ENDODONTIC EMERGENCIES

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ENDODONTIC EMERGENCIES
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-ENDODONTIC EMERGENCIES ARE CHALLENGE IN BOTH
DIAGNOSIS MANAGEMENT-EVERY CASE IS A COMPLETE
SEPARATE STORY
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-DENTIST SHOULD INTERFER-NEVER DEPEND ON
MEDICATIONS ALONE
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DEFINITIONOF EMERGENCYCASES ASSOCIATED WITH
PAIN / OR SWELLING REQUIRE IMMEDIATE DIAGNOSIS
TREATMENT
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KEYS QUESTIONS TO DETERMINE THE
CASE1-DISTRUPTION OF SLEEPING,WORKING
EATING2-DURATION3-PAIN MEDICATION
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CAUSES OF THESE EMERGENCIES ARE IRRITANTS
THAT INDUCE SEVERE INFLAMATION IN PULP
PERIRADICULAR TISSUES
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THESE IRRITANTS LEAD TO THE RELEASE OF A GROUP OF
CHEMICAL SUBSTANCES THAT INITIATE THE INFLAMATION
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THESE SUBSTANCES CAUSE PAIN IN TWO
WAYS1-DIRECTLY BY LOWERING THE RESPONSE
THRESHOLD OF SENSORY NERVES2-INDIRECTLYBY
INCREASING VASCULAR PERMIABILITY PRODUCING EDEMA
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THE MAIN CAUSE OF THE PAINISEDEMA RESULTS IN
INCREASED FLUID PRESSURE WHICH STIMULATES PAIN
RECEPTORS
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THE IMMEDIATE GOAL OF THE TREATMENT SHOULD BE THE
REDUCTION OF PRESSURE OR REMOVAL OF THE INFLAMED
PULP OR PERIRADICULAR TISSUE.
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PSYCHOLOGICAL MANAGEMENT IS THE MOST
IMPORTANT1-CONTROL THE SITUATION2-GAIN THE
CONFIDENCE OF THE PATIENT3-PROVIDE ATTENTION
SYMPATHY4-TREAT THE PATIENT AS AN IMPORTANT
INDIVIDUAL
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• -PATIENT IN PAIN OFTEN PROVIDE INFORMATION AND
  RESPONSES THAT ARE EXAGGERATED INACCURATE.
• -ALSO HE MAY GIVE YOU FALSE IMPRESSION.
• -BE AWARE OF THE REFERRED PAIN SYSTEMIC
  CONDITION.

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PROPER DIAGNOSIS IS VERY IMPORTANT TO TREAT THE
CASE1-OBTAIN MEDICAL DENTAL
HISTORIES2-SUBJECTIVE EXAMINATION3-VISUAL
EXAMINATION4-INTRAORAL EXAMINATION5-PULP
TESTING6-PULPATION PERCUSION7-RADIOGRAPH
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1-OBTAIN MEDICAL DENTAL HISTORIES
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2-SUBJECTIVE EXAMINATIONQUESTIONSHISTORY,LOCAT
ION,DURATION,SEVERITY,NATURE,STIMULATING AGENTS.
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PAIN CAUSED BY THERMAL CHANGES IS OF PULPAL
ORIGIN.PAIN CAUSED BY PRESSURE IS OF
PERIRADICULAR ORIGIN
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PAINSPONTANEITY,INTENSITY DURATION.
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-Initial diagnosis is reached after this
subjective question-OBJECTIVE TESTS
RADIOGRAPHICAL EXAMINATION ARE USED FOR
CONFIRMATION.
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3-OBJECTIVE EXAMINATIONS
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A-EXAMINATION OF FACE ORAL SOFT HARD
TISSUE.(SWELLING,RESTORATIONS,DISCOLARATION,CARI
ES,FRACTURES)
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B-PERIRADICULAR TESTS-PALPATION OVER THE
APEX-DIGITAL PRESSURE ON THE TEETH-LIGHT
PERCUSSION
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C-VITALITY TESTS OF THE PULPCOLD,HOT,ELECTRICA
L,,,,CAVITATION.
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D-PERIODONTAL EXAMINATIONPROBING IS VERY
IMPORTANT
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PERIODONTAL ABCESS CAN SIMULATE THE SYMPTOMS OF
ACUTE APICAL ABCESS BUT THE PULP HERE IS VITAL
POCKETS ARE PROBED.
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4-RADIOGRAPHIC EXAMINATION
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PROPER DIAGNOSIS IS REACHED
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TREATMENT PLAN
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THE IMMEDIATE GOAL OF THE TREATMENT SHOULD BE THE
REDUCTION OF PRESSURE OR REMOVAL OF THE INFLAMED
PULP OR PERIRADICULAR TISSUE.
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FIRST STEP IN TREATMNT IS PROFOUND
ANESSTHESIATO GAIN PATIENTS CONFIDENCE
COOPERATION
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UPPER JAWINFILTRATION OR BLOCKLOWER JAW
INFERIOR ALVEOLAR BLOCK.( LINGUAL LONG BUCCAL
BLOCK MAY BE HELPFUL)
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SOMETIMESPERIODONTAL,INTRAPULPAL OR
INTRAOSSEOUS INJECTIONS MAY BE NEEDED
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EMERGENCIES 1-PRETREATMENT2-INTERAPPOINTMENT3-
POSTOBTURATION
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PRETREATMENT
EMERGENCIES
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1-PAINFUL IRREVERSIBLE PULPITIS WITHOUT APICAL
PERIODONTITIS
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DIAGNOSIS1-PAIN ON THERMAL STIMULI (MAINLY
HOT)2-NO PAIN ON PERCUSION3-SPONTANOUS
PAIN4-NO RADIOGRAPHIC PERIAPICAL CHANGES
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TREATMENT-PROFOUND ANESTHESIA-COMPLETE PULP
EXTIRPATION -CLEANING SHAPING OF THE CANALS IS
DESIRABLE.-IN MOLARS PULPOTOMY MAY BE ENOUGH
TO RELEASE PRESSURE-MEDICAMENTS CAMPHOR SEALED
IN THE CANALS.-A MILD ANALGESICS BUT NO
ANTIBIOTIC
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2-PAINFUL IRREVERSIBLE PULPITIS WITH ACUTE APICAL
PERIODONTITIS
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-THE SAME AS ABOVE BUT WITH SLIGHT TO SEVERE PAIN
ON PERCUSION-RADIOGRAPHICALLY SLIGHT WIDENNING
OF THE LAMINA DURA AROUND THE APEX
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THE SAME TREATMENT BUT1-MAY NEED RELIEF OF
OCCLUSION2-ANTIBIOTIC IS NOT NEEDED
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3-PULP NECROSIS WITHOUT SWELLING
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DIAGNOSIS-TOOTH NOT AFFECTED BY THERMAL
STIMULOUS-PAIN ON PERCUSION-PERIAPICAL
RADIOLUCENT LESION MAY BE SEEN
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TREATMENT-ANESTHESIAINFLAMED PULP REMENETS IN
THE APICAL CANALS OR THE INFLAMED PERIRADICULAR
TISSUE-COMPLETE DEBRIDMENT IS THE TREATMENT OF
CHOICE-HEAVY IRRIGATION WITH COPIOUS AMOUNT OF
SODIUM HYPOCHLORITE
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-DRY THE CANALS WITH PAPER POINTS -FILL THE
CANALS WITH NON SETTING CALCIUM
HYDROXIDE.-MEDICAMENTS CAMPHOR SEALED IN THE
CANALS CLOSE IT WITH TEMPORARY FILLING-MILD
ANALGESIC IS NEEDED(ANTIBIOTIC IS RARELY NEEDED)
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4-PULP NECROSIS WITH LOCALIZED SWELLING(associate
d with acute apical abcess)
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-TOOTH MAY HAVE SOME MOBILITY VERY SINSITIVE TO
BITTING-THERE MAY BE BUS INSIDE THE CANALS WHEN
OPEN THE PULP CHAMBER.-THESE PATIENTS MAY HAVE
ELEVATED TEMPRATURES OR LYMPHADENOPATHY
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-RADIOGRAPHIC FINDINGS RANGE FROM NO PERIAPICAL
RADIOLUCENCY TO LARGE RADIOLUCENCY.
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DRAINAGE IS VERY IMPORTANT
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-TREATMENT IS BIPHASICFIRST DEBRIDMENT OF THE
CANALSSECONDDRAINAGE OF BUS
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LOCALIZED SWELLING SHOULD BE INCISED DRAINED TO
1-RELEASE OF PRESSURE2-REMOVAL OF THE VERY
POTENET IRRITANT ( THE BUS)
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-IN PATIENTS WITH A PERIRADICULAR ABCESS NO
DRAINAGE FROM THE CANALS,PENETRATION OF THE
APICAL FORAMEN WITH SMALL FILE(UP TO 25)MAY
INITIATE DRAINAGE RELEASE PRESSURE.-DRAINAGE
THROUGH THE TOOTH MAY BE ENOUGH IN SOME CASES.
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-MOST OF THE CASES NEED DRAINAGE THROUGH THE
TOOTH THE MUCOSAL INCISION-DRAIN MAY BE
NEEDEDTO PERMIT CONTINUED DRAINAGE
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TREATMENT - DEBREDMENT
DRAINAGE .-HEAVY IRRIGATION WITH DISTILLED
WATER -IT IS ADVISED NOT TO USE SODIUM
HYPOCHLORIDE WITH THE PRESENCE OF BUS BECAUSE
THIS MAY LEAD TO THE FORMATION OF PLUG. -DRY THE
CANALS WITH PAPER POINTS CLOSE.-MEDICAMENTS
CAMPHOR SEALED IN THE CANALS-CLOSE WITH GOOD
TEMPORARY FILLING-MILD ANALGESIC ANTIBIOTIC IS
NEEDED
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-Make sure that there is no bus in the canals
before you close-Dont leave these teeth open
for drainageButIf the drainage through the
canal is not stopped, the access may be left
opened for further drainage BUT NOT MORE THAN 24
HRs
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• Leaving the tooth on open drainageshould be
  avoided if possible,but if absolutely necessary
  for less than 24 hrs,as after this time further
  contamination of root canal by anaerobic bacteria
  makes subsequent RCT very difficult
• OXFORD HANDBOOK OF CLINICAL DENTISTRY 2003

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ANTIBIOTIC OF CHOICEA COMBINATION OF-WIDE
SPECTRUM ANTIBIOTIC FOR AEROBIC
BACTERIA(Penecillins)-METRONEDAZOLE(Flagyl) FOR
ANEROBIC BACTERIA
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5-PULP NECROSIS WITH DEFFUSE SWELLING
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• THESE LESIONS ARE RAPIDELY PROGRESSIVE SPREADING
  SWELLING THAT HAVE DISSECTED INTO TISSUE SPACES.
• -THESE PATIENTS OCCASIONALLY HAVE AN ELEVATED
  TEMPRATURE SYSTEMIC SIGNS

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-SPREADING OF INFECTIONS INTO FACIAL SPACES-VERY
DANGEROUS SITUATION-SYSTEMIC MANIFESTATION ARE
PRESENT-EYE CLOSURE IF ASSOCIED WITH UPPER TEETH
TRISMUS IF ASSOCIATED WITH LOWER TEETH
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TREATMENT
-DRAINAGE IS VERY IMPORTANT IF THERE IS
FLUCTUATION BUS.-EXTRAORAL INCISION WITH DRAIN
MAY BE NEEDED (ORAL SYRGEON)-REMOVAL OF
IRRETANTS BY DEBRIDMENT OF CANALS OR EXTRACTION
OF INFECTED TOOTH-STRONG ANTIBIOTIC (I.V.)
ANALGESIC .-MAY NEED HOSPITALIZATION.
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INTERAPPOINTMENT EMERGENCIES(FLARE UPS)
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CAUSITIVE FACTORS-PREOPERATIVE
COMPLICATION-OVERINSTRUMENTATION( BLOOD IN TH
CANALS)-REMAINING INFLAMMMED PULP
TISSUE-IMPROPER PREPARATION OF PATIENT
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-PROPER DIAGNOSIS IS ALSO NEEDED.-MOST
IMPORTANTIS TO REGAIN THE CONFIDENCE OF THE
PATIENT.
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TREATMENT OF FLARE-UPS-REASSURANCE OF THE
PATIENT-BREAK THE CYCLE OF PAIN WITH ANESTHESIA
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TYPES OF FLARE-UPS
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1-PREVIOIUSLY VITAL CASES WITHOUT SWELLING
TREARTMENT-ASSURANCE OF PATIENT-GOOD
ANALGESIC-REOPEN THE TOOTH( MAKE GOOD DEBRIDMENT
IRRIGATE)-INTRACANAL MEDICAMENTS
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2-PREVIOUSLY NECROTIC CASES WITH NO SWELLING
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TREATMENT-OPEN THE TOOTH-RECLEAN IRRIGATE
THE CANALS WITH SODIUM HYPOCHLORITE-DRY CLOSE.
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IF ACUTE APICAL ABCESS IS DEVELOPED-DRAINAGE
IS NECESSARY( THROUGH THE TOOTH OR THE SOFT
TISSUE)-CLEANING IRRIGATION OF THE CANALS-DRY
CLOSE.-ANTIBIOTIC NSAID IS NEEDED
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THE TOOTH SHOULD NOT BE LEFT OPEN
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3-CASE WITH SWELLING-INCISION DRAINAGE.-OPEN
THE CANALS CLEAN-DRY CLOSE.-STRONG
ANTIBIOTIC ANALGESIC IS NEEDED.
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POSTOPERATIVE EMERGENCIES
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ONE THIRD OF ALL ENDO CASES EXPERIENCE SOME PAIN
FOLLOWING OBTURATION.
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CAUSES-OVERFILLING IS THE MAIN CAUSE-HIGH
OCCLUSION-IRRITATION FROM THE SEALER OR
GUTTAPERCHA
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TREATMENT
-DISCOMFORT REASSURANCE MILD
ANALGESICS.-REMOVAL OF THE HIGH
POINTS-RETREATMENT IS INDICATED IF PAIN PERSIST
ENDO TREATMENT HAS BEEN OBVIOUSLY INADEQUATE.
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-APICAL SURGERY ( APECICTOMY) IN PATIENTS WITH
PERSISTENT PAIN WITH OVER FILLING-PATIENTS WITH
GOOD ROOT CANAL TREATMENT BUT WITH PERSISTENT
SWELLING AFTER OBTURATION,INCISION DRAINAGE MAY
BE ENOUGH.
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REFERENCES

• PRINCIPLES PRACTICE OF ENDODONTICS ( WALTON
  TORABINJAD)
• OXFORD HANDBOOK OF CLINICAL DENTISTRY ( 2003)
• PATHWAYS OF THE PULP ( COHEN BURNS)

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THE END