Step 1 |
Visually observe the patient for signs of being run-down or exhausted. For many people, the pain resulting from endodontic pathosis is often the most severe they have experienced. As a result, many patients appear at the dentist’s office without adequate food or fluid intake. This situation, in addition to the possibility that the patient may have had inadequate sleep, can render the person more prone to an office medical emergency. |
Step 2 |
A thorough medical history is necessary to be adequately pre pared to handle other medical conditions that could complicate treatment. Remember to look for medical indications that may require prophylactic antibiotics or even preclude emergency treatment. |
Step 3 |
Vital signs should be taken and recorded, including the patient’s temperature if the presence of infection is suspected. |
Step 4 |
To arrive at the correct diagnosis, the clinician must note and record any pertinent dental information relating to the emergency situation. The dental history is particularly important because recent dental therapy or a change in dental condition (eg, loss of a restoration, trauma, biting on a piece of bone, etc.) is often significant to the emergency situation. The patient’s description of the pain, including the history, causative, attenuating , and alleviating factors, and distribution, along with the pain’s intensity, can differentiate between a dental problem and other pain-causing problems. It is not unusual to be able to arrive at a tentative diagnosis by having the patient describe the problem. Once a tentative diagnosis has been established, clinical examination and testing and radiographic interpretation will corroborate the diagnosis. |
Step 5 |
The extraoral examination should note any maxillofacial swelling with lymph node involvement that is indicative of an infection. |
Step 6 |
During the intraoral examination, any dental or alveolar deviation from normal should be noted. The most obvious dental pathosis may not be the cause of the problem. It is helpful to use a checklist to ensure that all possible pathoses are evaluated. |
Step 7 |
Pulpal and periradicular testing are extremely important, even in the most obvious cases. These tests are necessary to corroborate the diagnosis. A determination of pulpal vitality should be made for the tooth in question and compared to adjacent and contralateral teeth to determine whether there is a deviation from those considered normal. Cold testing, particularly testing with refrigerants or carbon dioxide is the easiest and most reliable thermal test to perform. If a tooth responds to thermal testing , then further testing with an electric pulp tester adds little additional information (since quantifying the pulpal response to |
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electrical stimulation to determine the degree of pathosis has been shown to be unreliable). Determining the pulpal response to heat is often frustrating because the temperature required to stimulate the pulp is often difficult to obtain. An electric pulp tester should be used to help confirm a necrotic pulpal diagnosis when thermal testing is inconclusive. |
Palpation, percussion, and mobility, including a periodontal evaluation , typcially are reliable in determining the presence of periradicular inflammation. Evaluation of both the pulpal and the periradicular status of the teeth in the area of discomfort is necessary to provide the most thorough information in confirming a diagnosis. |
Step 8 |
Many clinicians consider the radiographic examination to be the most important aid in arriving at a diagnosis. At a minimum, a good quality periradicular film (an occlusal view may suffice for anteriors) must be obtained to determine the location and extent of the endodontic problem. A panographic film is helpful for focusing on general areas of pathosis. If periradicular testing suggests periradicular involvement that is not obvious on the radiograph, a second view with a different angulation is recommended . This second view is also necessary if a tooth that pulpally tests within normal limits exhibits radiographic evidence of a periradicular pathosis. |