OSCE DOC - Endo Flashcards
Discussion
Pain History
SOCRATES.
Explain how you would take an in depth pain history and the questions you would ask.
Write up notes.
Pt has spawntaneous dull achy pain that pain killers dont help and keeps them up at night.
Give provisional diagnosis.
- Introduce self and designation
1 mark - Ask about presenting complaint / reason for attendance
1 mark - Ask when patient began / how long patient has had pain
2 marks - Ask about changes over time
2 marks - Ask about site of pain
2 marks - Ask about character of pain now- offer prompt (aching / throbbing, etc.)
2 marks- 1 mark for asking for character and 1 for asking if it’s a dull ache or throbbing etc - Ask about stimulants- offer prompt (hot, cold, etc.)
2 marks- 1 mark for asking about stimulants and 1 for asking hot cold - Ask about relieving factors- offer prompt (cold, analgesics, etc.)
2 marks - Ask about duration of pain- offer prompt (minutes, longer, constant, etc.)
2 marks- need to ask if it lasts minutes, longer, constant - Ask if kept awake
2 marks - Provisional diagnosis
- Irreversible pulpitis
4 marks - Note taking
- Legible, well ordered complete
4 marks - Actor marks
- Clear communication, showed empathy
4 marks
Endo Restoration Options (6 mins)
Molar tooth has just been root treated. Explain to patient the options for restoring the tooth.
- Gold standard- cuspal coverage onlay
* Gold, composite, porcelain, zirconia
* - Reduces risk of tooth fracture / catastrophic failure
* - Less microbial leakage / better seal
* Two stage process, prep, impressions and fit
* cost as lab bill also and materials - Full coverage- MCC, GSC, all ceramic, all zirconia
* If less tooth structure remains- in order to cover and protect
* Two stage process
* cost as lab bill also and materials - Direct restoration- composite or amalgam
* If only occlusal cavity present
* Not as favourable- more leakage, more likely to fracture
* Attempt to extend cavity just past the cusps to provide cuspal coverage - Core build up if necessary
* Gold standard- composite core
* Explain to patient the tooth has been hollowed out need to put filling material to fill up the space and retain the crown
* Nayyar core- not favourable- can only be used for multi rooted teeth?- find out more about this
What is condensed osteitis?
Diffuse radiopaque lesion at apex of tooth representing localised bony reaction to low grade inflammatory stimulus.
Failed RCT- Causes and Options (6 mins)
When would you consider saying the rct has failed and what are some signs of a failed rct?
Patient has failed RCT. Explain why it might have failed. What options are available?
If after 4 years there is no improvement.
This is radiographically visible lesion has increased in size, or slightly decrease or signs of root resorption. The RCT should be reviewed at 6months, and then a year and monitored yearly.
Failure
* Overfilled extruded from apex
* Underfilled less than 2mm from apex
* Poorly compacted
* Accessory canals missed
* Missed canal
* Inadequately prepared
* Extrusion of debris
* Perforation
* RCF of incorrect shape
* Vertical root fracture
* Endo file fracture
* Blockage / obstruction of canal
* Poor coronal seal
* Failed restoration
* No penultimate rinse with EDTA
* Mixing CHX and NaOCl
* Lack of patency
Treatment options
* Leave and monitor- no active treatment, but may get infection- including abscess, may flare up later
* Retreatment- no surgery needed, but chances of success decreased, if post core present, removing may cause vertical root fracture (more complex if fractured instruments, blockages, ledges, severe curvatures so consider referral), second attempt might fail as well
* Periradicular surgery- if retreatment not possible, surgery more difficult to tolerate, invasive, time consuming, expensive, nerve damage, reduced support, scarring
* XLA- tooth loss, need replacement or non-functional and poor aesthetic
Broken File (6 mins)
Endo file separation during RCT. You temporise tooth and explain what happened.
Discuss options.
- Calmly explain to the patient that a fine instrument has seperated within the canal and you will try and remove it
- If you can see the broken file then attempt to remove with some fine mosquitoe forceps. If you are unable to remove then take a PA of the tooth to locate the broken file.
- Try to dislodge the broken file by passing a finer file alongside it.
- If this fails, consider trying a Masseran kit.
- If this is not successful explain to the patient that it is not possible to retrive the broken file with the equipment here and refer them to an endodontic specailist who will retrive the file +/- complete the root filling also. They may do this with ultrasonic instrumentation and EDTA to soften the dentine and working a small file alongside it. If this doesnt work the endodontist may fill the canal to the level of the blockage depending on its location.
- Explain that the tooth will need to be keep under observation as it may be necessary to carry out a apicectomy at a later stage.
- Ask patient if they have any questions and arrange a follow up appointment.
- Confirm option and check understanding.
- Record carefully in the notes the explaination given and the event.
RCT Risks vs Benefits (extra Q)
Explain RCT the whole procedure to the patient and then the risk and benefits.
Procedure (multiple appointments)
* RCT is the treatment of removing the infected nerve from your tooth, with instruments and irrigants. It requires LA (LA risks permanent / temporary nerve damage, altered sensations, numbness, lasts for hours, increased HR)- aids patient and makes procedure more comfortable
* Dental dam (nitrile / latex sheet)- isolation, moisture control, airway protection, prevents NaOCl incident- clamp can fracture, mouth open throughout procedure. Test CHX
* Radiographs are required pre, during, and post treatment
* Access- drills to remove nerve, high / slow speed
* Files- series of files to clean and shape canal
* Irrigation- NaOCl (bleach) throughout and EDTA
* Canal dried with paper points
* Intracanal medicament- resolves infection / symptoms
* Obturation- GP root canal filling, coated in sealer, packed with accessory points, burnt off
* Lining material placed to seal canal
* Restoration- temporary / permanent, ideally indirect restoration (extra appointments and expense)
* Review appointment needed
Prognosis
* Be specific for case- good / poor / limited
* Orthograde RCT- not guaranteed, but predictable and usually successful
* Up to 90% over 10 years for teeth with irreversible pulpitis
* Up to 80% over 10 years for teeth with necrosis
Alternatives
* No treatment
* Extraction
* retrograde RCT
Risks
* Instrument separation
* Failure to negotiate canals to working length
* Hypochlorite accident
* Material extrusion
* Post-op pain
* Post-op swelling
* Need for pain control
* Perforation and root fracture
* Failure to resolve symptoms
* Expensive
Benefits
* Resolution of infection +/- symptoms
* Retain tooth
* No loss of bone
* Abutment potential
* Don’t require replacement for missing tooth
* Best aesthetics
ProTaper Retreatment Files (extra Q)
Order in which they are used and speed of handpiece used. Choose 3 common irrigants you would use.
Retreatment
* ProTaper D1, D2, D3 files for coronal, middle and apical GP removal
Solvents for GP removal
* NaOCl (3%)
* Eucalyptus oil
Irrigants for instrumentation
* NaOCl (3%)
* EDTA (17%)
* CHX (2%)
Normal colours
* Purple, white, yellow, red, blue, black, yellow
* Yellow F5 has black stopped or double hand on rotary
* SX orange
* Arrange in order
Practical
Direct Pulp Cap (12 mins)
Assume dam placed, tooth with cavity close to pulp.
Please place a direct pulp cap on an exposed 36 following a pulpal exposure on the mesial axial wall.
Explain to patient:
* Pulp exposed and required pulp cap (explain what this is)
* Likely no actor so no need
* Address the need- vital therapy and risk of possible death of pulp which requires RCT
Indications for pulp cap:
* Tooth must be asymptomatic, vital, no history of pulpitis (e.g., prolonged pain, toothache)- achieve haemostasis
* Pulp exposure must be small and surrounding dentine must be relatively hard- otherwise extirpate (need to RCT if continuous bleeding, necrotic pulp, dentine chips in pulp)
Process:
* Dam should have been on before the pulp was exposed- saliva contamination must be avoided
* Haemorrhage from exposed pulp- copious irrigation with sterile saline (arrest bleeding with saline)
* Cavity irrigated with chlorhexidine (0.2%)- clean with CHX after bleeding arrested
* Cavity is blotted dry using sterile cotton wool pledgets (do not air dry)
* Exposed pulp covered with hard setting calcium hydroxide cement (Dycal or Life)
* RMGI lining placed (vitrebond) and the restoration completed as planned
* Continuing vitality monitored- and if symptomatic, RCT required
Explain how the process would differ if it was a carious tooth pulpal exposure and the tooth was symptomatic?
Process if carious pulp exposure:
* Dam already placed
* Extirpation- pulpectomy- coronal pulp removed with sterile spoon excavator, irrigated with saline and dried
* Discuss with patient that RCT or XLA will be required
* Odontopaste / Ledermix (antibiotic / steroid agent) as palliative agent in anticipation of RCT / XLA
* Cotton wool roll and GIC restoration
Explain the process of an indirect pulp cap.
Indirect pulp cap
- Cleanse cavity with 0.2% w/w CHX
- Stained firm dentine is left in situ and covered with a setting CaOH cement (Dycal or Life)
- A stronger lining material is placed (RMGIC- Vitrebond) to protect the CaOH and the tooth is restored with a provisional restoration (GI or RMGI)
- The tooth must be vital, asymptomatic and have no history or previous pulpitis
- The tooth is monitored for 3 months and, if vital and asymptomatic, the provisional restoration should be removed, stained dentine carefully excavated and definitive restoration placed
- If there have been any pulpal symptoms, then RCT should be undertaken
Access Cavity (12 mins)
26 RCT. Number of roots, canals and %
- 3 roots
- 4 canals in 72.5% of cases. MB1, MB2, D and P
- Remember when acessing use the endo Z bur once in.
Sodium Hypochlorite extrusion incident (6 minutes)
Explain how you would deal with a sodium hypochlorite extrusion incident
- Stop all treatment
- Advise patient of what has happened and reassure them regarding immediate treatment
‘Do you remember before we started root canal treatment we went over the possible risk of a sodium hypochlorite extrusion, where some of the bleach material leaves the root and goes into the surrounding tissues? Unfortunately that has happened, im going to manage it appropriately today and give some ad home advise for the next few days. Are you in pain? - Local anaesthetic block into region that is painful
- Allow bleeding through root canal until haemostasis is observed
- Place a steroid containing intracanal medicament such as odontopaste or ledermix – no pressure when applying
- Do not obturate, but seal coronal access via a temporary restoration
- Advise patient
a. Cold compress for first few days
b. Warm compress after this
c. Analgesics – ibuprofen and paracetamol interchangeable
d. Antibiotics case specific - Review in 24 hours
- If severe, refer
