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DMD2 sem 2 > Emergency Treatment and Pain Control > Flashcards

Emergency Treatment and Pain Control Flashcards

1
Q

What causes oral pain problems most commonly?

A

Caries

Bacteria within teeth (cracks, restorations breaking down, etc)

Pulp pathosis

Periapical conditions

Periodontal diseases

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2
Q

How are pre-operative and post operative pain related? What does this tell us about pain?

A

Strong relationship between pre-op and post-op pain. (if moderate to severe pre-op pain 5x more likely to have moderate to severe post-operative pain)

Patient’s psychological profiles for coping with pain modulates their perception of post-operative pain.

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3
Q

What factors complicate pain?

A

Lack of sleep

New patient

New dentist

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4
Q

What are the 3 Ds for managing dental pain?

A

Diagnosis

Dental treatment

Drugs

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5
Q

What are the principles to follow when dealling with dental pain?

A

Take a thorough history to come up with a provisional diagnosis (Take into consideration the pulp/root canal status and periapical status)

Thorough clinical examination (Tests - palpation, percussion, periodontal probing, mobility, pulp sensibility tests, radiographs)

Examination, tests, radiograph to: Confirm diagnosis, confirm which tooth, and help decide the cause)

Determine the management options and help to assess the prognosis.

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6
Q

How does dental treatment affect pain?

A

Most patients have marked or total pain relief within 24 hours following dental treatment. Antimicrobials alone are poor at controlling pain.

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7
Q

What are the principles of management?

A

Remove cause: All restorations to assess tooth for future restoration and its long term prognosis. (Access to caries, cracks, and marginal breakdown)

Remove the pulp/debris from canals using a barbed broach (If possible and with care)

Provide drainage (Only if required via canal or soft tissue incision)

Medication-intracanal

Interim restoration

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8
Q

How does pain during treatment impact post-op pain?

A

Pain during treatment significantly impacts on the amount of post-op pain. Adequate pain control is essential.

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9
Q

What are the goals of local anaesthesia?

A

3 goals:

Anaesthesia during treatment

Haemostasis during treatment

Prolonged post-operative pain control

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10
Q

How is pain control from LA achieved?

A

Direct: Block discharges from peripheral nerves. Duration: Minutes -> Hours

Indirect: Prolonged blocking of peripheral input reduces central sensitization

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11
Q

What happens if there is inadequate local anaesthesia?

A

Pain during treatment

More post-operative pain (Prolonged exposure to sensory input increases allodynia and hyperalgesia)

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12
Q

What is allodynia and hyperalgesia?

A

Allodynia: Pain from non-injuries stimuli

Hyperalgesia: Exaggerated sense of pain

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13
Q

Why does LA not work with acute irreversible pulpitis?

A

Various theories have been proposed but non proven, most commonly discussed are:

Inflammation activates nociceptors and associated central pain mechanisms

Inflammatory mediators reduce threshold of nociceptor activation

Mediated by prostaglandins

Prostaglandins sensitize nerve endings

Inflamed pulps have high levels of both prostaglandins and arachidonic acid

These theories are incomplete and do not explain why LA doesn’t work.

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14
Q

What stages of treatment can pain be felt?

A

Pre-operative

Dentine

Pulp

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15
Q

How can acute irreversible pulpitis pain be managed?

A

Pre-empt the difficult situation (Diagnosis)

Consider pre-medication with ibuprofen

Test tooth: Triplex air + percussion during exam

Give Gow-gates block

Re-test with triplex air and percussion (Pain = give IAN block + Buccal infiltration, no pain = place rubber dam and re-test)

Allow more time for LA to work

Place rubber dam using cuff technique

Re-test again with triplex air and percussion (No pain = proceed with treatment. Pain = Give PDL injection and test again)

If pain felt on reaching the dentin (PDL injection)

If pain felt on reaching the pulp (Intrapulp injection)

If still pain: Pulpotomy only -CS-AB dressing and reappoint 3 - 4 weeks later

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16
Q

What kind of pain is seen in acute irreversible pulpitis? (Order from least to most severe)

A

Pain with cold stimuli

Pain with head

Above 2 lead to short, very sharp pain followed by lingering ache/throb

Pain is spontaneous

Pain lying down

Pain wakes the patient up. Intense throbbing/aching pain; continuous or may come and go.

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17
Q

Where should the Gow-Gates mandibular block be done?

A

Lateral region of the neck of the condyle just below the insertion point of the lateral pterygoid muscle.

Entry point is medial to the deep tendon of the temporalis muscle and slightly below the palatal cusp of the upper second molar

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18
Q

What external landmarks are used for the gow gates mandibular block?

A

Apex of the intertragic notch and the lower border of the tragus through the opposite corner of the mouth

19
Q

What are the advantages and disadvantages to the gow-gates mandibular block?

A

Advantages:

High success rate (92 - 99%) compared to IAN (65 - 85%)

Complete mandibular nerve (V3) block

No supplementary injections needed (No need for long buccal or lingal nerve injections)

Less muscle involved

Less painful (even though needle used is larger @ 25 guage)

Safer technique

Less blood vessels at the injection site (Positive aspiration rate is negligible)

No vaso-constrictor required

20
Q

Is a buccal infiltration necessary when giving an IAN block?

A

There is a significant improvement in pain reduction following combination of IAN block + Buccal infiltration for acute irreversible pulpitis in lower molars.

However, some patients will STILL have pain

21
Q

What supplementary injections can be provided for increased pain relief?

A

Labial infiltration for lower anterior teeth

Palatal infiltration for upper molars

Palatal for upper premolars and anterior teeth (Anterior middle superior alveolar nerve block)

22
Q

What are the advantages to using the rubber dam cuff technique?

A

Enables PDL injections if required

Full access to the entire tooth

Better vision

23
Q

Can antibiotics be prescribed for pulpitis?

A

NO

They are unnecessary, contra-indicated, not pain relieving, and do not help treat inflammation.

Pulpitis is not a bacterial infection (It is caused by bacterial presence in the tooth but not an infection itself)

24
Q

What local drugs are used for pain management?

A

Local anaesthetic - long acting

Intra-canal medicaments

25
Q

What are the advantages to intracanal medicaments?

A

They deliver drugs to the site of the required action (periapical region)

Faster action

Can provide same amount of pain relief or more than oral ibuprofen

Safer to use intracanal medication

Avoids systemic complications and side effects

No problems with patient compliance

26
Q

What systemic medications are used for treatment of endodontic problems?

A

Anti-bacterial (ONLY USE WHEN INDICATED)

Analgesic

Anti-inflammatory

Depends on the diagnosis

27
Q

How should ibuprofen be used?

A

2x200mg 4 hourly as a course of medication

28
Q

Who are NSAIDs contra0indicated for?

A

Asthmatics

Peptic ulcers

Drug interactions

29
Q

What should be used if NSAIDs are contraindicated?

A

500 - 1000 mg paracetamol

30
Q

How should mild pain be treated?

A

If NSAIDs contra-indicated: 500 - 1000mg paracetamol

If NSAIDs indicated:

400mg ibuprofen 4 hourly

OR

600mg aspirin 4 hourly

31
Q

How should moderate to severe pain be treated?

A

if NSAIDs contra-indicated:

1000mg paracetamol + doxylamine succinate

No NSAID contra-indication:

400 - 600mg ibuprofen 4 hourly

and

Paracetamol 1000mg +/- doxylamine succinate 4 hourly

32
Q

How should ibuprofen and paracetamol be taken for severe pain management?

A

Alternate at 2 hourly intervals:

2 x nurofen immediately post op then panadeine forte 2 hours later

33
Q

How should antibiotics be used for endodontics?

A

Indications for antibiotics during endodontics are very few. Antibiotics should only be used as an adjunct to endodontic treatment.

Reserve for special circumstances

Use locally rather than systemically (intracanal for example)

34
Q

Who should antibiotics be given to in endodontics?

A

Patients showing signs of malaise: Elevated body temperature and lymph node involvement.

Suppressed or compromised immune system

Cellulitis or spreading infection

Rapid onset (<24 hours) of severe infection to avoid complications of the infection.

35
Q

What factors can affect immune response of patient?

A

Drugs

Old age

Anxiety

Alcoholism

Malnourishment

Systemic diseases

Other infections

36
Q

What are some possible complications of dental infections?

A

Bacterial endocarditis

Cavernous sinus thrombosis

Orbital cellulitis

Ludwig’s angina

Brain abscess

Mediastinitis

Osteomyelitis

37
Q

How should antibiotics be chosen for endodontics?

A

Choose appropriate, narrow spectrum antibiotics

High initial dose - double normal dose

Consider IM or IV if severe

Commence ASAP

Monitor progress of the patient daily

If ABs aren’t improving anything consider other ABs

38
Q

How long should antibiotics be used for?

A

Correct time is the time it takes for host’s defences to regain control.

Orofacial conditions rarely rebound once the source of bacteria is reduced/removed so continue for 1 - 2 days after signs of infection diminish

39
Q

How is antibiotic chosen for treatment?

A

Decision should be based on the type of organism present (Microbiological analysis)

Ideally microbiologicla analysis should be done for all ABs to identify bacteria and to test susceptibility to antimicrobial agents

40
Q

What are the problems with microbiological analysis?

A

Practical problems: Difficulties with anaerobic culturing, costs, and treatment usually resolves the disease before the results can be obtained

41
Q

What is the first antibiotic of choice for most odontogenic infections?

A

Penicillin V. 1000mg loading dose then 500mg every 6 hours. Take 1 hour before meals 5 - 7 days

42
Q

Which antibiotics are used for odontogenic infections?

A

Penicillin V (1000mg loading dose then 500mg every 6 hours. Take 1 hour before meals 5 - 7 days)

Metronidazole (800mg loading dose then 400mg every 12 hours for 5 - 7 days)

Clindamycin (300mg loading dose then 150mg every 8 hours for 5 - 7 days)

Amoxycillin (for prophylaxis 2g 1 hour preop): Not effective against penicillinase producing organisms and not recommended for dental patients.

Tetracycline: Recent research indicates it may prevent root resorption after dental trauma. More research is needed to confirm this.

Erythromycin (Weakly active antibiotic to most oral bacteria and susceptible to acid degradation if taken orally prone to resistance and high incidence of adverse effects.

43
Q

What are the signs of failing antibiotic use?

A

Fever, malaise, cellulitis, progressive swelling, trismus.

44
Q

How can orofacial infections be removed most ideally?

A

Removing as many organisms as possible.

Drainage of pus

DMD2 sem 2 (97 decks)

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