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Endodontic emergencies

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CONTENTS INTRODUCTION DEFINITION PRE-TREATMENT EMERGENCIES PULPAL PAIN TRAUMATIC INJURIES

CRACKED TOOTH SYNDROME CROWN FRACTURE ROOT FRACTURE AVULSION

MID-TREATMENT FLARE-UPS HYPOCHLORITE ACCIDENT HYDROPEROXIDE ACCIDENT AIR EMPHYSEMA POST-TREATMENT EMERGENCIES REFERRED PAIN CONCLUSION

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INTRODUCTION

Endodontic emergencies infringe on a tight, planned schedule of a dentist as well as a of the patient and tend to upset the day for everyone including the patient, dentist and staff.

Nevertheless they are practice builders as a dentist if often judged by the swiftness he sees a patient in pain, and his skill is judged by the speed by which he can alleviate pain.

It is but natural that a patient in pain must be rendered painless and comfortable as soon as possible.

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DEFINITION An endodontic emergency is defined as an “An unscheduled visit associated with pain or swelling

ensuing from pulpoperiapical pathosis requiring immediate diagnosis and treatment.”

or

Occurrence of severe pain and / or swelling following an endodontic treatment appointment, requiring an unscheduled visit and active treatment (Watson and Foud –1992).

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The fact that is associated with words like unscheduled and immediate, imply the emergency of the situation.

Pain is the most common factor that motivates the patient to seek dental treatment.

Approximately 90% of patients requesting dental treatment for the relief of pain have pulpal periapical disease and thus are candidates for endodontic therapy.

A true emergency is the condition which requires unscheduled visit with diagnosis & treatment at that time.

But urgency indicates a less severe problem in which next visit may be scheduled for mutual convenience of both patient as well as clinician.

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CLASSIFICATION According to Walton or Torabinejad

Pretreatment emergencies Inter appointment emergencies Post obturation emergencies

According to Cohen

Thermal pain Percussion pain Swelling Spontaneous pain Esthetic emergency

Before endodontic treatment

After initiation of endodontic treatment but before canal obturationAfter canal obturation

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According to Gutmann

Depending on the treatment plan. Vital pulps Reversible pulpitis Irreversible pulpitis with localized symptoms Irreversible pulpitis – symptoms not localized. Necrotic pulps Acute alveolar abscess Localized swelling Diffuse swelling

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MANAGEMENT OF ENDODONTIC EMERGENCIES

Management can be divided into the following steps:

Proper attitude Make an accurate diagnosis Provide profound anesthesia Render prompt and effective treatment

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Proper attitude: A calm and confident

professionalism should be displayed . a positive attitude to the patients problem can make the individual aware that an efficient and effective treatment will be done.

Make an accurate diagnosis: acute pain or swelling needs

immediate relief, the essential diagnosis should be rapid and accurate.

Attaining pertinent medical and dental histories to avoid important medical complications or allergic reactions or make modifications in the treatment.

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Subjective examinationQuestions relating to history, location, severity, duration character,

stimuli eliciting/ relieving pain should be asked.

Objective examination Visual examination of face, oral and hard soft tissues. Dental

examination should follow to note presence of defective restoration, discolored teeth, recurrent caries, fractures etc.

Perform vitality testing to note pulpal status. Thermal tests are more useful as they mimic the stimuli which elecit /relieve the pain.

Periradicular tests including palpation over apex and light digital pressure/ percussion should be done to identify periapical inflammation as the source of pain.

Periodontal examination to check for pockets should be done. Probing helps in differentiating endodontic from periodontal diseases.

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Radiographic examination: helps in detecting recurrent / inter proximal caries, possible pulpal exposures, resorptions, periapical pathosis etc. Remember radiographs are an aid to diagnosis. Learn to use them and not abuse them.

A differential diagnosis should be done to consider or rule out even non-odontogenic sources of pain which mimic odontogenic pain quite closely.

Periodontal prognosis Restorability

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Acute Reversible Pulpitis

It is a mild to moderate inflammatory condition of the pulp caused by noxious stimuli in which the pulp is capable of returning to the uninflammed state following removal of stimuli.

Clinical characteristics Quick, sharp, shooting momentary tooth pain suggesting

involvement of A-delta fibers. Sensitivity to mild discomfort. Pain is traceable to stimulus such as cold water or a draft of air.

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Treatment 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.

Recent history of pulp capping

Exposed restorations

Incipient caries or rapidly advancing carious lesions.

Orthodontic tooth movement

Periodontal disease

History of trauma

Recent restorations

Causative factors

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Diagnosis: is by patients’ symptoms and clinical tests.

Subjective symptoms: The patient reports of a pain which is sharp, lasts a few seconds and disappears on removal of stimulus such as cold, sweet or sour foods. It does not occur spontaneously. Although the paroxysms of pain are of short duration they may continue for months .

Dental examination may reveal caries, large restorations, fracture and deep wear facets ,recently placed restorations, exposed dentin.

Pulp vitality tests: Thermal tests: helps to locate the offending tooth. Cold test is

preferable. Percussion, palpation and radiographs give normal status. Electric pulp test may give a slightly early response

Radiographic examination are normal

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Treatment: removal of noxious stimuli normally suffices. If a recent restoration has a high point, recontouring the high

spot will relieve the pain. If persistent painful episodes occur following cavity preparation ,

chemical cleansing of the cavity or leakage of the restoration , one should remove the restoration and place a sedative dressing such as zinc oxide eugenol.

If symptoms do not subside then pulpal inflammation should be regarded irreversible and pulpectomy should be done.

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Hypersensitive Dentin It is characterized by short, sharp pain arising from exposed

dentin in response to stimuli – thermal, tactile, osmotic or chemical and which cannot be ascribed to any other form of dental defect or pathology.

Etiological factors Exposed dentinal tubules due to : Periodontal surgery Tooth abrasion Erosion Abfraction

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Treatment : Treatment modality includes chemical or physical blockage of the patients dentinal tubules to prevent fluid movements from within.

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.

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 : Chemical :

Laser technology provides a definite solution for sealing the dentinal tubules permanently. But this is in the experimental stages and the equipment is expensive.

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Differential Diagnosis Conditions that produce symptoms namely those of

dentinal hypersensitivity are: cracked tooth syndrome fractured restorations chipped teeth Dental caries post restorative sensitivity teeth in acute hyper function palatogingival groove

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Acute Irreversible Pulpitis

It is a persistent inflammatory condition of the pulp, symptomatic/ non-symptomatic, caused by noxious stimuli

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 palliative treatment.

21 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.

Treatment :

Pulpectomy followed by insertion of a medicated cotton pellet, 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.

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Acute Apical Periodontitis

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.

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.

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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.

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Pulp Necrosis

Rarely causes an emergency procedure. However, the patient may notice a swelling and request emergency treatment.

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.

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Acute Alveolar Abscess: (Acute periapical abscess )

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.

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Symptoms Local symptom Tenderness of the tooth remove by continuous slight process. Patient has throbbing sever pain with swelling of the overlying soft

tissue with or wothout tooth mobility. When swelling become extensive ,it result into cellulitis and the

patients facial changes.

Systemic symptomFever, Irritation, etc

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Where to expect swelling from which tooth???

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Ludwig's angina

Potentially life-threatening cellulitis or connective tissue infection, of the floor of the mouth, usually occurring in adults with concomitant dental infections.

usually develops in immunocompromised persons

 bilateral involvement of the submandibular, sublingual and submental spaces

Treatment involves appropriate antibiotic medications, monitoring and protection of the airway in severe cases, and, where appropriate, urgent ENT surgery, maxillo-facial surgery and/or dental consultation to incise and drain the collections. The antibiotic of choice is from the penicillin group.

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The acute episode may result from :

Pulpitis pulp necrosis abscess phoenix abscess

Periodontic- endodontic lesion

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Treatment Infiltration anesthesia contraindicated

Conduction or block anesthesia may be administered

test cavity tests for any remaining, vital pulp that could require anesthesiaand initiates emergency quickly, without waiting for anesthesia to take effect.

forcing anesthetic

solution into an acutely

inflammed and swollen area

localized acidic pH

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Procedure

access opening stabilize the tooth with finger pressure or impression compound (high speed)

Irrigate profusely Instrument 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. (dry within the canal 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.

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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 warm saline rinses for 3 minutes each hour. Prescribe analgesics or antibiotics if indicated and necessary.

Advantages of closed dressing are :

Prevents additional bacterial contamination.

Prevents contamination with food debris and blockage of canals.

Prevents the need for unnecessary follow-up appointments to close the tooth.

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Gutmann describes various modalities of treatment for localized or diffuse swellings associated with acute alveolar abscess.

•no need for incision and drainage. Advice warm saline rinses in addition to root canal therapy

swelling is slight and localized

•incise and drainswelling is soft, extensive and fluctuant

•antibiotic coverage and aggressive removal of any necrotic tissue in the pulp canal system

diffused swellings, where there is a generalized

tissue edema or cellulites

•Consider antibiotics and advice hot saline rinses

If the tissue swelling is non-fluctuant

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A non functional swelling can be converted to a soft fluctuant state by rinsing with warm saline solution 3-5 min at a time repeated every hour.

alkalinize the mouth

astringent

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Irrigants used in treating acute abscess

Initial stages sterile water and saline (NaOCl clumping debris)

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.

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.

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Incision and Drainage

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Rationale for I & D

Decreases number of bacteria Reduces tissue pressure

Alleviates pain/trismus Improves circulation

Prevents spread of infection Alters oxidation-reduction potential Accelerates healing

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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.

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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.

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Proper anesthesia is obtained.

A No.-15 scalpel blade is used to make a small (5mm) incision horizontally in the mucosa apical to the root apex.

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.

No. 6 or 8 round bur is used to penetrate the cortical plate only.

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.

Option – 1 Option – 2

Two Approaches

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Acute Periodontal Abscess

It is often mistaken for an acute alveolar abscess as periodontal abscess causes pain and swelling.

Etiology It is usually an exacerbation of infection with pus formation in an

existing deep infrabony pocket.

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Treatment

Vital pulp periodontal therapy

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.

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HOT TOOTH A hot tooth is a tooth that is difficult to anesthetize.

There is special class of sodium channels on C fibers, known as tetradotoxin-resistant (TTXr).

Sodium channel expression shifts from TTX-sensitive to TTXr during

neuro inflammatory reactions, and the TTXr resistant sodium channels play a role in sensitizing C fibers.

These sodium channels - resistant –lignocaine & is 5 times more resistant to anesthetic than TTX sensitive channels.

Bupivacaine – potent..

Supplementary intraligamentary or intraosseous injections have been found to ensure profound anesthesia.

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CRACK TOOTH SYNDROME

DEFINITION: A fracture plane of unknown depth and direction

passing through tooth structure, if not already involving, may

progress to communicate with the pulp and/or periodontal

ligament.

* History of pain on release of biting on a particular tooth, often

occurring with food having small, harder particles in them.

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VISUAL INSPECTION: Transillumination

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Magnifying loupes

Dyes-methylene blue

Tooth slooth- more reliable.

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Cracks in vital teeth

Urgent care -- immediate reduction of tooth from its occlusion by selective grinding

Sharp, intense pain of short duration during chewing and on release of food- even as no pulpal involvement.

Treatment for cracks not involving pulp: Compromised portion removed- occlusal adjustment, cuspal protection.- Restoration-Composite -Pinned amalgam-Cast restoration

•Full coverage restoration- as permanent

treatment.•If crack involves pulp-causes pulpal

inflammation & necrosis- RCT is advised

followed by full coverage restoration.

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As a rule of thumb, if the crack involves a root canal, extract the tooth.

If the crack involves the pulp chamber only, RCT and restore

Cracks in root filled or nonvital teeth:

cracks in teeth without a living pulp gives vague symptoms & origin is difficult to locate-& pain receptors in the pdl may be involved or bacteria may invade through the craze line causing periodontal inflammation – tooth tender to percussion.

Treatment: location of the crack-even surgical exposing of the crack is done and removal of the source of pain(infection)- followed by full coverage restoration if tooth can be saved.

In case if crack is vertical - involving the entire root – extraction is preferred.

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REFERRED PAIN

Referred pain may be initiated from inflamed pulp-other parts of

body on same side or in close proximity to another tooth Eg: infection of max ant teeth- referred to ocular pain, mandi

molars to back of ear.

pain from other parts of body- referred to tooth. Otitis media- refer pain- mandibular molars, tmj dysfunction-

toothache.

Accurately determine the origin of pain – radiograph is often useful here and in any case if pulpal pain is diagnosed – start with routine endodontic treatment.

51 Refered pain should be differentiated from other : MPDS Tmj problems Otitis media -- ear pain, fever , upper respiratory tract infection

with cough and nasal discharge Ocular pain --- eye irritation , fever , reduced vision, sharp

throbbing pain in eye , pain worsened by light.

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TRAUMATIC INJURIES Endodontic treatment may be required as a result of traumatic

injury.Most common endodontic emergencies are:

a) Crown fracture.b) Root fracturec) Avulsion

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CROWN FRACTURE If a green stick # of crown is present and crown segment doesn’t

shear off under pressure, a steel band is cemented around the tooth.

Relieve the occlusion- eliminates pain & re-evaluate status pulp later.

CROWN FRACTURE INVOLVING PULP: crown fractures involving enamel, dentin & pulp are called

‘complicated crown” fractures by Andreasen & class 3 by Ellis. Degree of pulp exposure--- pinpoint exposure to total unroofing

of coronal pulp. Initial reaction --- hemorrhage --- inflammatory response ---

destructive (necrotic) / proliferative (polyp)

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TREATMENT:Depends on maturity of the pulp…… Preservation of the pulp by vital pulp therapy--- pulp capping

/ pulpotomy Pulpectomy

Pulp Capping Modified pulpotomy technique (“Cvek type”)

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FOLLOW – UP AND PROGNOSIS:Acceptable results of evaluation following pulpotomy should be all of the

following: 1. No clinical signs or symptoms2. No evidence of periradicular pathologies3. No evidence of resorption – internal / external4. Evidence of continued root formationin developing tooth.

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ROOT FRACTURE: DESCRIPTION: fracture involves the root only; cementum ,

dentin, and pulp. INCIDENCE: account 2% of all dental injuries

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DIAGNOSIS :

Missed in conventional radiographs With conventional radiograph… 90 degree angulation ….if

fracture diagonal … missed Additional film angulation of 45 degree + 90 degree ---- reveal

root fracture.

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Management:

SPLINTING:

Repositioning the coronal fragment Fragments with close proximity --- splinting does not make

difference Semirigid splinting --- favour healing splinting after4 wks– does not make difference Delaying treatment for 24 hrs --- does not make difference

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TREATMENT OF CORONAL FRAGMENT:

most simplistic

Fracture site located more coronally on the root --- “new apex” which is wide and open--- open apex

Establishment of working length ---- radiographically

Conventional apexification- Calcium hydroxide ---- 3 to 12 months for barrier

formation- MTA --- immediate restoration

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TREATNG CORONAL FRAGMENT & REMOVAL OF APICAL FRAGMENT:

signs and symptoms of non-healing after coronal RCT.

SWELLING / radiolucent area at the site / apically.

Assuming coronal fragment stable--- surgical removal of apical fragment.

68% success rate Notable mobility of coronal

fragment --- implant through coronal fragment & into bone = endosseous implant.

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TREATING CORONAL & APICAL FRAGMENTS AT THE SAME TIME:

It is difficult to get apical seal when endodontically treating only coronal fragment.

To achieve this seal --- treatment of both coronal & apical fragment simultaneously which is almost impossible.

low success rate

Favorable approximation of fragments --- intra radicular splint --- rigid type of post (cobalt – chromium alloy [vitallium])

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REMOVING THE CORONAL FRAGMENT & TREATING THE APICAL SEGMENT

CROWN ROOT FRACTURE:

- Coronal fragment attached only by gingiva- Acceptable crown :root ratio 1:1 (for planning

post and core)- Endodontic treatment of apical segment .- Followed by crown lengthening --- orthodontic/

periodontal- Placement of appropriate crown.

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SEQUELE OF ROOT FRACTURE

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Extrusive Luxation

Displacement of tooth in coronal direction results in partial avulsion.

Tooth – mobile & continually traumatized by contact with opposing tooth --- premature occlusion

Radiographically --- “empty” radiolucent space

Immediate treatment – repositioning the tooth & stabilizing by functional splint for 4 to 8 wks.

Definitive treatment –vitality test RCT --- NECROSIS/ INFLAMATORY ROOT RESORPTION SEEN

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Lateral Luxation

Traumatic injury --- displacement of tooth labially , distally or mesially --- lateral luxation.

Very painfull --- premature occlusion e.g : max.incisor pushed palatally.

Crown makes contact long before centric occlusion.

Treatment plan depends on ---presence or absence of apical displacement at the time of injury.

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LATERAL LUXATION WITHOUT APICAL DISPLACEMENT:

Teeth pushed only in facial / lingual direction with apical root remaining in its original position within the socket.

Teeth loose enough – slight digital pressure to reposition the tooth.

Some sulcular bleeding --- typically seen

If there is no widening of PDL space as confirmed by radiographs --- good prognosis --- endodontic treatment may not be necessary.

Tooth is initially unresponsive to EPT and cold test.

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LATERAL LUXATION WITH APICAL DISPLACEMENT:

Tooth is frequently pushed palatally / lingually and firmly located in its new position.

Tooth will elicit dull metallic sound on percussion. palpating alveolar bone --- reveal new location of apex. Radiographically – PDL space widened around the midportion and

coronal portion of root. If apex moved out of its original position --- damage to

neurovascular bundle. negative response to cold and EPT . Closed apex cases --- advice endodontic treatmentREPOSITIONING THE TOOTH IN ITS SOCKETSPLINTING --- 3 TO 4 WEEKS PROGNOSIS GOOD --- if endodontic treatment done when indicated.

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TOOTH AVULSION/ EXARTICULATION

Incidence – 3% of all dental injuries True dental emergency – timely attention to replantation could

save the tooth. Sports and automobile accidents --- frequent causes. Examine --- tooth is replanted before coming to dental office. See for any debris / contaminants. Record the time of avulsion.

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Storage media

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TREATMENT :

IMMEDIATE TREATMENT

Radiographs --- fracture of alveolar bone- Socket --- foreign bodies and debris --- scrape gently from bony

walls.- Blood clot – gently suctioned and irrigated with saline- Avulsed tooth --- debris gently rinsed off- Do not hold the in hands --- always use some twizer / forceps to

hold the tooth - Gently and slowly insert the into socket --- aneasthesia may not be

necessary.

73 Check the alignment --- no hyperocclusion . Splinting not necessary if tooth fits firmly in socket. Mobility --- splinting recommended Orthodontic wire ( 0.3 mm) attached with composite on the

labial surface of tooth. Splinting should left for 1 to 2 wks Initial antibiotic course, tetanus prevention & RCT ( after 10 to

14 days). Calcium hydroxide is recommended as an intracanal medicament

--- 2 wks , during RCT.

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DURING

ENDODONTIC

TREATMENT

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Flare – ups

American Association of Endodontics

Definition :An acute exacerbation of peri radicular pathosis after initiation or continuation of root canal treatment.(1998).

> Studies reports 1.8-3.2 % flare-ups.

Inter-appointment flare-up is characterized by the development of pain, swelling or both, following endodontic intervention.

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The causative factors of inter appointment pain comprise mechanical, chemical, and/or microbial injury to the pulp or periradicular tissues, which are induced during root canal treatment.

Regardless of the type of injury, the intensity of the inflammatory response is directly proportional to the intensity of tissue injury.

The frequency of inter appointment pain has been reported to be significantly higher in teeth with periradicular lesions as compared to teeth with vital pulps and normal periradicular tissues.

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Medical status of patient :

Diabetic patient --- they are more prone for flare ups because increased sugar content in blood – uncontrolled diabetics--- treared only when there is an emergency

Hypertensive patients – care should be taken during giving local anesthesia– epinephrine contraindicateds

Pregnant patient – second trimester is the best time to treat --- first and third risk to foetus and patient. --- only emergency treatment given --- continuation of treatment after pregnancy

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Result of imbalance in host-bacteria relationship.

F. nucleatum, Prevotella species and Porphyromonas species were frequently isolated from flare-up cases.

- Enterococcus faecalis is present in retreatment cases.

Contributing factors: 1)Inadequate debridement 2)debris extrusion 3) over instrumentation

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Inadequate debridementResidual pulp in inadequately instrumented canalb) Undetected canals.

c) Teeth with necrotic pulps (with / with out associated peri radicular lesions)–more prone to mid endodontic flare-ups than vital teeth

Rx: Through debridement of entire root canal space- removal of entire pulpal tissue with broaches + irrigants.

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Debris extrusion Conventional hand instrumentation was shown to extrude the

more debris than rotary instrumentation.

Pulpal remnants, necrotic tissue, dentin filings, canal irrigants ( forced irrigation of NaoCl beyond apex-violent tissue reactions),

microorganisms and their toxins may extrude beyond the apical foramen during instrumentation.

More likely to cause flare up if pulp is necrotic and infected.

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instrumentation.

The crown down technique and balanced force technique shows significantly less debris extrusion.

The presence of an apical dentinal plug may prevent debris extrusion, over instrumentation and over obturation. But since it may harbor infectious material, the long term prognosis is compromised.

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Over instrumentation Incident of moderate –severe pain Gross O.I – causes acute apical periodontitis

producing primary inflammatory pain Over instrumentation beyond the apical foramen

results in intra-operative or post operative pain. apical periodontium is crushed producing pain

and inflammation.

overinstrumentation can be prevented by proper w.l-

Endodontic therapy may be continued, analgesics relieve pain.

Occlusal reduction is necessary.

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TESTING FOR OVERINSTRUMENTATION:

grasp the paper point 2mm more than the working length, the paper point will pass easily without any obstruction and on withdrawal there will be a reddish

brown discoloration of the tip indicating presence –inflamed tissue & absence of stop in apical preparation.

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Secondary apical periodontitis Term applied to severe tenderness to percussion immediately

after the treatment was initiated.

Extremely uncomfortable- causes throbbing, gnawing, pounding pain. Preoperative cond is either acute or chronic pulpitis.

If the access is opened, no productive exudate or escape of gas is noted- culture tests negative –as no infection present.

Main Cause is over instrumentation but may also occur due to over medication(too caustic or too much ICM), forcing debris into periapex.

Sympathomitic pain relief: access cavity opened, saline irrigation and use of corticosteriod-antibiotic paste as an intracanal medicament – pt recalled later for completion of endo treatment- thus avoiding painfull episode.

86 PREVENTION:

The canals are normally instrumented too close to the apex in an attempt , to ‘completely clean the canal’

Most studies on apical anatomy are of the opinion that over instrumentation 0.5mm beyond the radiographic apex may lead to secondary apical periodontitis.

If over-instrumentation has occurred- take remedial steps at the same sitting to avoid a flare–up.

A intracanal medicament+antibiotic coverage.

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Endodontic emergencies: Your medication may be the cause J Conserv Dent. 2009 Apr-Jun; 12(2): 77–79. Promila Verma

• Formaldehyde-containing medications, various compounds containing arsenic and paraformaldehyde used as pulp devitalizers.

• Such agents have some clinical benefit, although local soft and hard tissue necrosis occurs if they are not confined to the pulp.

case report describes tissue degeneration and swelling in a patient treated with formocresol during root canal treatment.

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Treatment & Prevention Of Flare-ups:

1. Occlusal reduction.2. Antibiotic prophylaxsis3. I & D ---Leaving tooth open for complete drainage- 20 min –

complete removal of pulp tissue and debris -followed by closed dressing

4. Calcium hydroxide therapy: intra canal dressing MOA:- hydrolyses lipid moiety of bacterial lipopolysaccharides. Disadvantages: Unable to kill enterococcus species which is

commonly associated with failed r.c.t.-

5. Antibiotics & Analgesics(releive pain)

6. Corticosteroids – antiinflammatory action.

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Hypochlorite accident

A hypochlorite accident refers to any event in which sodium hypochlorite extruded beyond the apex of a tooth and the patient immediately manifests a combination of some of the following symptoms:

Severe immediate pain swelling Profuse bleeding both

interstitially and through the tooth.

90Causes :

Forceful injection of Naocl due to wedging of the irrigating needle into the root canal.

Irrigating a tooth with a large apical foramen, apical resorption or an immature apex.

Features : Edema and ecchymosis, accompanied by tissue necrosis,

paraesthesia and secondary infection. Although most patients recover within 1-2 weeks. Long-term

paraesthesia and scarring have been reported.

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Management: Immediate aspiration Cold pack over the affected area. Regional block anesthesia administered. Pain management

difficult because symptoms from distant anatomic structures will continue to cause discomfort.

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Monitor tooth for the next half hour. Bloody exudation extended from canal denotes the bodies reaction to the irritant. Remove the fluid with high volume suction to encourage further drainage. If drainage is persistent consider leaving the tooth open.

Antibiotic coverage to prevent secondary infection

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Analgesics prescribed. Because of possible bleeding complication with aspirin and NSAIDs an acetaminophen-narcotic combination may be more appropriate.

Corticosteroids – inflammatory process Home care instructions: Cold compress to minimize pain and

swelling. Subsequently warm compresses to encourage healing.

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Prevention : Bend the irrigating needle at centre to confine the tip of the

needle to higher/coronal levels of root canal.

Never bind the needle in the canal

Oscillate the needle in and out to ensure that the tip is free to express the irrigant with out resistance

express the irrigant slowly and gently

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Hydrogen peroxide as a cause of iatrogenic subcutaneous cervicofacial emphysema:

the use of hydrogen peroxide 3% as an irrigant to newly operated tissue plans may cause emphysema.

facial swelling, tenderness and crepitation

Radiographs will be normal

paranasal computed tomography (PNCT) – detect the presence of air within the tissue spaces

prophylactic antimicrobial therapy

Emphysema will recover on its own within a week.

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Air emphysema Air introduced into periapical tissues during invasive root canal

treatment --- potential to do great harm.

Although rare occurance – but has a risk

In a study done on pigs – significant pressures during air drying beyond the apex of the roots with apical diameters larger than size #20

Compressed air should never be component in drying of a root canal that is open to periapical tissues.

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ASPIRATION / INGESTION OF ENDODONTIC INSTRUMENTS

Aspiration of endodontic hand instruments happens only when rubber dam is not in place.

Grossman had aptly stated (1955) that if an instrument is swallowed by the patient , the dentist is likely to be confronted lawsuite.

High power suction along with rubber dam help in prevention of aspiration of instruments.

Aspiration of endodontic instruments can be a clinical disaster ending up in life threatening situations or ending up in the need of major surgery to remove instrument.

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PERFORATION Perforation is an artificial opening in the tooth or root, created by

clinician during entry to the canal system or by a biologic event such as pathologic resorption or caries that results in communication between the root canal and periodontal tissues.

Time --- time elapsed between seal of the perforation and its inception --- important in determining prognosis . --- immediate treatment --- better prognosis.

Location : Subgingival – during access cavity prepation for search of canal Midroot – during post space preparation and aggressive BMP Apical --- during instrumentation – using large inflexible files violating

apical constriction Size of perforation --- smaller the defect better is prognosis

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Coronal third furcation management: Materials – Cavit, amalgam, calcium

hydroxide, GIC or haemostatic agent such as Gelform.

Barrier technique: Artificial barrier (floor) using either calcium

sulphate and hydroxyapatite improves sealing ability & provides successful barrier against its over extension.

Calcium hydroxide: Control bleeding placed in the area of perforation and left

for at least few days will leave the area dry and allow for inspection of perforation.

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MIDROOT PERFORATIONS Lateral perforation at midroot level tends to occur in curved canals when a

ledge has formed or along inside curvature of root as canal is straightened out.

MB canal of lower molar >>>

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STRIPPING

a “lateral”perforation caused by overinstrumentation through a thin wall of the root & mostly happens along the inside curvature of the root as the canal is straightened out

Distal wall of mesial roots in mandibular 1st molars>>

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Recognition:Sudden appearance of blood or complaint from patient.

Access is difficult, Repair- unpredictable.

Prognosis is poor. Lack of tooth structure & integrity of wall may eventually lead to fractures & microleakage due to inability to seal the perforation.

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Two Step method to repair midroot perforations

Root canals are first obturated, then the defect is repaired surgically.

removal of excess GP using a hot spatula & then cold burnishing the site.

To Prevent Stripping: anticurvature filing maintaining mesial pressure. Careful use of rotary instruments inside the canal

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APICAL PERFORATIONS

Maybe due to….

Not negotiating a curved canal or..

Not establishing WL & overinstrumentation.

Instrumentation beyond apical confines

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Emergencies during endodontic surgery

Excessive uncontrolled bleeding

Due to rebound phenomenon

Medical emergencies during endodontic treatment

Syncope Hypoglycemic shock

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POST ENDODONTIC TREATMENT

Over extension Under extension Hyperocclusion Missed canals

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UNDERFILLING

ETIOLOGY- - natural barrier in canal- ledge- insufficient flaring- poorly adapted master cone- inadequate condensation pressure

TREATMENT--removal and retreatment

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TREATMENT: Sealer – no treatment required as it removed from body by action

of macrophages. Gutta percha – re- rct / apical surgery followed by retrograde

filling

OVERFILLING- can either gutta percha or sealer

etiology-- sequel of over instrumentation- uncontrolled condensation pressure- inflammatory resorption- incomplete development of root- open apex

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Analgesics and Antibiotics

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Flexible Analgesic Plan

When aspirin like drugs are indicated

severe

600-800mg ibuprofen + 10 mg oxycodone

moderate

600-800 mg ibuprofen + 60

mg codeine

Mild

200-400 mg ibuprofen or

650 mg aspirin

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Aspirin like drugs are contraindicated

Mild

600-1000 mg acetaminoph

en

Moderate

600-1000 mg acetaminophen +opiate 60 mg

codeine

Severe

600-1000 mg acetaminophen +

opiate 10 mg oxycodone

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Indications for Antibiotic Therapy

Systemic involvement Compromised host resistance Fascial space involvement Inadequate surgical drainage

Select antibiotic with anaerobic spectrum Use a larger dose for a shorter period of time (“hard and fast” rule)

Guidelines for Antibiotic Therapy

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Penicillin V Still, the drug of choice for infections of endodontic origin Penicillin, is a bactericidal antibiotic with good oral absorption. It

also has a good spectrum of coverage against the main oral virulent microflora. It is well tolerated by patients and has a low toxicity profile.

Loading dose: 1-2 g then 500 mg qid x 7-10 days

Amoxicillin, has a more broad spectrum of coverage than penicillin, but it is an acceptable alternative. Its dosing regimen (three times daily) may lead to better compliance.

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Metronidozole (Flagyl) Used in conjunction with Penicillin V 500 mg of Penicillin V with 250 mg Metronidozole, qid x 7-10

days Covers anaerobic spectrum

Other antibiotics:CephalosporinsClindamycin penetrates well into abscesses

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CONCLUSION

KNOWING WHAT TO DO AND WHEN TO DO ARE AS IMPORTANT AS HOW TO DO

More than 80% of pts who reports to dental , clinic are with emergency symptoms with endodontically related pain. Therefore the knowledge, skill for the treatment of these endodontic emergencies is highly required for every clinician

An accurate diagnosis and effective treatment of acute situations are an important responsibility and priviledge of dental practice.

Effective caring and management of endodontic emergencies not only represents a service to the public, which the dentist can be proud of but also enhaces the positive image of dentistry.

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