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Advanced Pulpal Disease > Emergency endodontics > Flashcards

Emergency endodontics Flashcards

1
Q

Types of endo emergency

A 
Pulpitis (reversible/ irreversible)
Periapical infection
Cracked tooth
Mid & post-tx flare-ups
Trauma involving the pulp
Iatrogenic damage involving pulp
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2
Q

Types of periapical infection

A

Symptomatic (acute) apical periodontitis

Acute apical abscess

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3
Q

What is pulpitis?

A

 Inflammation of the pulp
 Need to differentiate between reversible and
irreversible pulpitis
 This is a clinical diagnosis and cannot be differentiated
histologically

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4
Q

Signs and symptoms of reversible pulpitis

A

 Pain brought on by hot, cold, sweet
 Short duration – does not linger for long after removal of the stimulus
 Can be very difficult to localise
 The tooth may give an exaggerated response to
sensibility testing
 Radiographs are generally of normal appearance (no PA radiolucency)

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5
Q

Treatment of reversible pulpitis

A

Removal of the causative factor e.g. caries, failed restoration etc.
Consider placing temporary restoration such as zn-ox/ eug
Monitor response to tx

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6
Q

Reversible pulpitis: instructions to pt

A

Pain will gradually decrease
Take analgesics as required
 Paracetamol 2x500mg up to QDS
 Ibuprofen 2x400mg up to TDS
 Prescribe co-codamol (2x30/500mg QDS) only if very severe pain
Emphasise the need to complete treatment if required
Return if symptoms become more severe

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7
Q

Signs and symptoms of irreversible pulpitis

A 
 Spontaneous pain
 Pain persists (hours)
 Pain triggered by heat and in the later stages relieved by
cold
 Kept awake at night
 Tooth can be TTP, but not always
 Pain can radiate
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8
Q

Treatment of irreversible pulpitis (if time and pain permit)

A 
 Local anaesthetic
 Access cavity
 Removal of pulp tissue (barbed broach)
 Coronal 2/3 opening
 Determine working length
 Complete chemo-mechanical debridement
 Copious irrigation
 Dry the canal
 Place CaOH into canal
 Place bacteria tight seal
*if possible complete RCT at same apt, completing obturation and place bacteria tight seal*
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9
Q

Treatment of irreversible pulpitis (if time does not permit)

A 
 Local anaesthetic
 Access cavity
 Removal of pulp tissue (barbed brooch)
 Copious irrigation
 Dry pulp chamber
 Place a sedative dressing (eg Leadermix/ Odontopaste)
 Place bacteria tight seal
 Complete root canal instrumentation in next few days
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10
Q

Irreversible pulpitis: hot pulps

A

Sometimes, a tooth with pulpitis can be incredibly painful and difficult to anaesthetise
In this situation, try the following methods:
 Regional anaesthesia
 Consider additional sources of innervation (eg long buccal)
 Multiple anaesthetics (eg lignocaine + articaine)
 Intra-ligamentary anaesthesia
 Intra-pulpal anaesthesia
 Intra-osseous anaesthesia
 Consider inhalational sedation

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11
Q

Irreversible pulpitis tx (if pain does not permit)

A

 Attempt to remove as much pulp tissue as possible and
place a sedative dressing
 If this is not possible, advise analgesics
 THERE IS NO PLACE FOR ANTIBIOTICS IN THE
TREATMENT OF PULPITIS
 The patient should return to continue treatment as soon
as possible

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12
Q

Irreversible pulpitis: instructions to pt

A 
Pain will gradually decrease
Take analgesics as required
Paracetamol 2x500mg up to QDS
 Ibuprofen 2x400mg up to TDS
 Prescribe co-codamol (2x30/500mg QDS) only if very severe pain
Emphasise the need to complete treatment
Return if symptoms become more severe
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13
Q

Signs and symptoms of symptomatic apical periodontitis

A

 Tender to percussion
 Tender to palpation especially over the apices
 Swelling and reddening of the mucosa
 No responses to vitality testing
 Pain can be severe especially in function or pressure
 Can be CONSTANT and worsening
 Can be present for several hours

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14
Q

Tx of symptomatic apical periodontitis (if time permits)

A 
 Local anaesthetic
 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
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15
Q

Tx of symptomatic apical periodontitis (if time does not permit)

A 
 Local anaesthetic
 Access cavity
 Coronal 2/3 opening
 Copious irrigation
 Dry the canal
 Place CaOH into canal
 Place bacteria tight seal
 Complete root canal instrumentation in next few days
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16
Q

symptomatic apical periodontitis: instructions to pt

A 
Pain will gradually decrease
Take analgesics as required
 Paracetamol 2x500mg up to QDS
 Ibuprofen 2x400mg up to TDS
 Prescribe co-codamol (2x30/500mg QDS) only if very severe
pain
Emphasise the need to complete treatment
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17
Q

Signs and symptoms of acute apical abscess

A

 Swelling
 Severe pain especially on pressure
 Feeling of the tooth being elevated in the socket
 Mobility may be present
 The patient may experience fever, malaise and
lymphadenopathy

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18
Q

Tx for acute apical abscess

A 
Attempt drainage through the tooth
 Local anaesthetic (regional?)
 Access cavity
 Drain the pus
 If no pus occurs immediately explore the canal/apex with a small
file to encourage pus discharge)
 Copious irrigation
 Dry the canal
 Place CaOH into canal
 Place bacteria tight seal
 Complete root canal instrumentation when patient is able
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19
Q

Acute apical abscess tx: burs

A

Use a diamond bur to reduce vibration
Enter the pulp chamber and watch the pus flow out!
‘Palpate’ or ‘push’ the swelling to maximize discharge

20
Q

Tx for acute apical abscess if no drainage through tooth (or drainage inadequate) AND fluctuant swelling is present

A

 Local anaesthetic: spray the swelling with ethyl
chloride or place topical LA for 3 minutes (also
consider regional LA)
 Incise the swelling VERTICALLY with a scalpel
 Aspirate the pus
 Copious irrigation
 Leave to continue to drain and heal (no need for
sutures)
 Complete root canal treatment when patient is able

21
Q

Acute apical abscess: are abx required?

A 
Only when
 Signs of spreading infection
(diffuse swelling, trismus etc)
 Signs of systemic involvement
(fever, malaise, 
 lymphadenopathy)
 Certain patients who are severely medically compromised
22
Q

Acute apical abscess: instructions to pt

A

Return to the dentist (or attend A&E) if:
 The swelling progresses
 Difficulty opening mouth
 They start to feel unwell
 Any difficulty swallowing/ breathing
Return for completion of treatment as soon as possible
following resolution of symptoms

23
Q

Cracked tooth syndrome

A

Up to 20% of patients with odontogenic pain had a
cracked tooth (incomplete fracture) as the main cause
Causes include masticatory incidents, bruxism, thermal
cycling etc

24
Q

Cracked tooth syndrome: which teeth most often affected?

A

Second premolars and first molars (especially those with large restorations

25
Q

Symptoms of cracked tooth syndrome

A

pain on chewing, sensitivity to cold and hot fluids, pain which is difficult to locate

26
Q

Cracked tooth syndrome fracture line

A

Usually from mesial to distal

27
Q

Cracked tooth syndrome diagnosis

A

 Ask the patient to bite on a cottonwool roll, wood stick, or fracture detector (tooth slooth)
 Pain on release of pressure is the most reliable aid and most expressive clinical finding
 Visual detection of crack
(fibreoptic, staining)
 Radiographs are of little value for detection

28
Q

Treatment for cracked tooth syndrome

A

 No signs of pulpitis: stabilisation of the tooth
with an adhesive restoration or partial/full coverage crown
 Consider using a copper or orthodontic band
to stabilise the tooth to aid diagnosis/provide
immediate relief/protection
 Signs of irreversible pulpitis (eg symptoms
when not in function): Endodontic treatment followed by full crown
 Fracture line extends below the alveolar crest:
Extraction

29
Q

Cracked tooth syndrome: vertical root fractures

A

 There will be a deep but narrow periodontal pocket which follows the
path of the root fracture
 The fracture may be clinically visible, but
often hidden under a restoration and the
gingivae
 Look for a ‘J’ shaped lesion on a
radiograph
 Difficult to diagnose definitively on a
radiograph unless the two segments
separate

30
Q

Mid and post-tx flare-ups

A

Define the source of the pain:
 Recent restorative treatment
 Recent endodontic treatment (mid-treatment, post-treatment)

31
Q

Mid and post-tx flare-ups: recent restorative treatment

A

 Risk of symptoms is related to the depth and amount of tooth
structure removed and the condition of the pulp
 Need to assess the symptoms and make a diagnosis (reversible/ irreversible pulpitis)
 Assess restoration – leakage, occlusion, exposed dentine etc?
 Consider monitoring and recommending analgesics, adjusting the occlusion, placing a sedative dressing, desensitising agent etc.

32
Q

Mid and post-tx flare-ups: endo flare-ups

A

Can occur either mid-treatment or post-treatment
Usually due to bacterial contamination/change in bacterial flora:
 Poor rubber dam technique
 Unsatisfactory temporary restoration
 Inappropriate intra-canal medication
 Incomplete chemo-mechanical preparation
 Missed canals
 Forcing debris through the apex
 Overfill of root filling material

33
Q

Mid and post-tx flare-ups: signs and symptoms from endo

A 
 Similar to acute apical periodontitis
 Tender to percussion
 Tender to palpation especially over the apices
 Swelling and reddening of the mucosa
 Pain can be severe especially in function or
pressure
 Can be CONSTANT and worsening
 Can be present for several hours
34
Q

Mid and post-tx flare-ups: ‘Pheonix abscess’

A

 When a non-vital tooth flares-up when it has
previously been asymptomatic
 Probably due to alteration in the internal environment
of the root canal space during instrumentation
 Bacterial flora is altered and causes symptoms

35
Q

Management of mid-tx flare-ups:

A

Assess the need to re-open the root canal
 Is the patient able to tolerate treatment?
 Is there clinical time available?
If not re-opening, provide advice regarding analgesics
etc
If re-opening:
 Follow conventional procedure
 Try to ascertain the reason for the flare-up
 Leave the tooth with well condensed CaOH in situ

36
Q

Management of mid-tx flare-ups: advice to pts

A

 Return if symptoms significantly worsen
 The symptoms are unlikely to affect the outcome of the
endodontic procedure
 Take analgesics as required
 Antibiotics are not indicated

37
Q

Management of post-tx flare-ups

A

 Often due to bacterial contamination at the apex or overfill of material
 Difficult to treat as the root filling is in situ and often also the definitive restoration
 Usually best to monitor symptoms and reassure patient that they should resolve with time
 Advise appropriate analgesics
 There is no indication for antibiotics unless the
previously identified criteria are present

38
Q

Trauma involving the pulp

A 
 A crown fracture involving
the pulp is also known as a
complicated crown fracture
 Diagnosis is usually straight forward and based on clinical presentation
 A history of trauma with
exposed pulp and pain will
be present
39
Q

Treatment for trauma involving the pulp

A

 In young patients with open apices, it is very important to preserve pulp
vitality by pulp capping or partial pulpotomy in order to secure further root
development
 This treatment is also the treatment of choice in patients with closed apices
 Pulp capping should only be attempted if the injury is very recent due to
the risk of contamination
 Calcium hydroxide compounds and MTA (white) are suitable materials for
such procedures
 In older patients with closed apices and an associated luxation injury with displacement, endodontic treatment is usually the treatment of choice.
 Additionally, if the injury is old and there are signs of pulpal necrosis, then
endodontic treatment is indicated

40
Q

Trauma involving the pulp: pulp capping

A

 Local anaesthetic
 Isolate with rubber dam
 Clean with water, saline or chlorhexidine
 Disinfect with NaOCl
 Apply pulp-capping material (either MTA, biodentine
or calcium hydroxide) over exposed pulp tissue
 Seal exposed dentine with GIC or composite
 Restore remaining tooth with composite

41
Q

Trauma involving the pulp: partial pulpotomy

A

 Local anaesthetic
 Isolate with rubber dam
 Clean with water, saline or chlorhexidine
 Perform pulpotomy to a depth of 2mm with a clean, round diamond bur under water spray
 Place a saline moistened cotton pellet over the pulp until
bleeding has stopped
 Apply pulp-capping material (either MTA, biodentine or
calcium hydroxide) over exposed pulp tissue
 Seal exposed dentine with GIC or composite
 Restore remaining tooth with composite

42
Q

Trauma involving the pulp: preferred treatment, follow-up and prognosis

A

Partial pulpotomy should normally be preferred over
pulp-capping due to slightly better long-term
outcomes
Follow-up
 Clinical and radiographic follow-up at 6-8 weeks and 1
year
Prognosis
 Depends on extent of initial injury, time before
intervention and stage of root development
 If the tooth becomes none vital, then endodontic
treatment is indicated
If the tooth is immature, successful treatment can
result in completion of root formation (apexogenesis)
The aim of treatment in
the case of trauma where
the pulp is still vital is to
preserve the vitality of the
pulp

43
Q

Iatrogenic damage involving pulp

A

Iatrogenic damage involving the pulp can be divided
into 2 categories
 Non-carious exposure
 Carious exposure
This affects the chance of the subsequent treatment
maintaining the vitality of the pulp
Extent of bacterial contamination seems to be the most important factor

44
Q

Non-carious exposure

A

 Usually occurs due to over-enthusiastic
cavity preparation or tooth preparation for an indirect restoration
 Although they should ideally be avoided
with careful clinical technique, they
generally have the best prognosis
 Management involves pulp capping as
previously described
 Prognosis for maintaining a vital pulp is
generally very good, provided a bacteriatight restoration can be provided

45
Q

Carious exposure

A

 Depends on the extent of the caries and the patient
symptoms
 If the exposure still has soft caries over it or the patient has
symptoms of pulpitis, then endodontic treatment should be undertaken
 If possible, leave ‘affected dentine’ over the pulp and place a bacteria-tight restoration to prevent pulp exposure
 If pulp exposure occurs, but all ‘infected dentine’ has been removed and the patient has no symptoms, attempt a pulp
cap or partial pulpotomy

46
Q

Iatrogenic damage involving the pulp: Pulp-cap versus partial pulpotomy

A

 Partial pulpotomy is preferred in this situation as it
removes the superficially and potentially infected layer of the pulp
 Surrounding dentine is also removed to create a well defined space for the pulp-capping material to be placed
 Follow the procedure a s described previously
 It is essential to stop the bleeding from the pulp before
placing the pulp-capping material
 If bleeding cannot be stopped, proceed to endodontic treatment

Advanced Pulpal Disease (7 decks)

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