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Endodontic Emergencies
Introduction
An emergency can be defined as a sudden, unforeseen event needing
prompt action.
Endodontic emergencies are usually associated with pain or swelling
originating from the pulp or periapical area. These emergencies, are a challenge
in both diagnosis and management. Knowledge and skill in several aspects are
required; failure to apply these will result in disastrous consequences.
Incorrect diagnosis and incorrect treatment will fail to relieve pain and
in fact may aggravate the situation. The clinician must have knowledge of pain
mechanisms, patient management, and appropriate treatment measure to both
hard and soft tissues.
Physiology of Dental Pain
The sensory mechanism of the pulp is composed of sensory afferent and
autonomic efferent systems. The afferent system conducts impulses perceived
by the pulp from a variety of stimuli to the cortex of the brain, where they are
interpreted as pain, regardless of the stimulus.
The sensibility of dental pulp is controlled by the myelinated (A-delta
fibres) and unmyelinated (C fibres) fibres.
1
A-delta fibres C-fibres
- Myelinated Unmyelinated
- 20% of the nerves of the pulp - 80% of the innervation
- Diameter – 2-5m 0.3-1.2m
- Conduction velocity – 6-30m/sec 0.4-2m/sec
- Distributed in the odontoblastic and
subodontoblastic zones and are
associated with dentinal pain
Distributed throughout the pulp tissue
and are associated with pain due to
pulp tissue damage
- Impulses are intercepted as sharp and
pricking pain
Conduct throbbing and aching pain
- Low threshold of excitability High threshold of excitability
Vitality tests A-delta fibres C-fibres
- Electric Positive (immediate) Negative ( except of high
levels of stimulation)
- Cold (ice) Positive (immediate) Negative
- Rapid heat (two phase response)
Immediate first response
(sharp, localized)
Delayed second response
(dull radiating)
Slow and sustained heat
Negative Positive (after 45°C to 47°C)
2
The impulse travels from C or A-delta fibres nerve endings, through the
plexus of Raschkow, to the nerve trunk in the central zone of the pulp. In the
periapical area, the nerve trunk joins the maxillary or mandibular division of
the fifth cranial nerve. Through the 5th cranial N. Pons Thalmus
Cortex.
The hydrodynamic theory explains the painful reaction of the pulp to
heat, cold, cutting of the dentin and probing of the dentin.
Diagnosis
Often a diagnostic decision concerning the pulpal status of a particular
tooth with respect to endodontic treatment can be made before any clinical tests
are performed. An immediate working diagnosis of either an irreversible
disease state requiring immediate treatment or a reversible disease state
requiring palliative treatment or observation can often be made based on
symptoms alone. For example, if the patient reports a histroy of severe,
spontaneous pain in a tooth for several days, an irreversible pulpitis is present
that requires root canal treatment. However if the patient has had a recent
restoration in the sensitive tooth or complains of a recent sensitivity to thermal
changes, a more conservative approach is recommended.
In general, a wait and watch approach is adopted when the following
conditions are present:
1. Short term sensitivity or discomfort (several days or weeks).
2. A history of recent dental treatment, gingival recession, loss of restoration
or possible fractured cusp.
3
Definitive pulpal treatment is more often indicated when these
conditions are present :
1. History of moderate to severe pain, with frequently recurring episodes of
spontaneous pain, over long periods of time.
2. Painful symptoms are produced by specific stimuli, such as biting,
touching, and hot or cold.
The 3 clinical determinants required before instituting endodontic
emergency treatment are :
1. Determine the presence or absence of pulp vitality.
2. Analyze the reaction of offending tooth to percussion.
3. Evaluate the radiograph.
TREATMENT
DIAGNOSIS
CONSULT REFERRAL
DATA EVALUATION
RADIOGRAPHIC INTERPRETATION
DIAGNOSIS TESTS PHYSICAL INSPECTION
MEDICAL HISTORY DENTAL HISTORY PATIENT INTERACTION
CHIEF COMPLAINT
Assembling patient data provides the foundation for determining
appropriate treatment of acute endodontic emergency.
- History
- Subjective symptoms
Pain
4
- Objective symptoms
Visual and tactile inspection
Percussion
Palpation
Mobility and depressibility
Radiograph
Electric pulp test
Thermal tests
Anesthetic test
Test cavity
Classification of Endodontic Emergencies
I. According to Walton or Torabinejad
1. Pretreatment emergencies
2. Inter appointment emergencies
3. Post obturation emergencies
II. According to Cohen
1. Thermal pain
Before endodontic treatment
2. Percussion pain
After initiation of endodontic treatment but
Before canal obturation
3. Swelling
After canal obturation
4. Spontaneous pain
5. Esthetic emergency
5
III. According to Gutmann
Depending on the treatment plan.
A. Vital pulps
1. Reversible pulpitis
2. Irreversible pulpitis with localized symptoms
3. Irreversible pulpitis – symptoms not localized.
B. Necrotic pulps
C. Acute alveolar abscess
1. Localized swelling
2. Diffuse swelling
Grossman discussed endodontic emergencies under following headings :
- Acute reversible pulpitis
- Acute irreversible pulpitis
- Acute alveolar abscess
- Acute periodontal abscess
- Emergencies during treatment
- Crown fracture
- Fractured root
- Tooth avulsion
- Referred pain
- Analgesics and antibiotics
6
Acute Reversible Pulpitis
Clinical characteristics
- Quick, sharp, shooting momentary tooth pain suggesting involvement of A-
delta fibres.
- Senstivity to mild discomfort.
- Pain is tracable to stimulus such as cold water or a draft of air.
Causative factors
- Recent history of pulp capping
- Exposed restorations
- Incipient caries or rapidly advancing carious lesions.
- Orthodontic tooth movement
- Periodontal disease
- History of trauma
- Recent restorations
Treatment
Since the pulp is inflammed the removal of causative factors usually
alleviates the patient discomfort. Sometimes-palliative treatment such as
placement of a zinc-oxide eugenol cement as a temporary sedative filling is
indicated. If the pain persists after several days, pulp tissue should be
extirpated.
7
Hypersensitive Dentin
Etiological factors
Exposed dentinal tubules due to :
- Periodontal surgery
- Tooth abrasion
- Erosion etc.
Treatment : Treatment modality includes chemical or physical blockage of the
patients dentinal tubules to prevent fluid movements from within.
Chemical : Chemical desensitizing method attempts to sedate the cellular
processes within the tubules with corticosteroids or to occlude the tubules with
a protein precipitate, a remineralized barrier, nitrate, fluorides, strontium
chloride or a crystallized oxalate deposit.
Physical : Attempts to block the dentinal tubules with composite resin,
varnishes, sealants, soft tissue grafts and glass ionomer cements. The
Iontophoresis techniques electrically drives fluoride ions deep into dentinal
tubules to occlude them.
Laser technology may provide a definite solution for sealing the dentinal
tubules permanently. But this is in the experimental stages and the equipment is
expensive.
8
Recent Restoration
Hyperalgesia following restoration procedures especially in young
patients is another complaint.
Causative factors like :
- Excessive heat generation while cavity preparation.
- Improper interproximal contracts.
- Premature contact points should be avoided.
Acute Irreversible Pulpitis
It is essential that this condition should be distinguished from acute
reversible pulpitis which has many similar symptoms because the emergency
procedure for each is different.
If a patient describes pain that lasts for minutes to hours, or is
spontaneous or disturbs sleep or occurs when bending over, then patient will
require pulpectomy rather than pallative treatment.
Symptoms can be localized or non-localized. The non-localized pulpitis
poses one of the most difficult and challenging problem to the practitioner
since the patient cannot identify the offending tooth.
- Diagnosis can be achieved through diagnostic tests
9
Treatment : Pulpectomy
The technique for pulpectomy.
- Anesthetize the tooth.
- Apply the rubber dam
- Prepare an access cavity
- Irrigate thoroughly
- Locate the canals and extirpate the pulp.
- Irrigate and debride, use a barbed broach.
- Dry the canal.
- Insert a medicated cotton pledget, moistened with an obtundent such as
eugenol into the pulp chamber.
- Place a temporary filling.
- Prescribe analgesics if necessary. Premedications or post medication with
antibiotic is indicated if the patient is medically compromised.
- If there is no sufficient time for pulpectomy, pulpotomy is indicated.
Acute Apical Periodontitis
- An acute condition that occurs before alveolar bone is resorbed.
- One of the most difficult emergency condition to treat is acute pulpitis with
apical periodontitis due to difficulty in achieving required depth of
anesthesia in such cases.
10
- There is a complain of the tooth feeling elevated in the socket or inability to
chew on the particular tooth.
- Diagnosis is usually simple, the tooth is tender on percussion.
- A radiograph of the tooth may appear normal or exhibit a thickening of the
periodontal ligament space or show a small periapical radiolucency.
Causative factors
- Occlusal trauma
- Irreversible pulpitis
Treatment
- Removal of causative factors
- If associated with non vital tooth, initiate endodontic therapy.
- Occlusion should be relieved.
- During endodontic therapy, heavy doses of anesthesia may be required to
attain required depth of aneshesia.
- Prescribe analgesics and anti-inflammatory drugs.
Pulp Necrosis
- Rarely causes an emergency procedure. However, the patient may notice a
swelling and request emergency treatment.
11
Treatment
- The proper treatment for pulp necrosis is canal debridement.
- No anesthetic is necessary in most instances but in some cases there are still
enough pain receptors to cause discomfort during the procedure.
- Ensure removal of all necrotic tissue and thorough irrigation of the canals is
required.
Acute Alveolar Abscess: (Acute periapical abscess accute apical
periodontitis).
- It is a localized collection of pus in the alveolar bone of the root apex of a
tooth following death of the pulp, with extension of the infection through
the apical foramen into the periapical tissue.
- It is accompanied by a severe local reaction of systemic toxicity such as
elevated temperature, gastrointestinal disturbance, nausea, dizziness and
other symptoms related to continuous pain and lack of sleep.
- The acute episode may result from :
1. Pulpitis that progressively developed into pulp necrosis affecting the
periapical tissues.
2. May be an excacerbation of a chronic periapical lesion (phoenix abscess).
12
3. May be caused by an endodontic periodontic lesion when the periodontal
abscess secondarily affects the pulp through the lateral root canals or a deep
infrabony pocket that extends to or beyond the root apex.
Treatment
- Local anesthesia is frequently contraindicated as insinuating a needle and
forcing anesthetic solution into an acutely inflammed and swollen area may
increase pain and may spread infection. Moreover, it may be ineffective as
acutely inflammed tissue has a localized pH that is acidic in spite of body’s
natural buffering action.
- Conduction or block anesthesia may be administered for a few cases in
which some pulp vitality persists, as long as the injection route is distant
from the inflammed area.
- The value of test cavity in treating teeth with acute alveolar abscess is two
fold. First, it tests for any remaining, vital pulp that could require
anesthesia: and second, it initiates emergency quickly, without waiting for
anesthesia to take effect.
Procedure
- Rubber dam application
- Complete the acess opening painlessly by stabilizing the tooth with finger
pressure or impression compound.
- Irrigate profusely, but avoid forcing any solution or debris into the
periapical tissue.
13
- Instrument each root canal within 1 mm of the root apex.
- Frequently, a purulent exudate escapes into the chamber and indicates that
the root canal is patent and draining. Other teeth may appear to be dry
within the canal but this may be due to the apical contriction preventing the
inflammatory products from draining through the tooth.
- To relieve this problem, a procedure called ‘apical trephination’ is followed.
Apical contriction is purposely violated and enlarged to a minimum of a
size 25 instrument to allow for exudate drainage through the tooth.
- Aspiration using any mild suction devices such as a wide gauge needle
placed in the saliva ejector will give sufficient negative pressure which aids
in establishing drainage through the canal.
- Leave the tooth open.
- Advice the patient to use hot saline rinses for 3 minutes each hour.
- Prescribe analgesics or antibiotics if indicated and necessary.
- Recently there has been an alteration in most desirable method for treating
an acute periapical abscess with drainage. The same regimen allowed for
drainage but the appointment ended with the acces cavity closed.
Advantages of this procedure are :
- Prevents additional bacterial contamination.
- Prevents contamination with food debris and blockage of canals.
14
- Prevents the need for unnecessary follow-up appointments to close the
tooth.
The tooth should be re-opened for drainage if symptoms persist or
worsen.
- When a tooth has been left open, if the access is sealed for the first time at
the same appointment in which canal enlargement is performed, a high
percentage of exacerbation will occur. To avoid this, the following rules are
made governing closure, in cases that has been left open for drainage.
If you file , don’t close
If you close, don’t file
- Gutmann describes various modalities of treatment for localized or diffuse
swellings associated with acute alveolar abscess.
- If the swelling is slight and localized, there is no need for incision and
drainage. Advice hot saline rinses in addition to root canal therapy.
- If the swelling is soft, extensive and fluctuant – incise and drain.
- In diffused swellings, where there is a generalized tissue edema or cellulitis
there is no indication for incision and drainage since the purulence is not
localized to any one specific area. There is a need for antibiotic coverage
and aggressive removal of any necrotic tissue in the pulp canal system.
- If the tissue swelling is non-fluctuant
Do not incise and drain
Consider antibiotics
Advice hot saline rinses
15
A non functional swelling can be converted to a soft fluctuant state by
rinsing with hot saline solution 3-5 min at a time repeated every hour.
Culturing the exudate
- Culture sample may be taken for antibiotic sensitivity testing.
- The culture should not be taken of the initial portion of the exudate when
considerable purulence discharges because the majority of the micro-
organisms at that time are dead and hence incapable of reproduction. The
sample should be taken when the exudate starts to change from yellowish to
a reddish hue.
Irrigants used in treating acute abscess
- The preferred irrigant in the initial stages of inducing drainage should be
warm sterile water or saline as sodium hypochlorite has a tendency to
clump the exudate, which might cause plugging of the apical constriction
and halt the drainage. When the patency through the apex is maintained,
sodium hypochlorite may be used for further canal preparation.
- For further appointments, an alternating solutions of sodium hypochlorite
and hydrogen peroxide is recommended.
Incision and Drainage
- Incision is performed with a No. 11 or 15 scalpel blade and a pair of
hemostats.
16
- Incision is made at the most dependent portion of the swelling to the depth
of the bone.
- Next, closed hemostats are placed into the incision and opened thus
dislodging loculated areas of purulence.
- If necessary, a drain placed, it should be secured to prevent it from being
either, enclosed in the wound or loosened by normal oral forces and
dislodged completely from the incision. Sutures may be used if a rubber
type drain is chosen. If a gauge type drain is preferred, the blood clot
which forms around the margins of the incision will usually stabilize the
drain. Drain should remain in place no longer than 2-3 days.
Trephination – Apical and surgical
Apical
- Apical trephination is accomplished by aggressively placing a No.15 to 25
K file beyond the confines of the apex.
A radiographic is taken for verification of file position.
Treatment problems with such procedure are :
- Destruction of the natural apical constriction.
- Zipping of the canal at the apex in curved canals.
However, the benefits of the procedure far outweigh the potential
problems.
17
Surgical
- Rarely indicated.
- However it is a reliable procedure to manage pain when all other
methods have failed.
- Indicated when the severe pain is due to increase in intracortical
pressure in the periradicular tissues, when apical trephination has
failed.
Two Approaches
Option – 1
1. Proper anesthesia is obtained.
2. A No.-15 scalpel blade is used to make a small (5mm) incision horizontally
in the mucosa apical to the root apex. This position is critical to avoid
penetration into tooth structures.
3. Retract the mucosa with a tissue retractors, periosteal elevator, or a wide
end of a sterile wax spatula.
4. A No.-6 or 8 round bur is used to penetrate the cortical plate at an angle
designed to reach the peri-radicular tissues or lesion, avoiding contact with
the root apex.
5. Immediate drainage for relieve of intra-cortical pressure is usually obtained.
6. The patient is placed on hot saline rinse.
18
Option – 2
Step 1-3 similar to option 1.
4. No. 6 or 8 round bur is used to penetrate the cortical plate only.
5. A large K-file (No. 40 minimum) is used to bore a path through the
cancellous bone to the periradicular tissues or lesion, avoiding
contact with the root apex.
6. Immediate drainage or relief of intra cortical pressure is usually
obtained.
7. Advise hot saline rinses.
- Option 2 is a safer approach, especially if vital structures are
adjacent to the tooth in question, if roots are closely approximated or
if the vestibule is shallow.
- Failure to adhere to these principles can result in destruction of the
root structure and periodontal ligament, with the potential for
subsequent external root resorption.
Acute Periodontal Abscess
- It is often mistaken for an acute alveolar abscess as periodontal
abscess causes pain and swelling.
19
Etiology
- It is usually an exacerbation of infection with pus formation in an
existing deep infrabony pocket.
Treatment
- If the pulp test indicates pulp vitality within the normal range, then
the treatment consists of curettage, debridement and establishment of
drainage of the infrabony pocket through the sulcular crevice. At
times incision of the soft tissue is necessary.
- When the pulp is abnormal and vital, the tooth is treated as if for
acute irreversible pulpitis.
- If the pulp is necrotic, treat as if for acute alveolar abscess.
In any case, emergency periodontal treatment must be done
simultaneously ; otherwise, the patient will not be relieved of the pain and
swelling.
Emergencies During Treatment
Endodontic emergencies can occur during the course of endodontic
treatment. There are usually caused by the following :
- Instrumentation beyond the root apex, with resultant trauma to the
periapical tissue.
20
- When debris and micro-organisms, are forced through the apical
foramina into the periapical tissue and cause an infectious reaction.
- Chemical irritants such as irrigating solutions or intracanal
medicaments, penetrating the periapical tissues, eg : hypochlorite
accident.
- Incomplete or inadequate debridement of all root canals.
- Lost or depressed access cavity seals, with recontamination of the
root canals.
- Overfilled root canals with subsequent periapical inflammation.
These emergencies can be avoided if proper care is taken during
treatment procedure.
- When severe periodontitis is present, the patients pain can be
relieved by re-opening the tooth under the rubber dam, removing the
sealed medicament, carefully wiping the root canal dry with sterile
absorbent points, and resealing the root canal with a cotton pellet
from which a mild obtundent, such as eugenol or cresatin, has been
expressed.
Also, a corticosteroid antibiotic medication can be used. A paper point
that will reach the periapical tissue is dipped into the medicament and the point
is placed in the canal with a pumping action, injecting the inflammed periapical
tissue with the anti-inflammtory agent. The antibiotic present prevents any
possible overgrowth of micro-organism.
21
- The occlusion should be adjusted if necessary.
- If pain or swelling occurs, the sealed medicament should be removed
and the tooth opened for drainage.
- Antiinflammtory analgesics should be prescribed and antibiotics if
indicated.
- Incision and drainage of a soft fluctuant swelling should be
considered when drainage is insufficient or when severe pain
persists.
Post-Obturation Emergencies
Post –obturation discomfort has been attributed to :
- Periapical irritation by obturating materials.
- Poor coronal seal.
- High occlusion
- Extrusion of sealer or gutta-percha into the periapical tissue.
- Obturation combined with cleaning and shaping in the same
appointment.
Treatment
- Information about possible discomfort during the first few days,
reassurance about the availability of emergency services and
administration of mild analgesics significantly reduces the patients
anxiety and prevents over reaction to discomfort.
22
- Discomfort due to slight overfilling of the root canals with either the
core or cement can be reduced by relieving the occlusion and
prescribing anti-inflammatory analgesics and antibiotics.
- Retreatment is indicated in persistently painful cases in which
treatment has been obviously incomplete.
- Apical surgery is required in patients with persistent pain without
swelling and overfilled canals or uncorrectable, inadequate root canal
treatment.
- A patients with acceptable root canal treatment who develop
swelling after obturation should undergo incision and drainage.
- In some cases surgical trephination (artificial fistulation) may be
necessary.
Emergency Treatment of Traumatic injuries – fractures
Crown Fracture
A traumatic injury to a tooth can cause a cracked crown, a fractured
crown, or a fractured root and may result in pain.
A cracked tooth can elicit bizarre symptoms such as sharp, piercing
pain, especially during mastication. At times, thermal changes cause fleeting
painful reactions.
23
Diagnosis
- Transillumination method
- Dyes
- A rubber polishing disc can be used. When the patient bites on the
disc, it acts as a wedge on the cracked tooth and causes pain.
Crown fractures without pulp exposure
- Chipping of a small position of enamel needs smoothing of the
jagged edge to prevent irritation to the tongue and lips.
- If the fracture involves dentin, it should be covered with a sedative
dressing and a stainless steel band is cemented in place.
- Adjacent teeth should be examined for any fractures.
- Regular follow-up is required.
Crown # with vital pulp exposure
- A radiograph should be taken to check the presence or absence of
apical closure.
- If closure has taken place, treatment is identical to treatment for
acute pulpitis.
- If apical closure has not yet taken place, a formocresol pulpotomy is
performed to aid apexogenosis. At periodic intervals, radiographs are
24
taken to evaluate and routine endodontic treatment may be initiated
once apical development has been completed.
Crown # with necrotic pulp exposure
- Treatment follows the pattern of treatment for pulp necrosis or acute
periapical abscess.
- In the following appointment, radiograph is taken to assess the apical
closure. If apical closure has taken place, routine endodontic
treatment is performed. If the apex has not developed apexification
procedures are instituted.
Fractured Root
- A horizontal # above the alveolar crest has an excellent prognosis.
Also, the closer the root # is to the root apex, the more favourable
the prognosis.
Emergency Treatment :
Consists of stabilization by ligation of the tooth and adjacent teeth if
mobility is present.
- Treat any soft tissue lacerations.
- Assume that pulp is vital and do not extirpate it. A # root that
contains a vital pulp has a better prognosis for root repair than one in
which the pulp has dead or has been extirpated. If later evidence
25
indicates the presence of pulp necrosis endodontic therapy can be
instituted.
- If the injury has caused pulpal death treatment consists of ligation for
stabilization and root canal therapy.
- A horizontal # at the midroot level has a guarded –to- poor prognosis
unless it is amenable to orthodontic root extrusion. Usually the
incisal segment is mobile and requires extraction. When the
remaining apical segment is long enough to retain a functional post-
core crown and has sufficient bony support, emergency treatment for
this segment is pulpectomy. If the pulp is necrotic, then the root
should be treated as if for an acute alveolar abscess.
- A tooth with a vertical # has a hopeless prognosis and the treatment
is extraction. On occasion, a multirooted tooth with vertical fracture
of a root can be hemisected and the # segment can be removed.
Endodontic therapy can be instituted for the remaining segment.
Tooth Avulsion and Replantation
The replacement of a tooth that has been removed from the alveolar
socket either intentionally or by accident is called replantation.
The longer the luxated tooth is out of its socket, the less likely it will
remain in a healthy, functional state after replantation.
26
Newer philosophies of replantation
For many years endodontists enlarged and filled root canals before
replanatation of the avulsed tooth. This procedure has been replaced by
Andersen based on clinical and experimental research. It has been observed
that a relatively good success rate was achieved when patients replanted the
avulsed tooth after trauma compared with replantation by a dentist.
Suggested Technique
Emergency at the site of injury
1. Instruct the patient or parent to wash the tooth in running water without
brushing or cleaning it, and examine it to be certain that the tooth is intact.
2. Have the patient rinse mouth. Replace the tooth in its socket using gentle,
steady finger pressure. If the patient is co-operative and able, have the
patient gently close the teeth together to force the tooth back into its
original position.
3. Take the patient to the dentist immediately.
4. If the tooth cannot replaced in its socket, the tooth must be carried to the
dentist in a moist vehicle to maintain the viability of the torn periodontal
ligament.
Emergency at the dental office
1. If the tooth is its socket, ligate, stabilize and disocclude the replanted tooth.
27
2. If tooth is out of the socket or improperly positioned, do not attempt to
curette or sterilize the root surface or socket. Wipe away gross debris
gently, irrigate the socket with saline. Handle the tooth all times with a
sponge / gauge soaked in saline and handle the crown only. Replant the
tooth and stabilize.
3. Take a radiograph to verify the position of the tooth in its socket and to
examine it for any root or alveolar bone fracture. Check the adjacent teeth
for possible root fracture.
4. Do not attempt endodontic treatment at this time unless the tooth requires
venting (drainage). In that case, open the pulp chamber, debride it and the
root canals, insert an intracanal medicament and seal the access cavity.
Endodontic treatment should be completed at a later date.
Completion of endodontic treatment
- One week after replantation prepare access cavity, perform canal
debridement and place ZoE temporary filling in the access.
- Teeth with undeveloped apices may be watched without pulp-
extirpation.
- Andreasen suggests that the splint should be removed one week
after replantation to prevent ankylosis or inflammatory response
leading to reposition as the periodontal ligament is not kept in
function.
- Two weeks after replantation, place, Ca(OH) paste in the canal to
inhibit and reduce external resorption.
28
- After the periodontal ligament and apices have healed
radiographically, institute routine endodontic therapy.
Post operation instructions
- Antibiotic coverage.
- Soft diet
- Refer to a physician for antitetanus serum or booster injection.
Transport medium (Referred from the article “Interim storage of avulsed
permanent teeth” published in Journal, May 1998).
Various transport media that can be used.
- HBSS (Hank’s Balanced Salt Solution).
- Viaspan (Transplant Organ Storage Media).
- Eagles medium (culture medium).
- Milk
- Saliva
- Saline
- Tap water
- Triton x-100
In the order of preference, HBSS, viaspan and eagles medium for
transportation followed by milk and saline, saliva, dry storage, tap water and
triton x-100.
29
Hank’s Balanced Salt Solution
Proposed by Krasner and Person. It was highly successful in 85.3% of
replantation cases.
The solution contains.
Sodium chloride
Glucose
Potasium chloride
Sodium biocarbonate
Sodium phosphate
Calcium chloride
Magnesium chloride
Magnesium sulphate
Krasner has developed an avulsed tooth storage system, named the
Emergency Tooth Preserving System (ETPS), which contains HBSS, a net for
holding the tooth atraumatically, and a container for bringing the submerged
tooth to the dentist.
- According to Weine, patient’s own saliva is best transport medium
for an avulsed tooth.
- Andreasen favors milk over saliva as a transport medium.
Disadvantage of milk is that it may contain many antigens that could
act negatively from an immunologic standpoint on the reattachment
process.
30
- Saliva is an immediately available storage medium at all accident
location, but its use should be limited to cases where the extra-
alveolar duration is less than one hour and superior storage media,
such as milk, saline, or HBSS or not available.
- Regarding the temperature, storage at lower temperature produce
best results.
Referred Pain
Accurately determining the origin of the patients pain is the first step in
emergency endodontic treatment. Although the most frequent cause of dental
pain is pulpoperiapical pathosis, the astute clinician knows that pain can
originate from many other sources.
Various causes
Sinusitis may cause pain referred to maxillary posteriors.
Myocardial infarction – Toothache on the left side of the mouth.
Otitis media – Mandibular molars
Basilar artony aneurysm – Lower molars
Herpes zoster of maxillary division of fifth cranial N – Maxillary lateral
incisors.
Other causes
Trigeminal neuralgea
Atypical facial neuralgea
Migrane
Cardiac pain
Temperomandibular arthrosis Intensive radiation
Periodontal abscess Systemic diseases
31
Occlusal trauma eg : Typohoid, influenza,
malaria.
Muscle spasm Neurogenic diseases
Pericoronitis Malignant diseases
- Conversely painful pulpitis may be referred to others areas of the same or opposing
arches as well as to the structures remote from the involved tooth.
Site of pain referral Tooth pulp initiating pain
Frontal (forehead regin) Maxillary incisors
Nasolabial area Maxillary canines
Maxillary premolars
Occular pain Anterior teeth
Temporal region Maxillary second premolars
Ear Mandibular molar
Maxillary molars occassionally
Superior laryngeal area Mandibular molars
Mandibular premolars Maxillary canines
Maxillary premolars
Obviously, if the pain does not originate from pulpoperiapical disease,
emergency endodontic treatment will not relieve it.
Analgesics and Antibiotics
The discussion on endodontic emergency will be incomplete without the
discussion on analgesics and antibiotics because their role is essential and
supportive to the previously described emergency procedures.
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Analgesics
Analgesics are pain relievers. Generally, the narcotic analgesics are used
to relieve acute, severe pain and the non-narcotic or mild analgesics are used to
relieve slight to moderate pain.
Most frequently used non-narcotic analgesics are :
- Aspirin
- Acetaminophen
- Ibuprofen
- Diclofenac sodium
- Nimuselide – recent inclusion
Aspirin
- Has potent anti-inflammatory, analgesic, antipyretic action.
Precaution and contra-indication
Contra indicated in patients who are sensitive to it and in peptic ulcers,
liver disease, bleeding tendencies, diabetes and 1 week before elective surgery.
- Dispensed as 300 mg and 600mg tablets.
Acetaminophen
- Relieves mild – moderate pain
- Lacks anti-inflammatory property.
- Lower incidence of side effects
- Safer in pregnant patients
- Dose – 500 mg tablets
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Ibuprofen
- Better tolerated than aspirin.
- Side effects are milder but can cause gastric discomfort.
- Should be avoided in asthma.
- Doses 200, 400, 2600mg tablets
Diclofenac sodium
- Analgesic and anti-inflammatory action is similar to ibuprofen but
lesser adverse effects.
- Dose : 50 mg tablets.
Nimuselide
- Safer in asthma patients.
Narcotic analgesics
- Control pain better than other drugs currently available but these
drugs must be used with caution.
- They may depress the central nervous system, can interact adversely,
sometimes fatally, with alcohol, anti-histaminics, local anesthetic
and tricyclic antidepressants.
- Eg : Morphine – No oral route.
Meperidine – 50 to 100 mg.
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Antibiotics
- Antibiotics are life saving therapeutic agents of inestimable value.
They are used for prophylactic coverage of medically compromised
patients and in special circumstances, an adjunctive treatment of
acute periapical or periodontal infection.
- Ideally, the selection of a prescribed antibiotic should be based on
the result of susceptibility tests.
- The most effective antibiotic for use in endodontic emergency is
penicillin. It is bactericidal and acts by inhibition of cell wall
synthesis during multiplication of micro-organisms.
- Recommended drugs
Penicillin V- Acid resistant
Amoxicillin – Better oral absorption
Cloxacillin – Active against penicillin resistant stains
- In case of allergy to penicillin erythomycin can be prescribed.
Other antibiotics used are :
Cephalexin – 250 – 500 mg every 6 hours
Clindamycin phosphate – 150-300 mg every 6 hours
Tetracyclines
Metranidazole
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Conclusion
The accurate diagnosis and effective treatment of acute situations are an
important responsibility and privilege of dental practice. Effective, caring
management of endodontic emergencies not only represent a service to the
public, which a dentist can be proud of, but also enhances the positive image of
dentistry.
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