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 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.
Signs and Symptoms
Patients will complain of pain or severe sensitivity to stimuli such as hot and cold foods, cold air, or sugary foods. A patient may be unable to chew if a cracked cusp or tooth is responsible. Physical stimulation, such as toothbrushing of unprotected dentin, can cause pain. There is no history of unprovoked pain.
Pulpal tests show a strong or severe response to hot and/or cold temperature. However, the symptoms are brief, with good recovery in 10 to 15 seconds. Electric pulp testing is positive and may respond at a lower reading than normal teeth. Percussion and palpation sensitivity should be absent except when the periradicular tissue has been irritated as a result of occlusal trauma.
Clinically, look for evidence of decay, a faulty restoration (fractured or open margin), cuspal or coronal fracture, unprotected dentin, or evidence of occlusal trauma such as a wear facet on the tooth or recent restoration.
Radiographically, look for decay, bone loss exposing root surfaces, or tooth fracture. The periradicular tissues should appear normal with the possible exception of a widened periodontal ligament space in cases resulting from occlusal trauma.
|Step 1||If decay is present, excavate and place a temporary sedative filling (eg, reinforced zinc oxide eugenol).|
|Step 2||For a faulty restoration, remove it and place a temporary sedative filling (eg, reinforced zinc oxide eugenol).|
|Step 3||Check for exposed dentin at the cervical areas. Etch and seal exposed dentinal tubules with a dentin-bonding agent.|
|Step 4||If a fractured cusp or tooth is likely, protect it with a copper or orthodontic band. In the case of a vertical tooth fracture, place a temporary crown to protect the tooth.|
|Step 5||Relieve any evidence of occlusal trauma by adjusting the occlusion with selective grinding.|
|Note:||The “emergency” nature of the problem is questionable when the diagnosis is reversible pulpitis. Be sure not to rush into any unnecessary treatment, and inform the patient that the additional insult of the emergency treatment may push the pulp into an irreversible situation. If the patient can take a nonsteroidal anti -inflammatory drug (NSAID), the recove ry time will be shortened.|
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.
Signs and Symptoms
Patients will complain of pain or severe sensitivity to hot and cold foods, breathing cold air, or eating sugary foods. Note that the pain lingers longer than 10 to 15 seconds. The patient may be unable to chew if a cracked cusp or vertical fracture of the tooth is causing the problem. There is often a past or present history of spontaneous pain. In late stages, a patient may have to keep ice water on the tooth to lower the intrapulpal pressure and prevent pain.
Pulpal tests show a strong or severe response to thermal stimuli with delayed recovery. Long-standing inflammation may be evidenced by both a delayed response to hot stimuli and/or a delayed recovery. Electric pulp testing is positive, usually responding at a lower reading than normal teeth. Percussion and palpation sensitivity should be absent except when the periradicular tissue has been irritated as a result of occlusal trauma or the inflammation is long-standing. The pain may be described as mild to severe, continuous or intermittent, diffuse or localized. Referred pain to other head and neck structures or to other teeth is very common.
Clinically, check for evidence of decay, a faulty restoration (fractured or open margin), cuspal or coronal fracture, unprotected dentin, or evidence of trauma. Teeth with an extensive restorative history are likely candidates for developing irreversible symptoms.
Radiographically, look for decay, bone loss exposing root surfaces, or tooth fracture. A tooth that has been pulp capped should be tested for abnormal responses. The periradicular tissues should appear normal with the possible exceptions of a widened periodontal ligament (PDL) space (Fig 7-1) or condensing osteitis. Both signify the presence of low-grade infection in the pulp.