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What is the incidence of a Flare-up and are there any predictable indicators?
- Walton – 3%; Female 2X more than males; Pre-op pain or swelling before initial appt are at greater risk
- Torabinejad – Pre-op pain was an excellent predictor; Females age 40-59; no or small PA lesions increased the frequency of interappointment emergency
What causes flare-ups?
Seltzer & Naidorf – Overinstrumentation, overmedication, extruded debris, incomplete pulp removal, over-irrigation, hyperocclusion, root fx, or another tooth
Is it ok to close a tooth previously left open?
August – only minimal flare-ups seen – 5%
Do prophylactic antibiotics help decrease flare-up rate?
- Reader – Pen VK did not decrease flare-ups with IP
- Amox did not help decrease flare-ups with necrotic, asymptomatic teeth
- Pen VK did not decrease flare-ups with necrotic, symptomatic teeth
When are Antibiotics indicated?
Pathways – Antibiotics are recommended in conjunction with appropriate endo tx for progressive infections with systemic signs and symptoms such as fever (100 deg F), malaise, cellulits, unexplained trismus, and progressive or persistent swelling. I & D is indicated for any infection marked by cellulites (fluctuant or indurated).
Are antibiotics indicated to reduce/prevent post-op pain?
Kennan 2006 – Cochrane systematic review; No evidence to support abx for pain relief in IP
What are other tx considerations for a flare-up?
- Occlusal Adjustment – Rosenberg – works for IP pre-op pain (perc. sens)
- Re-enter for complete debridement
- Establish Drainage – I & D; Trephination is ineffective (Moos, Reader)
- Evaluate for Analgesics – Hargreaves – 3D pain control (diagnosis, definitive tx, drugs )
- Flexible prescription plan – 1) max nonnarcotic (aceto or NSAID) or 2) add aceto (w or w/out opiod) to NSAID –
- Match the pts needs
- Evaluate for Antibiotics – systemic involvement or immunocompromised
- Evaluate for Steroids – Reader – Oral (48mg methylprednisilone) or IO
- Marshall & Walton – IM dexamethasone
What 3 spaces are involved in Ludwigs angina?
Submental, Submandibular & Sublingual - life threatening cellulites which can advance to the pharyngeal and cervical spaces, resulting in airway obstruction
Why are infections of the midface dangerous?
Cavernous sinus thrombosis – life threatening infection in which a thrombus formed in the cavernous sinus breaks free, resulting in a blockage of an artery or the spread of infection. Infections in the midface initiate an inflammatory response. Increased pressure can reverse the direction of venous blood flow (due to lace of valves) causing stasis in the cavernous sinus – this may initiate thrombus formation.
How do you classify crown fractures?
Andreasen: Crown infraction (craze line); Uncomplicated crown fx (enamel and/or dentin with no pulp exposure); Complicated crown fx (pulp exposed)
What is the probability of pulp necrosis following crown fx?
- Ravn – 6% with uncomplicated crown fx; if concussion & mobility, then 30%;
- 80% success with DPC and uninflammed pulps
- Cvek – 96% success cvek pulpotomy ( remove 2mm pulp up to 7days after fx)
What is the tx for a crown fx?
- Uncomplicated – Restore with GI or composite resin; attempt bonding fx’d segment
- Complicated – Cvek pulpotomy with Ca(OH)2 or RCT
What is the tx for a root fx?
- 3 radiographs; Reposition coronal segment & physiologic splint X3 wks; relieve occl
- -if fx is coronal, remove coronal segment; consider gingivectomy or ortho extrusion
What is probability of pulp necrosis with root fxs?
Andreasen – 25% of the coronal segment
What are the methods of healing for a root fx?
Andreasen – Calcified tissue; connective tissue; interproximat bone & ct; inflammatory tissue w/out healing
What is the tx for a luxation injury?
- Take multiple angled radiographs to discern root fx or not;
- Reposition tooth in normal position (consider ortho reposition with intrusion); physiologic splint X3 wks; relieve occlusion; monitor for pulpal necrosis/pathology
- -If intrusion of fully formed root apex, initiate RCT in 2wks
What is the probability of pulp necrosis following luxation injuries?
Andreasen – Concussion 3%; Subluxation 6%; Extrusion 26%; Lateral Luxation 58%; Intrusion 85%
How do you manage an avulsed tooth with an open apex (<1 hr dry)?
Clean root and socket with saline; Soak tooth in doxycycline 1mg/20mL for 5 min (Cvek- less ankylosis or inflammation); examine for alveolar fx & replant; physiologic splint X1 wk; monitor for necrosis/PA pathology
How do you manage an avulsed tooth with an open apex (>1 hr dry)?
Replantation is not indicated
How do you manage an avulsed tooth with a closed apex (<1 hr dry)?
Clean root and socket with saline; examine for alveolar fx & replant; physiologic splint X1 wk; initiate RCT X7-10 days
How do you manage an avulsed tooth with a closed apex (>1 hr dry)?
Clean root surface and soak in 2% stannous fl- X5min; clean socket with saline; examine for alveolar fx and replant; physiologic splint X1 wk; initiate RCT X7 days
What type of healing can you expect with an avulsed tooth?
Andreasen – normal, replacement resorption, surface resorption & inflammatory resorption; <30min before replanted, 90% no resorption; >90min = resorption
Discuss storage media for avulsed teeth?
- Trope: Best to worst: HBSS > Milk > Saline > Saliva > Water
- Blomlof – Milk gives you 6 extra hrs
Discuss splinting of avulsed teeth?
Castilli – splinting X7 days recovered uneventfully; 30 days induced resorption & ankylosis
What are some general adjuncts for trauma tx?
- Tetanus booster; chlorhexidine rinses; analgesics
- Antibiotics – Pen VK or doxyclycline (Trope – anti-resorptive) X1wk for avulsions
What is the role of Ca(OH)2 in replanted teeth?
- Trope – decrease incidence of inflammatory resorption; 1wk = 8wks
- Dumsha – NSD in inflammatory resorption with GP or 5mo tx with Ca(OH)2; recommends obturating immediately
What is the role of fluorides in replanted teeth?
- Klinge – SnF2 delays replacement resorption
- Coccia – delays resorption; 2X survival time
What is the recommended follow-up for traumatic dental injuries?
Pathways – after tx 3, 6, 12 mo and yearly thereafter