NSRCT maxillary premolar Flashcards
List different non‐odontogenic reasons that must be considered in the differential diagnosis of maxillary premolar pain.
Although most dental pain is related to endodontic and/or periodontal conditions, it is mandatory that the clinician consider and rule out other non‐odontogenic causes that can present as dental pain. According to Okeson (2014), some common non‐odontogenic pains are:
• Localized myofascial toothache (especially in maxillary posterior teeth when the masseter and temporal muscles are involved).
• Non‐odontogenic sinusitis (caused by inflamma- tion of the ostium and thus compression of nociceptors causing maxillary teeth pain).
• Migraine (specially midface migraine, which may cause direct pain over maxillary teeth).
• Neuropathic pain (episodic conditions such as trigeminal neuralgia or continuous localized pathologies like atypical odontalgia).
• Psychogenic pain (where no tissue lesion is present, but the patient replicates psychological problems as tooth pain).
Summarize important anatomical features that may be expected in root canal treatment of maxillary premolars.
Maxillary premolars may exhibit different anatomies that can transform a radiographically “simple”case into a“hard one.”To predict the real anatomy is almost impossible based only on the clinical and radiographic examinations. Even to compare the anatomy of these teeth within different populations is difficult. A recent review (Ahmad & Alenezi 2016) summarizes important aspects of the anatomy of maxillary premolars. Most of the maxillary 1st premolars have one (41.7%) or two (56.6%) roots; however, the number of root canals is not related to the number of roots: 86.6% of maxillary 1st premolars have two root canals, for example. Clinically, it is important to remember that the most common anatomic variation is the presence of a third root. Apically speaking, the majority of the teeth had either one foramen (29.5%) or two foramina (68.6%), and the majority of these foramina (66.6%) did not coincide with the apical root tip (Ahmad & Alenezi 2016).
List some considerations governing the selection of the anesthetic solution for the endodontic treatment of maxillary premolars.
A successful anesthetic blockade before endodontic treatment is crucial, and the most important aspect is anesthetic selection (Malamed 2013). When possible, the use of vasoconstrictors is always recommended in order to increase the duration of the effect and reduce the toxicity of anesthesia. In cases of local inflammation (due to pulpal necrosis or pulpitis) where the pH is low, choosing a molecule with low pKa is beneficial. In this sense, mepivacaine offers important advantages for the blockade of previously inflamed maxillary premolars. With a lower vasodilatory effect, a low pKa, and high lipophilicity, this anesthetic represents an important option.
What advantages does the use of pre‐emptive analgesia offer for the endodontic management of painful teeth?
Pre‐emptive analgesia offers important advantages for the management of painful endodontic cases.The first indication for this treatment is the presence of preoperatory pain, a condition related to anesthetic failure (Hargreaves & Keiser 2002) and intraoperative / postoperative pain (Pak & White 2011). Preadministration of several non‐steroidal anti‐inflammatory drugs (NSAIDs) such as ibuprofen demonstrate an increase in the anesthetic blockade (Noguera‐Gonzalez et al. 2013). Pre‐emptive analge- sia also prolongs the blockade duration, improving the post‐operative period for the patient. Another important advantage is the decrease in post‐opera- tive pharmacological treatment, thus diminishing possible side effects (Sagiroglu 2011).
What is the optimal pharmacologic approach for the post‐operative management of symptomatic endodontic pathologies?
In cases of moderate to severe preoperatory acute pain, when the anesthetic blockade was not fully obtained, when the clinical procedure was painful, or when mishaps happen, postoperative pharmacological treatment is advisable. Such an approach must combine not only the right mol- ecules, but also the optimal protocols in order to successfully control the pain.
The use of NSAIDs is still the first option to manage pain (Laskarides 2016).The molecules of several substances, such as ibuprofen, ketorolac, dexketprofen trometamol, and etoricoxib, among others, have been analyzed, with similar and accept- able clinical results. However, the final molecule of choice is related to the systemic condition of the patient including consideration of concomitant systemic diseases, history of allergies, and/or other medical treatments of the patient. If the use of NSAIDs is not indicated, the use of paracetamol or dual analgesics like tramadol may be the second choice. If the expected effect is not achieved by using a single‐drug approach, it is advisable to consider multimodal strategies, specifically analge- sic combinations (Buvanendran & Kroin 2009). If NSAIDs can be used, then combining them with paracetamol or tramadol is recommended. If not, combining tramadol and paracetamol is also recom- mended; however, this combination lacks anti‐ inflammatory efficacy.
A “dynamic” approach for the selection of proto- cols is advisable. A dynamic approach individualizes each treatment depending on the needs of the patient, since there are no standard prescriptions that can be generalized to all patients. For example, if the pre-operatory pain was severe, with a history of poor pharmacological pain response, then the use of multiple doses is advisable to manage the pain expected for the first 48 to 72 hours. In such a case, the protocol could involve analgesic combina- tions for the first doses. If the patient reported improvement in the short term, then one of the two compounds combined could be eliminated (i.e., continue only with the NSAID until complete absence of symptoms is achieved).
