7 – Endodontics



John F. Hatton, DMD

In an endodontic emergency, diagnosis should include not only any endodontic considerations, but also periodontal and restorative considerations, along with a differential diagnosis for those instances when the pain may not be of an endodontic origin. Definitive treatment (ie, endodontic therapy versus extraction) is based on a thorough analysis of the long-term restorative and periodontal prognoses for the tooth.

Managing an endodontic emergency not only consists of treatment, but may, more appropriately, consist of referral, should the diagnosis be questionable. It is prudent to delay irreversible treatment when the diagnosis is unsure. In the case of a bona fide endodontic emergency, the rule of thumb is, the more that can be accomplished at the emergency visit (ie, pulpotomy versus analgesics, pulpectomy versus pulpotomy), the better the potential for pain relief. An emergency that is a result of periradicular inflammation or infection requires cleansing of the pulp canal. Antibiotic the ra pyshould be considered for patients who have signs and symptoms of infection, such as cellulitis, fever, or lymphadenitis.

Basic Evaluation Procedures

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
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.

Symptoms of Pulpal Pathoses

Reversible Pulpitis

Reversible pulpitis is described as a sharp or intense pain response due to hyperemia or mild inflammation of the pulp. It can also be present in a tooth with exposed dentinal tubules. Abnormal responses are caused by any stimulus that creates fluid movement in the tubules toward or away from the pulp.

Irreversible Pulpitis

Irreversible pulpitis occurs when prior insults to a tooth lead to focal areas of inflammation or necrosis within the pulp. Pain results not only from dentinal tubule fluid flow, but also from elevation in intrapulpal tissue pressure. Increased intrapulpal pressure lowers the threshold of pulpal nerves such that normally subthreshold stimuli can cause pain, more severe stimuli causes pain with slow or delayed recovery, or spontaneous pain can occur.

Jan 5, 2015 | Posted by in General Dentistry | Comments Off on 7 – Endodontics
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