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The EndoFiles Fax

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The EndoFiles Fax
July/August 2003: Volume 4 Issue 7

A Periodic Review of Current Clinically Related Endodontic Topics
Tips and hints for the practicing Dentist

With editorial comment provided by:
Robert M. Kaufmann DMD MS (Endo)

Instant Online referrals or Call 783–2971

The Endodontic Emergency Patient- Nuisance or Opportunity?

It is estimated that 80 % of patients who present in the dentist office with emergency symptoms have endodontically related pain. These patients can either be regarded by the dentist as an unwelcome interruption in the day or as an opportunity to expand the practice. Regardless of whether you perform complete endodontic treatment yourself, the title DDS or DMD means that at a minimum (in most cases), you should be able to provide emergency procedures that provide relief of the patient's localized acute symptoms. There are always exceptions to the rule and for these patients; referral for a second opinion is sometimes an option.

However, in most cases, by dealing with this situation efficiently in a caring manner and with good technique, you have an excellent opportunity to:

1. Elevate Daily production levels - One of two quick pulpotomies or pulpectomies during the day can increase the profitability of a practice without causing disruption in the scheduled office procedures.

2. Create Great Public Relations - Patients in discomfort are very appreciative of prompt emergency endodontic care. Proving quick relief for the patient who has been up all night with a toothache is a wonderful way to help publicize your practice. They tell EVERYONE how great you are and how you helped them!

3. Expand your practice base - Patients who present with carious exposures frequently have other areas that require treatment. They often have been neglectful of their mouths, which is why many require acute care. Performing efficient, comfortable emergency procedures can convince these patients that you are the Dentist they should be seeing for their other treatment. Phobic patients are especially good candidates for "conversion". Lets examine how this is done.

1. Establish and confirm the patient's current complaint - LISTEN TO THE PATIENT
You are a busy clinician and this patient is unscheduled. That still means that you must take a good history. Good histories SAVE TIME. Listen for KEY WORDS to help with your diagnosis. Descriptions such as "PAIN TO HOT DRINKS, PAIN WHEN I LIE DOWN, PAIN RELIEVED BY COLD, EXAGGERATED BY CHEWING, SHARP MOMENTARY PAIN TO BITING" etc are crucial. These help you localize the problem and cut down the number of tests that you may need to do to confirm your diagnosis. Listening carefully and eliciting these verbal responses is the key to efficient diagnosis.

2. Radiographic Assessment
Several views of a tooth or teeth may be necessary. For posterior teeth, Bitewings are ESSENTIAL. They can often show caries along crown margins that are not visible in PA films. ALWAYS correlate the patient's current complaint with clinical and radiographic findings. E.g./ Opening a necrotic tooth with a periapical lesion will NOT help a patient complaining of sensitivity to cold stimulus or symptoms of Cracked Tooth Syndrome. Those symptoms are associated with VITAL teeth. Yes, that tooth with the long-standing lesion and pulpal necrosis does need endo - but that is NOT why the patient presented! TREAT TO THE SYMPTOMS- NOT to the films.

3. Make a firm diagnosis
You must be able to reproduce the patients current complaint in the chair. This is done with standard pulp tests (hot, cold and cavity tests) mobility, percussion, palpation, Transillumination, periodontal and chewing (Cracked Tooth) tests. If you can't reproduce the patients current complaint then DO NOT INITIATE TREATMENT, or at least consider referral. Chances are (with some level of experience) that you will open the right tooth, but it can be very embarrassing (and costly) when you guess wrongly. If you are unsure, wait until symptoms localize. Sometimes 48 hrs. can make the difference between being unable to locate a tooth and having definite percussive sensitivity.

Another advantage of being able to provide emergency treatment for your patients is that there is less pressure on your endodontist to "get them in right away". You have provided emergency care that allows both the endodontist and the patient to schedule at a time that is most convenient for them both. In that way they get the best treatment possible.

EMERGENCY Appointments - Common Pulpally Related Reasons for Presentation

Patients presenting with symptoms of Reversible Pulpitis:

1. Cervical Hypersensitivity-
In cases where there is no obvious decay or faulty restorations, always explore the buccal surfaces of teeth along the gingival margin. Look for loss of enamel. Cervical Hypersensitivity from recession can be a "new complaint" in patients over 30, something they have not had in the past. While this may not seem to be an emergency, many patients reaching middle age have sharp sensitivity that they interpret as an emergency.
Emergency Treatment- Localized topical Desensitization (can be applied by your hygienist)

2. Single Weak Cusp -
Symptoms reproducible with sharp sensitivity to cotton roll test. Localize with Tooth Slooth.
Emergency Treatment- If no signs of Irreversible Pulpitis - Remove and Shoe weak cusp with IRM or interim composite. Explain possible need for endo if symptoms do not resolve. Reappoint for definitive restoration at a later time. Always check with the patient the next day to confirm resolution of symptoms.

3. Faulty Restoration, Cracked Filling, Open Margin etc.- Positive response to cold and sweets - brief and reproducible. Heat tests show minimal or normal response.
Emergency Treatment- IRM Temp, close margin etc. Reappoint for definitive restoration at a later time. Always check with the patient the next day to confirm resolution of symptoms.

4. Sinusitis - Patients complain of acute dull ache in maxillary sinus area with associated percussive sensitivity in several posterior teeth. Test by having patient bend over - lowering the head elevates cephalic pressure and increases symptoms. Radiographic cloudiness of the sinus sometimes visible in PA films.
Emergency Treatment- Antihistamines and decongestants - referral to ENT Specialist if necessary.

5. Reversible Pulpitis due to Caries- Confirm radiographically and clinically.
Emergency Treatment
FULLY Excavate decay and place sedative dressing if possible. Alert patient to possibility of pulp becoming IRREVERSIBLY involved.

Patients presenting with symptoms of Irreversible Pulpitis:

1. Toothache with NO Percussive sensitivity - Early Irreversible Pulpitis
Patients arrive with lingering symptoms to cold stimulus or spontaneous discomfort. There may be a history of recent restoration. Discomfort sometimes managed with analgesics. Pulp has become irreversibly involved WITHOUT periapical involvement. Since the problem is in the CORONAL pulp, percussion is generally negative. Emergency Treatment- Pulpotomy is frequently adequate for patients such as this. Pulpectomy is the preferred treatment if you have the time. (Broach and/or file the canal contents) If you insert files, make sure to use an electronic apex locator to monitor instrument insertion depth. Do the minimum necessary to remove the pulp. Place CaOH in chamber and close. Reappoint for Endo ASAP. ANTIIBIOTICS ARE NOT INDICATED AND SHOULD NOT BE PRESCRIBED.

2. Toothache with Heat sensitivity- Late Irreversible Pulpitis
Classic symptoms are the patient who arrives with a glass of ice water, bathing the tooth at regular intervals to prevent pain. Tooth hyper-reactive to heat, relieved by cold. Pain to lying down common. Patients unable to sleep. Serious, severe pain not managed by analgesics. Percussive sensitivity can indicate the beginnings of periapical involvement.
Emergency Treatment- Pulpectomy. Best results are achieved with obtaining accurate working lengths via films and/or EAL and cleaning canals to a minimum size #15 or 20 instrument. Final shaping need not be done but canal contents must be debrided thoroughly. Place CaOH in canals and close. Reappoint for Endo ASAP. ANTIIBIOTICS ARE NOT INDICATED AND SHOULD NOT BE PRESCRIBED.

3. Acute Apical Abscess (AAA)
Although the situation frequently looks the worst to the patient, it is often one of the easiest to manage. Patients exhibit classic signs of intra and/or extra-oral swelling, hyper-occlusion (due to periapical pressure), tooth mobility and extreme sensitivity to percussion and palpation. (NEVER percuss an AAA!)
Emergency Treatment- Obtaining drainage (either through the canal or via I&D) provides the most rapid relief of symptoms. Patients exhibiting large areas of firm cellulitis should be placed on Antibiotics until the swelling localizes to a fluctuant area that can be drained via the tooth or by I&D. The canal can sometimes be left open to drain if necessary.

Endodontic Emergencies can be relatively easily handled with proper diagnosis and minimal single tooth operative/endodontic procedures. Efficient emergency treatment of the endodontically involved patient offers the dentist an excellent opportunity to showcase his case management skills and expand the practice. In cases where diagnosis is difficult or treatment complex, referral to a specialist is the best strategy.

The Endo Files is provided free of charge. If you know a Dentist who would like to receive a copy,
e-mail, call (204)783 2971 or fax at (204)786 7467 and request that they be put on the mail or fax list.