9. Endodontic Emergency Flashcards by J L

“what is an endodontic emergency?”
____ patients: ones that you didn’t plan to see this morning
they present with pain, discomfort, swelling and trauma
photo shows a patient with a necrotic lower molar - typically seen in an emergency endo situation

unscheduled

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What is an endodontic emergency?

____ inflammation or infection

most of the problems are leading to pulpal and periaplical inflammation and infection
Left side - fractured restoration and caries = discomfort for patient
Right side - fractured cusp with recurrent decay = caries reaching pulp = significant pain for patient
middle photos = premolar necrotic tooth & periapical radiolucency (infection)
all of these = patients seeking emergency care

pulpal and periapical

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What is an endodontic emergency?
An external injury of significant magnitude or
duration injures the pulp.
Low ____ environment. Damaged tissue degenerates.

• an injury to the pulp of significant magnitude and duration causes injury to the pulp tissue
• ____ tissue is low compliance environment: encased in ____ dentin structure, no room for inflammation
or expansion
• starts to break down and degenerate = patient presents with symptoms
• extensive restoration caused pulp to become necrotic and forms radiolucency = swelling ensues and patient
comes to emergency

compliance
pulp
rigid

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study done by Iqbal (from Penn)
• 2000 patients from emergency
• most common reason that they pursue treatment = ____
◦ decay reaches pulp and causes significant pain • other reasons =
◦ ____ restorations: 18%
◦ post treatment ____: flare-up after root canal started
◦ ____ and fracture = 3%

caries
faulty
AP
trauma

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3 different types of emergencies
• most common =____
◦ never had endo treatment before
• ____= cases that were started (sometimes they require multiple visits)
• ____ = rarest
◦ all of a sudden the patient gets swelling, biting / percussion sensitivity

pre-treatment
intra-treatment
post-obturation

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Nonodontogenic pain

Orofacial pain can mimic ____pain.

Patient may interpret pain as a “____ ”.

• before we talk about any endodontic problem = want to talk about nonodontogenic pain
• sometimes the patients won’t have endodontic problems
• x-ray shows maxillary right area - multiple teeth treated endodontically
◦ ____ everything looks fairly normal
◦ no pathology noted
◦ but patient is experiencing extreme pain
◦ orofacial pain can mimic pulpal/periradicular pain
◦ patient may interpret this pain as a toothache
◦ but retreating these teeth will not solve the issue

pulpal/periradicular
toothache
radiographically

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Nonodontogenic pain
\_\_\_\_
Myocardial pain 
\_\_\_\_ 
Atypical facial pain 
\_\_\_\_ tooth pain 
Herpes zoster
\_\_\_\_ disease

trigeminal neuralgia
maxillary sinusitis
phantom
neoplastic

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Assessment of a patient in pain

Perceive all symptoms as ____.
Listen, express empathy, and do not judge.
Be ____.
Show a ____ attitude of the patient’s problem. Inform ____ during and after treatment.

real
calm and confident
positive
expectations

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Pain perception and reaction

Varies greatly according to ____ and physical state.
Reduce ____.
Gain patient ____.
Provide ____.

psychologic
anxiety
confidence
empathy

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• diagnostic data has to be collected
◦ ____ exam: questions regarding the patient’s pain
◦ ____ exam: clinical tests that we’ve learned to do
‣ percussion, palpation, thermal testing, electric pulp test
◦ ____ exam: X-rays, CBCT images

subjective
objective
radiographic

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Subjective exam
____
Location of the complaint.
____ of symptoms. Clinical manifestations. ____ of the complaint. Intensity of the complaint. ____ factors.

chief complaint
inception
quality
affecting

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Chief complaint

always in the patient’s own ____

words

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Location of the chief complaint

• just because we can take an X-ray doesn’t mean that we can determine what the ____ tooth is

offending

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Location of the chief complaint

Maxillary molars refer pain to the ____, parietal, and ____ regions.

Mandibular molars refer pain to the ____, angle of the jaw and ____ regions of the neck.

zygomatic
occipital

ear
posterior

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Location of the chief complaint
Correctly localize pain: ____%
Periradicular pain: ____%

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Inception of symptoms
History of ____.
History of ____.
Other events such as ____ surgery or infections.

• always ask for history of dental procedures: was the filling recently placed? did the pain start after the
restoration vs. after a long time (pulp becoming necrotic)
• always ask for history of trauma - especially ____ teeth that develop radiolucencies (maybe they had trauma when they were a kid many years ago and now it is becoming a periapical abscess)
• always ask about sinus surgery / infections: they have more ____ to maxillary teeth, more sensitive to temperature or percussion
* always ask what type of work was done to the teeth before

dental procedures
trauma
sinus

anterior
sensitivity

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Clinical manifestations

Mode: is the onset or reduction of symptoms ____ or provoked? Sudden or gradual? ____ or delayed?

Period: are symptoms ____ or occasional?

Frequency: ____ or persistent?

Duration: how ____ do the symptoms last? Momentary or lingering?

spontaneous
immediate

sporadic
intermittent
long

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Quality of the complaint

____ ● dull ● burning throbbing ● stabbing ● shooting aching ● spontaneous

sharp

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Intensity of the complaint
____: on a scale of 0-10, how much pain are you experiencing now?

____ terms: mild, moderate, or severe.

quantity

descriptive

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Affecting factors

• affecting factors that intensify or influence the pain that the patient is feeling
• these questions are important because we need to ____ patient’s pain in their own mouth to make our
accurate diagnosis
• reads slide
• sweets or acid = probably ____ problem
• head position - may indicate ____ infection vs. endodontic problem
• have to ask what makes the pain worse or better?
• there are situations where patient has large cup of cold water to constantly drink to keep pain away = ____
• could see diagnosis before examining patient

reproduce
restorative
sinus
partial necrosis

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if patient drinks something cold and experiences sharp pain is different than dull pain = tells us about the pulp ____

degenerating

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• biting and chewing are also important questions
• left photo = large spanning bridge - looks fairly normal but patient reports pain biting down - no missing canals, periodontally nothing wrong, but checking occlusion = patient only contacting on ____ spot of the bridge
• right photo: pulpal testing = normal, radiographically no radiolucency, checked occlusion and patient making contact with tooth
• if we didn’t ask about this then we might assume that the pulp needs to be treated and we would be
wrong
• if root canal done, and occlusion is off, patient would still experience these symptoms

one

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Affecting factors
Head position may indicate ____ infection.
No ____ needed.

sinus

endodontics

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Affecting factors
Is the discomfort more pronounced at certain times of the day or at night?
bruxism

• another affecting factor = clenching and grinding
• does it happen all day long or is it certain times of the day?
• patient might tell you that teeth are sore in the morning = clenching / grinding while sleeping = recommend
____
• can pulp test teeth, even though it looks normal it comes from clenching / grinding = endo tx not needed
• if pain comes at end of the day / nighttime = from ____ during the day

nightguard

clenching

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Sequence of emergency treatment 1. Locate ____ of the complaint. 2. Make a ____ diagnosis. 3. Make a ____ diagnosis. Avoid the temptation to do something if the diagnosis is not cer tain or before a ____ can be made.

source pulpal periapical definitive diagnosis

``` Making pulpal & periapical diagnosis ____ tests ____ test ____ test ____ analysis ```

thermal percussion palpation x-ray

Making a pulpal diagnosis Thermal test Heat test Electric pulp test - ____ for anterior • most common thing to use = thermal testing • spray endo ice onto cotton pellet and place pellet on the ____ for anterior / ____ surface for posterior • if they have extreme symptoms to temperature and they're scared - tell them that we need to make an accurate diagnosis / treating the right tooth / have to confirm what tooth they're talking about - they will understand because they don't want a root canal that is not necessary • give instructions beforehand: tell patient going to place something cold on tooth to reproduce the pain that you're feeling - when you feel cold sensation on tooth raise hand - when raise hand will take cold away - but hold hand up until you can't feel the cold any longer

incisal edge incisal edge occlusal

A vital pulpal diagnosis Normal Reversible pulpitis Symptomatic irreversible Asymptomatic irreversible if the patient feels a positive response to cold = pulp is ____ to some degree • different choices for pulp vitality • could be normal pulp: feel cold when pellet is on and don't feel it once it's off - no ____ • reversible pulpitis: if you had a recent filling / OTC bleaching and ____ • symptomatic irreversible pulpitis: hand still remains up when you take pellet off = ____ • asymptomatic irreversible pulpitis: recurrent ____ seen in photo, if you test tooth it might test normal, caries has reached pulp and it has become irreversible • irreversible = need to do ____, pulp not going back to normal

``` vital lingering sensitive lingering decay ```

A non-vital pulpal diagnosis | - ____

necrosis

Making a periapical diagnosis | Percussion: a painful response may indicate ____ inflammation or a ____ tooth.

periradicular | cracked

Making a periapical diagnosis First use mild ____ pressure. If there is no response, increase with ____ pressure or bite stick.

finger | mirror

Making a periapical diagnosis | ____: the sense of touch to determine texture, rigidity, and tenderness.

palpation

Making a periapical diagnosis No ____ response. Periodontal ligament is intact ____.

percussion | radiographically

Making a periapical diagnosis Apical ____. Loss of ____ space. Painful to ____. symptomatic apical periodontitis

radiolucency PDL percussion

Necrotic tooth percussion: ____ palpation: ____ cold response: ____ heat response: ____ electric pulp test: ____

``` + + - - - ```

Emergency: necrotic tooth ____ throughout the entire root canal system. Objective: to clean, shape, and disinfect the entire canal system.

bacteria

Emergency: necrotic tooth 1. Establish ____ length. 2. ____ instrumentation of the entire root canal. 3. Allow for any ____. 4. Irrigation ____, EDTA, CHX.

working biomechanical drainage NaOCl

Emergency: necrotic tooth 5. ____ root canal system. 6. Place intra-canal ____. 7. ____ access. 8. Schedule for next visit.

dry medication seal

Emergency: necrotic tooth ____ If we don't have any drainage from the tooth, we might need to create an incision to relieve the pressure Then we will suture a ____ in place, so it will keep draining for as long as we want Q: how long after the appointment will it take for the patient to be out of pain? A: Symptomatic irreversible pulpits = right after the procedure If it is percussion positive, it might take a few days If there is swelling/necrotic tooth, it might take a few days too

incision and drainage | drain

Vital tooth caries entering the pulp percussion: ____ palpation: ____ cold response: ____ heat response: ____ electric pulp test: ____ - Palpation negative b/c we have no ____ infection - Expect cold response to be positive and lingering

``` + - +++ + + ``` peri-apical

Emergency: vital tooth Pulpotomy: removal of the inflamed ____ portion of vital pulp. Used only for time ____.

coronal | constraints

Emergency: vital tooth Bacteria and inflammation limited to ____ portion. Objective: due to limited time, minimally remove the inflamed ____ portion.

coronal | coronal

Vital tooth: pulpotomy 1. ____ tooth. 2. ____ removal. 3. Removed ____ portion. 4. Irrigate with ____. 5. No ____. 6. ____ is placed over the canal orifice. 7. ____ restoration (Cavit) to seal access. 8. Continue at next visit.

``` access caries inflamed NaOCl instrumentation calcium hydroxide temporary ```

Post-operative instructions Allow for setting of temporary material. (Cavit takes ~____mins) Allow of ____ to dissipate. Expect no ____ from a vital case. OTC analgesics, if needed. NSAIDs

45 anesthesia thermal sensitivity

Anesthesia and irreversible pulpitis The inflammatory process causes ____ and ____, hampering profound anesthesia. Hyperalgesia: ____ sensitivity to pain. Allodynia: reaction to a stimulus which does not ____ provoke pain.

hyperalgesia allodynia heightened normally

Anesthesia and irreversible pulpitis Sodium channels in nociceptors are 4x more ____ to local anesthetics. Presence of ____ channels in symptomatic pulp. ____ can compromise the entire axon extension, reducing the efficacy of anesthesia blocks. -Nav1.9 are resistant to anesthetics we use today, so they make these teeth difficulty to numb

resistant Nav1.9 inflammation

Does volume of anesthetic matter? No ____ between the two groups.

significance

Does type of anesthetic matter? No ____ between groups (lido v articaine)

significance

Do supplemental infiltrations help? (IANB and then a BI) Supplemental infiltration with ____ is ____ more successful.

articaine | significantly

Are antibiotics needed? ____ for localized swellings or if drainage is achieved. Recommend for diffuse ____ or when drainage is not possible. Systemic involvement, elevated temperature. Amoxicillin ____mg

unnecessary swellings 500

``` Inter-appointment emergencies Inadequate ____ Debris extrusion Over-____ Overfilling ____ lesion Retreatment cases ```

debridement instrumentation periapical

Leaving teeth open Drainage is usually achieved within a few ____. Recommend ____ all teeth to prevent contamination from the oral cavity. With rare exception all teeth should be closed.

minutes | closing

ou only feel discomfort when you drink something cold? Yes, every time something cold touches it 1. B/c it shows that the tooth is ____. 2. B/c if the tooth is sensitive to cold, we can test it against ____ teeth to see which one really is infected

vital | neighboring

If water touches it, the pain stays for at least 5 minutes | That means the pain is ____. It's not a short-lived pain

lingering

``` #30 percussion: ____ palpation: ____ cold response: ____ heat response: ____ EPT: ____ ``` Pulpal diagnosis #30: ____ Periapical diagnosis #30: ____ B/c it is ____ positive, the peri-apical diagnosis is symptomatic apical periodontitis

``` + - ++ + + + ``` symptomatic irreversible pulpitis sympatomatic apical periodontitis percussion

We had a limited amount of time, so just did a ____ to get the patient out of pain until we could schedule a full appointment to finish treatmen

pulpotomy

Do you feel discomfort when you drink something cold? Yes, even cold air sets it off This shows us that we most likely have a ____ pulp situation

vital

Clinical manifestations How long do the symptoms last? - it's just throbbing. i could not ____ at all last night This is a sign of ____ pain

sleep | spontaneous

What makes it worse? Just about everything: ____ water, hot coffee, and even putting my teeth together This shows she has ____ and percussion sensitivity

cold | thermal

#8 percussion: + palpation: - cold response: +++ heat response: ++ EPT: + Pulpal diagnosis #8: ____ Periapical diagnosis #8: ____

sympatomatic irreversible pulpitis | sympatomatic apical periodontitis

Available time 1. ____ the tooth. 2. Complete caries removal. 3. Determine ____ 4. Instrument to MAF. 5. ____ irrigation. 6. Dry root canal system. 7. Place ____ medication. 8. Seal access with temporary material (Cavit). 9. ____ for next visit. -Why do we medicate the tooth instead of just closing/finishing it? Because the patient is still in ____! We don't want to obdurate unless the patient is asymptomatic

``` access working length NaOCl intra-canal schedule pain ```

So she isn't experiencing pain. She only noticed the ____ ``` #10 percussion: + palpation: ++ cold: - heat: - EPT: - ``` Pulpal diagnosis #10: ____ Periapical diagnosis #10: ____ The peri-apical diagnosis is not acute apical abscess b/c she is not having any ____ or pain. She's ____. It'd be different if she was experiencing pain Q: Why wouldn't it be a chronic apical abscess? A: A chronic apical abscess is when there is a ____ and the infection is draining from it

swelling necrosis symptomatic apical periodontitis discomfort asymptomatic sinus tract

1. ____ the tooth. 2. Complete caries removal. 3. Establish ____. 4. BMI of the entire root canal. 5. Allow for any ____. 6. Irrigation with NaOCl, EDTA, CHX. 7. ____ root canal system. 8. Place intra-canal medication. 9. Seal access with ____ material (Cavit). 10. Schedule for next visit. - We shouldn't inject ____ above #10 b/c it is swollen there - We'll inject in ____ tissues and allow it spread into the area we want - Don't want to go into infected tissue and spread infection deeper

``` access working length drainage dry temporary ``` directly adjacent

We'd expect to see that the ____ has all subsided by the time the patient comes in for the next visit

swelling

Emergency: vital tooth Pulpotomy: if ____ amount of time. Complete BMI: if time is ____. -With a vital tooth, we have 2 different options! Pulpotomy (limited time) and complete BMI (more time) -Complete BMI is the more ____ procedure to get the patient out of pain

limited available predictable

Emergency: necrotic tooth | Complete BMI: since bacteria has spread ____ the entire root canal system.

throughout

An emergency patient Be prepared. Take ___ x-rays. Don’t assume a previous diagnosis is accurate. Get as much ___ from the patient as possible

additional | information

An emergency patient Complete diagnosis and review with faculty. Explain the need for ___ visits for root canal treatment and final restoration. Discuss what to expect ___ and after treatment. -You need to tell patients they will have to come in for ___ appointments to finish the tooth canal -Need to also tell them they will need to come in after the root canal is finished for a ___ restoration -Root canal is scary, so make sure the patient is aware of what is going on and what problems to look out for in-between appointments

follow-up during multiple final