Endo: Procedural Accidents/Misadventures Flashcards
Preventing perforations during access cavity preparation:
- Tay parallel to long axis of tooth
- Judicious tooth removal
- Account for tooth rotation
- Know anatomy and morphology
- Molars- 7mm to middle of pulp chamber
- maxillary premolars-cusp tip to roof of pulp chamber=7mm
- Anterior Teeth: Lingual surface to pulp chamber: 4.5-6mm
- Magnification and illumination
- diagnostic radiographs
- estimate depth of access to pulp chamber
Perforation repair:
- Treat quickly
- Better if:
- smaller performatin
- above crestal bone
- healthy periodontium
- good access=better recovery
Repair of root perforation:
- 86% healed
- Higher healing with:
- experienced provider
- no post places
- most disease occurs within first 4 years
How to prevent treating the wrong tooth?
- Mark tooth
- thompson stick
- notch tooth before rubber dam place
- clmap or foil placed on tooth; take radiograph
How to prevent seperated instruments:
- Keep canals wet
- straight line access
- slowly advance instruments
- never force instruments
- recapitulate
- Check for multiplanar curves
- Check files before placing in canal (Flutes)
- discard bent files
Seperated instrument prognosis:
- Patient must be informed
- Best when large instrument seperates at late stage of canal preparation
- Poorer when small instrument seperates in apical 1/3 of canal or beyond
- Healing rate: 92%; worse than control
How to prevent NaOCl accidents
- Do not wedge needle tip into canal
- avoid blunt tip needles
- use side vented needled
- Gentle pressure
- Keep the past in the canal
- ph=12; alkali burn
- obtain postop PAs to excheck for overfill into inferior alveolar canal, mental foramen
- timely referral within 24 hours
Mishaps during Obturation
- Overfill
- strip perforation
- can repair
Mishaps during Post preparation
- root perforation
Vertical Root fracture
- Extract
- caused by:
- post placement
- obturation-to much condensation force
Endo Emergencies
- Determination of status:
- is it a true emergency or Emergency of Convenience
- How urgent?
- Review medical history
- Identify source of pain
- reproduce chief compaint
- identify site of pain
- finalize diagnosis
- pulpal
- apical
- Develop treatment plan
- Perform treatment
- Pos Op instructions and consideerations
Determination of Status:
True emegency or Emergency of Convenience.
- Determine urgency:
- How long has this problem been bothering you?
- or: When did this thing start?
- Does the problem disturb daily activities?
- What pain medications have you been taking? Have they helped?
- Tylenol + NSAID
- How long has this problem been bothering you?
- True emergency:
- immediate unscheduled visit with diagnosis and treatment
- disrupts aptients daily activities or quality of life
- Emergency of Convenience
- problem of less severity
- Appointment scheduled
Endo Diagnostic tests:
- Air and Water ARE NOT
Exam and Diagnosis:
- Before touching the patient:
- Greet the patient and ask to point where the pain is
- Extraoral exam before intraoral exam:
- look for swelling
- Review Health History
- psychological
- allergies
- neuropathies
- heart conditions
- Sinusitis
-
Observe patients gait and appearance
- __look at patients eyes–look sick=malasia
- Take and Review radiographs
- may not need to go further
Percussion Test
- hurts to bite or touch
- first:
- touch and push with your finger
- if that hurts-don’t percuss with a mirror handle
- touch and push with your finger
- first:
- no pain to biting or tapping teeth togeth:
- use mirro handle to gently percuss teeth
- begin away from suspected area and work toward
- Trying to see how far the inflammatory process extends
- does it extend into periapical tissues
- no pain receptors in dental pulp
Mobility test
- is the tooth depressible in the sock?
- health of periodontium-poor prognosis
- no endo
- health of periodontium-poor prognosis
Vitality Test
- Cold Tests
- Heat test
- Electric Pulp Test
Cold Tests
- Vitality Test
- Endo ice: most commonly used
- Carbon dioxide snow
Heat test
- Vitality Test
- Jiffy point (polishing point) to generate heat
- Hot Gutta purcha:
- Dental stopping=lubricant
- always coat tooth with lubricant, so gutta purcha doesnt stick to the tooth
- Dental stopping=lubricant
Electric pulp tests
- Vitality Test
- Adjacent teeth vs control teeth
- SynbronEndo: Set at 1
- coat tip with sensodyne
- place tip on tooth and patient touches probe
- when patient feels=take finger off
Transillumination
- Cracked teeth-Pain on biting or release
Staining:
- Methylene Blue dye
- Plaque indicating dye
- show where cracks are
Tooth Slooth
- Device used to localize pain on biting
- placed on particular cusp of tooth
- want to reproduce cc
Cracked Tooth
- Want to stabalize tooth w:
- orthoband
- noninvasive treatment
- prompt relief
- anesthesize
- Crown prep and temporary
- orthoband
- Start endo treatment
Cracked tooth: Diagnosised w/Reversibile pulpitis
- Crown placed
- 20% will need root canal therapy
- 80% can be managed conservatively without RCT
Maxillary sinus
- Can confuse diagnosis: Pulpal pain vs sinusitis
- allergies; pollen, winter
- Multiple teeth percussion sensity=Sinusitis
- must locate source of pain
- not necessarily tooth relatd
Radiographic exam
- Never make a diagnosis from radiograph
- consider CBCT
- Root morphology
- fast break
- coronal restoratoins
- recurrent caries in margins of restorations
- pathosis
Diagnosis:
- Pulpal
- Periapical
Pulpal Diagnosis
- Normal
- Inflamed:
- reversible pulpitis
- symptomatic irreversible pulpitis
- asymptomatic reversible pulpitis
- Necrotic
- Perviously initiated treatment
- previously treated
Reversible pulpitis
- Due to:
- Recent restoration
- cold sensitive
- Patient with no previous restorations
- Trauma
- Recent restoration
- Treatment options:
- adjust occlusion
- sedative temporary-if really bad previous restoration-remove
- Mild analgesic
Symptomatic Irreversible Pulpitis
Normal Periapical Tissues:
Treatmen?
- Single Root
- pulpectomy
- Multi-root
- pulpotomy
Symptomatic irreversible pulpitis
Symptomatic Apical periodontitis:
- Symptoms:
- spontaneous pain
- percusion sensitive
- Tx:
- Single root
- pulpectomy
- Multi-root
- pulpectomy largest canal
- Single root
Pulpectomy
- Pulpectomy: Single root
- total removal of pulp
- Partial Pulpectomy: Multi root
- total removal of pulp from largest canal
- Determine Working length
- verify with radiography
- can’t verify-do not put a file in the canal!
Pulpotomy
- Sugrical amputation of the coronal portion of an exposed vital pulp
- Emergency pain relief!
- medicaments did not relieve pain
Chronic Apical Abscess
- Usually not an emergency
- no swelling
-
Sinus Tract=indicative
- clogged can cause swelling
- patient can pop
- trace w/gutta purcha
- coat gutta purcha with topical anesthesia
- Cause:
- necrotic pulp
- previously treated tooth
Acute apical abscess
Pay careful attnetion to-can get very bad quick!
- usually have underlying medical condition
- Signs and Symptoms:
- Swelling: on floor of mouth
- Temperature:
- >102
- Malaise
- Dysphagia
- Trismus
- Causes:
- necrotic pulp
- previously treated tooth
- previously initiated therapy
- interappointment flare-up
- Niti files decreased
- Tx:
- establish drainage=I&D
- rubber dam drains
- close f/u (<1 week)
Need Antibiotics:
Presence of: Febrile/Fever & Drainage
- Fever—->Drainage—->Antibiotics:
- No—Yes—No
- Yes–Yes—Yes
- Yes–No–Yes
- No–No–No
- Irreversible pulpitis
- does not appear to reduce toothache
- Systemic involvement:
- fever
- malaise
- cellulitis
- Trismus
- Dysphagia
- Lympadenopathy
- Immunocompromised
Penicillin VK
- Drug of choice for oral infections
- shiftingm ore toward amoxicilllin
- effective against aerobic and anaerobic bacteria
- inhibits cell wall synthesis
- Dosage:
- 1 gram loading dose
- then 500mg every 6 hrs for 7 days
Amoxicillin
- Broader spectrum than Penicillin
- More readily absorbed
- absorption not impaired by food
- longer half life than penicillin
- Dosage:
- 1 gram load dose
- then 500mg every 8 hrs for 3-7 days
Metronidazole
- aka Flagyl
- Synthetic antibiotic
- effective against obligate anaerobes
- ineffective against facultative anaerobes
- use in combo with penicllin when penicillin is ineffective
- Antabuse effect
- Dosage:
- loading dose=500mg
- then 250 mg every 6 hours for 5-7 days
Antibiotics: Patient with penicillin allergy
- Macrolides
- zithromax
- biaxin
- erythromycin is not an option
- Lincosamide
- clindamycin
Clindamycin
- used in penicilllin allergy
- not 1st line antibiotic
- Amox–>Metronidazole–>Clindamycin
- not 1st line antibiotic
- Beta-lactamase resistant
- Highly effecrtive
- Dosage:
- 600 mg loading dose
- 300mg every 6 hrs for 7 days
- inhibits bacterial protein synthesi at 50S subunit
Analgesics:
- NSAIDs
- manage inflammaory issues in endo
- if can’t take NSAIDs–>tylenol <2g/day, Liver toxicity
- ibuprofen
- APAP
- Narcotics
- last line of defense
What can cause SIRS:
- Infection
- trauma
- burns
- pancreatitis
Not required to make the diagnosis of septic shock?
Pancreatitis
what are the qSOFA critea for the diagnosis of sepsis?
- altered mentation
- respiratory rate>22/min
- SBP less than or equal to 100mmHG
What is the most common cause of myocarditis in the USA?
enterovirus including coxsackie A and B
What is not a cause of myocardial injury by viruses?
- Myocardial ischemia
What causes subacute endocarditis:
Viridans streptococci
What causes 10-20% of the cases of acute endocarditis?
Staphylococcus aureus
Require prophylactic antibiotics before dental procedure?
- Repaired congenital heart disease with residual defects
According to the American Heart Association guidelines, which of the following require phrophylactic antibiotics before dental procedures?
History of endocarditis
What type of pericarditis is due to uremia?
Fibrinous
68 year old man
Increased bood urea nitrogen level
Type of pericarditis?
Hemorrhagic
Type of Pericarditis?
Tuberculosis/fungal
Statement about spider telangiectasia is false:
Neoplasm
An 18-year-old boy presents to the emergency department complaining of frequent nosebleeds and the onset of hemoptysis. Physical examination is remarkable for the lesions shown in the illustration. Imaging of the lungs reveals an arterio-venous malformation. The patient has which one of the following?
Osler-Weber-Rendu syndrome
A port-wine stain in the distribution of the right trigeminal nerve accompanied by the angiomas of the right leptomeninges is most characteristic of which one of the following
Sturge-Weber syndrome
A 10-year-old boy has a 2-cm spongy, dull red, circumscribed lesion on the upper outer left arm. this lesion has been present since infancy, and the appearance has not appreciably changed. The lesion is excised, and its microscopic appearance is shown in the figure. Which of the following is the most likely diagnosis
hemangioma
A 6-year-old previously healthy child has had increasing size of his neck for the past year. Physical examination reveals an ill-defined, soft mass deforming the left side of his neck, but no other abnormalities. Surgical resection of the 10 cm mass is attempted, but the borders of the lesion are not discrete. The resected tissue shows dilated spaces filled with milky fluid and lined by flattened endothelium and surrounded by collagenous tissue and smooth muscle with collections of small lymphocytes. Which of the following is the most likely outcome associated with this child’s lesion?
local recurrence
A 67-year-old lady is diagnosed with squamous cell carcinoma of the lung. She presents to her primary care physician complaining of fullness and swelling in her head and neck accompanied by respiratory distress. Upon examination, you notice that she has distended neck veins and cyanosis of the head and neck. She most likely has which one of the following?
Superior Vena Cava syndrome
A 73-year-old woman has a 1- week history of episodes of chest pain. She is afebrile. Vital signs are within normal limits. Auscultation of the chest reveals distant heart sounds but clear lung fields. Neck veins are distended to the angle of the jaw, even while sitting. A darkly pigmented, irregular, 1.2-cm skin lesion on the right shoulder is biopsied and diagnosed as melanoma. Chest X-ray shows prominent left and right borders of the heart. Pericardiocentesis yields bloody fluid. Laboratory findings include a normal serum troponin level. Which is the most likely cause of these findings?
epicardial metastases
A 48-year-old, previously healthy woman has suddenly lost consciousness four times in the past 6 months. In three instances, she was unconsciousness for only a few minutes. After the fourth episode 1 month ago, she was unconscious for 6 hours and had weakness in her right arm and difficulty speaking. On physical examination, she is afebrile, and her blood pressure is normal. No murmurs are heard. She has good carotid pulses with no bruits. Which of the following cardiac lesions is most likely to be present in this woman?
left atrial myxoma
The most common location for a cardiac myxoma is in the:
Left Atrium
This benign primary tumor of the heart found in the left atrium of a 56-year-old woman at autopsy is most likely which one of the following:
Myxoma
Which cardiac neoplasm is commonly seen in patients with tuberous sclerosis?
rhabdomyoma
A 2-year-old boy presents with signs and symptoms of left mitral valve obstruction. He is taken to surgery where several gray-white masses are found in the myocardium protruding into the left ventricle and narrowing the opening of the mitral valve. Histologic examination is remarkable for bizarre, enlarged myocytes, many of whom look like “spiders”. This child has which one of the following tumors?
rhabdomyoma
This tumor found incidentally on a 65-year-old gentleman during cardiac catheterization is most likely which one of the following?
Fibroelastoma
An 18-year-old gentleman is referred to you for evaluation of multiple jaw cysts. You notice that he has frontal bossing of his skull, some nodular, ulcerated lesions on his face, and palmar and plantar pitting. These findings are associated with which one of these cardiac tumors?
Fibroma
