ENDODONTIC EMERGENCIES

AND MANAGEMENT

INTRODUCTION

•Approximately 60% of patients with oral or

maxillofacial pain are in need of endodontic

emergency treatment (Tronstad, Thieme 2003)

•Nearly 90%of patients seeking emergency dental

treatment have symptoms of pulpal or periapical

disease (Carrotte, Br Dent J 2004)

Pain in endodontic emergencies are related to two factors

Chemical mediators

lowers pain threshold

increase vascular permeability

edema

edema Pressure

SYSTEM OF DIAGNOSIS

Medical and dental histories

Subjective examination

Objective examination

Periodontal examination

Radiographic examination

Endodontic Emergency Categorized into 4

types:

Pretreatment

Intra appointment

Post obturation

Emergencies related to trauma

Before treatment:

1. Pulpal pain

a) Reversible pulpitis.

b) Irreversible pulpitis.

C)Dentin hypersensitivity.

2. Cracked tooth syndrome.

3.Acute periapical abscess.

PATIENTS UNDER TREATMENT:

1. Recent restorative treatment

2. Periodontal treatment

3. Exposure of the pulp

4. Fracture of the root or crown

5. Pain as a result of instrumentation

a) acute apical periodontitis

b) Phoenix abscess

Reasons for pain in vital teeth:

•Caries, restored or unrestored--88,6

%

•Cusp fractures (cracked tooth)-- 5,8

%

•Hypersensitive teeth--3,6 %

•Traumatic occlusion--2,0

DENTIN HYPERSENSITIVITY

Attrition: Tooth surface loss by two-body wear (tooth to tooth contacts)

Abrasion: Tooth surface loss by three-body wear (e.g., habits, toothpaste)

Acidic erosion: Non-carious tooth surface loss by exogen acids (e.g., acidic foods and drinks, gastric acids > anorexia nervosa, bulimia, reflux disease)

HYPERSENSITIVITYDESENSITISING AGENTS >

PRIMARY GOAL IS TO CLOSE THE TUBULES BY

INSOLUBLE SALTS

TTT HYPERSENSITIVITY

potassium salts

potassium-Phosphate

fluorides

strontium chlorides

oxalate

Seal & Protect Dentsply

Single Bond 3M Espe

Sensodyne F,C

Significant effect after 3 days

active

substances

REVERSIBLE PULPITIS

The pain is of very short duration and does

not linger after the stimulus(hot ,cold,sweets) has been removed.

The tooth is not tender to percussion. except…….

The pain may be difficult to localize.

The tooth may give an exaggerated response to vitality tests.

The radiographs present wit a normal appearance, and there is no apparent widening of the periodontal ligaments

REVERSIBLE PULPITIS

Treatment:

Check the occlusion and remove nonworking facets.

•Removal of the caries; sealing of exposed dentin place sedative dressing

•bacteria-tight coronal restoration: either permanent or temporary restoration (glass ionomer)

Apply a fluoride varnish or a dentine bonding resin to sensitive dentine and prescribe a desensitizing toothpaste

IRREVERSIBLE PULPITIS

As long as pulpal inflammation has not

spread to the periodontal ligament > pain

radiates and patient is not always able to

pinpoint the source of the symptoms

correctly

Management?????

DIFFERENTIAL DIAGNOSIS REVERSIBLE VS.

IRREVERSIBLE PULPITIS

Characteristic features for an irreversible pulpitis are:

Spontaneous pain

Pain persists after the stimulus

Pain triggered by heat later stages relieve by cold

Pain at night

Longer history of pain

X ray???

Percussion: (-) or even (+)

LOCALIZING THE CORRECT TOOTH

warm water after application of a

rubber dam

gutta-percha

stick

Anaesthetic test

TREATMENT:

aseptic techniques!!

Access cavity, pulp exposure and (if

possible) removal of the pulp tissue

from the pulp chamber

-Anodyne medicament (Ledermix or

eugenol) and bacteria-tight seal

Irrigation of the pulp chamber using a

solution of sodium hypochlorite 5%

PULPOTOMY + ANODYNE

MEDICAMENT IN THE PULP CHAMBER +

BACTERIA-TIGHT MEDICAMENT 91%

COMPLETE DEBRIDEMENT +

INTRACANALDRESSING + BACTERIA-

TIGHT SEAL 99%RELIEVING PAIN

PAIN RELIEF

1 Additional infiltration anaesthesia, such as

long-buccal, lingual and palatal.

2 Intraligamental (intra-osseous) injection.

3 True intra-osseous injection.

4 Intrapulpal analgesia.

5 Inhalational sedation with local analgesia.

Continous pain after ttt?????

CRACKED-TOOTH-SYNDROME

Up to 20% of patients suffering from

odontogenic pain > cracked tooth

(incomplete fracture) as main cause

(Geurtsen & Garcia-Godoy, Am J Dent 1999)

•Predisposing factors: masticatory incidents,

bruxism, thermal cycling

CRACKED-TOOTH-SYNDROME

Second premolars and first molar are most often affected (especially those with extensive restorations)

Symptoms: pain on chewing (hard food), sensitivity to cold and hot fluids, pain which is difficult to locate

Fracture line: from mesial to distal (important: fracture lines in coronal restoration

Cracked-tooth-syndrome

How to detect?

Ask the patient to bite on a cotton-roll, wood stick, or fracture detector (Tooth Slooth) > pain on release of pressure > most reliable aid and most expressive clinical finding

Visual detection of crack (fiberoptic, staining)

radiographs are of little value for detection

TREATMENT

Without any signs of pulpitis > stabilization of the tooth by means of adhesive restorations or partial or full crowns (full cusp coverage!)&band of ortho

Pain when not in use > indication of irreversible pulpitis > root canal treatment and full crown

Fracture lines extending below the alveolar crest > extraction

A crack will block and reflect the light when

transilluminated

SYMPTOMATIC APICAL PERIODONTITIS

Pain:Tooth is sensitive to mastication and

percussion; no swelling is present

Sensibility: (-)

Percussion:(+) to (++)

Symptomatic apical periodontitis

-Treatment-

Instrumentation not possible:

Access cavity

Remove necrotic tissue from the pulp chamber

Copious irrigation of the pulp chamber using NaOCl

Placement of eugenol in the pulp chamber

Bacteria-tight seal

Root canal instrumentation within the next 2-3 days

Instrumentation possible:

Access cavity

Determination of WL (electronic apex locator)

Chemo-mechanical instrumentation of the root canals

ntracanal dressing (mixture of calcium hydroxide + 2% CHX)

Bacteria-tight seal

SYMPTOMATIC APICAL PERIODONTITIS

•Chemo-mechanical instrumentation only

results in pain decrease of 50% within 1 day

and 90% within 2 days (Holstein et al.,

Endodontic Topics 2002).

•Access cavity + irrigation of the pulp

chamber + placement of eugenol in the pulp

chamber > pain relief in about 70% of

patients within 1 day (Tronstad, Thieme

2003).

SYMPTOMATIC APICAL PERIODONTITIS

Analgesics (ibuprofen)

Long-acting anaesthetic (bupivacaine) >

duration of analgesia 8-10 h (Keiser &

Hargreaves, Endodontic Topics 2002)

Fluctuancyof a swelling > incision and

effective drainage

Further treatment > same day (scheduled)

ACUTE PERIAPICAL ABSCESS

= Apical periodontitis with swelling

Dd: from lateral PDL abscess

Swelling &pain

Feeling of teeth elevated in its socket

May not have radiographic evidence of tooth destruction

Fever &malaise

Mobility may or may not present

Immediate relief is obtained as pus

drains feely from an access cavity.

TREATMENT:

scenario 1: fluctuancy and drainage through the tooth

Gently grip the tooth and use a small, round, diamond bur to reduce the trauma of the operation > drainage

Chemo-mechanical instrumentation > exudation has stopped > intracanal dressing > coronal seal

optional: if the tissue is fluctuant > incision

•TREATMENT

scenario 2: fluctuancy no drainage through the tooth

Open the tooth > no drainage

explore the apical foramen with a very fine

(size 08 or 10) file

Chemo-mechanical instrumentation > intracanal dressing > coronal seal

incision and effective drainage (optional: drain)

scenario 3: no fluctuance, drainage through the tooth

Open the tooth > drainage

Chemo-mechanical instrumentation > intracanal dressing > coronal seal

no indication to incise and drain the soft tissues

INCISION TO ESTABLISH DRAINAGE

copious amounts of surface analgesia

should be applied, for example ethyl chloride or

topical lignocaine ointment.

Regional anaesthesia !!!!!!!!

Incise the swelling vertically with . 11 or 15

scalpel blade, & aspirate, using a widebore

needle and disposable syringe.???

insert a drain(inter , extraorally)

ROOT CANAL TREATMENT

1-access

2-sodiumhypochlorite

3-full debrid canal if possible

4-dry canal

5-48h complete debride canal

6-dressing CaOH

7-ANTIBIOTICS??????

PATIENTS UNDER TREATMENT

1.Recent restorative treatment

2. Periodontal treatment

3. Exposure of the pulp

4. Fracture of the root or crown

5. Pain as a result of instrumentation

a) acute apical periodontitis

b) Phoenix abscess

PHOENIX ABSCESS

Sudden exacerbation of a previously

symptomless periradicular lesion

Activates the bacterial flora??

Treatment consists irrigation,debridement of

the root canal and establishing drainage

it may be necessary to prescribe an

antibiotic

POST-ENDODONTIC TREATMENT

1. High restoration

2. Overfilling

3. under filling

4. Root fracture