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Endodontic Emergencies

Endodontic Emergencies. Definition. Defined as an unscheduled visit associated with pain or swelling from pulpoperiapical pathoses requiring immediate diagnosis and treatment. Causative Factors. Pathosis in pulp Pathosis in perradicular tissues Both Trauma.

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Endodontic Emergencies

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  1. Endodontic Emergencies

  2. Definition • Defined as an unscheduled visit associated with pain or swelling from pulpoperiapical pathoses requiring immediate diagnosis and treatment

  3. Causative Factors • Pathosis in pulp • Pathosis in perradicular tissues • Both • Trauma

  4. Pain in endodontic emergencies are related to two factors • Chemical mediators  act on nociceptors • lowers pain threshold • increase vascular permeability • edema • edema increased fluid Pressure (mechanically stimulate nociceptors)

  5. Effective treatment measure: • Reducing concentration of mediators and allowing release of pressure from root canal system and periapical region.

  6. WALTON • Pretreatment emergencies • Inter-appointment emergencies • Post obturation emergencies.

  7. BEFORE TREATMENT (pretreatment) - Pulpal pain Reversible pulpitis Irreversible pulpitis - Acute periapical abcess - Cracked tooth syndrome Dentin hypersensitivity

  8. DURING TREATMENT (Interappointment) - Recent restorative treatment - Periodontal treatment - Exposure of the pulp - Fracture of the root or crown - Pain as the result of instrumentation Acute apical periodontitis Phoenix abscess • POST-ENDODONTIC TREATMENT - High restoration - Overfilling - Root fracture

  9. Patient Presentation • Pain • Pain and swelling • Trauma

  10. True emergency • Urgency

  11. Pain • Physiologic • Psychologic (emotional and mental status)

  12. Management of Psychologic component of pain • Reduce anxiety by providing attention and sympathy and obtain information about chief complaint. • Inform patient: • Recommended treatment plan • Alternative treatment • Risks and benefits of treatment • Expected prognosis under present circumstances

  13. Patient may elect • endodontic treatment • OR • extraction • OR • request for second opinion Never force treatment plan on patient

  14. 3 D’s of Successful Management • Diagnosis • Definitive dental treatment • Drugs

  15. Determine the Chief complaint Take an accurate medical & dental history Complete a thorough exam, with all necessary tests Perform a radiographic exam Analyze and synthesize results & establish a diagnosis Design a treatment plan (both emergency & definitive) Diagnosis

  16. Irreversible pulpitis With normal periapex With acute apical periodontitis Pulp necrosis Without swelling With localized swelling With diffuse swelling Pretreatment emergencies • Acute Reversible pulpitis

  17. Acute reversible pulpitis Definition: • It is mild to moderate inflammatory condition of pulp caused by noxious stimuli in which the pulp is capable of returning to the uninflammed state following removal of stimuli. Causes: • Trauma • Thermal shock • Excessive dehydration • Galvanic shock • Chemical stimulus • Bacteria from caries • local vascular congestion • Circulatory disturbances • Recent restoration

  18. Diagnosis: • Subjective symptoms , Clinical examination,Clinical tests Treatment: • Recontour the high point • Use of sedative cement i.e. ZOE • Prevention – 1 Pulp protective base 2 Avoid marginal leakage 3 Properly contour all restorations 4 Avoid thermal shock.

  19. Acute irreversible pulpitis Definition: It is a persistent inflammatory condition of the pulp, symptomatic or asymptomatic caused by noxious stimulus. • Causes: • Bacterial involvement of pulp through caries. • factors - chemical , thermal, mechanical • Deterioration of Reversible Pulpitis Irreversible Pulpitis

  20. Symptoms: Pain – severe, sharp, piercing/shooting, spontaneous,intermittent/continuous, referred, heat cold - change of position - Later stages- throbbing • – deep cavity, # restoration, # tooth odour of decomposition • EPT– early/delayed/no response • R/E - lesion inv. pulp horn - lesion below a restoration - widening of the PDL space

  21. Treatment: Anterior – pulpectomy Posterior – pulpotomy/pulpectomy

  22. ACUTE APICAL PERIODONTITIS • DEFINITION:- It is a painful inflammation of periodontium as a result of trauma, irritation or infection through root canal whether the pulp is vital or non vital. • CAUSES Vital - trauma , high points, wedging of foreign objects Non vital - sequelae to pulpal disease - overinstumentation

  23. TYPES primary secondary • Symptoms: Pain & tenderness of the tooth,sometimes the tooth may be extruded. Tenderness over the apex of the tooth in buccalsulcus . • Diagnosis history , tender on percussion , radiograph • TREATMENT:- Vital – occlusal adjustments Nonvital – RCT

  24. Acute alveolar abscess • Acute periapical abscess/Acute apical pericementitis /Acute radicular abscess Definition: • It is a localized collection of pus in the alveolar bone at the root apex following death of pulp, with extension of the infection through the apical foramen into periapical tissues Cause: • Pulpitis-pulpal necrosis. • Exacerbation of chronic periapical lesion • Endodontic - periodontic lesion- lateral root canals, deep infrabony pocket. • Trauma Three forms - without swelling - with localized swelling - with diffuse swelling

  25. Acute alveolar abscess without swelling • Symptoms: Pain - quite severe, Very tender, Mobile, systemic reactions • EPT – no response • R/E– no change to periapicalradiolucency • Rx Procedure Stabilize the tooth with finger pressure/impression compound Anesthesia Access cavity Locate root canal orifices Extirpate the pulp Irrigate & debride + saline Close dressing

  26. Acute alveolar abscess with localized swelling • Pain – absent, throbbing/lingering pain in a tooth or gum area • Lymphadenopathy • Bad breath or foul taste in mouth • Swelling, systemic reaction, mobile, extruded • EPT- no response • R/E– periapicalradiolucency • Treatment : • Biphasic – I phase – canal debridement - II phase – drainage

  27. Procedure : • No anesthesia • Stabilize the tooth with finger pressure/ impression compound • Access cavity • Irrigate + saline • # 10 / # 15 file/reamer Locate root canal orifices & debride • Walton & Weine – apical foramen violated & enlarged to #20/25 - for exudate drainage through tooth • Gentle finger pressure on mucosa • No drainage – leave the tooth open for about 1hr • Hot saline rinses for 3 min each hour • Analgesic/antibiotics

  28. Post & core, crown, sectioned silver point/calcified canal • Incision and drainage Procedure • Dry the mucosa + spray with topical anesthetic • Stab Incision is made with # 11scalpel at the most dependent point • Apical bone is probed with an explorer to ensure proper venting • Incision is left open with 20×20 strip of H/ tube/ triangular shaped rubber dam • Antibiotics • Recalled after 4 – 7 days

  29. Trephination Definition: • Trephination is the surgical perforation of alveolar cortical plate [over the root end] to release the accumulated tissue exudate that is causing pain. • Flap is raised + round bur periapical bone is removed • Rubber dam drain • Antibiotics • Tooth is disoccluded • Later apicoectomy is performed

  30. Acute alveolar abscess with diffused swelling • Infection spreads through adjacent soft tissues, dissecting the fascial planes & turning in to a medical emergency • This can be potentially life threatening • Access cavity is prepared, canals debrided

  31. Acute periodontal abscess • It is a disease of periodontium associated with infection & pus formation in an existing infra-bony pocket. • Occur in vital as well as nonvital • Pain & swelling Treatment : • Vital – curettage & drainage via sulcular crevice • Nonvital – RCT + Curettage

  32. Referred pain • Trigeminal neuralgia , migraine, cardiac pain, TMJ arthrosis, sinusitis max posterior teeth. • Occlusal trauma, pericoronitis, otitis media mand teeth • Max lateral incisor  herpes zoster • TMJ dysfunction, MI, Angina pectoris  tooth ache • Disease of Pulp / periodontium of ant. teeth  ocular pain • Max. post teeth  max sinus, back & side of the head • Mand molar  ear / back of the head

  33. Three D’s of Successful Management • Diagnosis • Definitive Dental Treatment • Drugs

  34. Drugs • Pre - op / loading dose • Long acting anesthesia • Prescription

  35. “Should I leave the toothOPENor CLOSED?”

  36. “Should I place anIntracanal Medicament between appointments?”

  37. “Should I prescribe ANTIBIOTICS?”

  38. Role of drugs Analgesics • Essential & supportive • Analgesics—pain relievers -narcotic analgesics—acute, severe pain -non-narcotic-slight to moderate pain. • Non- opioid analgesics • aspirin, acetaminophen, diflunisol, naproxen, ibuprofen.

  39. Narcotic analgesics: • Morphine – not given orally • Mepridine - 50 to 100mg, • Codeine - 30mg, • Oxycodone - 5mg,with acetominophen,325mg, • Hydrocodone - 5mg,with acetaminophen 500mg, • Tramadol – 50mg • Drugs should not be used with alcohol, antihistaminic, barbiturates, local anesthetics, tricylic antidepressants etc.

  40. Use a Flexible AnalgesicStrategy

  41. Flexible Analgesic Plan 400-600mg OR + 650mg acetaminophen + 1000mg acetaminophen

  42. Flexible Analgesic Plan

  43. Antibiotics Standard regimen: • Penicillin v- 2gm orally 1 hr before procedure then 1gm 6 hr later. • Allergic to penicillin—Erythromycin 1gm orally1 hr before, then 500mg 6 hr later • Cephalexin 250-500mg every 6 hr, • Clindamycin 150-300mg every 6 hr etc.

  44. Indications for Antibiotic Therapy • Systemic involvement • Compromised host resistance • Fascial space involvement • Inadequate surgical drainage • Diffuse swelling

  45. Guidelines for Antibiotic Therapy • Select antibiotic with anaerobic spectrum • Use a larger dose for a shorter period of time (“hard and fast” rule)

  46. Penicillin V • Still, the drug of choice for infections of endodontic origin • Loading dose: 1-2 g then 500 mg qid x 7-10 days

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

  48. Clindamycin • Loading dose: 300 mg • 150-300 mg qid x 10 days

  49. Components of aSuccessful Management • Appropriate attitude of dentist • Proper patient management • Accurate diagnosis • Profound anesthesia • Prompt and effective treatment

  50. Patient Instructions

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