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ENDODONTICEMERGENCIES
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-ENDODONTIC EMERGENCIES
ARE CHALLENGE IN BOTH
DIAGNOSIS & MANAGEMENT
-EVERY CASE IS A COMPLETE
SEPARATE STORY
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-DENTIST SHOULD
INTERFER-NEVER DEPEND ON
MEDICATIONS ALONE
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DEFINITION
OF EMERGENCY
CASES ASSOCIATED
WITH PAIN &/ ORSWELLING & REQUIRE
IMMEDIATE DIAGNOSIS
& TREATMENT
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KEYS QUESTIONS TO
DETERMINE THE CASE:
1-DISTRUPTION OF
SLEEPING,WORKING &
EATING
2-DURATION3-PAIN MEDICATION
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CAUSES OF THESE
EMERGENCIES
ARE IRRITANTS THAT INDUCE
SEVERE INFLAMATION IN PULP &
PERIRADICULAR TISSUES
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THESE IRRITANTS LEAD TO
THE RELEASE OF A GROUP
OF CHEMICAL SUBSTANCESTHAT INITIATE THE
INFLAMATION
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THESE SUBSTANCES
CAUSE PAIN IN TWO
WAYS:
1-DIRECTLY : BY LOWERING THE
RESPONSE THRESHOLD OF SENSORY
NERVES
2-INDIRECTLY:BY INCREASING
VASCULAR PERMIABILITY &PRODUCING EDEMA
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THE MAIN CAUSE OF THE PAIN
IS
EDEMA RESULTS ININCREASED FLUID PRESSURE
WHICH STIMULATES PAINRECEPTORS
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THE IMMEDIATE GOAL
OF THE TREATMENT
SHOULD BE THE
REDUCTION OF
PRESSURE ORREMOVAL OF THE
INFLAMED PULP ORPERIRADICULAR
TISSUE.
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PSYCHOLOGICAL MANAGEMENT IS
THE MOST IMPORTANT:
1-CONTROL THE SITUATION2-GAIN THE CONFIDENCE OF THE
PATIENT
3-PROVIDE ATTENTION & SYMPATHY4-TREAT THE PATIENT AS AN
IMPORTANT INDIVIDUAL
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-PATIENT IN PAIN OFTEN PROVIDE
INFORMATION AND RESPONSES THAT
ARE EXAGGERATED & INACCURATE.
-ALSO HE MAY GIVE YOU FALSE
IMPRESSION.
-BE AWARE OF THE REFERRED PAIN &
SYSTEMIC CONDITION.
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PROPER DIAGNOSIS IS
VERY IMPORTANT TOTREAT THE CASE:
1-OBTAIN MEDICAL & DENTAL HISTORIES
2-SUBJECTIVE EXAMINATION
3-VISUAL EXAMINATION
4-INTRAORAL EXAMINATION5-PULP TESTING
6-PULPATION & PERCUSION
7-RADIOGRAPH
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1-OBTAIN MEDICAL &DENTAL HISTORIES
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2-SUBJECTIVE EXAMINATION
QUESTIONS:HISTORY,LOCATIONDURATION,SEVERITY,NATURE,
STIMULATING AGENTS.
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PAIN CAUSED BY THERMAL
CHANGES IS OF PULPALORIGIN.
PAIN CAUSED BY PRESSUREIS OF PERIRADICULAR
ORIGIN
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PAIN
SPONTANEITY,INTENSITY
& DURATION.
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-Initial diagnosis is reached after this
subjective question
-OBJECTIVE TESTS &RADIOGRAPHICAL EXAMINATION AREUSED FOR CONFIRMATION.
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3-OBJECTIVEEXAMINATIONS
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A-EXAMINATION OF FACE &
ORAL SOFT & HARD TISSUE.
(SWELLING,RESTORATIONS,DISCOLARATION,CARIES,
FRACTURES)
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B-PERIRADICULAR TESTS:
-PALPATION OVER THE
APEX
-DIGITAL PRESSURE ON THE
TEETH
-LIGHT PERCUSSION
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C-VITALITY TESTS OF THEPULP:
COLD,HOT,ELECTRICAL,,,,
CAVITATION.
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D-PERIODONTAL EXAMINATION
PROBING IS VERY IMPORTANT
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PERIODONTAL ABCESS CAN
SIMULATE THE SYMPTOMS
OF ACUTE APICAL ABCESS
BUT THE PULP HERE ISVITAL & POCKETS ARE
PROBED.
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4-RADIOGRAPHICEXAMINATION
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PROPER DIAGNOSIS IS
REACHED
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TREATMENT PLAN
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THE IMMEDIATE GOAL
OF THE TREATMENT
SHOULD BE THE
REDUCTION OF
PRESSURE ORREMOVAL OF THE
INFLAMED PULP ORPERIRADICULAR
TISSUE.
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FIRST STEP IN TREATMNTIS :
PROFOUND ANESSTHESIA
TO GAIN PATIENTS
CONFIDENCE & COOPERATION
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UPPER JAW:INFILTRATIONOR BLOCK
LOWER JAW: INFERIORALVEOLAR BLOCK.(
LINGUAL & LONG BUCCALBLOCK MAY BE HELPFUL)
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SOMETIMES:
PERIODONTAL,
INTRAPULPAL ORINTRAOSSEOUS INJECTIONS
MAY BE NEEDED
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EMERGENCIES
1-PRETREATMENT2-INTERAPPOINTMENT
3-POSTOBTURATION
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PRETREATMENTEMERGENCIES
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1-PAINFUL IRREVERSIBLE
PULPITIS WITHOUT
APICAL PERIODONTITIS
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DIAGNOSIS
1-PAIN ON THERMAL
STIMULI (MAINLY HOT)
2-NO PAIN ON PERCUSION3-SPONTANOUS PAIN
4-NO RADIOGRAPHICPERIAPICAL CHANGES
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TREATMENT:
-PROFOUND ANESTHESIA-COMPLETE PULP EXTIRPATION-CLEANING & SHAPING OF THE
CANALS IS DESIRABLE.-IN MOLARS ;PULPOTOMY MAY BE
ENOUGH TO RELEASE PRESSURE
-MEDICAMENTS :CAMPHOR SEALED
IN THE CANALS.
-A MILD ANALGESICS BUT NO
ANTIBIOTIC
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2-PAINFUL IRREVERSIBLE
PULPITIS WITH ACUTE
APICAL PERIODONTITIS
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-THE SAME AS ABOVE BUT
WITH SLIGHT TO SEVERE PAINON PERCUSION
-RADIOGRAPHICALLY :SLIGHT
WIDENNING OF THE LAMINA
DURA AROUND THE APEX
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THE SAME TREATMENT
BUT:
1-MAY NEED RELIEF OF
OCCLUSION2-ANTIBIOTIC IS NOT
NEEDED
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3-PULP NECROSIS
WITHOUT SWELLING
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DIAGNOSIS
-TOOTH NOT AFFECTED BY
THERMAL STIMULOUS
-PAIN ON PERCUSION
-PERIAPICAL RADIOLUCENT
LESION MAY BE SEEN
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TREATMENT
-ANESTHESIA:INFLAMED PULPREMENETS IN THE APICAL
CANALS OR THE INFLAMED
PERIRADICULAR TISSUE-COMPLETE DEBRIDMENT IS THE
TREATMENT OF CHOICE
-HEAVY IRRIGATION WITHCOPIOUS AMOUNT OF SODIUM
HYPOCHLORITE
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-DRY THE CANALS WITH PAPER
POINTS-FILL THE CANALS WITH NON
SETTING CALCIUM HYDROXIDE.
-MEDICAMENTS :CAMPHORSEALED IN THE CANALS & CLOSE
IT WITH TEMPORARY FILLING
-MILD ANALGESIC ISNEEDED(ANTIBIOTIC IS RARELY
NEEDED)
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4-PULP NECROSIS WITHLOCALIZED SWELLING
(associated with acute apical
abcess)
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-TOOTH MAY HAVE SOME
MOBILITY & VERY SINSITIVE TOBITTING
-THERE MAY BE BUS INSIDE THE
CANALS WHEN OPEN THE PULPCHAMBER.
-THESE PATIENTS MAY HAVE
ELEVATED TEMPRATURES ORLYMPHADENOPATHY
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-RADIOGRAPHIC FINDINGS
RANGE FROM NO PERIAPICAL
RADIOLUCENCY TO LARGERADIOLUCENCY.
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DRAINAGE IS VERY
IMPORTANT
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-TREATMENT IS BIPHASICFIRST: DEBRIDMENT OF THE
CANALS
SECOND:DRAINAGE OF BUS
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LOCALIZED SWELLING
SHOULD BE INCISED
&DRAINED TO :
1-RELEASE OF PRESSURE
2-REMOVAL OF THE VERY
POTENET IRRITANT ( THE BUS)
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-IN PATIENTS WITH A PERIRADICULAR
ABCESS & NO DRAINAGE FROM THECANALS,PENETRATION OF THE APICAL
FORAMEN WITH SMALL FILE(UP TO 25)
MAY INITIATE DRAINAGE & RELEASE
PRESSURE.-DRAINAGE THROUGH THE TOOTH MAY
BE ENOUGH IN SOME CASES.
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-MOST OF THE CASES NEED
DRAINAGE THROUGH THE
TOOTH & THE MUCOSAL
INCISION-DRAIN MAY BE NEEDED
TO PERMIT CONTINUED
DRAINAGE
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TREATMENT- DEBREDMENT & DRAINAGE .
-HEAVY IRRIGATION WITH DISTILLED WATER
-IT IS ADVISED NOT TO USE SODIUM HYPOCHLORIDEWITH THE PRESENCE OF BUS BECAUSE THIS MAY
LEAD TO THE FORMATION OF PLUG.-DRY THE CANALS WITH PAPER POINTS &
CLOSE.
-MEDICAMENTS :CAMPHOR SEALED IN THE
CANALS
-CLOSE WITH GOOD TEMPORARY FILLING
-MILD ANALGESIC &ANTIBIOTIC IS NEEDED
Make sure that there is no bus in
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-Make sure that there is no bus in
the canals before you close
-Dont leave these teeth open fordrainage
ButIf the drainage through the canal
is not stopped, the access may be
left opened for further drainageBUT NOT MORE THAN 24 HRs
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Leaving the tooth on open drainageshould
be avoided if possible,but if absolutelynecessary for less than 24 hrs,as after this
time further contamination of root canal by
anaerobic bacteria makes subsequent RCTvery difficult
OXFORD HANDBOOK OFCLINICAL DENTISTRY 2003
ANTIBIOTIC OF CHOICE:
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ANTIBIOTIC OF CHOICE:
A COMBINATION OF-WIDE SPECTRUM
ANTIBIOTIC FOR AEROBICBACTERIA(Penecillins)
-METRONEDAZOLE(Flagyl)
FOR ANEROBIC BACTERIA
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5-PULP NECROSIS WITH
DEFFUSE SWELLING
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THESE LESIONS ARE RAPIDELY
PROGRESSIVE &SPREADINGSWELLING THAT HAVE DISSECTED
INTO TISSUE SPACES.
-THESE PATIENTS OCCASIONALLY
HAVE AN ELEVATED TEMPRATURE
& SYSTEMIC SIGNS
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-SPREADING OF INFECTIONS INTO
FACIAL SPACES
-VERY DANGEROUS SITUATION
-SYSTEMIC MANIFESTATION ARE
PRESENT
-EYE CLOSURE IF ASSOCIED WITH
UPPER TEETH &
TRISMUS IF ASSOCIATED WITH
LOWER TEETH
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TREATMENT
-DRAINAGE IS VERY IMPORTANT IF THEREIS FLUCTUATION & BUS.
-EXTRAORAL INCISION WITH DRAIN MAY
BE NEEDED (ORAL SYRGEON)
-REMOVAL OF IRRETANTS BY
DEBRIDMENT OF CANALS OR EXTRACTION
OF INFECTED TOOTH
-STRONG ANTIBIOTIC (I.V.)&ANALGESIC .
-MAY NEED HOSPITALIZATION.
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INTERAPPOINTMENTEMERGENCIES
(FLARE UPS)
CAUSITIVE FACTORS
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CAUSITIVE FACTORS
-PREOPERATIVE COMPLICATION
-OVERINSTRUMENTATION( BLOOD IN
TH CANALS)
-REMAINING INFLAMMMED PULP
TISSUE
-IMPROPER PREPARATION OF
PATIENT
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-PROPER DIAGNOSIS IS
ALSO NEEDED.
-MOST IMPORTANT:IS TOREGAIN THE CONFIDENCE
OF THE PATIENT.
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TREATMENT OF FLARE-
UPS:
-REASSURANCE OF THE
PATIENT
-BREAK THE CYCLE OF PAIN
WITH ANESTHESIA
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TYPES OF FLARE-UPS
1-PREVIOIUSLY VITAL
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CASES WITHOUT
SWELLING
TREARTMENT-ASSURANCE OF PATIENT
-GOOD ANALGESIC
-REOPEN THE TOOTH( MAKE GOOD
DEBRIDMENT & IRRIGATE)
-INTRACANAL MEDICAMENTS
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2-PREVIOUSLY NECROTIC
CASES WITH NO SWELLING
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TREATMENT
-OPEN THE TOOTH
-RECLEAN & IRRIGATE THE
CANALS WITH SODIUM
HYPOCHLORITE
-DRY & CLOSE.
IF ACUTE APICAL ABCESS IS
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IF ACUTE APICAL ABCESS IS
DEVELOPED:
-DRAINAGE IS NECESSARY( THROUGH
THE TOOTH OR THE SOFT TISSUE)
-CLEANING & IRRIGATION OF THE
CANALS
-DRY & CLOSE.
-ANTIBIOTIC & NSAID IS NEEDED
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THE TOOTH SHOULD NOT
BE LEFT OPEN
3-CASE WITH SWELLING
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3 CASE WITH SWELLING
-INCISION & DRAINAGE.-OPEN THE CANALS &
CLEAN-DRY & CLOSE.
-STRONG ANTIBIOTIC &
ANALGESIC IS NEEDED.
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POSTOPERATIVE
EMERGENCIES
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ONE THIRD OF ALL ENDO
CASES EXPERIENCE SOME
PAIN FOLLOWING
OBTURATION.
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CAUSES:
-OVERFILLING IS THE MAIN
CAUSE-HIGH OCCLUSION
-IRRITATION FROM THE SEALER
OR GUTTAPERCHA
TREATMENT
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TREATMENT
-DISCOMFORT: REASSURANCE&MILD ANALGESICS.
-REMOVAL OF THE HIGH POINTS
-RETREATMENT IS INDICATED IF
PAIN PERSIST &ENDO TREATMENT
HAS BEEN OBVIOUSLYINADEQUATE.
APICAL SURGERY (
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-APICAL SURGERY (
APECICTOMY) IN PATIENTS
WITH PERSISTENT PAIN WITH
OVER FILLING
-PATIENTS WITH GOOD ROOTCANAL TREATMENT BUT WITH
PERSISTENT SWELLING AFTER
OBTURATION,INCISION &DRAINAGE MAY BE ENOUGH.
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REFERENCES
PRINCIPLES & PRACTICE OF
ENDODONTICS ( WALTON & TORABINJAD)
OXFORD HANDBOOK OF CLINICALDENTISTRY ( 2003)
PATHWAYS OF THE PULP ( COHEN &
BURNS)
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THE END