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Advanced Pulpal Disease > Emergency Endodontics > Flashcards

Emergency Endodontics Flashcards

1
Q

Name the types of endodontic emergency

A 
Pulpitis - reversible/irreversible 
Periapical infection - symptomatic apical periodontitis, acute apical abscess 
Cracked tooth
Mid and post tx flare ups
Trauma involving the pulp
Iatrogenic damage involving the pulp
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2
Q

Signs/symptoms of reversible pulpitis?

A 
Pain brought on by hot/cold/sweet
Short duration
Difficult to localise
Exaggerated response to sensibility testing
Normal radiograph
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3
Q

How to treat reversible pulpitis?

A

Removal of cause - caries, failed restoration
Consider planning temp restoration e.g. zn-ox/eug
Monitor response to tx
Severe pain - prescribe co-codamol 2x30/500mg QDS

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4
Q

Instructions to give the pt for reversible pulpitis?

A 
Pain will gradually decrease
Analgesics:
Paracetamol 2x500mg QDS
Ibuprofen 2x400mg TDS
If severe pain prescribe 2x30/500mg co-codamol
If symptoms get worse return
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5
Q

Symptoms of irreversible pulpitis?

A 
Spontaneous pain
Keeps pt awake at night
Lasts hours
Caused by hot, relieved by cold 
Tooth can be TTP
Pain can radiate
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6
Q

Treatment of irreversible pulpitis if time and pain permit?

A 
LA
Access cavity
Removal of pulp
Coronal 2/3 opening
Determine WL
Chemo-mechanical debridement
Copious irrigation
Dry canal

THEN
Place calcium hydroxide in canal and place bac tight seal
OR
Obturate if have time and place a bac tight seal

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7
Q

Treatment of irreversible pulpitis if time does NOT permit?

A 
LA
Access cavity
Removal of pulp
Copious irrigation
Dry pulp chamber
Place sedative dressing (Odontopaste/leadermix)
Place bac tight seal
Complete root canal instrumentation in next few days
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8
Q

Treatment of irreversible pulpitis if pain does not permit?

A

Remove as much pulp as possible and place sedative dressing
- If not possible advise analgesics
No antibiotics for pulpitis
Pt return to complete tx asap

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9
Q

Irreversible pulpitis - what to consider if very painful and difficult to anaesthetise?

A 
Regional anaesthesia
Multiple anaesthetics (articaine and lignocaine)
Intralig anaesthesia
Intraosseous anaesthesia
Intrapulpal anaesthesia
Consider inhalation sedation
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10
Q

Instructions to give to the pt for irreversible pulpitis?

A 
Pain will gradually decrease
Analgesics:
- Paracetamol 2x500mg QDS
- Ibuprofen 2x400mg TDS
- If severe pain prescribe 2x30/500mg co-codamol 
Emphasise need to complete tx 
Return if symptoms more severe
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11
Q

Symptoms of symptomatic apical periodontitis?

A 
TTP
Tender to palpation esp over apices 
Swelling and reddening of mucosa
No response to vitality testing
Pain can last hours
Severe pain esp if in function or pressure
Constant and worsening
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12
Q

Symptomatic apical periodontitis tx if time permits?

A 
LA
Access cavity
Coronal 2/3 opening
Determine WL
Chemo-mechanical debridement
Irrigation
Dry canal 
CaOH in canal 
Bac tight seal
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13
Q

Symptomatic apical periodontitis tx if time does not permit?

A 
LA
Access cavity
Coronal 2/3 opening
Irrigation
Dry cnal 
CaOH in canal 
Return within next few days to complete RCT
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14
Q

Symptomatic apical periodontitis - instructions to pt?

A

Pain will gradually decrease
Analgesics - paracetamol, ibuprofen, co-codamol
Emphasise need to complete tx

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15
Q

Acute apical abscess symptoms?

A 
Pain esp on pressure
Swelling
Mobility
Feeling of tooth being elevated in the socket
Fever, malaise, lymphadenopathy
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16
Q

Acute apical abscess treatment - drainage via the tooth?

A

LA, access cavity
Drain pus (if no pus explore the apex/root canal with a small file to encourage pus discharge)
Push down on swelling to maximise pus discharge
Irrigate, dry canal
CaOH, bac tight seal
Complete RCT when pt is able to

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17
Q

Acute apical abscess tx -if no drainage through the tooth and fluctuant swelling present?

A

LA - spray swelling with ethyl chloride or topical LA on swelling for 3 minutes
Incise swelling VERTICALLY with a scalpel
Aspirate pus
Copious irrigation
Leave to continue to drain and heal (no sutures)
RCT when pt able to

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18
Q

When are antibiotics required for acute apical abscesses?

A

If pt severely medically compromised
If signs of systemic involvement - fever, malaise, lymphadenopathy
Signs of spreading infec (diffuse swelling, trismus)

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19
Q

Acute apical abscess - instructions for pts?

A

Return to dentist or A&E if:
- Swelling progresses
- Feel unwell
- Difficulty breathing/swallowing/opening mouth
Return for completion of tx asap following resolution of symptoms

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20
Q

What percentage of pts with odontogenic pain had a cracked tooth?

A

20%

21
Q

Causes of cracked tooth syndrome?

A

Bruxism
Thermal cycling
Masticatory incidents

22
Q

Symptoms of cracked tooth syndrome?

A

Pain on chewing
Pain difficult to localise
Sensitivity to hot and cold fluids

23
Q

Which teeth are most commonly affected by cracked tooth syndrome?

A

5s and 6s

24
Q

How to diagnose cracked tooth syndrome?

A

Ask pt to bite down on cotton wool roll, wooden stick, tooth slooth
Pain on release of pressure = most reliable aid
Visual detection of crack - staining
Radiographs of little value

25
Q

How to treat cracked tooth syndrome?

A

No signs of pulpitis: adhesive restoration or partial/full coverage crowns
Consider metal ortho/copper band for protection and stabilisation
Signs of irreversible pulpitis (symptoms when not in function) = RCT and full crown
Fracture extends below the alveolar crest = extraction

26
Q

Cracked tooth syndrome - diagnosis of vertical root fractures?

A

Deep but narrow periodontal pocket which follows the path of root fracture
J shaped lesion on radiograph
Fracture may be clinically visible or hidden under radiograph or gingivae

27
Q

What to consider with flare ups?

A

Define pain source

  • Recent restorative tx?

- Recent endo tx? - mid or post tx?

28
Q

What to consider with restorative causes of flare ups?

A

Risk of symptoms related to depth and amount of tooth structure removed and the condition of the pulp
Assess symptoms, make diagnosis
Assess tooth - exposed dentine, occlusion, leakage
Consider monitoring and recommending analgesics, adjust occlusion, place sedative dressing

29
Q

Endo tx flare up signs and symptoms?

A 
TTP
Tender to palpation, esp over apices 
Reddening and swelling of the mucosa 
Pain constant and worsening
Last several hours
30
Q

Why do teeth flare up post endo tx? (phoenix abscess)

A

Phoenix abscess

  • When a non-vital tooth that was previously asymp flares up - due to change in the internal environment of the RC space
  • Due to change in bac flora - causes symptoms
31
Q

What can cause mid/post endo tx flare ups?

A

Bac contam/change in bac flora:

  • Poor rubber dam
  • Unsatisfactory temp restoration
  • Inappropriate intra-canal med
  • Incomplete chemo-mechanical preparation
  • Missed canals
  • Overfill of root filling material
  • Forcing debris through apex
32
Q

How to manage mid treatment flare ups?

A

Assess need to re-open the canal - clinical time? can pt tolerate it?

Open canal

  • Cause of flare up?
  • CaOH

If not re-opening - analgesic advice

33
Q

What advice to provide the pt providing mid tx flare ups?

A

Analgesics
Antibiotics not indicated
Return if symptoms worsen
Symptoms unlikely to alter outcome of endo tx

34
Q

Management of post endo tx flare ups?

A

Usually due to bac contam at the apex or overfill of material
Monitor symptoms
Symptoms will resolve with time
Analgesic advice
Antibiotics not indicated unless spreading, systemic, med compromised

35
Q

What is a complicated crown fracture?

A

Crown fracture involving the pulp

36
Q

How to treat trauma involving the pulp in different pts?

A

Young pt

  • Preserve pulp vitality
  • Pulp cap (CaOH/MTA if recent due to risk of contamination) or partial pulpotomy
  • If open apices - helps allow more root development

Elderly pt, closed apices with signs of pulpal necrosis = endo tx
Elderly pt, luxation with displacement injury = endo tx

37
Q

Steps to pulp capping?

A 
LA
Rubber dam
Clean with water/saline/chlorhexidine
Disinfect with NaOCl
MTA/CaOH/Biodentine
Seal dentine with GIC/Composite
Restore with composite
38
Q

Steps to a partial pulpotomy?

A 
LA
Rubber dam
Clean with saline/water/chlorhexidine
Pulpotomy to a depth of 2mm with a round diamond bur under water
Saline moistened cotton pellet over pulp until bleeding stopped 
Pulp capping material over pulp exposure
Seal dentine with GIC/composite
Restore with composite
39
Q

Is pulp capping or partial pulpotomy preferred?

A

Partial pulpotomy - better long term outcomes

40
Q

What does the prognosis of pulp trauma depend on?

A

Extent of injury, time before intervention, stage of root development

41
Q

What to do if a tooth with pulp trauma becomes non-vital?

A

Endo tx

42
Q

When to follow up pulp trauma tx?

A

6-8 weeks and 1 yr after

43
Q

Why is it important for treatment of pulp traumatised teeth to be successful in immature teeth?

A

Root formation will complete

44
Q

Categories of iatrogenic damage involving the pulp?

A

Carious exposure

Non-carious exposure

45
Q

What does iatrogenic damage involving the pulp impact?

A

Chance of subsequent tx maintaining vitality of the tooth

46
Q

Non-carious pulpal exposure?

A

V good prognosis
Due to overenthusiastic cavity prep or tooth prep for indirect restoration
Pulp cap tx

47
Q

Carious pulpal exposure tx?

A

Exposure with soft caries and symptoms of pulpitis = endo tx
If possible leave affected dentine over pulp
Exposure with no infected dentine and no symptoms of pulpitis = pulp cap or partial pulpotomy

48
Q

Is a pulp cap or partial pulpotomy preferred for iatrogenic damage to pulp?

A

Partial pulpotomy - removes potentially infected layer of pulp and surrounding dentine = creates well defined shape for pulp capping material
- If bleeding cannot be stopped = endo tx

Advanced Pulpal Disease (7 decks)

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