#16 – Screen emergency clients

“Be kind, for everyone you meet is fighting a hard battle.”

– Plato (427-347 B.C.)

One of our primary functions in dentistry is to help people avoid pain (as well as to look attractive and maintain their teeth for a lifetime). Often, clients don’t come to us quickly enough and they allow pain to occur. When this happens, our job is to get them out of pain as quickly as possible. The emergency sheet is our guide to quickly and effectively relieving our clients pain.

Emergency exam form

Section A Secretary

When the client calls or walks in, the secretary will complete this section. The client will be brought in as soon as possible if not immediately, then within two hours. If the client is not experiencing pain (perhaps only a broken tooth or a filling out) they will be scheduled at their own convenience (and ours). One reason we have a relatively unscheduled chairside assistant is so emergencies can be handled quickly. “Don’t tell someone what you’re not going to do until you’re not going to do it.” This means don’t tell someone over the phone we don’t pull teeth. Do tell them we’ll do everything we can to help them.

Also, don’t try to explain over the phone. Don’t appear evasive.
Just honestly say “Mrs. Hall, it’s really impossible to tell you more until one of the doctors can see what’s happening. We can arrange for that time in _____ minutes.

Section B Assistant

When emergency clients arrive, greet them, introduce yourself, and shake hands to establish your initial contact. Bring them to the operatory. Use the information the secretary has given you.

Often these clients will feel guilty for having a problem and apologize for their lack of care, etc. Don’t ignore their feelings or down play their importance. Look straight into their eyes and tell them there can be lots of good reasons for why they are having problems right now, but we can’t change the past. We’ll just work together so the future will be the way they want it. Don’t criticize or judge them. Try to find a positive to compliment. “This tooth is badly decayed, but your other teeth seem very healthy.”

Many emergency clients haven’t seen a dentist for several years. Your task is to help them understand that their choice to avoid us has created the problem they now have and not make them uncomfortably guilty.

When you have gained your client’s trust, review the medical history. Make note of any active medical problems. Some of these problems such as sinus congestion, tumors, angina, or neurological diseases can imitate a toothache, look for this combination of symptoms

1. No thermal sensitivity
2. Pain has occurred off and on for months or years
3. Client has been treated for depression
4. There is pain or soreness in TMJ or muscles of mastication (clinch and grind)
5. History of trauma to the tooth or area in the past

Now is the time to learn about this client. Your goals with every emergency client is to:
1. Hear what the client wants
2. Determine the problem
3. Find out the client’s treatment preference
4. Get them to come back for a thorough exam (if they haven’t had one in the past)
Begin this process by deciding if it’s a tooth, gum, or other problem.
5. Not all patients want a thorough exam which is OK. Those who do want a thorough exam are taking a preventive approach with their teeth and gums. Those who do NOT want a through exam are taking an Emergency approach with their teeth and gums. These people usually only want to deal with the problem that is bothering them the most and usually only want inexpensive care. Do not try and talk these people into a through exam. Focus on the immediate concern.

Ask questions and confirm the information on the emergency sheet. Look for this information
1. Is the tooth painful now?
2. Can the client point to the sore tooth? This helps you know where to focus your exam, take your x ray, etc. Don’t be surprised if your client doesn’t point to the right tooth.
3. Does the tooth hurt worse at night? When the client lays down , the blood pressure to the head increases and since the client is quiet, the client is more aware of any discomfort. This often means the tooth is abscessed.
4. Has the tooth been filled recently?
5. Does the tooth have a deep filling?
6. Has gum infection caused a gum recession that has exposed a portion of the root that has been exposed and may have become cold sensitive.
7. Cold sensitivity often comes and goes. Heat sensitivity usually means an abscessed tooth. If cold sensitivity lasts more than 10 12 weeks (enough time for a tooth to lay down secondary dentin), then the tooth may be abscessed.

Look in their mouth, if they can point to the exact tooth, your job is much easier. Often they will only be able to tell you it’s on one side not even if it’s an upper or lower tooth. For some people they may have several badly broken down teeth. Your job is to locate the tooth or other problem that is causing the pain.

Our ability to respond to our client’s requests determines how satisfied they are.

In case of trauma, think in terms of the whole client, not just a specific tooth.
1. Record the time, place, and how the injury occurred.
2. Check the lips, cheeks, tongue for cuts
3. Check all the teeth for chips, looseness
4. If your client is a child check for possible brain damage
a. Are they sleepy, confused, have a headache
b. Vomiting
c. Pupils of unequal size
5. If skin is broken and dirt is contaminated, make sure Tetanus shots are current.

Every emergency client needs an emergency sheet. It may seem quicker to chart your findings on the treatment sheet. Don’t do it. The emergency sheet organizes the tests, the results, and your mind so you can come up with a correct diagnosis.

Also, the emergency sheet helps protect us from malpractice. Client comments to secretaries, your findings, and treatment all organized is a perfect defense.

Tips on x rays

1. Place a gutta percha point (or have doctor do this) in the fistula as far as it will go (this is not painful). The point usually goes very near the apex of the infected root.
2. A long lingual root on upper molar x rays indicates distortion and makes it impossible to for the dentist to measure the x ray to determine the root length.
3. Rinn for uppers film must be parallel to the tooth. Put the film more to the middle of the month to help this line up. Use one to two cotton rolls for the client to bite on if uncomfortable to close.
4. If you can’t make the Rinn work, use a hemostat on the edge of the film. Avoid being too low, too forward, too shaky and bad cone angles (stay parallel).
5. Never bend the film
6. Less than 50% of abscessed teeth will show on an x-ray

Toothache Emergencies

Check the color of the tooth

Tooth Color:

Shine light through the teeth with the mouth mirror or a fiberoptic light. Look for a color difference (usually this can only be done in anterior teeth since the posterior teeth are too thick. Some of the color differences you may observe:

a) Tooth appears darker and has a grayish tint

A number of conditions may cause this:

i) Usually, the pulp has died

ii) The tooth has had a previous root canal treatment and now has a cyst around tip of root.
When a standard root canal fails, a specialist will need to retreat. If this is within 3 years of us performing the root canal, we will often refund the clients payment to us and refer the client to a root canal specialists who has 2 extra years training. When a root canal fails, the specialists will either
1. Clean out the space and reseal
2. Clean out the space and reseal then lay back the gums and make an opening through the bone clean out the infection in the bone (cyst), reseal the tip of the root and replace the gums ( suture in place.) This is done in 1 appointment in the specialists office

iii) A blow to the tooth caused blood in the dentinal tubules. The x ray usually looks normal. Sometimes this discoloration will go away a few months after the trauma.

b) The x ray shows the canal is calcified.

c) The tooth looks pink, near the gumline.
The x ray shows the pulp is eating away the inside of the tooth (internal resorption). The “thinned” dentin allows the vital pulp tissue to show through pink.

Condition of the tooth

A few of the things you may see:

a) Fractured Filling

b) Fractured Crown of tooth
1. no pulp exposed- usually just restore
2. pulp exposed- may be abscessed

c) Large area of decay

d) Crown or onlay

e) Large fillings

When you have decided on the teeth, decide on whether to take an x ray or not.

1. Filling out, broken cusp, no pain, an x ray of the area was taken within the last 12 months no xray
2. Slight pain, not sensitive when you tap on the tooth, no apparent decay into the pulp chamber decay xray
3. Pain or apparent decay into the pulp chamber hurts when tap on the tooth periapical xray
4. Looseness of the tooth. Often when a tooth is abscessed the tooth will actually be slightly pushed up out of the socket by the infection around the tip of the root. The client may feel that this is the first tooth to touch when s/he closes. Gently test each tooth laterally. Mobility or pain will help determine the area to xray.

While the xray is developing, complete the rest of your tests.

Ice test: This is probably the most efficient, reliable pulp test we can perform. A tooth that responds to ice has a vital pulp. How the tooth responds may help us in evaluating the status of the pulp.

Method of Application:

Use Endo Ice: Spray Endo ice on a cotton applicator and place on the tooth in question.

Procedure: When testing with ice, say, “Raise your hand when the tooth feels cold,” and, “Put your hand down when the cold feeling goes away.” (Usually 3-5 seconds. 7+ means pulp dying.) So the procedure would go like this “I’m going to put ice on a few teeth I want you to tell me when the tooth feels cold.”

Place the ice on the labial surface. Always start with a normal tooth. After testing the tooth, ask the patient, “Tell me when the cold feeling goes away.” Usually, it is gone in a few seconds. Normally, the incisors respond rapidly (two to four seconds), the cuspid takes a little longer due to the thicker dentin. The bicuspids are not as rapid in responding as the incisors unless the root surface is exposed or a buccal restoration is present (this is true for any teeth with abrasion, erosion, or large metallic fillings). The molars give the most variation in responses. Therefore, if you don’t get a good response on the buccal test the lingual and/or the occlusal surface.

a) Special “Ice Test” Procedures:

1.) Gold crown – Teeth with metal crowns usually give good responses to ice. An electric pulp test won’t work on these teeth. The current is carried to the gingival tissues and gives a false early response.

2.) Porcelain “to metal” crowns. Place the ice on the metal portion of the crown. The metal will conduct the cold to the underlying tooth structure.

3.) Full porcelain crowns are difficult to pulp test. The margins of these crowns have wide shoulders. This is the area where the cold can penetrate and cause a response.

Procedure: Place the ice on the gum tissue. Tell the patient that the ice will feel cold, but that is not the response we are looking for. Then place the ice near the gingival margin.

If the tooth is healthy, the patient will feel a cold, sharp response. However, if the tooth has a pulpitis, the client will feel significantly more pain than on other adjacent teeth.
a. irreversible pulpitis ( pain lasts longer than 5 seconds)- endodontics/extract
b. reversible pulpitis ( pain lasts more than 5 seconds)- attempt to save the nerve. This test doesn’t work all the time.

b) Interpretation of Results

i) Most teeth with normal pulps respond to ice. If a tooth does not respond to ice, it may: be abscessed; be too insulated, have calcified canals, (especially in older patients); have just received a blow and is vital but there is no response; be normal, but not respond to ice.
ii) An abscessed tooth usually responds to ice immediately and the pain lingers for 15 seconds up to a few minutes.
iii) In reversible pulpitis, the tooth usually responds to ice immediately and the pain lingers 15 seconds.
iv) In some abscessed teeth stops in less than, the tooth is very sensitive to heat; ice on the tooth relieves the pain. The client may come into our office holding a glass of ice water by placing the water over the tooth, the pain is relieved. Therefore, let the tooth warm up then place the “ice carpule” on the offending tooth the pain will go away.
v) In some cases abscessed teeth, there is a normal response to ice. This happens when a tooth still has some vital pulp tissue. This tooth usually has been sensitive to hot and/or cold, will have spontaneous pain within the last week or two. The pulp has “died” in the coronal portion of the tooth, but is still inflamed and vital in the apical root section.
vi) In chronic abscessed teeth, the pulp is totally necrotic and will not respond to the ice test.

Electric Pulp Test- Do not use on clients who have a pacemaker!

An analytic technology pulp tester is the best device marketed.
Note: Don’t refer to this device as electrical in front of the patient. The pulp tester is not extremely accurate. It provides a rough estimate of whether the tooth has a nerve or not compared to the adjacent teeth.

Method of Application:

a) On the lower right front, there is a dial which sets how fast the instrument records from 0 to 80. Set the dial at a low to intermediate rate.

On the lower left front, there is a digital readout window. The readings will go from 0 to 80.

The probe of the pulp tester is connected to the instrument by a long conductive cord. The probe has a small red light that is activated when a “good” contact is made with the tooth.

b) Dry the teeth to be tested with a 2×2 gauze and isolate with cotton rolls. If the tooth is wet, current will be transmitted into the gums and adjacent teeth giving you false positive readings.

Note: do not dry the teeth with air. Since this can be very painful.

c) Dip the probe tip into toothpaste, squirted on the clients bib. Place a dot on each tooth to be tested.

d) Tell the patient, “Please touch the handle lightly. As soon as you will feel a “tingling” or warm sensation in your tooth, let go.” Record the digital number on the emergency blue sheet.

e) Always start with a normal tooth first and place the electrode on the midportion of the posterior crown or on the incisal edge of an anterior (unless dentin is exposed).

Note: Don’t place the probe on metal or composite fillings/crowns or the gums. The current may be conducted to the gingival tissues (metal restorations) and give a false reading or give no response (composites) since they may not conduct the current.

f) When the patient removes their hand, the digital display will automatically stop. Record this number on your blue diagnosis sheet.

g) Go on to another tooth. When the probe is applied to another tooth, the digital display will automatically reset to zero and begin a new numerical readout.

h) By testing a few normal teeth first, a baseline reading will be established. The tooth that is causing the problem usually gives a higher reading than the normal teeth.

i) If a tooth has a full crown, the test can’t be run.

j) The sensitivity of the tooth varies with the type of tooth, the enamel, and the placement site. Exposed dentin is very sensitive.

k) Molars often give false readings. One canal may be abscessed, but the other canals may give normal readings.

l) Be sure to test the tooth in front and back of the one you suspect. If the suspected tooth is the only molar or bicuspid on that side, be sure to test a similar tooth on the other side. Different size teeth respond differently.

m) A tooth that has been hit will often test non vital for several months due to the shock produced by the blow. You can run the test, but don’t think the non vital response means an abscessed tooth unless you get other tests to agree with your diagnosis
.
n) Electronic pulp tests are not accurate on primary teeth or permanent teeth with incompletely formed root tips (again, usually in children under the age of 8).

o) If a tooth has been hit, all pulp tests will be inaccurate for at least one month and perhaps as long as one year.

Interpretation of Results:

i) A normal tooth responds to the pulp tester in the range of 25 to 50 (approximately).
ii) A high reading 70 to 80 (less sensitive), can mean the tooth is abscessed.
iii) A low reading, less than 20 (more sensitive), doesn’t really mean much. You should use other tests (ice) to determine if therapy is needed.

Percussion to test for apical inflammationPercussion

Using the butt end of the mirror, lightly tap all the teeth in the quadrant. Tapping an acutely infected tooth can be very painful. If the teeth don’t respond to the light tap, go back and tap harder. Although a tooth sensitive to percussion is often abscessed, other problems (a high filling or crown, clenching/grinding, or gum disease) can also make the tooth sensitive.

 

PalpatePalpation

Palpation: With your finger, push on the gums above the roots of the teeth. An abscessed tooth usually hurts in this area. Be sure e to move your finger or thumb slowly and push hard.

Swelling

Swelling: Examine the patient for facial asymmetry;

Intraoral: the swelling may be:

i) Vestibular

Vestibular

 

 

 

 

 

 

ii) Palatal

Palatal

 

 

 

 

 

 

iii) OR gingival

Gingival

 

 

 

 

A swelling, means the infection has driven through the cortical bone.

Note: If the swelling is hard (boardlike) and feels hot to the touch, it is a cellulitis. This simply means the inflammation has not “organized” and no “pus” (localized collection of dead PMN’s and cell debris) is present. If the swelling is localized (“pus” is present), it is classified as fluctuant. The swelling is soft and is getting ready to drain. This is a much better condition for the client than a cellulitis.

In some cases, the infection has not broken through the cortical plate. This pressure causes severe pain. The usual cause is a bacterial infection (strep, staph, or gram negative organisms). This may occur when the patient’s systemic resistance is lowered or they are under a great deal of stress.

Temperature

Whenever swelling is present, take the patient’s temperature. Often you can just ask the client if they feel like they have a temperature.

Perio Pocket

Periodontal Condition: If a periodontal condition is suspected, use a periodontal probe to detect any pockets. Have one of our hygienists show you how to use a probe. Used wrong it hurts! A gum abscess hurts in much the same way as an abscessed tooth. Look for red, inflamed gums. Place a sickle explored flat between the teeth and push down. If this hurts your client, ask “Is this the kind of pain and the area where the pain has been bothering you?

In molars, check the interproximal areas and furcations for pockets.

Fistulous tract

When the infection drives through the bone and through the gums, it makes a small draining hole in the gums.

A fine medium gutta percha point can be used to trace the source of the sinus tract. Anesthesia may be required.

Caution: Test the point for brittleness by pushing it against an alcohol gauze 2×2. If the point bends easily, it is OK to use. A brittle gutta percha could break off in the tissue.

Place the point into the opening (Fig.29) and gently tease it forward until a stop is felt.

X ray the tooth with the gutta percha in place. Frequently the tooth is different from the one you had suspected. Also, a deep pocket caused by gum disease can produce a fistula.

Never try to diagnose an abscessed tooth from an x ray alone. Less than half of abscessed teeth will show on x rays. Also, some anatomical structures can superimpose on the tip of the x ray and make a healthy tooth look abscessed. Examples would be: The mental foramen in the lower jaw between the bicuspids, sinuses, the mylohyoid depression near the lower molars, or the patchy pattern of bony mineralization.

Look for the odd sorts of things that could cause pain:
1. Pulp calcification
2. Narrow canals

Lymph nodes

Lymphadenopathy:
Palpate the lymph nodes below the border of the mandible and under the anterior aspect of the sternocleidomastoid muscle. If nodes are tender, record under lymph nodes tender.

Intraoral examination

With the mouth mirror and explorer, examine the teeth:

Your x ray should be ready by now. Get it and see if you see an abscess, etc.

Radiograph:
Compare the current x ray with any previous films, if available.
The apex looks normal. than half of abscessed teeth will show an abscess. Not seeing an area on the x ray doesn’t mean the tooth isn’t abscessed.

A thickened periodontal ligament. Means an abscessed tooth.

OR if a radiolucency (cyst) is present. May mean surgery will be needed to remove it after the root canal.

Tooth condition: as seen on the x ray

a) Large Decay

b) Deep fillings, possible pulp cap

c) Root fracture – A vertical root fracture probably won’t show on the x-ray, but often causes a radiolucency that surrounds the root. Presence of a post increases the possibility of a fracture.

d) Periodontal Involvement – look for:
1. pocketing
2. mobility
3. bone loss
4. clenching and grinding
5. tooth often more sensitive to lateral pressure rather than vertical
6. pulp will test vital

e) Previous endodontic treatment pulpotomy
1. short seal

2. seal exposed by decay in leakage and recurrent infection
3. extra canal – not found or sealed
4. separated instrument

Just because a seal is short, doesn’t mean the root canal needs to be done. The tooth needs to be retreated by a specialist if:
1. The tooth is growing.
2. The cyst is growing.

If the client asks why this happened, tell him you don’t know, but a root canal specialist has new techniques today to improve the length of success.

a) Impacted third molar

b) Maxillary sinus involvement (cloudy sinus)

c) Internal resorption

d) External resorption

e) Calcified canals

Cracked Tooth

A tooth can be fractured and still be in one piece. At least once a week I will screen an emergency that has these symptoms:

1. Pain when client bites down or puts pressure on a tooth.
2. Pain goes away as soon as the pressure is removed from the tooth.
3. X ray is normal.
4. Pulp tests are normal.
5. Often the tooth is not even sensitive to heat or cold, other times the tooth is sensitive to cold.
6. Often sensitive to sweets.
7. Pain remains the same for months
8. X ray is normal

Some of the signs or symptoms to look for:

1. History of a blow to the area where the tooth is, or other cracked teeth.
2. Clenching/grinding
3. Large filling
4. Cast inlays
5. Older client teeth become more brittle with age
6. Almost always a lower molar

To make sure, use the bite stick. Center it over a cusp. Have your client bite down. Repeat this for each cusp. The client will report no pain on 2 3 cusps, but “the pain” occurs when pressure is placed on the fractured cusp.

A second test is to shine light through the tooth. The fracture will show as a dark line in the tooth. This test doesn’t work very often.

A third test is to use disclosing solution or any other staining medium on the tooth. Rinse and the stain may imbed in the crack and make it visible.

4 Types of Cracked Teeth

1. Crazelines
a. present in most teeth of adults over 30 years old
b. usually along buccal/lingual grooves of posterior teeth and vertical crazing of front teeth
c. effect enamel only, not painful, no treatment necessary

2. Fractured cusp
a. fractured cusp may or may not separate from the rest of the tooth
b. sometimes this can be differentiated from a craze line by illuminating the tooth. The whole tooth will illuminate the same if it’s a craze, but the light won’t pass through a fracture line

3. Split tooth
a. involves the root as well as the crown
b. painful when chewing
c. often see pocketing and bone loss

4. Vertical fracture of tooth that has had a root canal
a. requires extraction of at least a root and usually the whole tooth
b. Symptoms
a. periodontal pocket on only 1 side of tooth
b. Sensitive to percussion/bite
c. Mobility swelling

Clenching and Grinding

When all else fails, when every test is essentially normal, evaluate for clenching and grinding.

Clenching and grinding can overload a tooth and make it sore. The symptoms can be very similar to an abscessed tooth. In fact, if the stress occurs long enough, the tooth may abscess.

Look for these symptoms:

1. The client gives a history of clenching and grinding. Remember that this is usually an unconscious habit. The fact that the client denies it doesn’t mean they don’t clench and grind. It only means they may not be aware of it.

2. You can see worn areas on some of the teeth in the area that is sore. Use your mirror to shine light on the teeth. Look from different angles.

3. Have your client bite down and grind side to side. When your grind side to side the back teeth shouldn’t touch. If this causes pain, then grinding may be the problem.

Referred Pain

Okay, everything is normal, but your client still feels pain. Think about referred pain. Is there an at risk tooth in the opposing arch? Run tests on that tooth. Also muscles, TMJ, and other problems can send pain signals into teeth. These are rare, and extremely difficult to diagnose. Most of these cases will be referred to an endodontist.

Sinusitis (inflammation of sinus)

Clients with sinus drainage may have pain in their upper back teeth. The teeth will test normal, but several of the teeth will ache. The pain will feel worse if they bend over. Look for these
symptoms:
1. All of the teeth on one side will be tender.
2. The apex of the canine, first bicuspid will be sensitive to percussion.
3. Extreme pain will occur if the client bounces on his/her heels

Dry Socket

Severe pain can develop if the bony socket becomes infected following an extraction. You can expect a socket to be sore, but a “dry” socket really hurts. Five factors predispose a person to this problem.

1. Women
2. 30 50 years old
3. Lower molars (followed in order by premolars, upper molars, and finally, incisors)
4. Difficult extraction
5. Smoking

The throbbing pain usually begins 24 72 hours after extraction. The breath smells bad, the socket is open (no little clot), bone is visible, adjacent gums are swollen, neck lymph nodes are often sore.

Sinus Problem

1. Use Afrin nasal spray for 2 days

Now we are ready for the clinical examination.

Now you have enough information to make your own diagnosis. Section C is designed for you to put all your test results together. Here are some diagnoses.

To determine the cause of pulpal and periapical disease.

When diagnosing, the cause of the problem. “Why does this tooth need root canal therapy?” Usually, the answer is obvious: a large decay area; previous pulp cap; large restoration (crown, pin amalgam); a fractured crown exposing the pulp; etc. Except in the cases of crown fracture, cause of the abscess is usually related to decay and the cumulative trauma of operative procedures. An example is clients who developed an abscess after placing a crown on a tooth.

Here’s an example that starts at age 12. Think of all the trauma this tooth has absorbed over the years. When a client comes in and you make the correct diagnosis of an abscess tooth, you will often
be asked, “Why did this happen?” Often there is no answer. Just that recently some added stress was enough to make the tooth acutely sore “The straw that broke the camel’s back.”

caries and restorations at 12 years of age

MOD amalgam at age 15

cusp fracture and recurrent decay at age 21

Locked Jaw (limited opening)

Get this information for your dentist
1. How long has the jaw been locked?
2. Has this ever occurred before? If yes, how was it treated?
3. Is there a known course (infection, blow, etc.)?
4. Did the condition occur suddenly or over time?
5. Does the client have any health problems?
6. Is the client on any medications?

Clinical Exam
1. Measure the maximum intercisal distance
2. Measure lateral and protrusive movements
3. Palpate for muscle or TMJ soreness
4. Any signs infection or trauma (redness, swelling)

Drug Abuse

Occasionally, a drug dependent person may try to get prescription narcotics from us. Look for these signs of chemical dependency:
1. Asking specifically for Percodan, Codeine, etc. “This is the only thing that helps me.”
2. Fail scheduled appointments and only show up as emergencies.
3. Extreme moods: severe reaction to pain, paranoid, depressed
4. No visible reason for the extreme pain
5. A red, runny nose
6. Bloodshot eyes
7. Nervous, slurred speech
8. Very thirsty, constant licking lips

Child Abuse

Although we all think child abuse can’t happen in our community, there were 80,000 reported cases in 1990. Look for these signs:
1. Bite marks
2. Bruises on the face
3. Burns
4. Loose teeth

Sinusitis

Clients occasionally complain that all the upper posterior teeth hurt. This may be an abscessed tooth that hasn’t localized, a gum problem, or sinusitis. Indications of a sinusitis are:

1. All teeth appear normal
2. Gums appear healthy
3. Recent history of cold or sinus problems
4. Afrin nasal spray relieves the symptoms (never use more than 5 days in a row or there may be a rebound effect)

Other non-endodontic pathology that can be confusing:

1. dentigerous cyst
2. odontogenic cyst
3. odontogenic adenomatoid cyst
4. cemento blastoma
5. amelo blastoma
6. central giant cell granuloma
7. nasopalatine cyst

Anatomy that can look like an abscess on x rays

1. Mental foramen (between lower bicuspid root apices)
2. Incisive foramen (between upper central incisor root apices)
3. Superimposition of mandibular root apices over mandibular canals or maxillary sinus

Tooth partially or completely knocked out
1. Tooth needs to be put back into the socket within ½ hour
2. Test the tooth in 2 weeks – if non-vital, will need root canal
3. Tooth must be stabilized to other tooth for several weeks

Here are some examples. See how you do!

1) Tooth is sensitive to biting, thermal changes, and has pain when biting on tooth, but goes away when not closing down on the tooth but no restorations or decay are present.

Explanation tooth has a fracture. The tooth is probably not abscessed. The prognosis is good if a crown is done, but the client must be warned an abscess if possible. Many posterior teeth have cracks, but they aren’t deep enough to create a slippage along the plane of the crack that can pinch the nerve fibers and cause pain. Its almost impossible to know for sure that a tooth is cracked. X-rays, staining, light transillumination, standard tests, nothing really is a perfect test. The best test is the “tooth sleuth.” This plastic instrument has a depression that will fit one cusp. Fit it over the cusp and have your client bite down. Usually the fractured cusp will be sensitive.
Here are some other observations.
1. First molars have the greatest number of cracks
2. Pins, clench/grind, aging and endodontics cause cracks
3. A vertical fracture between the lingual cusps of an upper molar can continue up the palatal root
4. Bruxism runs in families
5. Vertical root fractures are untreatable
6. Everything (hot, cold, pressure) can bother a fractured tooth, but it will never hurt spontaneously
7. If dye shows the crack it is very deep
8. When the client had pain and the pain went away, one of two things happened.
a. The pain was caused by something other than a cracked tooth and it healed itself.
b. A second crack occurred that relieved the stress from the first crack that was painful.

2) Tooth has no restorations or decay, but is sensitive to percussion, pain is very acute and lingers for 2 3 minutes after application of ice. X ray shows much bone loss. You can probe deeply on the distal of the first bicuspid.

Explanation

This is called an endo perio lesion. These are very difficult to treat. The infection feeds on bacteria from the mouth. Treatment begins with endodontics. Next, the tooth is thoroughly cleaned and root planed. Finally, the client is given thorough instructions in home care and a prescription for Peridex. Several months later the tooth will be evaluated to see if bone has filled in.

3) Shallow fillings or no fillings present, x ray looks normal, but the client is having pain. The teeth test normal to ice, percussion and EPT.

Another x ray shows an impacted third molar.

Explanation

Even though the patient thought the pain was coming from the first molar, the pain was referred from a gum infection associated with the third molar.

4) A deep restoration on the first molar pulp tests and radiograph are normal; patient has pain in this area.

Explanation

Took a “wait and see” approach two days later the e patient called and explained that she had an acute ear infection, just diagnosed by her E.N.T. specialist.

5) Lower anteriors, deep restorations, but normal pulp tests, no pain, radiolucencies around several lower teeth.

Explanation

Bone is involved with a cementoma. Pulps are not involved. It’s important not to jump to a conclusion!

d) Upper molars ache, shallow restorations, normal pulp tests, palpation is positive, slight sensitivity to percussion on all molars.

Explanation

Patient has a maxillary sinusitis. (A good history usually reveals previous sinus problems.) Refer to physician.

e) Gingival swelling, deep restorations, dull pain, all teeth pulp test normal. Periodontal probe goes down 6 7mm between the molars .

Explanation

The client has a periodontal “abscess”.

A “reversible pulpitis” only means that the tooth has been stressed, but the nerve is still healthy.
Examples:
1. Root sensitivity give desensitizing paste
2. Crown prep with temporary crown remove temporary crown, place desensitizer for 1 2 days, then replace with regular temporary cement.
3. Deep decay client gets priority for filling within 24 48 hours. Try to place temporary filling in the meantime.

An “abscessed tooth” has 3 possibilities:
1. “Non necrotic” means a recent abscess that still has much vital nerve tissue remaining.
2. “Chronic” means an abscess that has existed for some time, but is usually not very painful. Remember, less than 1/2 of abscessed teeth will show an area on the x ray or have any pain.
3. “Acute” means pain. These are easy to diagnose.

When you have made your tentative diagnosis, record it on the bottom line of section “C” labeled diagnosis.

Remember, there are other causes for pain. It could be a sinus infection, impacted food, canker sores, burns from hot foods, or clenching and grinding stress on teeth.

Now it’s time to discuss what you are seeing with your client. Remember, you may be wrong, so don’t be too positive, but say something like, “I believe” or “The tests seem to show” etc.
Many emergency clients have had other emergencies in the past. Often they have had teeth extracted. One of our goals is to help people keep their natural teeth all their life. While you are counseling this client, try to get them to look to the future. Don’t focus on this one tooth. Focus on whether they plan to lose all their teeth or not. The best question is “Do you want to have your natural teeth all your life or do you plan on wearing false teeth?” Never ask “Do you want to have a root canal or an extraction of this abscessed tooth?” The client may easily choose a single extraction. It is cheaper, quicker, and easier than a root canal. However, if the client wants his natural teeth, then it’s cheaper and more comfortable for him to save his tooth than to be involved in the replacement and maintenance in the future.

If your client is in pain, use the following steps:
1. Empathize with your client show them you care that they are in pain and you’ll do your best to help them get rid of the pain.
2. Determine the kind of pain the way your client responds to this pain is often how they will respond to our treatment: panic, resigned, accepting, uncontrollable, etc.
3. Have they ever had a similar pain in another tooth
4. If yes, how was it treated
5. If client says had root canal, they go ahead and plan toward root canal, if had pulled, then time to future focus also ask if they had wanted to save the tooth.

It is fair to say to your client “If I were you, I’d do _______.

If I didn’t have the money, I’d do _________.

Look to see if your client is on welfare. A root canal requires an xray and a preauthorization (takes time to receive the approval). We will work to get your client free of pain while we’re waiting on the authorization. If they don’t want to wait, they can make a financial arrangement for the fee that the welfare department pays (substantially less than our regular fee) and we will start the root canal now. When we receive payment, we will reimburse the client.

A client with dental insurance, explain to them that their insurance will cover part of the fee. If they want to know exactly how much, excuse yourself and check with the secretaries. This may affect your client’s decision.

Fees are posted in various areas around the office. Be sure to find out the fee and tell your client. Focus your client on the future “Are you planning to lose all your teeth and wear dentures or would you like to have your natural teeth?” If you ask about this one tooth only, they may very well decide to have it pulled. However very few people plan to wear dentures.

When your client is relaxed, understands the problem, and how s/he wants to solve it, call your doctor in. If you have some free time before the doctor arrives, learn about your client. Where does s/he live? What does s/he like to do? Reassure the client about the gentleness and skill of your doctor. Don’t just sit quietly. Now is a great time to begin to develop your client’s relationship to the office. Write down as much of this information as possible either in the treatment section if the comments are about the tooth or in the client remarks section if they are about themselves as a person.

Although it’s quite early in your professional career, this is a good time to practice your communication skills. Here are some tips:
1. Be personal Don’t be too technical. Look clients in the eye . Learn about them as people. Smile. Be confident.
2. Find out what your clients want discuss all treatment in terms of what is important to your client.
3. Explain what you are doing.
4. Explain your interpretation of the tests.

Look for the benefits that people want:
1. Health
2. Save money
3. Avoid pain
4. Good appearance
5. Approval of others friends, business

Many emergency clients hate to come to a dentist. They’ve been through this before in other offices. Rushed. Talked down to. Made to feel stupid and guilty. Hurt. Cost too much money. All these thoughts are passing through your client’s mind. Discuss the value of a thorough exam to sort out the problems so your client can set priorities. Try these phrases:
1. You have other problems that could also be painful within 1- 2 years.
2. Pain is the body’s warning of last resort. It only comes after much healthy tissue has been lost.
3. You’ll likely experience this again without regular care and that is exactly what you’d like to avoid.
4. The longer you wait, the more difficult, painful, and expensive treatment becomes.
5. last, and best! Would you like to have your natural teeth all your life?

Your job is to begin to change your client’s attitude. You can be responsible for turning a dental cripple in to a happy, dentally healthy missionary for our office. Discuss the value of a thorough exam to sort out the problems so your client can set priorities. Try these phrases:
1. You have other problems that could also be painful within 1-2 years.
2. Pain is the body’s way of warning of last resort. It only comes after much healthy tissue has been lost.
3. You’ll likely experience this again without regular care and that is exactly what you’d like to avoid.
4. The longer you wait the more difficult, painful, and expensive treatment becomes.
5. Last and best! Would you like to have your natural teeth all your life?

Show your concern in every way possible. Don’t treat emergencies like an unwanted interruption in your day. Be on time. Be confident. Be friendly. Smile. Help your client feel at home.

When the doctor comes in, introduce the doctor to your client and then review:
1. Your test results
2. Your tentative diagnosis
3. How your client feels about potential treatment

Now it’s the doctor’s job to take over. Take good notes in the yellow sheet treatment section and support the doctor. S/he may run additional tests such as anesthesia, a test cavity, or “wait and see”.

Anesthetic Tests:
Anesthetic testing involves giving a local anesthetic to differentiate where the pain is coming from. It won’t differentiate pain in adjacent teeth. The most common use is to differentiate pain in the maxilla from pain in the mandible. Referral of pain can go from the mandibular teeth to the maxilla and from the maxillary teeth down to the mandible. Pain referral never crosses the midline. Usually a peripress is used. This numbs only one or two teeth at a time.

Interpretation of Results:
i) If anesthetic is given in the mandible, for example, and the pain goes completely away, it is a mandibular tooth that is causing the problem. However, you still had to determine which tooth it was before giving the anesthetic; otherwise, there would be no way to test the teeth after being numbed.
ii) If anesthetic is given in the mandible, for example, and the pain is still present, it is probably a maxillary tooth. Since it isn’t numb, you may be able to isolate the offending tooth.

An Important Note: This test is not used for routine pulpal diagnosis. It is used in differentiating
abnormal or difficult diagnostic endodontic problems.

Wait and See:

In some cases, the patient has had pain, or is now having pan but cannot localize it to a specific tooth. Your pulp tests are not conclusive and there are no radiographs changes. What do you do?
Be honest. Tell the patient, “We have tested your teeth and the results are not conclusive. The radiograph doesn’t show any change; however, this is not unusual when teeth are just starting to “abscess.” The problem is we are not sure which tooth needs a root canal. We can start a root canal on a tooth, but that may not help you with your problem If a tooth is “abscessing” you and I will know in time since the discomfort will localize a tooth and there may be a change on the x ray which we can see.”

Reappoint the patient in a day or two, and retest the teeth then.
Usually, this is enough time to be able to diagnose the problem. However, in some cases a longer time interval is needed.

Often your doctor will give the patient a prescription for a pain medication in case the pain become severe before the next appointment. Nursing mothers should avoid aspirin. It can be very toxic to the baby.

When the doctor leaves, make sure your client understands what happened today and what future treatment will involve. You should make sure they are given any appropriate handouts, such as “Am I Losing My Nerve?” When you escort your client to the secretary, tell her what, if any, prescriptions need to be called in, and the time for the next appointment. If the tooth was opened, explain this to your client. “Today the doctor opened your tooth to let the infection drain and relieve the pressure that caused the pain.”

Malpractice Write down everything the doctor and client say. Did your doctor warn the client about possible problems? Why didn’t the client make an appointment? The clients emotions anger, fear, distrust, should be recorded.

New Patient Emergencies

You can help a new patient who starts out in our practice with a dental emergency by giving them a choice – do they want to have their natural teeth all their life or are they planning on dentures? They get to choose – and you can help them to make this decision.

Here are some of the objections you may hear:

1) Money Issues
Let the patient know: A comp exam and CMS is preventive way and is a cheaper route in the long run. If you decide you want your teeth all your life then it only makes sense for me to do a thorough exam. The better I understand what’s going on, the fewer costly mistakes we’ll make and the easier for you to set priorities you can afford. We can spread the cost out over 4-5 years. As long as you’re better every year and you can stay in your budget, you’ll get where you want without pain or expensive surprises.

2) Time
It only takes 1&1/4 hours

3) Why not just a cleaning?
We can do a cleaning on the same day as your thorough exam but they are very different. A cleaning includes 5 minutes with me to look for decay and big problems. A complete exam gives me time to learn everything about your head, and neck( bone level, abscesses and the front teeth which do not show just on bitewing x-rays) so you can know what’s going on-problems, choices, fees, so you can set your priorities.

4) Will insurance pay for it?
I don’t know. Most insurances cover it well once every 60 months because the insurance companies prefer this approach. It save them significant in the long run.

To get signed off on this section, you need to make a tape of this conversation.

______________________________
Dr.  date

Pain

Many of our clients that come to us for an emergency are in “pain.” Much has been learned about pain in the last four years.
Here is a condensed version of the results from several pain conferences.

Pain is not an unpleasant sensation caused by a stimulus. Pain is anything that hurts.
Pain is an emotion tied to:
1. Past experience of the person
2. The environment where it is experienced
3. Our staff communication/rapport with the client
4. Client’s fear/anxiety level
5. Whether client wants procedure
6. Only then the stimulus strength
7. Men won’t tell you when in pain as often as women

Ways to decrease pain emotion
1. Calm the client and help them desire the procedure
2. Communicate to your client “I care about you.”

Post Operative Pain Suggestions
1. Ask how much pain relief client wants
2. Ask what they have taken before that helped
3. Codeine is only effective for 3 hours

Only 1/3 of our clients follow our instructions
1. Clients don’t always understand our instructions
2. Clients don’t always listen to or remember instructions

Ways to help client follow our instructions
1. Explain what each medication is for
2. Give out a pink medication sheet and circle the medications they will have

Remember, it’s as important to know what kind of client has the disease as well as what disease has the person

Children

1. Baby tooth knocked out leave out. There is no chance of success by re-implanting. If the tooth is very loose from trauma, it should be extracted.

2. Tooth displaced (knocked out of position) Reposition it. Stabilize it if too loose.

3. Intruded tooth (push into gums) let it re erupt on it own. Tooth should be extracted if it doesn’t re erupt.

Emergency Exam Cheat Sheet

Assistant:
1. Seat patient
2. Assess problem
3. Review medical history
4. Bring blue sheet to DDS
5. Run tests
6. Bring results to DDS
7. Support/dismiss
8. Computer, schedule, check out

Charting:
1. Emergency exam (x-rays)
2. Description of problem with tooth #
3. Discussion of tx options
4. Tx decision
5. Today’s tx if any
6. Medications