is not drainage through the tooth or drainage is inadequate and fluctuant swelling is present?
LA: spray the swelling with ethy chloride or place topical LA for 3 mins (consider regional LA)
Incise the swelling vertically with scalpel
Aspirate the pus
Copious irrigation
Leave to continue to drain and heal
Complete RCT when the patient is able
When are the only times antibiotics are required if pt presents with acute apical abscess?
Signs of spreading infection (diffuse swelling, trismus)
Signs of systemic involvement (fever, malaise, lymphadenopathy)
Certain patients who are severely medically compromised
What are the instructions to patient if present with acute apical abscess?
Return to dentist or A&E if: the swelling progresses, difficulty opening mouth they start to feel unwell, any difficulty swallowing/breathing, return for completion as soon as possible
