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Endodontic Emergencies: Classification and Management

This article discusses the classification and management of endodontic emergencies, including dentinal pain, acute pulpitis, acute periapical abscess, and more. Learn about the different types of pain and treatment options.

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Endodontic Emergencies: Classification and Management

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  1. GOOD MORNING

  2. Contents • DEFINITION • AIMS AND OBJECTIVES • CLASSIFICATION

  3. “ By definition, endodontic emergencies are usually associated with pain and swelling and require immediate diagnosis and treatment. These emergencies are caused by pathosis in the pulpal or periradicular tissues. They also include severe traumatic injuries that results in fractures, avulsion or luxation.” • Walton – Torabinejad- 2nd edition

  4. A true emergency is the condition which requires unscheduled visit with diagnosis & treatment at that time. • But urgencyindicates a less severe problem in which next visit may be scheduled for mutual convenience of both pt as well as clinician.

  5. CLASSIFICATION: • Before endodontic treatment • During endodontic treatment • Post endodontic treatment • P.CARROTTE– BDJ -2004..

  6. BEFORE ENDODONTIC TREATMENT • Dentinal pain – Hypersensitivity • Pulpal pain - Acute pulpitis > Acute irreversible * Acute pulpitis with apical periodontitis * Acute periapical abscess * Phoenix abscess * Hot tooth * pulp necrosis * Crack tooth syndrome * Traumatic injury

  7. DURING ENDODONTIC TREATMENT • Flare – ups. - Over instrumentation. - Inadequete debridement. - Extrusion of debris. > Procedural errors….. > Sodium hypochlorite accident. > Air emphysema

  8. POST ENDODONTIC TREATMENT • High restoration • Overfilling • Under filling • Root fracture

  9. Assessment of Pain Definition (IASP) Pain is defined as an unpleasant, sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Types of Pain Pulp Status Spontaneous Nocturnal >>> Irreversible: Non-vital treatment Constant, lingering. Thermal, sharp Short, piercing. >>> Reversible: Vital treatment Intermittent

  10. DENTINAL PAIN – HYPERSENSITIVITY. 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. By International work shop on dentin hypersensitivity(1983). Mainly attributed to hydrodynamic pain theory espoused by Brannstrom. Etiology: - occlusal wear, tooth brush abrasion, erosion, abfraction, gingival recession, parafunctional habits.

  11. Treatment: Desensitization of occluding dentinal tubules. use of topical agents:- fluorides, silver nitrate, strontium chloride, pottasium oxalate, varnishes, dentin bonding agents Restorative options:- GIC, composites. Lasers : co2, argon lasers..

  12. Acute pulpitis (Reversible): Charactrerized by: Localized inflammation of the pulp. Lowering threshold stimulation for A-delta nerve fibres Exaggerated, non lingering response to stimuli. Management: Removal of the cause Recontouring of recently placed restoration which causes pain. Removal of the restoration and replacing it with the sedative dressing if painful symptoms still persists following the tooth preparation. Releiving the occlusion

  13. Acute pulpitis (irreversible): • For the diagnosis to be made the pain must be originating from vital pulp in a tooth which is not tender to percussion – shows that inflammation.., Not yet reached to periapex & is confined to coronal pulp. • Minimal time : Access open- spoon excavator – coronal pulp removed leaving behind the vital pulp tissue in root canals – cotton pellet is moistened with formocresol placed over orifices -1 min- discarded, • new cotton pellet slightly dampened- formocresol is placed- chamber –sealed with temporary restorative material - & pt is recalled later for the completion of root canal therapy.

  14. Formocresol- caustic-as long as vital pulp tissue present b/w drug – periapical tissues- there will be no damage to periapical tissues. • Considerable time present: complete pulpectomy Removal of the entire pulp ensures the pt is free from pain.

  15. ACUTE PULPITIS (irreversible) WITH APICAL PERIODONTITIS: • Here pulpal inflammation has spread to periradicular tissues resulting – pulpal and periradicular symptoms. • Here tooth is tender to percussion- heat aggrevates pain, cold relieves. • R/E: a small periapical radiolucency, thickening of pdl space. • Treament: - Releivethe occlusion. - Best treatment is – complete pulpectomy - ca(oh)2 as intracanal medicament + sealed with temp rest mat

  16. ACUTE PERIAPICAL ABCESS: -It is an inflammatory process in the peri radicular tissues of teeth, often accompanied by exudate formation within the lesion. -This condition is related to bacterial invasion of the peri radicular region from an infected and necrotic pulp canal. - It may develop spontaneously or may follow initial endodontic treatment if bacteria are forced into the peri radicular tissue. • Tooth is tender to percussion, mobile, lacks vitality.

  17. Whenever possible acute periapical abscess should be incised and drained through the root canal space. • 2 methods of treating acute periapical abscess: • 1. drainage followed by antibiotic coverage. • 2. antibiotic followed by drainage. DCNA ENDODONTICS APRIL 1992……

  18. Penicillin(penicillin V) orally Best - 2 gms-1 hr prior & 1gm -6 hrs - after the procedure.-Effective against staphyco, strepto, some anaerobes as these are mainly responsible for APA. • If pt allergic- then erythromycin(1 gm orally 1 hr prior, 500gms 6 hrs after. • In many cases drainage occurs immediately on removing pulp chamber roof- thoroughly irrigate the canal- followed by completion of RCT at a latter date.

  19. In acute periapical abscess associated with extensive diffused swellings--- A stab incision is made on the most prominent point of the swelling with a #11 scalpel .

  20. Closed dressing Vs open dressing Old concept-“if you file don’t close, if you close don’t file” • Acc to Weine. He strongly advocates that if the canal is enlarged( use of files /reamers) don’t close in the 1stappoinment. Newerconcept-where ever possible a closed dressing should be given, unless profuse & continues drainage seen.. In the next sitting, canal enlargement should be performed and a closed dressing is mandatory.

  21. PHOENIX ABSCESS • Acute exaberation of a chronic lesion such as cyst or granuloma: • Etiology: • Chronic periradicular lesions such as granulomas are in a state of equilibrium during which they can be completely asymptomatic. But sometimes, influx of necrotic products from diseased pulp or bacteria and their toxins can cause the dormant lesion to react. This leads to initiation of acute inflammatory response.

  22. Symptoms: mobility, tender to percussion, swelling. Elevation of the tooth from socket. Treatment: same as that of for acute periapical abscess. incision & drainage. Once symptoms subside – Complete Root Canal Treatment

  23. HOT TOOTH • A hot tooth is a tooth that is difficult to anesthetize. • Supplementary intraligamentary or intraosseous injections have been found to ensure profound anesthesia.

  24. PULP NECROSIS • Rarely causes emergency-in case if a pt notice swelling and may request for emergency treatment. • The ideal treatment is complete removal of the entire necrotic pulp tissue+ proper irrigation with warm saline, NaoCl. • Closed dressing placed and the pt recalled later for the completion of endodontic treatment.

  25. CRACK TOOTH SYNDROME • DEFINITION: The crack tooth syndrome means incomplete fracture of a tooth with vital pulp. The fracture commonly involves enamel and dentin but sometimes pulp and periodontal structure may also get involved. • It is commonly seen with large and complex restoration. Diagonisis • Proper History of the Patient • Visual Examination • Transillumination Magnifying loupes Dyes-methylene blue • Tooth sloth- more reliable

  26. Patient can be asked to bite on Orangewood stick, rubber wheel or the tooth sloth. The pain during biting or chewing especially upon the release of pressure is classic sign of cracked tooth syndrome.

  27. VISUAL INSPECTION • Transillumination

  28. Magnifying loupes Dyes-methylene blue Tooth sloth- more reliable.

  29. Cracks in vital teeth: • 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-causespulpal inflammation & necrosis- RCT is advised followed by full coverage restoration.

  30. * 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

  31. Cracks in root filled or nonvital teeth: • vague symptoms & origin is difficult to locate-& pain receptors in the pdl may be involved or bacteria may invade through the craze line causing periodontalinflammation – 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.

  32. TRAUMATIC INJURIES Endodontic treatment may be required as a result of traumatic injury. Most common endodontic emergencies are: a) Crown fracture. b) Root fracture c) Avulsion

  33. CROWN FRACTURE • IF a green stick # of crown is present - a steel band is cemented around the tooth. • Releive the occlusion- eliminates pain & re-evaluate status pulp later. • Crown fracture with vital pulp exposure :: • If apical closure has complete--Pulp extirpation is done via the fractured opening. • If apical closure- not taken place--- a formocresolpulptomy is done for completing apexogenesis. Radiographic evaluation done every 3-6 months to determine degree of apical development. • Crown fracture involving necrotic pulp: • remove entire necrotic pulp tissue… • If apical closure is complete - routine endodontic treatment, if apical closure is incomplete- apexification

  34. ROOT FRACTURE: • Prognosis – location & direction of #. • A horizontal # above alveolar crest-good prog-toothThe closer the root # to apex is better prog. • Horizontal # at mid root, # below the crest of alv.bone –poor prog. • Vertical # of root –hopeless prog. • Treatment: • A #ed root–vital pulp-better prog for repair.

  35. Emergency treatment – horizontally #rd root above alv crest-- stabilization of the tooth with adj tooth if mobility seen. can be restored after endodontic treatment. • Teeth with poor prog–horizontal # below the alv crest- mid root #- vertical # of root. - extraction. • In case of vertical root # of multirooted teeth, only the #red root is hemisected and removed saving the rest of the tooth structure –then pulpectomy is done for the retained tooth segment.

  36. SUBLUXATION:Def – tooth that is slightly mobile after a traumatic injury but not displaced from the socket. • Treatment is palliative. Splinting for stability. -Pulpal necrosis seen in 6% of cases – so endodontic therapy. • LATERAL/EXTRUSIVE LUXATION: Is a injury in which tooth is displaced out from its socket. • If teeth are displaced without damage to socket- teeth - repositioned-stabilized with splint. • Incidence of pulp necrosis is high-so endodontic therapy initiated in the later appointment. • INTRUSIVE LUXATION: Tooth intruded into bone-rarely mobile. treatment depends on apical development-if root formation not complete-teeth may re-erupt, if not tooth can be extruded out surgically/orthodontically. • Poor pulpal prognosis - RCT initiated at a later stage.

  37. Tooth avulsion: • Cause: accidental cases, fall, or any type of trauma. • Mostly seen in anterior teeth- common in children, young adults. • Longer the avulsed tooth is out of socket the less likely it will remain in a healthy, functional state after replantation. (optimal time not exceed 30 min) • Instruction to be given to pt after he informs to dentist of the avulsion: wash tooth in running water- no brushing/cleaning- rinse the mouth-replace the tooth back into socket.. if replacing is difficult then the ideal vehicle – pts mouth as tooth bathed in saliva.

  38. Other vehicles- HBSS - developed by Krasner, milk, saline , coconut water, if not last clean water. • On ptsarrival- if tooth is in socket- splint-stabilize & disocclude the replanted tooth, & if not and the tooth is brought in vehicle then place it back – socket. • Do not attempt any endo treatment at this appointment and recall the pt after 1 week for the initiation of endo therapy.

  39. REFERRED PAIN • Referred pain may be initiated from inflamed pulp-other parts of body on same side or in close proximity to another 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.

  40. DURING ENDODONTIC TREATMENT

  41. 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 2-25% flare-ups. • Inter-appointment flare-up is characterized by the development of pain, swelling or both, following endodontic intervention. • 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.

  42. Inadequate debridement a) Residual pulp in inadequately instrumented canal B) 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.

  43. Debris extrusion conventional hand instrumentation was shown to extrude the more debris than rotary instrumentation. • More likely to cause flare up if pulp is necrotic and infected. • 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.

  44. Over instrumentation • Incident of moderate –severe pain • Gross O.I – causes acute apical periodontitis producing primary inflammatory pain • In vital teeth, the apical periodontium is crushed producing pain and inflammation. Test for over instrumentation-: 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

  45. Rx & prevention of flare-ups: 1. Occlusal reduction. 2. Antibiotic prophylaxsis • I & D ---Leaving tooth open for complete drainage- 20 min – complete removal of pulp tissue and debris -followed by closed dressing • Calcium hydroxide therapy: intra canal dressing • Antibiotics & Analgesics(releive pain) • Corticosteroids – antiinflammatory action

  46. SODIUM HYPOCHLORITE ACCIDENT • NaoClis most used root canal irrigant, effec against broad spectrum of microorganisms • It’s a cytotoxic agent and when –contact with vital tissues – haemolysis, ulceration, damages endothelial ,fibroblast cells. Caustic effect – alkalinity- PH :10-12.9 & hypertonicity that causes injury by oxidation of proteins • SYMPTOMS OF NaoClaccident-: -Immediate severe pain , edema, Ecchymosis on skin or mucosa ,Trismus, profuse bleeding from root canal, Chlorine taste or foul odour

  47. HOW TO TREAT: • Remain calm – inform pt, cause , nature of complication. • Immediate irrigate with saline to decrease soft tissue irritation • Pain control: L.A.,acetominophen - norcotic analgesics advised……………….. No Nsaids • Extraoral cold compresses to reduce pain, swelling. (ice pack) -24 • After 24 hrs advice for warm compress and frequent warm mouth rinses for stimulation –local systemic circulation. • Antibiotic coverage -7 days • severe inflammation – corticosteriod • Recall

  48. HOW TO AVOID: • Use of rubber dam, adequete access prep, • needle placed b/w coronal to middle third of root • passively not wedged, • Use of side vented needles, 27-guage. • Flow back of solution should be observed. • Slow administration of irrigant –canal.

  49. INSTRUMENT ASPIRATION & INGESTION • Aspiration and ingestion of endodontic instruments. • Endodontic procedures - in the absence of a rubber dam

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