INTRODUCTION
Reason for endodontic emergency treatment is pain and at times swelling ensuing from pulpo periapical pathosis. Grossman – “endodontic emergencies are like unwelcome guests at a dinner table”.
Dentist must provide speedy and effective relief because such care is an essential part of daily practice and such act will create goodwill on the part of the patient and are practice builders.
90% of the patients reporting to the clinic with pain or swelling have pulpal or pulpoperiapical disease.
PAIN
Pain is an unpleasant sensory and emotional
experience associated with actual or potential tissue
damage.
Patients perception of the pain
Usually – pulpal or periapical tissue
inflammation. Referred pain, more complex facial pain, TMJ pain, non-odontogenic pain–difficult to diagnose
Individual responds to pain in many different
ways
Dentist
must
recognize and distill
these from
personal them the
interpretations
clinically objective terms
The professional‟s perception of the patient in pain Doctor‟s reaction to the patient is important for both pain and patient management.
Both the physical problem & emotional state
must be understood
Always maintain eye contact Show support for the complaint
Reduce the anxiety of the patient.
PHYSIOLOGY OF PULPAL PAIN
The sensibility of the dental pulp is controlled by myelinated (A-delta) and unmylinated (C) fibers. Both sensory fibers conduct nociceptive input to the brain. Difference between the two sensory fibers enables the patient to discriminate and characterize the quality, intensity, location and duration of pain response.
REVERSIBLE PULPITIS
Causative Factors Restoration with high point Incipient caries Fractured restoration Fractured cusp Exposed dentinal tubules
Clinical Characteristics
Sensitivity of tooth Pain of short duration or shooting sensation Infrequent episode of discomfort
Symptoms usually subside immediately or shortly
after removal of etiology
Rx – removal of causative factors, restoring lesions,
ZOE dressing for deep cavities
IRREVERSIBLE PULPITIS
Acute Pulpitis large carious lesion or with defective restoration
Severe pain is elicited in thermal change, particularly cold
Pain is of piercing or lancinating type
The intensity increases when patient lies down
Reacts to electric pulp tester at a lower level of current than in a normal tooth Not sensitive to percussion Radiographically – no change
ACUTE PULPITIS WITH APICAL
PERIODONTITIS
Clinical Characteristics Entire pulp is inflamed Pain on percussion Heat causes intense pain, cold relieves Radiographically – may appear normal, may
show small periapical radiolucency, or exhibit a
thickening of lamina dura.
TREATMENT
Minimal amount of time Single rooted teeth Multi rooted teeth
Pulpectomy and closed
dressing
Pulpotomy and
formocresol application closed dressing
Considerable amount of time
Pulpectomy + cleaning and shaping Pulpectomy & working length determination Tooth is relieved from occlusion Pulpectomy- treatment of choice
Open dressing or Closed dressing ? Weine et al – tooth left open during inter appointment visit, needed 5-6 visit to complete the treatment. 3-4 visits for tooth left with closed dressing. Any tooth without continuous exudation should be given a closed dressing.
PULP NECROSIS
Usually pain is not a symptom
Patient may note a swelling and request for
treatment
Radiographically - large periapical radiolucency. Definite thickening of the periodontal ligament.
Mild or no sensitivity to percussion. No response to pulp vitality tests.
Treatment Anaesthesia usually not required Access cavity prepared, W/L determined, canal sufficiently enlarged. Copious irrigation with saline Closed dressing given
ACUTE PERIAPICAL ABSCESS
Large diffused swelling Tenderness to percussion Mobility of the tooth Generalized swelling may be absent, but patient usually reports that the pain was present before the appearance of swelling. Radiographically–radiolucency margin with diffused
Treatment
Treatment of choice- incision and drainage Always attempt to drain the pus through the root canal itself
Procedure Block anaesthesia is recommended Standard access prepared Drainage starts, on removal of roof of the pulp chamber Apical constriction purposely widened to file size 20-25
Aspiration using a suction device to aid drainage
Irrigation - warm saline
Canal left open or closed depending upon drainage
If closed dressing is planned…. Wait till forceful exudation has dissipated Determine W/L, enlarge the canal to several sizes Canal thoroughly irrigated and dried Closed dressing
Advantages of giving a closed dressing
No
new
type
of
microorganism
system
is
introduced Total no of appointments reduced Neither food nor debris is packed into the canal
Disadvantage
Very long and sometimes inconvenient initial appointment
Open dressing is planned …… First appointment – access opened and patient
send with an open canal Second appointment – W/L is determined and
canal enlarged to desired no of size and canal left open. Third appointment – Canal thoroughly irrigated
with NaOCl and H2O2. But not instrumented this time. Closed dressing given.
Drainage through the tissue and bone Indication Failure of drainage through the root canal Presence of a post and core restoration Sectioned silver point Heavily calcified canal
PROCEDURE
Artifistulation
Anaesthesia, small stab incision made just below
most dependant area
Using a sterile sharp instrument a small window is made
To prevent closure of the incision a „T‟ or „H‟ shaped rubber dam drained is sutured at the site.
Trephination
Perforating the cortical bone using engine – driven
burs or a hand operated trephine to release the pressure and exudate around the apex of the tooth. Flap increased to allow visualization Bone is removed until the tip of the root is uncovered „H‟ or tube drain placed
Inadequate analgesia
Main reasons
Pulpal inflammation produces hyperexcitability of the nerve fibres (C-
fibres), L.A sol. Is unable to block conduction of all impulses
There is Increased vascularity of the tissue – LA rapidly removed Tendency for pain to increase neural transmission in the spinal cord –
countering the effect of analgesics
The pH of inflammatory products may be more acidic – making LA sol.
potentially less effective
Alternative techniques
Intrapulpal anesthesia Periodontal ligament injection Intraosseous injection Use of more potent anesthetic (Bupivacaine) Sedation or general anesthesia
MID TREATMENT FLARE UPS
Acute exacerbation of periradicular pathosis after initiation or continuation of RCT Incidence – 2.5 to 15%
VITAL TEETH
Presence of pulp tissue
Overmedication, Debris extrusion
Over instrumentation, hyper occluding teeth
Rx – Through debridement, copious irrigation selective occlusal reduction, NSAIDs
PULPLESS TEETH
Sustained periapical inflammatory reaction Phoenix abscess associated with periapical lesion & absence of sinus tract More predisposed than vital teeth Incidence – 2.5%, after initial treatment 10%, retreatment
TREATMENT Through debridement
Canal patency
Incision and drainage
Surgical trephination
Antibiotics and analgesics
OPERATOR FACTORS IN FLARE UPS
WALTON & FOUAD (1992)
Biting or chewing pain, or parasthesia Reassessment of the periapical tissue for over instrumentation, overfilling or under filling
Fracture of the crown or the root
Rx – Retreatment
Surgical trephination
Root end surgeries
EMERGENCY TREATMENT FOR TRAUMATIC INJURIES
Crown fracture, root fracture, luxation or avulsion Causes – accidents, sports, games. 7 to 14 years
Treatment may be complicated by local edema, bleeding or other consequences of accidents like- loss of consciousness . Temporary parasthesia occurs, difficult to evaluate condition of the injured pulp
CROWN FRACTURE WITHOUT PULP EXPOSURE
fracture deep into dentin , chipped a small portion of enamel
Dentin exposed- thin mix of ZOE placed over exposed dentin celluloid crown festooned, filled with thick mix of ZOE cemented into place – sedative effect following appointment – both fractured & neighboring tooth checked before permanent
restoration
CROWN FRACTURE WITH PULP EXPOSURE
Presence determined
or
absence
of
apical
closure
is
Closed apex - pulpectomy and conventional endodontic treatment
Open apex – pulpotomy, leaving the apical portion of the pulp for completing apexogenesis.
Tooth monitored - three to six months interval Routine endodontic treatment after completion of root formation.
AVULSED TEETH Complete displacement of the teeth from out of the socket. Replantation - carried out immediately Poor prognosis – more than 20 mins
TECHNIQUE FOR REPLANTATION
Part I - emergency treatment at site of injury
After washing the tooth under running tap water,
the patient or a responsible person should replant the tooth immediately. Touching the root surface – avoided Report to a nearest dental surgeon
If it becomes impossible to reinsert the tooth, tooth has to be carried in a suitable transport medium.
TRANSPORT MEDIUM
Saliva, milk, water Hank’s Balanced Salt Solution (optimal storage media) Ability to rejuvenate cells of the PDL Sodium chloride Potassium chloride Calcium chloride Magnesium chloride Magnesium sulfate Glucose Sodium bicarbonate Sodium phosphate
Part II - emergency treatment at dental office
Take history, examine the area
Radiograph – tooth‟s position in the socket and if satisfactory, splint the tooth
If tooth is not replanted Do not curette or attempt to sterilize Clean the root surface gently with a wet sponge Irrigate the socket with saline
Do not attempt RCT or cut the root tip Implant the tooth firmly into socket Splinting – orthodontic wire, arch bars, acrylic and wire combination
Pre-op
After replantation and splinting
Part – III completion of endodontic treatment After one week, perform cleaning and shaping, place Ca(OH)2 Teeth with undeveloped apices may be watched without pulp extirpation – pulp may revitalize sufficiently for continued apical development If necrosis has occurred – debride the canal followed by apexification procedure
After three to four months – obturate the canal
Recall the patient in every 3 months
4 month post-op
3 year recall
3 year recall
Removal of Splint (Andreasen)
Splint should replantation be removed one week after
Splint in place too long – ankylosis or inflamatory resorption
Postoperative Instruction
Soft diet Antibiotic and analgesic is prescribed Anti tetanus booster
HYPOCHLORITE ACCIDENT
Comparatively rare occurrence Reaction is intense, occurring instantly with severe pain and swelling Locking the needle, forcibly injecting the irrigant Management
Administer a regional block
Assure and calm the patient Monitor tooth for half an hour for bloody exudate High volume evacuation Antibiotics and analgesics
CONCLUSION
The art and science of endodontic diagnosis and treatment have undergone a tremendous scientific & technologic evolution . As a result the dental profession is prepared and able to remedy one of man’s most painful and feared afflictions with compassion, knowledge, and skill