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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)
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
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
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