ENDODONTIC EMERGENCIES

INTRODUCTION EMERGENCY according to Dorlands Medical dictionary is defined as a sudden, urgent, usually unforeseen occurrence requiring immediate action. Life threatening emergencies can and do occur in the practice of dentistry. Although, all forms of medical emergency may develop in dental practice, some are seen with greater frequency. These are situations produced entirely by stress or those that are acutely e acerbated when the patient is under stress. These situations include! " " " " " " Vasodepressor syncope. Respiratory difficulty. Airway obstructions. Hyperventilation syndrome. Ast ma. Acute cardiovascular emer!encies. #ffective management of $T%#$$ in the dental office will minimi&e the occurrence of these situations.

'

(ther life threatening situations that occur with greater frequency in dental practice are those reactions associated with the administration of D%)*$. The most frequently observed reactions are those associated with administration of local anesthetics. (thers are! " " Drug overdose. Drug allergy. Most dental emergencies are unscheduled intrusions into the routine of daily practice. +evertheless the dentist must provide speedy and effective relief because such care is essential part of daily practice. The reason for endodontic emergency treatment is ,A-+ and at times $.#LL-+* ensuing from pulpoperiapical pathosis. /ecause dental pain has many causes, t e adept clinician must dia!nose t e ori!in of pain as "uic#ly as possible to render rapid and effective relief. $%nowin! w at to do and w en to do it are as important as #nowin! ow to do it&. DIAGNOSIS -n an A0)T# pain emergency, the ,12$-0AL as well as the #M(T-(+AL state of the patient should be considered. The doctors 3

reactions to the patient is important for both pain and patient management. The patients needs, their fears about the immediate problem and their defenses for coping with the situation must be understood. The chief tool in establishing a correct diagnosis remains in careful history ta4ing followed by a thorough but quic4 clinical e amination. According to *rossman 5 The diagnostic methods available to clinicians are! -. $)/6#0T-7# $2M,T(M$ ! .hich is the chief complaint of patient eliciting either! 8A9 '9 ,ain 39 $welling :9 Lac4 of function ;9 #sthetics --. -. --. D#+TAL 1-$T(%2 M#D-0AL 1-$T(%2 (/6#0T-7# $2M,T(M$ .hich are determined by tests and observations performed by clinicians.

The tests are as follows! '. 7isual and Tactile -nspection. 3. ,ercussion. :. ,alpation. ;. Mobility and Depressibility. <. %adiographs. =. #lectric pulp test >. Thermal tests " 1ot " 0old ?. Anesthetic test @. Test cavity

CLASSIFICATION OF ENDODONTIC EMERGENCIES 'A( a9 b9 c9 '-( '9 Accordin! to )A*+,N ,retreatment emergencies. -nterappointment emergencies. ,ost"obturation emergencies Accordin! to GR,..MAN Acute 0onditions '. %eversible pulpitis ;

3. -rreversible pulpitis. :. Alveolar abscess. ;. ,eriodontal abscess 39 :9 #mergencies During Treatment Aractures 0rown %oot ;9 <9 Avulsed tooth %eferred pain

'C( Accordin! to G/++MAN 01 +REA+MEN+ ,2 V0+A* 3/*3 " " " " " Acute reversible pulpitis 1ypersensitive dentin. %ecurrent decay. %ecent restoration. 0rac4ed tooth syndrome.

001 +REA+MEN+ ,2 N,N4V0+A* 3/*3 " " " " Acute apical periodontitis. +ecrotic pulp. Acute alveolar abscess. ,hoeni abscess.

<

"

Acute irreversible pulpitis

" Locali&ed. " +on"locali&ed

III] AESTHETIC EMERGENCY " " " Aracture of crown. Aracture of root. Avulsed tooth.

0oming to the ,%#"T%#ATM#+T #M#%*#+0-#$

ACUTE PULPITIS
ACUTE REVERSIBLE PULPITIS [HYPEREMIA] Definition: %eversible pulpitis is a mild"to"moderate inflammatory

condition of the pulp caused by no ious stimuli in which the pulp is capable of returning to the uninflamed state following removal of the stimuli. Symptoms: A.%.,. is characteri&ed by! '. . arp pain lasting for a moment. 3. . ootin! pain lasting for short"duration. :. ,ain brought on by cold beverages and sweets. ;. 0linically 5 the patient can identify t e toot by pointing to it.

Causes and Treat ent '9 0aries Lesion which are close to pulp can cause mild to moderate sensitivity to patients. Treatment 0aries e cavation and placing a sedative cement li4e dycal and &inc o ide eugenol 8-,09. 39 point. Treatment %econtouring or removal of high points. :9 ,ersistent pain and severe sensitivity after cavity preparation $uggesting chemical lea4age. Treatment %emoval of restoration and placing sedative cement li4e B(#. ;9 %ecurrent caries "C under an old restorations. Treatment %emove all caries and replace with a sedative cement. <9 Thermal shoc4 from preparing a cavity with a dull bur or 4eeping the bur in contact with the tooth for a long time can cause acute reversible pulpitis which e aggerates on placing a metallic restoration over the tooth. %ecent restoration which has a premature contact

>

Treatment %emoval of metallic restoration and palliative treatment by placing the cement. /ecause the best treatment of reversible pulpitis is removal of irritants of any sorts. Prognosis ! The prognosis is favourable if early removal of irritant is achieved otherwise the condition may develop into irreversible pulpitis. ACUTE IRREVERSIBLE PULPITIS Definition: -rreversible pulpitis is a persistent inflammatory condition of the pulp, caused by a no ious stimuli. As opposed to that of reversible pulpitis, irreversible pulpitis is caused by both ot 5 or cold stimuli . Therefore, the difference between reversible and irreversible pulpitis is distinguished by the duration of pain e perienced by the patient.

S! "t# s$ " " " " " " " " ,ain lasts for minutes to hours. -t is spontaneous. -t often continuous even when the cause is removed. ,ain is present even on bending over. ,atient complains of disturbed sleep. ,ain is e perienced on sudden temperature change. (n ta4ing sweets or acidic foodstuff. Arom pac4ing of food into cavityDfood impaction.

Causes$ '. The most common cause of irreversible pulpitis is bacterial involvement of pulp t rou! caries . 3. %eversible pulpitis may also deteriorate into irreversible pulpitis. -n irreversible pulpitis the pulp may be 7ital +on"vital

%&

V%ta' "u'" According to *rossman, the preferable emergency treatment is

E,)L,#0T(M2 i.e. complete removal of the pulp and placement of an intracanal medicament to act as a disinfectant or obtundent. According to many authors li4e .eine, .alton and *rossman, in posterior teeth, where time is a factor, ,)L,(T(M2 or removal of coronal pulp and placement of formocresol or similar dressing on the radicular pulp should be performed as an emergency treatment whereas in single rooted teeth pulpectomy can be performed directly. Pr#(edure$ " " " After administration of local anaesthesia. Access cavity is prepared. .ith a spoon e cavator and round bur the coronal pulp is removed. " A cotton pellet moistened with formocresol is placed in the cavity and it is sealed with Bn(# cement. After removal of the tissue the site of inflammation precipitating a painful response is gone. The formocresol fi es the non"inflammed tissues in the canal until the subsequent treatment of endodontics is followed. The tooth involved is then relieved out of occlusion.

'F

%%&

N#n)V%ta' Pu'" +ecrotic pulp rarely causes an emergency procedure. Most of the time these teeth do not respond to stimuli such as

hot, cold or electric stimulation, they may still contain vital inflamed tissue in the apical portion of root canal and also inflamed periapical tissue which causes pain. Rad%#*ra"+%(a''!$ A9 -f a lesion is seen 5 A0)T# A,-0AL A/$0#$$. /9 -f no lesion is seen 5 A0)T# A,-0AL ,#%-(D(+T-T-$ ACUTE ALVEOLAR ABSCESS Also called as! " " " Acute periapical abscess. Acute apical pericementitis ,hoeni abscess.

Definition: -s defined as a locali&ed collection of pus in the alveolar bone at the root ape of the tooth following death of pulp with e tension of infection through the apical foramen into the periapical tissue.

''

Causes ,N#n)-%ta' "u'". a9 /acterial involvement. b9 1D( trauma. c9 Mechanical or chemical irritation. The acute episode may result from! '9 ,)L,-T-$ that progressively developed into pulp necrosis affecting the periapical tissues. 39 :9 A0)T# #GA0#%/AT-(+ of a chronic periapical lesion #+D(",#%-( lesion when the periodontal abscess secondarily affects the pulp through the lateral canals or deep infrabony poc4ets. SYMPTOMS There are local reactions li4e! " " " " Tenderness of tooth. $evere throbbing pain. $welling. $inus tract.

S!ste %( rea(t%#ns are$ " #levated temperature.

'3

" " " " "

*astro"intestinal disturbances. Malaise. +ausea. Di&&iness. Lac4 of sleep.

TREATMENT The main treatment is bip asic in nature i.e. - 5 Debridement of canals. -- 5 Drainage of abscess. The emergency treatment of acute alveolar abscess differs from acute irreversible pulpitis, as the pulp is necrotic, local anaest esia is not re"uired and frequently 0(+T%A-+D-0AT#D. 2orcin! anaest etic solution into an acutely infected and swollen area may increase pain and may spread infection. /BLOC0 MAY BE USED IN SUCH CASES1 Most of the pain that occurs during access cavity preparation is caused by tooth movement resulting from vibration of the bur therefore one should stabili&e tooth with finger pressure so that the pain is reduced.

':

Treatment procedure follows as! '9 Access cavity preparation. 39 ,rofuse irrigation avoiding forcing of any solution or debris into the periapical tissue. :9 -n most cases ,)%)L#+T #G)DAT# escapes into the chamber and indicates that root canal is patent and draining. ;9 -f drainage does not occur, the apical constriction is purposefully violated and enlarged to a minimum of 3FD3< +o. instrument to allow for e udate to drain because in most cases the apical constriction may prevent the drainage.

According to *%($$MA+ H 0(1#+ leaving the tooth (,#+ for drainage reduces the possibility of continued pain and swelling. (pen root canals permit drainage and frequently eliminate the need for surgical incision as well as routine administration of oral antibiotics and analgesics. According to .ALT(+, after copious irrigation, the canals are dried with paper points and a medicated temporary cotton pellet is 4ept 5 in other words 5 open dressing is given. $ome clinicians suggested that acutely abscessed teeth be sealed with an intracanal medicament after the initial emergency treatment is

';

done. According to them this stops the infiltration of new microorganisms. As opposed to them A)*)$T found that only :I out of :'' abscessed teeth which had been left open reacted adversely. Therefore, the decision to 4eep the canal patent or closed must be made depending on the amount of drainage and si&e of swelling. S2ELLINGS ASSOCIATED '9 -f it is slight and locali&ed it will disappear 3; to ;? hours after drainage. 39 -f it is e tensive, soft and fluctuant an incision through soft tissue is a must. :9 -f swelling is hard 5 it can be converted to soft fluctuant state by rinsing with hot saline solution :"< minutes at a time repeated every hour. ACUTE PERIODONTAL ABSCESS -t is often mista4en for an acute alveolar abscess. Cause -t can occur with either 7ital pulp +ecrotic pulp

'<

'9 -ts origin usually is an A0)T# #GA0#%/AT-(+ of infection with pus formation in an e isting deep infrabony poc4et. -f the pulp is 7-TAL Treatment 0onsists of curettage, debridement and establishment of drainage of the infrabony poc4et through sulcus. -f the pulp is +#0%(T-0 Treatment 5 e tirpation and pulpectomy, similar to acute alveolar abscess. -f the pulp is A/+(%MAL and 7-TAL. Treatment is same as acute alveolar abscess. -n any case, emergency periodontal treatment must be done simultaneously otherwise the patient will not be relieved of pain and swelling. EMERGENCIES DURING TREATMENT #ndodontic emergencies can occur during the course of treatment.

'=

Most emergency are reactive phenomenon to pressure and chemical mediators created as a result of inflammatory response in periradicular tissues. A((#rd%n* t# Gr#ss an The emergencies can be due to! '9 -nstrumentation beyond the root ape periradicular tissue. 39 .hen debris and microorganisms are pushed beyond the apical foramen which can cause an infectious reaction. :9 0hemical irritants li4e " -rrigating solution. " -ntracanal medicament ;9 -ncomplete debridement of all root canals. <9 Lost or depressed access cavity seals leading to recontamination. =9 (verfilled root canals with subsequent periapical inflammation. causing trauma to

The inflammation in the peri"radicular tissue is induced as a result of release of substances such as vasoactive amines, 4inins and arachadonic acid metabolites. This interappointment emergency as classified by .ALT(+ is referred to as JALA%#"),K.

'>

.ALT(+ has suggested the possible factors related as discussed before as! '9 -rritants within the pulp system. 39 (perator controlled or iatrogenic factors. :9 1ost factors. ;9 *eneral systemic factors which are related to Alare"up.

,atients can accept that pain may continue to a lesser e tent when they come to the dental office for emergency treatment. .hat is difficult for patients to comprehend is when they enter the office having little or no pain before therapy but then encounter an e plosive flare"up after the treatment is done. Therefore ,%#7#+T-(+ (A ALA%#"),$ 0an be done by! '9 The most important preventive measure is preparing the patient to accept some discomfort which should subside in a day or two i.e. psychological preparation of patients. 39 )sing long acting anaesthetic solution. :9 0omplete cleaning and shaping of root canals.

'?

;9 Administration

of

appropriate

analgesics,

prophylactic

analgesics before ne t appointment reduces the incidence of discomfort and flare"ups. HYPOCHLORITE ACCIDENT Another very important but rare emergency is due to e pelling of an irrigant such as +a(0l beyond the ape . This happens only by loc4ing the needle of the irrigating syringe in the canal and forcefully inLecting the irrigant. .ithin minutes the patient feels $)DD#+ #GT%#M# ,A-+. $.#LL-+* within minutes. ,rofuse, prolonged /L##D-+* through the root canal. This bleeding is the bodys reaction to the irrigant. %emove the to ic fluid with high volume evacuation to encourage further drainage from periradicular tissue.

+reatment6 '9 Allow the bleeding to continue. -f the body rids itself of to ic fluid healing may be faster.

'@

39 -f the treated tooth is pulpless consider prescribing an antibiotic and an analgesic for < and : days respectively. :9 $ince this may be hypersensitive reaction consider prescribing an antihistaminic. TRAUMATIC 3 ESTHETIC EMERGENCY -t can be broadly classified as! '9 0rown fracture. 39 %oot fracture. :9 Tooth avulsion. A traumatic inLury to a tooth can cause a! " 0rac4ed crown " Aracture crown. " Aracture root And all this results in pain. C# %n* t# 4CRAC0ED TOOTH SYNDROME5 Causes$ '9 -ntact tooth that has an opposing plunger cusp occluding centrically against a marginal ridge. 39 /iting une pectedly on a hard obLect li4e stone. :9 Trauma D blow. S! "t# s$

3F

'. $harp, piercing pain during mastication. 3. Aleeting pain on thermal changes. :. 1ypersensitivity. DETECTION is made by! '9 Dental history. 39 Transillumination. :9 ,lacing a disc and ma4ing the patient bite, the disc acts li4e a wedge on the crac4ed tooth and causes pain. ;9 Dye. <9 .hen a visible crac4 is found, lateral pressure, either digital or from the handle of an instrument is applied to see if the segment shears off or not. TREATMENT '9 -mmediate treatment is covering the e posed dentin with a sedative cement li4e Bn(# and cementing a stainless steel band. 39 -f a green stic4 fracture of the crown is present and the crown segment does not shear off under pressure, one should cement stainless steel band. :9 -f the pulp is e posed, a band should be placed and cemented and a pulpectomy should be performed.

3'

;9 This should be immediately followed by relieving of occlusion by grinding the cusps of the tooth. /ecause any traumatic accident can temporarily affect the usual responses to the electric pulp test, cold test and test cavity, negative test responses for pulp vitality are non diagnostic and should not be the basis for selecting endo emergency treatment. -t is wiser to assume that pulp is vital as vital pulp in the root canal of fractured tooth can enhance the prognosis of healing. CRO2N FRACTURES 0rown fractures can be divided into ; maLor groups! '9 (nly enamel. 39 #namel and dentine without pulp e posure. :9 #namel and dentin with pulp e posure. ;9 )ntreatable. ONLY ENAMEL 0an be treated by composite restoration. ENAMEL AND DENTINE 2ITHOUT PULP E6POSURE 0an be treated by early placement of restoration with pulpal protection li4e sandwich technique.

33

ENAMEL AND DENTINE 2ITH PULP E6POSURE These fall into two categories Developing ape (pen ape -t ape is developed pulpectomy. -f ape is open pulpotomy 5 patient is chec4ed for apical

closure after every : months and then routine endodontic treatment. UNTREATABLE These imply to crown fracture in which an aesthetic and periodontally healthy condition is impossible. ROOT FRACTURE 0an be divided as ! " 7ertical " 1ori&ontal 0oronal third. Middle third Apical third. 7ertical fractures have hopeless prognosis because it is not possible to either stabili&e the fragments or remove one part surgically and leave the other in situ.

3:

H#r%7#nta' 8ra(tures Above alveolar crest e cellent prognosis. The closer the root fractures to the ape the more favourable the prognosis as sufficient root length is seen if fracture fragment is to be removed. Treatment stabili&e by ligation to adLacent teeth. 0hec4 pulp vitality after = wee4s as the pulp will be in a $stunned& state. -f the fracture is at mid root or below the alveolar crest poor prognosis. -f remaining root portion is left post and core can be given. TOOTH AVULSION The avulsed or lu ated tooth is both a dental and an emotional problem. Cause$ %esult of trauma to an anterior tooth of a young adult or child. The longer the lu ated tooth is out of its soc4et, the less li4ely it will remain in a healthy, functional state after replantation.

3;

The instruction to the patients are! '9 To carry the avulsed tooth in a moist vehicle preferably in the patients mouth i.e. saliva to maintain the viability of periodontal ligament. (thers are mil4, saline etc. The tooth should not be dried. The e tra"oral time for a tooth should not e ceed :F minutes. Pr#(edure The tooth is placed in the soc4et Ligated. $tabilised and disoccluded. %adiograph to verify the position should be ta4en. This procedure was first given by A+D%#A$(+

REFERRED PAIN Although the most frequent cause of pain is pulpoperiapical pathosis, the clinician 4nows that the pain can originate from many other sources. According to 1urwit& dental pain can have its origin in! " Trigeminal neuralgia.

3<

" " " "

Atypical facial neuralgia. Migrane. 0ardiac pain. Temporomandibular arthrosis. $inusitis or cold may refer to ma illary posterior teeth.

Pa%n ar%s%n* 8r# " " " " "

"er%#d#nta' "r#9'e s$

,eriodontal abscess. (cclusal trauma. Muscle spasm. /ru ism and clenching. ,ericoronitis may be confused as pulpoperiapical pain. $picer reported pain referred to a lower molar from a basilar

artery aneurysm that produces pressure in the trigeminal nerve. 7erbin and colleagues described odontalgia in a ma illary lateral incisor due to herpes &oster of trigeminal nerve. $anubai and %ichardson described vascular nec4 pain referred to mandibular posterior teeth. (titis Media may refer to mandibular molars. Myocardial infarction or angina pectoris may cause tooth ache on left side especially if it occurs while patient is e ercising.

3=

(ther causes of referred or unusual pain are! " " " " -ntensive radiation. Malaria, typhoid, influen&a. Menstrual pain. $ome malignant diseases and tumors. Thus, the role of diagnosing a true endo emergency cannot be over emphasi&ed.

ANALGESICS AND ANTIBIOTICS The use of analgesics and antibiotics is important in endodontic emergency treatment. #very clinician should be familiar with their! " " " " " " " Mode of action. Dosage. -ndications. -nteractions with other drugs. %oute of administration. To icity 0ontraindications.

3>

ANALGESICS Analgesics are pain relievers +A%0(T-0 analgesics are used to relieve acute, severe pain. +(+"+#0%(T-0 or mild analgesics are used to relieve slight to moderate pain.

The most frequently used non"narcotic analgesics are! " " " " Aspirin. Acetaminophen. +apro en. -buprofen.

A$,-%-+ alone or in compound is used most often in the dosage of =FFmg. Aspirin should be ta4en with caution as it can cause an anaphylactoid reaction in an allergic person or an adverse reaction in persons with gastric ulcers. Aspirin is contra"indicated in patients receiving anticoagulant therapy, diabetes and arthritis. A0#TAM-+(,1#+, the second most commonly used

analgesics is effective for mild"to"moderate. -t has lower incidence of

3?

side effects than aspirin. -t lac4s anti"inflammatory effect of aspirin. -t is recommended for children and is available in liquid form. -/),%(A#+ a proprionic acid derivative prescribed in doses of :FF";FFmg ; times daily is more effective for severe pain relief than aspirin. /ut it should not be used in patients with hDo peptic ulcer or aspirin intolerance. +A%0(T-0 A+AL*#$-0$ li4e morphine, codine :Fmg neperidine, hydrocone <mg with acetaminophen <FFmg etc are generally not used or are used with caution as it may depress the 0.+.$. They interact adversely sometimes fatally with alcohol, local anaesthetic, antihistaminics etc. ANTIBIOTICS Antibiotics are life saving therapeutic agents which are used for prophylactic coverage of medically compromised patients and as an adLunctive treatment for acute periapical and periodontal infections. -deally, the selection of antibiotics should be based on the susceptibility tests that indicate effectiveness against the infecting microorganisms. Therefore, the more lethal the antibiotic the less li4ely resistant the microorganisms will develop to it.

3@

The most effective antibiotics for use in endodontic emergencies is ,#+-0-LL-+. ,enicillin acts by inhibiting the cell wall synthesis during multiplication of microorganisms and are effective against gmMve cocci, viridans strains, many anaerobes which are involved in endodontic infections. The standard regime for dental procedures is penicillin 7, 3.Fgm ' hr before treatment and '.Fgm = hourly later. This is quite feasible according to the #uropean standards owing to their larger physique and body wt and higher /M%, but according to -ndian $tandards this regime wor4s out to be on a larger scale owing to its less body wt. Therefore, the dosage reduces in accordance to the body wt which is 3<Fmg to <FFmg tid. -n case of ,#+-0-LL-+ ALL#%*2, ERY+HR,MYC0N may be prescribed which acts by inhibiting proteins synthesis. The dosage in 3<Fmg"<FFmg = hourly. (ther antibiotics useful for treating endo"emergencies are! " " " 0ephale in 5 3<F"<FFmg = hourly. 0lindamycin phosphate 5 '<F":Fmg = hourly. Tetracycline 1cl 5 3<F":FFmg = hourly. :F

Tetracycline is the least effective of all antibiotics for endo emergencies. CONCLUSIONS A satisfying and rewarding e perience is to successfully manage a distraught patient who initially presented with severe pain for an emergency appointment. ,roper operators attitude, patient control, accurate diagnosis, and profound anaesthesia as well as prompt and effective treatment are all integral components of management of endo"emergencies. REFERENCES $ " " " " " *rossman. .eine. .alton. 0ohen. -ngle.

:'