Diagnosis review

Many patients will present at this stressful time with pain. We need to distinguish if this is odontogenic or non odontogenic, reversible or irreversible. We will have less time with the patient in the surgery, so maybe consider getting a good pain history, over the phone, before booking an appointment . Speak directly to the patient yourself.. I will list a few symptoms to look out for as an aide memoire . As is the case normally, only access the pulp chamber if you are convinced the pulp is necrotic and access will relieve symptoms.We do not want aerosols produced un necessarily.If you dont have the appropriate mask then think carefully about producing an aerosol.You must use rubber dam. A pre treatment rinse with 1% hydrogen peroxide is advised , then disinfect the tooth with hypochlorite solution 1-5 %

Tests

Palpation - check for tender masseter, temporalis or pterygoid ? Is the patient bruxing. Is the answer occlusal adjustment or splint - quick splints made of acrylic will not result in aerosol production .

Cold test.  83% accuracy ie if negative 83/100 pulps are necrotic

Bite test.  Tooth slooth to search for fractured cusps -Transillumination with curing light will reveal a fractured cusp if present - Can we adjust/remove the cusp  ?

Selective anaesthesia can help localise problem teeth when there is referred/diffuse pain.

Fractures- vertical root fracture = XLA  probing depths will be increased around site of #, pain can be illicited when percussing from a specific direction, tooth sleuth on individual cusp might give a response.

Pulpal health 

A normal pulp will respond to stimuli, recovers quickly . Normal radiographic appearance- ie contra lateral tooth to suspected problem tooth.

Reversible pulpitis is caused by caries , exposed dentine, recent treatment, occlusal interferences. Response to stimulus is rapid - A delta fibres.

Irriversible pulpitis can be symptomatic or asymptomatic. Symptomatic may be the most difficult to control, particularly in the lower arch. Consider possible anatomical issues- bifurcated ID nerve, cervical nerve fibres. You may need to deposit anaesthetic intra ligamental interproximal, possibly distal to last molar on the ramus of the mandible. For upper teeth consider posterior superior alveolar nerve block . Nerve fibres (C) might continue to send signals before tooth becomes completely necrotic. Anaesthetic may take longer to work if there are changes apically in terms of pH, so blocks might be more useful. Access tooth if necessary to remove inflamed tissue from the pulp chamber or establish drainage. Give the tooth a minute or so to equalise the pressure (possibly aspirate) .Dress with CaOH , or if hyperaemic use a steroid containng paste -Ledermix/odontopaste .Place a robust temporary - cavit/colt  covered with GIC

Necrotic teeth will often give pain response to hot.You may need to access to relieve symptoms.Establish drainage 

Acute Apical Abscess - pt may well have a temperature. Difficult to determine if this is abscess or Covid 19 - take a good history. In this scenario maybe refer for coroavirus test and or consider antibiotics, rather than risk the team/other patients ?

Treatment 

Reversible pulpitis - adjustment , desensitising paste/varnish, TMJ therapy

Irriversible pulpitis - LA, rubber dam, access-remember the canal is in the middle of the tooth, look at the root shape at the gingival margin...Well fitting mask -visor.

Swelling - incise and drain , consider antibiotic- follow up by phone to see if symptoms ease ?  I would prefer access and  possibly open drainage aswell - (we need to minimise aerosol.)

Antibiotics- we do not want patients going to A&E at this time with dental issues.Swelling ,trismus , progressing infection, cellulitis can be managed with antibiotics but if we cant get drainage then access of the offending tooth is desirable.It seems the teeth that present with swelling but dont drain often flare up.Keep in contact with these patients and monitor improvements.

Analgesics. Nurofen 600mg QDS with or without 1000mg Paracetemol. Consider alternate dose every 2 hours.

More info at https://britishendodonticsociety.org.uk/covid-19-guidance-for-primary-dental-care/