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ENDODONTIC EMERGENCIES
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
inflammation. Referred pain, more complex facial pain, TMJ pain, non-odontogenic paindifficult to diagnose
Dentist
must
these from
interpretations
The professionals perception of the patient in pain Doctors reaction to the patient is important for both pain and patient management.
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
IRREVERSIBLE PULPITIS
Acute Pulpitis large carious lesion or with defective restoration
TREATMENT
Minimal amount of time Single rooted teeth Multi rooted teeth
Pulpotomy and
formocresol application closed dressing
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
Treatment Anaesthesia usually not required Access cavity prepared, W/L determined, canal sufficiently enlarged. Copious irrigation with saline Closed dressing given
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
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
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
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
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-
Alternative techniques
Intrapulpal anesthesia Periodontal ligament injection Intraosseous injection Use of more potent anesthetic (Bupivacaine) Sedation or general anesthesia
VITAL TEETH
Presence of pulp tissue
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
Canal patency
Incision and drainage
Surgical trephination
Antibiotics and analgesics
HIGHEST No. OF FLARE UPS ACUTE PERIAPICAL ABSCESS - NECROTIC PULP - RETREATMENT PRE-EMINENT FACTORS CROWN DOWN TECHNIQUE
Females - more susceptible Phobic patients tolerance low psycho-physiological of their particular
Biting or chewing pain, or parasthesia Reassessment of the periapical tissue for over instrumentation, overfilling or under filling
Rx Retreatment
Surgical trephination
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
restoration
Presence determined
or
absence
of
apical
closure
is
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
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
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
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
4 month post-op
3 year recall
3 year recall
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
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