Diagnosis, Emergency Treatment, and Pain Control

HIS ARTICLE will deal with diagnosing dental pain and treating it in conjunction with pain management. Most of the time, the patient will present with a toothache that is easy to localize. The tooth can be identified by a painful response to percussion or to chewing on a cotton roll. However, in some cases a tooth will respond only to hot or cold liquid or a tooth will calm down only in response to cold liquid. If the only source of pain is hot liquid, then isolate each tooth in the quadrant with a rubber dam and pour hot water over them one at a time. The one in which the patient feels pain is the culprit tooth. Now if the pain can only be relieved with cold water, then the patient has an acute pulpitis. Wait for the pain to become intense and then apply a cotton pellet soaked with Endo-Ice to each individual tooth. When you touch the right tooth the pain will subside. The condition of the pulp will also influence the decision about the type of treatment. If the tooth has an inflamed pulp, a quick pulpotomy will be all you need to do to relieve the pain. If the pulp is necrotic, you will need to instrument the canals down to the apex up to a #25 reamer. Quick broaching of the canals will not be sufficient, because in that case all you would be doing is removing partial necrotic tissue from the canal. You would miss the most important tissue, which is at the apex, the source of the infection and pain. After instrumenting to the apex, you can use Ca(OH)2 as an intracanal dressing until the next visit. If the tooth has already had root canal therapy done and has an infection, you will treat it as in the necrotic pulp scenario. Now if the infected root happens to have a post in it and you do not have time to remove it, trephination into the jaw to drain the abscess is the only way. I would refer a patient in that condition to an oral surgeon for the trephination procedure. If you have a mechanical exposure on a healthy vital tooth, pulp cap it using MTA. The prognosis for pulp capping with MTA on vital exposure without contamination is quite good. Teeth that are percussion sensitive or painful to chewing should have the occlusion reduced. Pain management is as important as performing the root canal procedure. I normally prescribe Vicodin ES and Lodine 400 mg for pain. Sometimes, when the pain is too intense, you

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can have the patient alternate between these two painkillers. The reason for the alternation is that sometimes the pain comes back before the six-hour period between doses of a single painkiller. Alternation will allow the patient to have painkillers every three hours without overdosing on either painkiller. The antibiotics for necrotic pulp and root with PAR are Augmentin 875 mg #14 BID or Clindamycin 150 mg #28 QID for Pen allergy. If the canal is weeping and you cant dry it, place the patient on Pen VK 500 mg #28 QID with Flagyl 500 mg #14 BID. This combination is great for those severely infected canals.