A pregnant patient in her THIRD trimester attends in severe pain. The radiograph appears normal. What is the most appropriate management?

Correct answer: A. Open the tooth, extirpate the pulp and place a sedative dressing

• A. CORRECT. Acute pain is an urgent indication for treatment in any trimester — untreated infection and severe pain pose a greater risk to mother and fetus than the treatment does. The appropriate emergency intervention is to access the tooth, EXTIRPATE the inflamed or necrotic pulp, and place an intracanal medicament and a temporary restoration. This eliminates the source of pain quickly, in a SHORT appointment, allowing the patient to be positioned comfortably and definitive treatment to follow.
• B. Completing a full root canal in the third trimester is not wrong in principle, but the LENGTH of the appointment is the practical problem. In the third trimester, prolonged supine positioning risks SUPINE HYPOTENSIVE SYNDROME from caval compression by the gravid uterus, and the patient is generally uncomfortable. Keep appointments short, position the patient in a left lateral tilt with a wedge under the right hip, and allow frequent breaks.
• C. Opioid analgesia masks the problem without treating it. Acetaminophen is the analgesic of choice in pregnancy; NSAIDs should be avoided in the third trimester because of premature closure of the ductus arteriosus.
• D. Antibiotics do not treat irreversible pulpitis — they do not penetrate an inflamed or necrotic pulp — and deferring care leaves the patient in pain and risks the infection spreading. Emergency dental care is appropriate in every trimester.

Note: Pregnancy quick reference: SECOND trimester is optimal for elective care. Radiographs with a lead apron and thyroid collar are acceptable when diagnostically necessary at any stage. Safe drugs — acetaminophen, penicillins, cephalosporins, clindamycin, lidocaine with epinephrine. Avoid — NSAIDs in the third trimester, tetracyclines throughout, metronidazole in the first trimester, and nitrous oxide in the first trimester.