ENDODONTIC EMERGENCIES

FLOWCHART Definition Introduction Presentation of endodontic emergency 1) Pre- Treatment Pulpal pain Reversible pulpitis Hypersensitive Dentine Definition Theories Irreversible pulpitis Acute pulpitis ith apical periodontitis Acute periapical abscess !anagement In"ection Techni#ues Different types of $laps %rac&ed tooth syndrome Traumatic in"ury ') Patients (nder Treatment Recent restorative treatment Periodontal treatment )*posure of the pulp $racture of the root or cro n $lare-ups Treatment and Prevention of flare + ups !edications Hypochlorite accident ,) Post- )ndodontic Treatment High restoration -ver filling (nder filling Root fracture

 %-.%/(0I-. Endodontic emergency (def) -ccurrence of severe pain and 1 or s elling follo ing an endodontic treatment appointment2 re#uiring an unscheduled visit and active treatment 34atson and $oud +155')6 )ndodontic emergencies include situations of pain or s elling that re#uire the immediate attention of a dentist61 The aim of emergency endodontic treatment is to relive pain and control inflammation or infection that may be present6 It has been reported by Hasslar and !itchell6 /ater corroborated by !itchell and Tarplee that 578 of patients see&ing emerging dental treatment have symptoms of pulpal or periapical disease6 Presentation of endodontic emergency ' Patients ho present endodontic emergencies can be divided into three main groups9 1) Pre- Treatment Pulpal pain Reversible pulpitis Irreversible pulpitis Acute pulpitis ith apical periodontitis Acute periapical abscess %rac&ed tooth syndrome Traumatic in"ury ') Patients (nder Treatment Recent restorative treatment Periodontal treatment )*posure of the pulp $racture of the root or cro n

 $lare-ups ,) Post- )ndodontic Treatment High restoration -ver filling (nder filling Root fracture

:efore Treatment 1) Pulpal pain Irritation of the pulp causes inflammation and the level of response ill depend on the severity of the irritant6 If it is mild2 the inflammatory process may resolve in a similar fashion to that of other connective tissues2 a layer of reparative dentine may be formed6 Ho ever2 if the irritation is more severe2 ith e*tensive cellular destruction2 further inflammatory changes could eventually lead to pulpal neorosis6 a) Reversible pulpitis The essential feature of a reversible pulpitis is that pain ceases as soon as the stimulus is removed6 The teeth are non tender to percussion6 Initially2 the follo ing treatment may be all that is necessary6 %hec& the occlusion and remove non- or&ing facets6 Place a sedative dressing in a cavity after removal of deep caries6 Apply a fluoride varnish to sensitive dentine6 Hypersensitive Dentine Definition9 The term dentine hypersensitivity has been used to describe a specific condition that is defined as pain arising from e*posed dentine6, Dentinal hypersensitivity is a painful response to a non-no*ious stimulus applied to e*posed dentine in the oral environment 6;

 )*posed cervical dentine from gingival recession2 periodontal surgery2 abrasion or erosion can result in root hypersensitivity6 Any chemical 3osmotic gradient)2 thermal 3contraction 1 e*pansion) or mechanical 3:iting or digital scratching) irritant can disturb the fluid contact in the dentinal tubules and e*cite nociceptors in the pulp6

Theories 0everal theories have been cited to e*plain the mechanism involved in dentinal hypersensitivity6< The transducer theory2 The modulation theory2 The =gate> control and ?ibration theory2 and The hydrodynamic theory The latter2 =hydrodynamic theory>2developed in the 15@7As and based upon t o decades of research2 is idely accepted as the cause of tooth sensitivity6@ Assumptions of the hydrodynamic theory conclude that hen the fluids ithin the dentinal tubules are sub"ected to temperature changes or physical osmotic changes2 the movement stimulates a nerve receptor sensitive to pressure2 hich leads to the transmission of the stimuli6 The various stimuli that are reported to cause this transmission of sensation are cold2 hot2 osmotic2 electrical2 dehydration2 and chemical6B

:erman describes this reaction as9

=The coefficient of thermal e*pansion of the tubule fluid is about ten times that of the tubule all6 Therefore2 heat applied to dentin ill result in e*pansion of the fluid and cold ill result in contraction of the fluid2 both creating an e*citation of the CmechanoreceptorA6>

Treatment of hypersensitive dentin has had limited success6 Treatment modalities include2 chemical on physical bloc&age of the patent dentinal tubules to prevent fluid movement from ithin2 chemical desensitiDation attempts to sedate the cellular processes ithin the tubules ith cortiscosteriods or to occlude the tubules ith a protein precipitate2 a remineralised barrier or a crystalliDed o*alate deposit6 Physical techni#ues attempt to bloc& dentinal tubules ith composite resins2 varnishes2 sealants2 soft tissue grafts2 and glass ionomer cements6 The lontophoresis techni#ue electrically drives fluoride deep into dentinal tubules to occlude them6

 /aser technology may provide definitive solutions for sealing the tubules permanently6 :ut it still needs lots of studies to determine the efficacy and safety6 Reversible p lpitis Pain is of very short duration and does not linger on removal of stimulus6 .o tenderness on percussion Pain difficult to localiDe )*aggerated response to vitality Radiographs present ith a normal appearance !rreversible p lpitis H1- spontaneous bouts of pain that may for a fe seconds to several hours6 Aggravation of pain on application of heat1cold6 In later stages2 heat is more significant6 %old may ell relieve pain6

 Pain may radiate initially2 but once the PD/ is involved2 the patient ill be able to localiDe the tooth6 4idened PD/ space may be seen on the radiographs in the later stages6 Patients ith irreversible pulpitis ait longer to see& emergency endodontic treatment6 !ost 3E1-E,8) patients ith mod6 to severe pain ill use analgesics to control their discomfort 3narcotic '7-',82 non-narcotic B<-E782 antibiotic @-178)6 IP patients ho ta&e analgesics ill get pain relief @'-@<8 of the time6E Tre"tment# Pulpectomy is done for tooth single rooted and multirooted both6 .o formocresol or other drugs used6 -cclusion chec&ed after placing the temporary cement6 0upraocclusion may cause pericementitis6 This ould complicate the ne*t phase of endodontic therapy since healing of the periapical tissue is the ob"ective of endodontic treatment6 Also2 a high occlusion may result in loss of portion of Fn-)2 leaving the tooth open for salivary contamination6 Ac te $ lpitis %ith Apic"l $eriodontitis !ost difficult emergency condition to treat6 This is particularly true in mandibular molars2 here an insufficiency in depth of anesthesia is not an uncommon problem6 Diagnosis is usually simple6 Pt6 is a a are of the toothAs tenderness to percussion6 In the classic situation2 heat causes2 intense pain and cold relieves it6 Radiograph may sho a small periapical radiolucency2 e*hibit a thic&ening of PD/ space or appear normal6 &"n"gement Heavy dosage of local anaesthetic may be needed6 %omplete pulpectomy6 Painful teeth ith acute apical periodontitis that had been dressed ith /edermi* paste gave rise to less pain than that e*perienced by patients

ho had a dressing of calcium hydro*ide or no dressing at all6 /edermi* is an effective intracanal medicament for the control of postoperative pain associated ith acute apical periodontitis2 ith a rapid onset of pain reduction65 Ac te $eri"pic"l Abscess Is an inflammatory process in the periradicular tissues of teeth2 often accompanied by e*udate formation ithin the lesion6 This condition is related to bacterial invasion of the periradicular region from an infected and necrotic pulp canal6 It may develop spontaneously or may follo initial endodontic treatment if bacteria are forced into the periradicular tissue6 'i"gnosis The patient has a large diffuse s elling2 the responsible tooth is tender to percussion2 is mobile and lac&s vitality6 GeneraliDed pain may be absent despite the discomfort of the s elling6 In many patients pain is present before the s elling occurs6 -nce the bone is perforated and there is room for the e*udate to e*pand through the soft tissues2 pain may be relieved6 Radiographs range from no periapical change hen the inflammation is rapid to definite radiolucency6 In the latter case2 the acute abscess may develop from a chronic lesion hereas in the former2 the abscess is acute6

 :roo& et al. 0ampled the e*udate from endodontic abscesses in ,5 patients2 and demonstrated anaerobic bacteria in the ma"ority of cases 35; per cent)6 Polymicrobial anaerobic and aerobic flora have been recovered from endodontic abscesses6 The predominant anaerobes are Bacteroides spp2 Porphyromonas gingivalis and P.endodontalis, Fusobacterium spp 3especially F.nucleatum), Prevotella spp 3P. intermedia and P. oralis)617 &"n"gement The abscess should be drained via the root canal space6 Access prepared6 Patients may be sensitive to vibration2 hich results in increased pain6 A stic& impression compound may be softened and placed against the labial surfaces of the abscessed and ad"acent teeth6 It acts as a splint to lessen the vibrations6 /ocal infiltration anasthetic should not be administered as it may cause pain2 chance for dissemination of microorganisms and the ineffectiveness of such anaesthesia6 :loc& anaesthesia usually is effective6 In"ection Techni#ues !a*illary Anesthesia Supraperiosteal Injection Posterior Superior Alveolar Nerve Bloc !iddle Superior Alveolar Nerve Bloc

 In"raorbital Nerve Bloc Palatal Anesthetic #echni$ues %reater Palatine Nerve Bloc Nasopalatine Nerve Bloc !a&illary Nerve Bloc

!andibular Anesthesia In"erior Alveolar Nerve Bloc !ental Nerve Bloc Incisive Nerve Bloc Periodontal 'igament Injection Intraseptal Injection Intraosseous Injection Intrapulpal injection

(ther !ethods o" Anesthesia Electronic Dental Anesthesia) #ranscutaneous electrical nerve stimulation *#+NS) has been used "or management o" chronic and acute pain. #heory on the mechanism o" action o" electrical stimulation o" the nerve "or pain control involves the release o" endorphins and en ephalins a"ter prolonged *over ,- minutes) e&posure to electrical stimulation. It has been postulated that $uic er healing may be aided by the muscle contraction and vasodilation provided during electric stimulation. 'idocaine Patch *.entiPatch)

 Surgical trephination can and does provide immediate relie" o" pain, surgical drainage o" the in"ection and related "luids, and in most cases does not re$uire supplementary administration o" antibiotics and only minimal amounts o" analgesics.,,

In many cases2 drainage occurs immediately on deroofing the chamber ith a bloody and1or purulent discharge6 Aspiration using a mild suction device ill further aid in establishing drainage6 A ide gauge needle placed in the saliva e"ector ill give sufficient negative pressure to establish and maintain e*udation6 The apical constriction prevents the inflammatory products form draining through the tooth6 To relieve this problem2 the apical constriction is purposely violated and enlarged to a minimum of H'7 1 '< instrument to allo for e*udates drainage through the tooth6 If

drainage still doesnAt occur2 use a to H,7 file6 :ut even then if there is no drainage do not attempt further6 4hich sufficient drainage has occurred and patient is a febrile + antibiotics prescribed6 $or many years2 the patient as dismissed ith the access cavity open after establishment of drainage6 Recently there has been an alteration in this regimen6 The access cavity is closed but only after the patient has sat ith the tooth draining for as long as an hour or even more6 The drainage follo s a very predictable pattern2 starting ith pus of a yello ish2 hitish or greenish color mi*ed ith bloo6 Gradually2 the pus decreases and primarily blood drains6 $inally2 the blood flo decreases2 and only a clear serum e*udation emerges6 At this point2 a film ith files in place is ta&en and the or&ing length calculated6 The canal is enlarged and may be closed ith sterile cotton and Fn-)6 Advantages of this approach are that no ne type of micro-organisms are introduced into root canal system6 As suggested by $ran& et al2 a sulfonamide 3sulfanilamide or sulfathioDole) po der is ta&en onto a paper point dipped in sterile distilled ater and placed into the canal6 A sterile pledget of cotton is then placed into the chamber and access sealed ith F-)6 In case of patients allergic to sulfonamide2 this method is contraindicated6 (se of antimicrobials 3e6g62'<7 mg amo*ycillin plus 1'< mg clavulanic acid tds2or metronidaDole '77 mg tds) is indicated hen pyre*ia and other systemic signs are present61'

If amo*ycillin is selected2 the therapy should account for the fact that many anaerobes of importance in periapical abscesses produce betalactamase61, $inally2 it should be emphasiDed that antimicrobial therapy ithout surgical drainage is not an effective therapy over the long term6 In the management of localiDed acute apical abscess in the permanent dentition2 the abscess should be drained through a pulpectomy or incision and drainage6 This analysis indicated that antibiotics are of no additional benefit6 In the event of systemic complications 3e6g62 fever2

lymphadenopathy or cellulitis)2 or for an immunocompromised patient2 antibiotics may be prescribed in addition to drainage of the tooth61; C lt ring the e( d"tes %ulture is invaluable hen information on antibiotic needed is re#uired6 The culture is not ta&en of the initial portion of the e*udate as ma"ority of the microorganisms are dead and incapable of reproduction6 Ho ever2 hen the e*udate starts to change from yello ish to reddish hue2 the sample is ta&en ith a sterile paper point6 !icrobes often Detected in Infected Root %anals1< -bligate Anaerobes $acultative Anaerobes Gram-negative bacilli Gram-negative bacilli Porphyromonas %apnocytophaga Prevotella )i&enella $usobacterium %ampylobacter :acteroides

!rrig"nts sed in tre"ting "c te "bscesses At the emergency appointment + arm sterile ater or saline .aocl has the tendency to clump the e*udates hich might cause plugging of the apical constriction and halt drainage6 4hen patients returns after emergency opening + alternating use of .aocl and H'-'6 These t o solutions ill cause foaming hen used together and ill aid in the bubbling out of debris6 To prevent building up .ascent -*ygen2 .a-%l must be the final irrigant used2 until all foaming has stopped6 'r"in"ge thro gh tiss e "nd bone

 The presence of a post and core cro n2 sectioned silver points2 calcified canals2 prevent obtaining intra canal drainage6 Therefore2 drainage is established either by Trephination or Artificial $istulation 3Artifistulation)6 4hen intracanal drainage is possible2 trephination or cutting a hole in the bone is undesirable as the effect is short lived since2 nidus of infection remains undisturbed in the canal6 Artifistulation 1 trephinaton is performed only hen the s elling is sufficiently localiDed to permit ade#uate drainage follo ing incision6 $or artifistulation a stab incision is made "ust belo the most dependent point of the s elling ith a H11 scalpel6 Apical bone is probed ith an endodontic e*plorer to locate a perforation hich may be enlarged ith a spoon e*cavator 3or) endodontic file to ensure venting of the apical area6 This is done by using a strip of rubber dam material6 3'7mm*'7mm) hich is cut to resemble the letter H or rolled into a tube and disinfected by dipping into a chemical solution6 -ne half of the dam drain is placed underneath the flap the ings allo ed to e*tend underneath the tissue6 A suture is placed to attach the unretracted edge of the flap6 An antibiotic is prescribed and the patient rescheduled after ;-Bday6 -nly if artifistulation fails to provide drainage2 trephination is done6 The flap should increased in siDe for visualiDation6 :y using a fissure bur in the airotor ith ater spray2 the periapical bone is removed until the tip of the root is uncovered and drainage established6 The H or tube drain is placed and an antibiotic prescribed66 Cr"c)ed tooth syndrome %raDing of the enamel surface is a common finding but on occasions it may indicate a crac&ed tooth6 If the crac& runs deep into dentin che ing may be painful6 Initially2 this may not be of sufficient intensity but once it involves the pulp2 symptoms of pulpitis ill ensue the various types of presentations are6 Pain especially on che ing 0ensitivity to hot 1cold

Pain difficult to localiDe Pain referred to areas supplied by ? nerve Acute pulpal pain Alveolar abscess6

A tooth that is susceptible to crac&ing is one that is e*tensively restored but lac&s cuspal protection 3=cuspal crac&>) or an intact tooth that has an opposing plunger cusp occluding centrically against a marginal ridge 3=vertical crac&>)6 Pain generated by disocclusion2 drives oral fluids ithin the crac& in the pulpal direction6 This phenomenon is uni#ue to a crac&2 and it is inspired by the the diagnostic test of selective closure on the suspected tooth to elicit pain on release6 -ther diagnostic aids are transillumination6 Radiographs reveal a fracture only if it runs in a bucolingual plane6 &"n"gement *rgent c"re + immediate reduction of the toothAs occlusal contact by selective grinding6 'efinitive tre"tment + pulp vitality preserved for a vertically crac&ed tooth by means of a full coverage cro n6 -ther ise2 the defect ill migrate pulpally and cause symptoms re#uiring endodontic intervention6 The e*tent of the fracture line determines if the tooth can be saved or not6 If it is a vertical fracture involves the R% system and e*tends belo the level of alveolar crest6 )*traction is indicated6 Ho ever2 if the fracture line is horiDontal or diagonal and superficial to the alveolar crest then the prognosis is better6

 Tr" m"tic in+ ry Endodontic tre"tment m"y be re, ired "s " res lt of tr" m"tic in+ ry# )mergency treatment can be complicated by local edema2 bleeding or other conse#uences of the accident6 %ro n fracture ithout pulp e*posure %hipped enamel is smoothened ith a sandpaper dis& and rubber hich to prevent irritation to the lips and tongue6 )*posure of dentin re#uires definitive treatment6 A thin mi* of F-) is placed over the e*posed dentin6 Then a celluloid cro n is festooned2 filled ith a thic& mi* of F-) accelerated ith Dine acetate crystals and cemented into place6 This provisional restoration is replaced ith a more permanent restoration later6 Radio radiographically assesed and vitality tests are done regularly6 Cro%n fr"ct re %ith vit"l p lp e(pos re If apical closure has ta&en place2 treatment is similar to that of acute pulpitis hich is the condition present6 Pulp e*tirpation is done via the fractured opening instead of the lingual access cavity henever permissible6 If apical closure has not ta&en place2 a formocresol pulptomy is done to &eep the apical pulp tissue unimpeded in its function of completing ape*ogenesis6 Pulpotomy is preferred over pulp capping as the temporary cro n1dressing covering the pulp e*plosure is difficult to retain hich results in further contamination of the pulp hich microorganism leading to pulpal necrosis eventually6 The pulpotomy dressing is placed deep enough into the canal so that it ill be unaffected if the cro n becomes loosened6 Radiographic evaluation done every ,-@ months to determine degree of apical development6 Then routine endodontic treatment may be instituted6 Cro%n fr"ct re %ith necrotic p lp e(pos re

 This condition may occur as a result of an earlier accident2 caries or deep restoration or by severing of pulpal blood vessels in the most recent traumatic accident6 )mergency treatment is that of an acute periapical absces 1pulpal necrosis6 If apical closure is complete routine endodontic treatment if apical closure is incomplete ape*ification6 Hori-ont"l root# fr"ct re Does not al ays re#uire endodontic treatment6 Periodic radiographic evaluation and vitality tests done6 If mobility is present2 ho ever2 some types of stabiliDation is needed6 It may be in the form of orthodontic ires2 acrylic ire combination etc6 Av lsed teeth The replacement of tooth that has been removed from the alveolar soc&et2 either intentionally or by accident is called replantation6

Treatment Protocol Part I9 )mergency treatment at the site of in"ury :est results obtained if tooth is replanted as soon as possible2 even at the site of accident6 34ithin ,7 minutes) even if badly contaminated2 it should be replaced ithout steriliDation or scrubbing ith soap or detergent6 The tooth may be rinsed under running ater6 $irm pressure by means of a small to el bet een incisal edges &eeps the tooth in the soc&et6 If it is not possible to reinsert the tooth2 it is carried in a suitable transport medium6 Part II )mergency treatment at the Dental office If tooth has not been replanted2 it is &ept in a glass of saline6 History and e*amination and radiographs made as #uic&ly as possible6 The tooth is held in a et gauDe sponge and grasped only at the cro n6 4ipe a ay gross debris gently from the root surface ith a et sponge6 Irrigate soc&et ith saline6 !easure the tooth length and record it6

 0plinting is done after placing the tooth bac& in the soc&et6 If tooth as already been replanted and seems acceptable2 splinting is done directly6 0plint ith ire + composite2 soft diet advised6 $"rt !!!# Completion of endodontic tre"tment -ne ee& after replantation prepare access cavity and perform canal debridement2 F-) placed6 If tooth had an incomplete root ape*2 no treatment is done6 -nly routine evaluation is done as it allo s for repair of severed pulpal vessels6 If pulp necrosis develops canal debridement and ape*ification procedures underta&en6 To prevent an&ylosis2 remove splint at this appointment6 T o ee&s after replantation 31 ee& after canalpreparation) place %a 3-H)' paste in the canal to inhibit e*ternal resorption6 If the paste is placed too soon2 before PD/ is regenerated2 it may cause increased resorption6 Recall monthly6 Re- open the tooth after ,-@ months prepare the canals and fill ith Gutta Percha and sealer6 Recall after one month initially2 then at , months6 )*ternal resorption occurs usually in the first year or not at all6 (se of transport medium Han&As balanced salt solution 3H:00) ?ery favourable transport medium Developed for endodontics by Irasner H:00 contains + .acl2 glucose2 &cl2 .aH%o,2 sodium phosphate2 %acl'2 !gcl'2 !g0o;6 Irasner has developed an avulsed tooth storage system called =emergency tooth preserving system> 3)TP0) containing H:00 a net for holding the tooth and a container for bringing the submerged tooth to the dentist6 ."liv" The tooth is placed in the patientAs mouth under the tongue6 :ut chance of s allo ing if the patient is to young6 :ecause of its non

physiologic osmolality and presence of microorganisms it is not may desirable to use saliva as a transport medium6 &il) Physiologic osmolality and mar&edly fe er bacteria than saliva6 0torage in mil& for J@ hours is not satisfactory6

W"ter /ast resort if no other medium is available Post operative instructions and systemic treatment9 0oft diet 0ystemic antibiotics contribute significantly to replantation success 3 ithin 1 ee& of replantation) Anti tetanus booster 3in consultation ith the physician) !ild analgesics Replantations after an e*tended e*traoral time9 Replantation should be attempted6 :ut chances of resorption increase6 Andre"son "nd Andre"son "nd H+orting H"rsen h"ve divided periodont"l he"ling into / types0 Healing ith normal periodontal ligament9 %omplete repair of PD/6 .o inflammatory changes small areas of resorption at the site of damage to the PD/ 3surface resorption)6 Healing ith an&ylosis or replacement resorption6 Root resorption follo ed by its replacement ith bone6 )tiology is absence of a vital PD/ on the root surface2 progenitor cells ith osteogenic potential from ad"acent bone marro migrate into the damaged area6 Radiographically no PD/ space can be seen6 !nfl"mm"tory Resorption Root resorption ith surrounding granulation tissue in PD/ space6 These defects occurs on root surface ad"acent to areas of damage of PD/6

 )tiology is communication bet een surface resorption and pulp via the dentinal tubules6 !echanism of action is to*ic products1bacteria migrating into the PD/ from the pulp via the dentinal tubules6 $"tients nder tre"tment Recent restorative treatment 9 $ollo ing a restorative procedure2 pain may be provo&ed by a thermal stimulus that ould normally not cause a response 3hyperalgesia) this may be a result of High filling !icro lea&age !icro-e*posure of the pulp Thermal mechanical in"ury cavity preparation or an inade#uate lining under metallic restorations %hemical irritation from the restoration or restorative material Galvanism due to dissimilar metal restorations6 Inade#uate1e*cessive interpro*imal contacts hich promote food impaction or e*cessive stresses along the root6 $eriodont"l tre"tment9 chance of e*posure of lateral canals that communicate ith PD/ hen periodontal treatment is carried out6 E(pos re of the p lp 9 If carious e*posure is suspected the decision to e*tirpate the pulp or simply carry out pulp capping depends on hether the pulp has been irreversibly damaged or not6 Cro%n 1 root fr"ct res # !ost cro n root fractures can be prevented by ade#uately protecting the tooth during the course of endodontic treatment6 If tooth structure is damaged2 pain might result as a conse#uence of salivary and bacterial contamination of the root canal6 If the fracture is vertical2 and belo the crest of the alveolar bone the prognosis is poor6 In multi rooted teeth2 radisection of the involved root may be done6 Fl"re ps0 American Association of )ndodontics definition 9An acute e*acerbation of periaradicular pathosis after initiation or continuation of root canal treatment63155E)6

 Inter-appointment flare-up is characteriDed by the development of pain2 s elling or both2 follo ing endodontic intervention61@ 2efore Obt r"tion Etiology # 3c) 31) %ontents of the Root %anal 3a) pulp tissue 3b) bacteria 3c) bacterial products 3d)endodontic therapy material 3') Dentist %ontrolled $actors 3a) overinstrumentation 3b) inade#uate debridement missed canal 3d) hyperocclusion 3e) debris e*trusion 3f) procedural complications perforation separated instrument Dip strip hypochlorite accident air emphysema rong tooth 3,) Host $actors 3a) allergies 3b) age 3c) se* 3d) emotional state 3e) tooth After Obt r"tion Etiology #

Debris )*trusion -verinstrumentation -verfilling (nderfilling !issed %anal

Contrib ting f"ctors # Inade#uate debridement Residual pulp in inade#uately instrumented or undetected canals teeth ith necrotic pulps ith or ithout periradicular lesions are more predisposed than vital teeth to develop mid treatment flare ups6 Debris e*trusion 9 Pulpal fragments2 necrotic tissue2dentin filings canal irrigants and microorganism and their to*ins may e*trude beyond the apical foramen during instrumentation6 !ore li&ely to cause flare up if tooth pulp is necrotic and infected6 Debris e*trusion occurs ith all techni#ues of root canal instrumentation6 The cro n do n techni#ue and balanced force techni#ue sho s significantly less debris e*trusion6 The presence of an apical dentinal plug may prevent debris e*trusion2 over instrumentation and over obturation6 :ut since it may harbor infectious material2 the longterm prognosis is compromised6 -ver instrumentation -ver instrumentation beyond the apical foramen results in intraoperative or post operative pain6 In vital teeth2 the apical periodontium is crushed producing pain and inflammation6 Problematic e*udation due to overinstrumentation can be controlled by placing a %a3-H)' preparation6 Also corticosteroid antibiotic combination6 )ndodontic therapy may be continued2 analgesics relieve pain6 -cclusal reduction is necessary6 -verfilling 9 Is an indication1sign of over instrumentation and the resultant pain may be due to that2 rather than due to the e*truded GP1sealer furthermore2 it may not be possible to achieve a good apical seal in over instrumented canals if the foramen has been transported6 In such

cases residual bacteria are not sealed off and percolation of apical tissue fluids into the root canal space may provide the nourishment for these bacteria to gro 6 /arge overfills are a factor in post obturation pain6 Gross nerve damage due to chemical to*icity of the e*truded material or mechanical nerve damage caused by compression61B K6 $6 0i#ueira Kr6 The causative factors of flare-ups encompass mechanical2 chemical and1or microbial in"ury to the pulp or periradicular tissues6 -f these factors2 microorganisms are arguably the ma"or causative agents of flare-ups6 &icrobiology "nd imm nology /ocal adaptation syndrome Introduction of a ne irritant into inflamed tissue e*acerbates chronic inflammation6 %hanges in periapical tissue pressure Increase in e*udate - increased pressure - pain due to pressure on nerve endings Increase in pressure - aspiration of irritant1microbes into periapical space - e*acerbation of inflammation %hemical mediators such as PG2 leu&otrienes2 Hageman factor and complement cascade %hanges in cyclic neucleotides such as a cA!P and biodegradative path ays Immunologic response-production of antibiodies6 Psychologic factors- fear and an*iety may e*acerbate the patients perception of pain6 Periapical lesions The pulps of teeth ith large periapical radiolucencies have more bacterial strains and are more infected6 These may cause an a acute problem if inoculated periapically6 There ere fe er problems hen an apical lesion or sinus tract is found because of the potential space for pressure release6 Intact PD/ cannot vent the increased pressure that develops after an inflammatory response6

 Retreatment9 Higher incidence of flare ups6 Due to host response to e*truded filling material2 to*ic solvents 3*ylene) or due to presence of periapical pathoses ith symptoms6 Host factors9 Patients ith dental phobias9 Phychophysiologic tolerance to pain premedication ma&es their endodontic e*perience less traumatic6 -ther factors include paitents age2 gender2tooth position and presence of allergies6 Ten endodontic flare-ups 3E618) ere recorded in the multiple visit group compared to 15 31E6,8) flare-ups for the single visit group2 P L 767'6 $or both single and multiple visit procedures2 there ere statistically significant correlations bet een pre-operative and post-obturation pain 3P L 7677' and P L 76777; respectively)6 Teeth ith vital pulps reported the lo est fre#uency of post-obturation pain 3;E6E8)2 hile those ith nonvital pulps ere found to have the highest fre#uency of post-obturation pain 3<76,8)2 P L 76561E Tre"tment "nd $revention of fl"re 3 ps %leaning And 0haping -especially concepts of cro n do n techni#ue and confirming apical patency are important in management of teeth most li&ely to e*hibit mid treatment flare ups6 Incision and drainage for s ellings Periapical surgery 16 In cases such as gross overfills2 '6 $ailing retreatment and ,6 %orrection of procedural errors6 /eaving teeth open 9 tooth is left open for purulence to escape2 it is left open for upto '7min or longer and then closed ith a temporary dressing6 /eaving the tooth open results in recontamination and increased incidence of mid treatment flare up6 -cclusal reduction 9 High temporary filling2 over instrumentation pain2 is reduced by selective occlusal reduction6 Intracanal !edicaments9 the decision to use intracanal medicaments should be guided by antibacterial efficacy2 to*icity and specificity of the drug6

 !edicament of choice - chlorhe*idine %a3-H)' Iodine potassium iodide !edications15 Analgesics 1) !ild Pain 31) Aspirin ,'< mg 3') Ibuprofen '77 mg Tylenol ,'< mg ') !oderate Pain a) Ibuprofen ;772 @772E77 mg M 1' 1 tab every ; - @ hrs6 b) Aspirin Intolerance Tylenol <77 mg M '7 ' tabs every ; - @ hrs6 ,) 0evere Pain a) Tylenol ,'<mg M 17 1 tab every ; hrs6 b) %ombination Tylenol ,'<mg Ibuprofen %omparative )fficacy of -ral Analgesics'7 Ibuprofen E77 mg Ibuprofen @77 mg Acetaminophen @<7 mg N -*ycodone 17 mg Acetaminophen 12777 mg N %odeine @7 mg Ibuprofen ;77 mg !orphine 17 mg I! in"ection Acetaminophen 12777 mg Ibuprofen '77 mg Acetaminophen @771@<7 mg Tramadol 177 mg

 %odeine @7 mg Placebo Antibiotics 1) Penicillin <77 mg M 'E 1 tab every @ hrs6 Generally2 Antibiotic of 1st %hoice /oading Dose for Penicillin 31) '67 g stat ') Penicillin Allergy a) %leocin 1<7 mg M 'E 1 tab every @ hrs6 %leocin Generally2 Antibiotic of 'nd %hoice

(se of antimicrobials 3e6g62'<7 mg amo*ycillin plus 1'< mg clavulanic acid tds2or metronidaDole '77 mg tds) is indicated hen pyre*ia and other systemic signs are present6 If amo*ycillin is selected2 the therapy should account for the fact that many anaerobes of importance in periapical abscesses produce betalactamase6 The'1 ma"ority of patients ith symptomatic necrotic teeth had significant postoperative pain and re#uire analgesic medication to manage this pain6 The administration of penicillin postoperatively did not significantly 3p J 767<) reduce pain2 percussion pain2 s elling2 or the number of analgesic medications ta&en for symptomatic necrotic teeth ith periapical radiolucencies6 Hypochlorite "ccident A hypochlorite accident refers to any event in hich sodium hypochlorite e*truded beyond the ape* of a tooth and the patient immediately manifests a combination of some of the follo ing symptoms9 0evere pain s elling Profuse bleeding both interstitially and thorugh the tooth6

 %auses 9 $orceful in"ection of .a-%l due to edging of the irrigating needle into the root canal6 Irrigating a tooth ith a large apical foramen2 apical resorption or an immature ape*6 $eatures 9 -edema and ecchymosis2 accompanied by tissue necrosis2 paraesthesia and secondary infection6 Although most patients recover ithin 1-' ee&s6 /ongterm paraesthesia and scarring have been reported6 !anagement9 Immediate aspiration %old pac& over the affected area6 Regional bloc& anesthesia administered6 Pain management difficult because symptoms from distant anatomic structures ill continue to cause discomfort6 !onitor tooth for the ne*t half hour6 :loody e*udation e*tended from canal denotes the bodies reaction to the irritant6 Remove the fluid ith high volume suction to encourage further drainage6 If drainage is persistent consider leaving the tooth open6 Antibiotic coverage to prevent secondary infection Analgesics prescribed6 :ecause of possible bleeding complication ith aspirin and .0AIDs an acetaminophen-narcotic combination may be more appropriate6 %orticosteroids + inflammatory process Home care instructions9%old compress to minimiDe pain and s elling6 0ubse#uently arm compresses to encourage healing6 Prevention 9 :end the irrigating needle at centre to confine the tip of the needle to higher1coronal levels of root canal6 .ever bind the needle in the canal -scillate the needle in and out to ensure that the tip is free to e*press the irrigant ith out resistance e*press the irrigant slo ly and gently chec& the heads of the needle for a tight fit to prevent in advertent separation and accidental e*posure of the irrigant to the patients eyes6 Post endodontic treatment 9 Pain after completion of R%T may be due to9 High restoration

 -ver filling (nder filling Root fracture A high restoration is managed by occlusal rehabilitation to avoid apical periodontitis or orse2 a fractured tooth6 -ver filling cause pain more as a result of over instrumentation and trauma to apical periodontium1presence of infected material in root canal space6 The options are 9 Prescription of analgesics and in case of infection + antibiotics removal of the root filling and reprepration of the canal6 Apisectomy2 in case retrieval of the e*truded filling is not possible to be considered only in case of gross e*trusion or persistence of infection due to improper apical seal6 16 (nderfilling cause pain due to inade#uate debridement management is re-treatment6 '6 Root fracture occurs due to e*cessive forces during lateral condensation6 the most common type is the vertical root fracture6 Prognosis is poor e*traction of sectioning of the root in case of a multirooted tooth2 is all that can be recommended6 Concl sion The ma"ority of patients see&ing dental treatment report to the dentist ith complaints of pain6 Pain of endodontic origin is distressing and agoniDing and providing prompt relief from such pain may re#uire an emergency appointment6 Although this may inconvenient the dentist2 the procedures2 are relatively simple and relieving the patients agony may be a truly re arding e*perience6

REFERE4CE.
16 &"dison .0%urr -pin Dent6 1551 DecO13@)9B;;-56 '6 P6%arrotte6:DK '77; 0ept9@

,6 %ohen

;6 Al-0abbagh !2 Andreana 02 %iancio 0G6K Int Acad Periodontol6 '77; KanO@31)9E-1'6 <6 :erman /H6 Dentinal sensation and hypersensitivity6 A revie of mechanisms and treatment alternatives6K Periodontol 15E<O<@O'1@-''6 @6 :rannstrom !2 Astrom A6 The hydrodynamics of the dentineO its possible relationship to dentinalpain6Int Dent K 15B'O''9'15-'B6 B6 Pader !6 -ral Hygiene Products and Practice6 De&&er2 .e Por&2 15EE2 %hap6 176 50 'r02orer0Or"l . rg 6789::/#9:;<9=>0 56 :roo& I2 $raDier )2 Gher !6 Aerobic and anaerobic microbiology of periapical abscesses6 Int )ndod K6 '77, DecO,@31')9E@E-B< 176-ral !icrobiol Immunol 1551O@91',-<6 ,,.#rephination "or Acute Pain !anagement. /enry, Brian !. Fraser, 0ohn %.0ournal o" +ndodontics. 12*1)),334,35, February 1--6. 1'6/e is !A2 %armichael $2 !ac$arlane T42 !illigan 0G6 A randomised trial of co-amo*iclav 3Augmentin) versus penicillin ? in the treatment of acute dentoalveolar abscess6 :r Dent K 155,O1B<91@5B;6 1,6$inegold 0!2 0trong %A2 !cTeague !2 !arina !6 The importance of blac&-pigmented gram-negative anaerobes in human infections6 $)!0 Immunol !ed !icrobiol 155,O@9BB-E'6 1;6 &"tthe%s 'C? . therl"nd .? 2"sr"ni 20K %an Dent Assoc6 '77, .ovO@5317)9@@76 1<6K6 %raig :aumgartner6K(.)6'77;6?-/6,'6.-6@6%DA6K-(R.A/ 1@6K6 $6 0i#ueira Kr6K-)6'77, 1B6 !ntern"tion"l Endodontic @o rn"l6?olume ,@ Issue B Page ;<, Kuly '77, 1E6)ndodontic flare-ups9 comparison of incidence bet een single and multiple visit procedures in patients6 Adele)e O OginniA "nd Christopher ! *doyeA0:io!ed %entral 1563.A?A/ P-0TGRAD(AT) D).TA/ 0%H--/ :)TH)0DA2 !ARP/A.D2 .0 20 &CCLA4AHA4) '763Ienneth Hargreaves2K(.)6'77;6?-/6,'6.-6@6%DA6K-(R.A/The -*ford /eague Table of Analgesic )fficacy '16Kournal of )ndodontics6 'B3')911B-1',2 $ebruary '7716 /enry, !ar ..S, !S7 8eader, Al ..S, !S7 Bec , !i e ..S, !A