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BDS3.5 Endodontics > Management of Endo emergencies > Flashcards

Management of Endo emergencies Flashcards

(79 cards)

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1
Q

What is an endodontic emergency?

A

Pain associated with inflammation of the pulp and/or peri radicular tissues or pain caused by infection if the root canal system and/or periradicular tissues

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2
Q

What are the 3 Ds for managing dental pain?

A

Diagnosis
Definitive dental treatment
Drugs

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3
Q

What are the different types of odontogenic pain?

A

Pulpal pain (reversible or symptomatic irreversible pulpitis)
Peri radicular pain (symptomatic peri radicular periodontitis or acute periapical abscess)
Cracked or fractured tooth

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4
Q

What are the treatment options for odontogenic pain?

A

Anxiety management
Emergency pulpotomy
Pulpectomy
Incision and drainage
Extraction
Pharmacological pain management
Analgesics
Antimicrobials

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5
Q

What could be causing pain if the patient is undergoing a treatment plan?

A

High restoration, pulp exposure, root fracture, pain following endo treatment

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6
Q

How to tell if the pain is of non odontogenic origin?

A

No apparent aetiology / exclude dental origins
No caries, trauma, fracture, failing restorations
Pain not consistently relieved by LA
Bilateral pain or multiple teeth painful

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7
Q

What kind of pain may be non odontogenic?

A

Burning, electrical, pain that increases with different emotional states, has trigger points, crosses midline

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8
Q

What to do with patients who have non odontogenic pain?

A

Refer to oral medicine consultant (except sinusitis)

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9
Q

What are some causes of non odontogenic pain?

A

Migraine, cluster headache, paroxysmal hemicrania, SUNCT

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10
Q

What treatment can be done for symptomatic irreversible pulpitis?

A

Emergency pulpotomy

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11
Q

What is the procedure for emergency pulpotomy?

A

LA and rubber dam
Open pulp chamber roof and irrigate with NaOCl
Do not enter canals
Dry with dampened cotton pledget
Seal with calcium hydroxide non setting paste
Cover with PTFE and GIC (e.g. Fuji triage)
Post-operative instructions including analgesic advice and need to return for RCT / treatment planning

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12
Q

Does emergency pulpotomy relieve pain?

A

Yes, a significant reduction of pain within 24 hours in 90% of patients

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13
Q

How does emergency pulpotomy relieve pain?

A

Alters pulpal haemodynamics and interstitial tissue pressure
Decreases local tissue pressure
Decreases inflammatory mediators
Severs terminal endings of nociceptors

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14
Q

What are some reasons not to enter the root canals during an emergency pulpotomy?

A

Can introduce bacteria to the canal system
Pulp may be haemorrhagic so visibility can be difficult

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15
Q

When would you do a pulpectomy?

A

Non vital and symptomatic peri radicular periodontitis or acute periapical abscess

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16
Q

What can an acute apical abscess develop from?

A

Symptomatic or asymptomatic periradicular periodontitis or a chronic apical abscess
Caused by bacteria that egress infected RCS and invade peri radicular tissues

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17
Q

What type of bacteria are found in acute apical abscesses?

A

Mixture of aerobic and anaerobic bacteria but mostly anaerobic

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18
Q

How does acute apical abscess present clinically?

A

Pain

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19
Q

What might be found intraorally with an acute apical abscess?

A

TTP
Tender to palpate buccal sulci adjacent to site
Possible mobility
Possible swelling
Possible involvement of facial spaces to form a cellulitis abscess

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20
Q

What type of tooth is associated with a periapical abscess?

A

Non vital

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21
Q

What type of tooth is associated with a periodontal abscess?

A

Vital

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22
Q

Treatment options for acute periapical abscess?

A

Remove source of infection or relieve pressure through drainage
Extraction
Pulpectomy and drainage through root canal system
Incise and drain through soft +/- hard tissue
(If can be evacuated through root canal system, patient usually experiences immediate pain relief)

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23
Q

What are the stages for Pulpectomy and drainage through root canal system?

A

LA, rubber dam, access
Instrument to root canal system to working length, if no drainage take an 08 or 10k file through apical constriction (this may establish drainage, if not irritate and dress and usual)
Do not leave open to drain
If persistent drainage, allow patient to sit for 30 minutes with rubber dam in place
Dress with calcium hydroxide and seal access
Adjust occlusion if needed

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24
Q

Why do we not want to leave teeth to open drain?

A

Risk of reinfection

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25
What are Fascial spaces?
Potential spaces between the layers in the body that infection can collect in
26
What are the two ways a tooth can drain?
Through the root canal system by opening the tooth Externally via incision and drainage
27
Where is the submandibular space?
Between the mylohyoid muscle and the Platysma
28
What is the source of infection if the infection is in the submandibular space?
Posterior tooth
29
Where is the submental space?
Potential bilateral space between the mentalis muscle and Platysma
30
Why is Ludwig's angina dangerous?
Can advance into pharyngeal and cervical spaces causing airway obstructions
31
What is the source of infection in the mental space?
Lower anterior tooth
32
Which spaces are involved with Ludwig's angina?
Submental, submandibular, sublingual spaces bilaterally
33
Where is the sublingual space?
Between buccal cortical plate, overlying alveolar mucosa, buccinator muscle (posterior), mentalis muscle (anterior)
34
How to manage someone with Ludwig's angina?
Straight to A and E - often need extraoral drainage
35
Which teeth tend to cause Ludwig's angina?
Lower 6s and 7s
36
Where is the mandibular buccal vestibule?
Between mandibular plate and overlying mucosa, and buccinator / mentalis muscles
37
Where is the buccal vestibular space?
Between buccal cortical plate and overlying mucosa, and the buccinator muscle
38
Where is the buccal space?
Between lateral surface of buccinator muscle and medial surface of skin of cheek
39
Where is the pterygomandibular space?
Between lateral surface of medial pterygoid and medial surface of ramus
40
Which teeth can cause problems in the pterygomandibular space?
Lower 7s and 8s
41
What tends to be the cause if there is an infection in the base of the upper lip?
Maxillary central incisor
42
What tends to be the cause if there is an infection of the palate?
Maxillary lateral incisors mostly (as apex lies close to palate)
43
What is the canine or infraorbital space?
Between Levator anguli oris muscle and Levator labii superioris muscle
44
What tends to be the cause of an infection in the canine or infraorbital space?
Maxillary canine or first premolar
45
Why can infections of the midface be very dangerous?
Risk of cavernous sinus thrombosis - thrombus breaks free blocking an artery or the spread of infection
46
How to manage abscesses and cellulitis?
Ensure correct diagnosis Remove cause of infection Provide a pathway to prevent further spread of abscess / cellulitis May need to place an extraoral drain
47
When is the only time you should use antibiotics instead of treatment of an infection?
If patient is so swollen that they have limited mouth opening meaning you can't do the treatment
48
What treatments are available for abscesses and cellulitis?
Relieve pressure - extraction, incision and drainage if localized fluctuating swelling, root canal treatment, palliative (antibiotics and analgesics)
49
When to urgently refer to A&E for abscess / cellulitis?
If dysphagia / compromised airway / eye closure
50
Which drugs are cold standard for relieving dental pain?
Paracetamol and ibuprofen (ibuprofen first choice as is anti-inflammatory)
51
How much ibuprofen to give for dental pain?
400-600mg
52
What is the mode of action of NSAIDs?
Prostaglandin synthesis - inhibits inflammatory mediators and suppresses the release / synthesis of mediators at the site of noxious stimulus
53
What is the over the counter dose of ibuprofen?
200-400mg 3 times a day
54
What is the prescribed dose of ibuprofen?
800mg three times a day
55
What advice to give patients about taking their ibuprofen?
By the clock rather than as required to maintain effectiveness
56
Advantages of NSAIDs?
Analgesic and anti-inflammatory Useful in symptomatic irreversible pulpitis to decrease PGE2 levels in pulp Decreases peripheral nociceptor sensitization No addiction
57
Side effects of NSAIDs?
Ulcers especially peptic ulcers Asthma Liver dysfunction Diabetes Gout Influenza - Reye's syndrome (aspirin)
58
Disadvantage of NSAIDs?
Is a ceiling to their analgesic effect
59
Which drug is analgesic and antipyretic?
Paracetamol
60
Dose for paracetamol?
250mg to 1g 4 times a day
61
Which drug is the leading cause of liver failure in the US?
Paracetamol
62
Max dose for paracetamol?
4g a day (2x500mg four times a day, four hours apart)
63
What to do if you suspect a paracetamol overdose?
Refer to A&E
64
What is the most effective pain relief for oral surgery and endodontic treatments?
Paracetamol and ibuprofen in combination e.g. 400mg ibuprofen and 1000mg paracetamol
65
Are paracetamol and ibuprofen effective for pulpal necrosis?
No because tooth has no blood supply
66
When to prescribe antimicrobials?
Pulpal necrosis + diffuse swelling / drainage can't be achieved / patient has systemic involvement / fever, malaise, lymphadenopathy, pain, trismus etc.
67
What guidelines are available for prescribing?
SDCEP, FGDP UK, BNF
68
What post-operative instructions should be given after endo treatment?
Usual LA post-operative instructions Injection site may be tender Gingivae may be sore or bleed when brushing (if rubber dam clamp traumatized it) Be careful on tooth as is temporarily restored Temporary crowns will pick up stain - avoid highly colored foods and drinks Tooth may be tender or acutely painful for 2-3 days and then should subside Analgesia advice Emergency arrangements
69
What is a 'flare up' also known as?
Acute exacerbation / phoenix abscess
70
What is a flare up?
Significant increase in pain and swelling within a few hours or days of an endodontic procedure Or sudden exacerbation of a previously symptomless periradicular lesion Usually emergency or unscheduled visit
71
How do flare ups affect outcomes of endodontic treatment?
No significant effect
72
What makes a flare up more likely?
Pre-operative signs and symptoms
73
How can flare ups be prevented?
NSAIDs / analgesia post-operatively
74
How to manage a flare up?
Open and redress canal
75
What causes a flare up?
Apical extrusion of debris Incomplete instrumentation Secondary intracanal infections Cracked / lost / leaking temporary restorations Medicaments / sealer extruded through apical foramen
76
Risk factors for flare ups?
Females > males Diabetes Pre-operative pain Tooth - lower 5,6,7s more likely Necrotic pulp Single visit RCT
77
How to prevent flare ups?
Advice on analgesia Use rubber dam Crown down sequence of files Don't extrude debris Achieve full working length Use of intra-appointment medicament e.g. Ca(OH)2 Give clear and written post-operative instructions
78
What causes pain immediately after obturation?
Same as for flare ups Excessive force for lateral compaction
79
How to treat a pain immediately after obturation?
If RCT sound, reassure, analgesics, review

BDS3.5 Endodontics (17 decks)

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