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Department of Public Health Dentistry

ENDODONTIC EMERGENCIES

GUIDED BY:Dr.N.C Rao Dr.Nidhi Dr.Shelja Dr.Vipul

SUBMITTED BY:Arshdeep kaur BDS INTERN ROLL NO.8017

CONTENTS
INTRODUCTION PAIN PATIENTS PERCEPTION OF PAIN PROFESSIONALS PERCEPTION EMERGENCY TREATMENT OF REVERSIBLE PULPITIS, IRREVERSIBLE PULPITIS PULP NECROSIS ACUTE APICAL ABSCESS MID TREATMENT FLARE UP POST ENDODONTIC COMPLICATION TRAUMATIC INJURIES NaOCl ACCIDENT CONCLUSION

INTRODUCTION
Reason for endodontic emergency treatment is pain and at times swelling ensuing from pulpo periapical pathosis. Grossman endodontic emergencies are like unwelcome guests at a dinner table.

Dentist must provide speedy and effective relief because such care is an essential part of daily practice and such act will create goodwill on the part of the patient and are practice builders.

90% of the patients reporting to the clinic with pain or swelling have pulpal or pulpoperiapical disease.

PAIN
Pain is an unpleasant sensory and emotional

experience associated with actual or potential tissue


damage.

Patients perception of the pain


Usually pulpal or periapical tissue

inflammation. Referred pain, more complex facial pain, TMJ pain, non-odontogenic paindifficult to diagnose

Individual responds to pain in many different


ways

Dentist

must

recognize and distill

these from

personal them the

interpretations

clinically objective terms

The professionals perception of the patient in pain Doctors reaction to the patient is important for both pain and patient management.

Both the physical problem & emotional state


must be understood

Always maintain eye contact Show support for the complaint

Reduce the anxiety of the patient.

PHYSIOLOGY OF PULPAL PAIN


The sensibility of the dental pulp is controlled by myelinated (A-delta) and unmylinated (C) fibers. Both sensory fibers conduct nociceptive input to the brain. Difference between the two sensory fibers enables the patient to discriminate and characterize the quality, intensity, location and duration of pain response.

REVERSIBLE PULPITIS
Causative Factors Restoration with high point Incipient caries Fractured restoration Fractured cusp Exposed dentinal tubules

Clinical Characteristics
Sensitivity of tooth Pain of short duration or shooting sensation Infrequent episode of discomfort

Symptoms usually subside immediately or shortly


after removal of etiology

Rx removal of causative factors, restoring lesions,


ZOE dressing for deep cavities

IRREVERSIBLE PULPITIS
Acute Pulpitis large carious lesion or with defective restoration

Severe pain is elicited in thermal change, particularly cold


Pain is of piercing or lancinating type

The intensity increases when patient lies down


Reacts to electric pulp tester at a lower level of current than in a normal tooth Not sensitive to percussion Radiographically no change

ACUTE PULPITIS WITH APICAL


PERIODONTITIS
Clinical Characteristics Entire pulp is inflamed Pain on percussion Heat causes intense pain, cold relieves Radiographically may appear normal, may

show small periapical radiolucency, or exhibit a


thickening of lamina dura.

TREATMENT
Minimal amount of time Single rooted teeth Multi rooted teeth

Pulpectomy and closed


dressing

Pulpotomy and
formocresol application closed dressing

Considerable amount of time


Pulpectomy + cleaning and shaping Pulpectomy & working length determination Tooth is relieved from occlusion Pulpectomy- treatment of choice

Open dressing or Closed dressing ? Weine et al tooth left open during inter appointment visit, needed 5-6 visit to complete the treatment. 3-4 visits for tooth left with closed dressing. Any tooth without continuous exudation should be given a closed dressing.

PULP NECROSIS
Usually pain is not a symptom

Patient may note a swelling and request for


treatment

Radiographically - large periapical radiolucency. Definite thickening of the periodontal ligament.

Mild or no sensitivity to percussion. No response to pulp vitality tests.

Treatment Anaesthesia usually not required Access cavity prepared, W/L determined, canal sufficiently enlarged. Copious irrigation with saline Closed dressing given

ACUTE PERIAPICAL ABSCESS


Large diffused swelling Tenderness to percussion Mobility of the tooth Generalized swelling may be absent, but patient usually reports that the pain was present before the appearance of swelling. Radiographicallyradiolucency margin with diffused

Treatment
Treatment of choice- incision and drainage Always attempt to drain the pus through the root canal itself

Procedure Block anaesthesia is recommended Standard access prepared Drainage starts, on removal of roof of the pulp chamber Apical constriction purposely widened to file size 20-25

Aspiration using a suction device to aid drainage

Irrigation - warm saline


Canal left open or closed depending upon drainage

If closed dressing is planned. Wait till forceful exudation has dissipated Determine W/L, enlarge the canal to several sizes Canal thoroughly irrigated and dried Closed dressing

Advantages of giving a closed dressing

No

new

type

of

microorganism

system

is

introduced Total no of appointments reduced Neither food nor debris is packed into the canal

Disadvantage
Very long and sometimes inconvenient initial appointment

Open dressing is planned First appointment access opened and patient

send with an open canal Second appointment W/L is determined and

canal enlarged to desired no of size and canal left open. Third appointment Canal thoroughly irrigated

with NaOCl and H2O2. But not instrumented this time. Closed dressing given.

Drainage through the tissue and bone Indication Failure of drainage through the root canal Presence of a post and core restoration Sectioned silver point Heavily calcified canal

PROCEDURE
Artifistulation

Anaesthesia, small stab incision made just below


most dependant area

Using a sterile sharp instrument a small window is made

To prevent closure of the incision a T or H shaped rubber dam drained is sutured at the site.

Trephination
Perforating the cortical bone using engine driven

burs or a hand operated trephine to release the pressure and exudate around the apex of the tooth. Flap increased to allow visualization Bone is removed until the tip of the root is uncovered H or tube drain placed

Inadequate analgesia
Main reasons
Pulpal inflammation produces hyperexcitability of the nerve fibres (C-

fibres), L.A sol. Is unable to block conduction of all impulses


There is Increased vascularity of the tissue LA rapidly removed Tendency for pain to increase neural transmission in the spinal cord

countering the effect of analgesics


The pH of inflammatory products may be more acidic making LA sol.

potentially less effective

Alternative techniques
Intrapulpal anesthesia Periodontal ligament injection Intraosseous injection Use of more potent anesthetic (Bupivacaine) Sedation or general anesthesia

MID TREATMENT FLARE UPS


Acute exacerbation of periradicular pathosis after initiation or continuation of RCT Incidence 2.5 to 15%

VITAL TEETH
Presence of pulp tissue

Overmedication, Debris extrusion


Over instrumentation, hyper occluding teeth

Rx Through debridement, copious irrigation selective occlusal reduction, NSAIDs

PULPLESS TEETH
Sustained periapical inflammatory reaction Phoenix abscess associated with periapical lesion & absence of sinus tract More predisposed than vital teeth Incidence 2.5%, after initial treatment 10%, retreatment

TREATMENT Through debridement

Canal patency
Incision and drainage

Surgical trephination
Antibiotics and analgesics

OPERATOR FACTORS IN FLARE UPS

WALTON & FOUAD (1992)

HIGHEST No. OF FLARE UPS ACUTE PERIAPICAL ABSCESS - NECROTIC PULP - RETREATMENT PRE-EMINENT FACTORS CROWN DOWN TECHNIQUE

- CONFORMING CANAL PATENCY


IMPORTANT ADJUVANT Ca(OH)2 - NaOCl __

HOST FACTORS IN FLARE UPS


Patients allergens heightened immunoreactivity to

Females - more susceptible Phobic patients tolerance low psycho-physiological of their particular

Rx informing patient endodontic situations

Medication chosen specifically to counteract pain


Mood altering drugs or sedatives

POST ENDODONTIC COMPLICATIONS


Pain is usually mild, transient and managed with appropriate analgesics 10% of single visit RCT

Imp. Factors - case selection and clinicians expertise


Attention given to patients description of pain

Persistent pain, unremitting pain, continuing thermal pain.


Misdiagnosis or overlooked canal

Biting or chewing pain, or parasthesia Reassessment of the periapical tissue for over instrumentation, overfilling or under filling

Fracture of the crown or the root

Rx Retreatment
Surgical trephination

Root end surgeries

EMERGENCY TREATMENT FOR TRAUMATIC INJURIES

Crown fracture, root fracture, luxation or avulsion Causes accidents, sports, games. 7 to 14 years

Treatment may be complicated by local edema, bleeding or other consequences of accidents like- loss of consciousness . Temporary parasthesia occurs, difficult to evaluate condition of the injured pulp

CROWN FRACTURE WITHOUT PULP EXPOSURE

fracture deep into dentin , chipped a small portion of enamel


Dentin exposed- thin mix of ZOE placed over exposed dentin celluloid crown festooned, filled with thick mix of ZOE cemented into place sedative effect following appointment both fractured & neighboring tooth checked before permanent

restoration

CROWN FRACTURE WITH PULP EXPOSURE

Presence determined

or

absence

of

apical

closure

is

Closed apex - pulpectomy and conventional endodontic treatment

Open apex pulpotomy, leaving the apical portion of the pulp for completing apexogenesis.
Tooth monitored - three to six months interval Routine endodontic treatment after completion of root formation.

AVULSED TEETH Complete displacement of the teeth from out of the socket. Replantation - carried out immediately Poor prognosis more than 20 mins

TECHNIQUE FOR REPLANTATION


Part I - emergency treatment at site of injury

After washing the tooth under running tap water,


the patient or a responsible person should replant the tooth immediately. Touching the root surface avoided Report to a nearest dental surgeon

If it becomes impossible to reinsert the tooth, tooth has to be carried in a suitable transport medium.

TRANSPORT MEDIUM

Saliva, milk, water Hanks Balanced Salt Solution (optimal storage media) Ability to rejuvenate cells of the PDL Sodium chloride Potassium chloride Calcium chloride Magnesium chloride Magnesium sulfate Glucose Sodium bicarbonate Sodium phosphate

Part II - emergency treatment at dental office

Take history, examine the area


Radiograph tooths position in the socket and if satisfactory, splint the tooth

If tooth is not replanted Do not curette or attempt to sterilize Clean the root surface gently with a wet sponge Irrigate the socket with saline

Do not attempt RCT or cut the root tip Implant the tooth firmly into socket Splinting orthodontic wire, arch bars, acrylic and wire combination

Pre-op

After replantation and splinting

Part III completion of endodontic treatment After one week, perform cleaning and shaping, place Ca(OH)2 Teeth with undeveloped apices may be watched without pulp extirpation pulp may revitalize sufficiently for continued apical development If necrosis has occurred debride the canal followed by apexification procedure

After three to four months obturate the canal


Recall the patient in every 3 months

4 month post-op

3 year recall

3 year recall

Removal of Splint (Andreasen)


Splint should replantation be removed one week after

Splint in place too long ankylosis or inflamatory resorption

Postoperative Instruction
Soft diet Antibiotic and analgesic is prescribed Anti tetanus booster

HYPOCHLORITE ACCIDENT
Comparatively rare occurrence Reaction is intense, occurring instantly with severe pain and swelling Locking the needle, forcibly injecting the irrigant Management

Administer a regional block


Assure and calm the patient Monitor tooth for half an hour for bloody exudate High volume evacuation Antibiotics and analgesics

CONCLUSION

The art and science of endodontic diagnosis and treatment have undergone a tremendous scientific & technologic evolution . As a result the dental profession is prepared and able to remedy one of mans most painful and feared afflictions with compassion, knowledge, and skill