Emergency Endodontics Flashcards
Name the types of endodontic emergency
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
Signs/symptoms of reversible pulpitis?
Pain brought on by hot/cold/sweet Short duration Difficult to localise Exaggerated response to sensibility testing Normal radiograph
How to treat reversible pulpitis?
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
Instructions to give the pt for reversible pulpitis?
Pain will gradually decrease Analgesics: Paracetamol 2x500mg QDS Ibuprofen 2x400mg TDS If severe pain prescribe 2x30/500mg co-codamol If symptoms get worse return
Symptoms of irreversible pulpitis?
Spontaneous pain Keeps pt awake at night Lasts hours Caused by hot, relieved by cold Tooth can be TTP Pain can radiate
Treatment of irreversible pulpitis if time and pain permit?
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
Treatment of irreversible pulpitis if time does NOT permit?
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
Treatment of irreversible pulpitis if pain does not permit?
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
Irreversible pulpitis - what to consider if very painful and difficult to anaesthetise?
Regional anaesthesia Multiple anaesthetics (articaine and lignocaine) Intralig anaesthesia Intraosseous anaesthesia Intrapulpal anaesthesia Consider inhalation sedation
Instructions to give to the pt for irreversible pulpitis?
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
Symptoms of symptomatic apical periodontitis?
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
Symptomatic apical periodontitis tx if time permits?
LA Access cavity Coronal 2/3 opening Determine WL Chemo-mechanical debridement Irrigation Dry canal CaOH in canal Bac tight seal
Symptomatic apical periodontitis tx if time does not permit?
LA Access cavity Coronal 2/3 opening Irrigation Dry cnal CaOH in canal Return within next few days to complete RCT
Symptomatic apical periodontitis - instructions to pt?
Pain will gradually decrease
Analgesics - paracetamol, ibuprofen, co-codamol
Emphasise need to complete tx
Acute apical abscess symptoms?
Pain esp on pressure Swelling Mobility Feeling of tooth being elevated in the socket Fever, malaise, lymphadenopathy
Acute apical abscess treatment - drainage via the tooth?
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
Acute apical abscess tx -if no drainage through the tooth and fluctuant swelling present?
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
When are antibiotics required for acute apical abscesses?
If pt severely medically compromised
If signs of systemic involvement - fever, malaise, lymphadenopathy
Signs of spreading infec (diffuse swelling, trismus)
Acute apical abscess - instructions for pts?
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
What percentage of pts with odontogenic pain had a cracked tooth?
20%
Causes of cracked tooth syndrome?
Bruxism
Thermal cycling
Masticatory incidents
Symptoms of cracked tooth syndrome?
Pain on chewing
Pain difficult to localise
Sensitivity to hot and cold fluids
Which teeth are most commonly affected by cracked tooth syndrome?
5s and 6s
How to diagnose cracked tooth syndrome?
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
How to treat cracked tooth syndrome?
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
Cracked tooth syndrome - diagnosis of vertical root fractures?
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
What to consider with flare ups?
Define pain source
- Recent restorative tx?
- Recent endo tx? - mid or post tx?
What to consider with restorative causes of flare ups?
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
Endo tx flare up signs and symptoms?
TTP Tender to palpation, esp over apices Reddening and swelling of the mucosa Pain constant and worsening Last several hours
Why do teeth flare up post endo tx? (phoenix abscess)
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
What can cause mid/post endo tx flare ups?
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
How to manage mid treatment flare ups?
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
What advice to provide the pt providing mid tx flare ups?
Analgesics
Antibiotics not indicated
Return if symptoms worsen
Symptoms unlikely to alter outcome of endo tx
Management of post endo tx flare ups?
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
What is a complicated crown fracture?
Crown fracture involving the pulp
How to treat trauma involving the pulp in different pts?
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
Steps to pulp capping?
LA Rubber dam Clean with water/saline/chlorhexidine Disinfect with NaOCl MTA/CaOH/Biodentine Seal dentine with GIC/Composite Restore with composite
Steps to a partial pulpotomy?
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
Is pulp capping or partial pulpotomy preferred?
Partial pulpotomy - better long term outcomes
What does the prognosis of pulp trauma depend on?
Extent of injury, time before intervention, stage of root development
What to do if a tooth with pulp trauma becomes non-vital?
Endo tx
When to follow up pulp trauma tx?
6-8 weeks and 1 yr after
Why is it important for treatment of pulp traumatised teeth to be successful in immature teeth?
Root formation will complete
Categories of iatrogenic damage involving the pulp?
Carious exposure
Non-carious exposure
What does iatrogenic damage involving the pulp impact?
Chance of subsequent tx maintaining vitality of the tooth
Non-carious pulpal exposure?
V good prognosis
Due to overenthusiastic cavity prep or tooth prep for indirect restoration
Pulp cap tx
Carious pulpal exposure tx?
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
Is a pulp cap or partial pulpotomy preferred for iatrogenic damage to pulp?
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
