Pregnant patient with lingering pain

Correct answer: C. Symptomatic irreversible pulpitis

• A. A chronic apical abscess is characterised by a draining sinus tract and is typically asymptomatic or only mildly uncomfortable — the opposite of this presentation.
• B. In reversible pulpitis the pain is sharp but resolves within seconds of removing the stimulus, and there is no spontaneous or nocturnal pain. Removing the irritant lets the pulp recover.
• C. CORRECT. Pain that LINGERS after the stimulus is removed, is spontaneous, wakes the patient at night, and is relieved by cold in a hot-sensitive tooth is the classic picture of symptomatic irreversible pulpitis. The pulp cannot recover and must be removed.
• D. A necrotic pulp does not respond to thermal testing at all. This pulp is responding vigorously.

Note: Full diagnosis for this tooth: symptomatic irreversible pulpitis WITH symptomatic apical periodontitis. INBDE expects both a pulpal and a periapical diagnosis for every endodontic case.

Correct answer: A. Immediately — pulpectomy or root canal treatment should not be deferred

• A. CORRECT. Pulpectomy is performed IMMEDIATELY. Untreated infection and uncontrolled pain are themselves risks in pregnancy — pain generates maternal stress and catecholamine release, and untreated dental infection is associated with adverse pregnancy outcomes. The second trimester is the most comfortable operative window, and this patient is in it, but urgency overrides timing in any trimester.
• B. Waiting for swelling means waiting for the infection to spread. That is precisely what treatment is meant to prevent.
• C. Deferring until delivery leaves months of pain and an infected pulp. Analgesic management of irreversible pulpitis is not treatment.
• D. The third trimester brings supine hypotensive syndrome and simple physical discomfort in the chair. It is the LESS favourable window, not the more favourable one.

Note: Radiographs when clinically indicated are safe throughout pregnancy with a lead apron and thyroid collar — the fetal dose from a dental film is negligible. Position the patient slightly on her LEFT side in the later stages to keep the gravid uterus off the inferior vena cava.

Correct answer: C. Acetaminophen

• A. NSAIDs are avoided, especially in the third trimester, because prostaglandin inhibition can cause premature closure of the ductus arteriosus, oligohydramnios and prolonged labour.
• B. Benzodiazepines are avoided in pregnancy and are not analgesics in any case.
• C. CORRECT. Acetaminophen is the analgesic of choice throughout pregnancy. It has the longest safety record and no established teratogenic or fetal circulatory effect at therapeutic dose.
• D. High-dose aspirin carries the same prostaglandin-mediated risks plus bleeding risk for both mother and neonate. (Low-dose aspirin prescribed by an obstetrician for pre-eclampsia prophylaxis is an entirely different matter.)

Note: Safe in pregnancy: acetaminophen, penicillins, cephalosporins, clindamycin, lidocaine with epinephrine, isoniazid, folic acid, levothyroxine. AVOID: NSAIDs and high-dose aspirin, tetracyclines, benzodiazepines, nitrous oxide in the first trimester.