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Management of Endodontic Emergencies

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Management of Endodontic Emergencies CHAPTER 18 Management of Endodontic Emergencies SAMUEL O. DORN | GARY SHUN-PAN CHEUNG CHAPTER OUTLINE Emergency Classifications Symptomatic Teeth with Previous Endodontic Treatment Emergency Endodontic Management Leaving Teeth Open Teeth with Vital Pulps Systemic Antibiotics for Endodontic Infections Reversible Pulpitis Analgesics Irreversible Pulpitis Laboratory Diagnostic Adjuncts Pulpal Necrosis with Acute Apical Abscess Flare-Ups Fascial Space Infections Cracked and Fractured Teeth Management of Abscesses and Cellulitis Summary Incision for Drainage EMERGENCY CLASSIFICATIONS 4. Necrotic pulp, fluctuant swelling, with drainage through the canal The proper diagnosis and effective management of acute dental 5. Necrotic pulp, fluctuant swelling, with no drainage through pain are possibly the most rewarding and satisfying aspects of the canal providing dental care. An endodontic emergency is defined as 6. Necrotic pulp, diffuse facial swelling, with drainage pain or swelling caused by various stages of inflammation or through the canal infection of the pulpal or periapical tissues. The cause of dental 7. Necrotic pulp, diffuse facial swelling, with no drainage pain is typically from caries, deep or defective restorations, or through the canal trauma. Sometimes occlusion-related pain can also mimic There are other endodontic emergencies that were not dis- acute dental pain (Fig. 18-1). Bender8 stated that patients who cussed in these surveys. These emergencies pertain to trau- manifest severe or referred pain almost always had a previous matic dental injuries, as discussed in Chapter 20, to teeth that history of pain with the offending tooth. Approximately 85% have had previous endodontic treatment, as discussed in of all dental emergencies arise as a result of pulpal or periapical Chapters 8 and 19, and endodontic flare-ups that may disease, which would necessitate either extraction or endodon- occur between treatment sessions. Of course, there are also tic treatment to relieve the symptoms.38,68 It has also been many types of facial pain that have a nonodontogenic origin; estimated that about 12% of the U.S. population experienced these are described in detail in Chapter 17. a toothache in the preceding 6 months.65 In the decades between the previously cited surveys, there Determining a definitive diagnosis can sometimes be chal- have been several changes pertaining to the preferred clinical lenging and even frustrating for the clinician; but a methodical, management of endodontic emergencies. Many of these objective, and subjective evaluation, as described in Chapter treatment modifications have occurred because of the more 1, is imperative before developing a proper treatment plan. contemporary armamentarium and materials as well as new Unfortunately, on the basis of the diagnosis, there are conflict- evidence-based research and the presumption of empirical ing opinions on how to best clinically manage various end- clinical success. odontic emergencies. According to surveys of board certified endodontists by Dorn and associates in 197722,23 and 199031 EMERGENCY ENDODONTIC and by Lee in 2009,63 there are seven clinical presentations that are considered endodontic emergencies: MANAGEMENT 1. Irreversible pulpitis with normal periapex Because pain is both a psychological and biologic entity, as 2. Irreversible pulpitis with symptomatic apical periodontitis discussed in Chapters 4 and online Chapter 28, the manage- 3. Necrotic pulp with symptomatic apical periodontitis, with ment of acute dental pain must take into consideration both no swelling the physical symptoms and the emotional status of the 706 CHAPTER 18 Management of Endodontic Emergencies 707 A B FIG. 18-1 A, Patient complained of acute pain on biting at the lower right molar. B, The pain was resolved after removal of an overerupted upper right wisdom tooth. Notice the presence of wear facet on the mesial marginal ridge and surface of this tooth before extraction. patient. The patient’s needs, fears, and coping mechanisms Reversible Pulpitis must be compassionately understood. This assessment and Reversible pulpitis can be induced by caries, exposed dentin, the clinician’s ability to build rapport with the patient are recent dental treatment, and defective restorations. Conserva- key factors in the comprehensive success of the patient’s tive removal of caries, protection of dentin, and a proper res- management.8,30,48,91 toration will typically resolve the symptoms. However, the The methodical steps for determining an accurate diagnosis, symptoms from exposed dentin, specifically from gingival based on evaluation of the patient’s chief complaint, review of recession and cervically exposed roots, can often be difficult the medical history, and the protocols used for an objective and to alleviate. Topical applications of desensitizing agents and the subjective diagnosis, are described in detail in Chapter 1. Once use of certain dentifrices have been helpful in the management it has been determined that endodontic treatment is necessary, of dentin hypersensitivity; the etiology, physiology, and man- it is incumbent on the clinician to take the proper steps neces- agement of this are discussed in Chapter 12. sary to manage the acute dental emergency. As described in Chapters 3 and 29, the clinician has a Irreversible Pulpitis responsibility to inform the patient of the recommended The diagnosis of irreversible pulpitis can be subcategorized as treatment plan and to advise the patient of the treatment asymptomatic or symptomatic. Asymptomatic irreversible pul- alternatives, the risks and benefits that pertain, and the pitis pertains to a tooth that has no symptoms, but has deep expected prognosis under the present circumstances. Given caries or tooth structure loss that, if left untreated, will cause this information, the patient may elect extraction over end- the tooth to become symptomatic or nonvital. On the other odontics, or possibly request a second opinion. The treatment hand, the pain from symptomatic irreversible pulpitis is often plan should never be forced on a patient. The informed an emergency condition that requires immediate treatment. course of treatment is made jointly between the patient and These teeth exhibit intermittent or spontaneous pain, whereby the clinician. exposure to extreme temperatures, especially cold, will elicit In the event of an endodontic emergency, the clinician must intense and prolonged episodes of pain, even after the source determine the optimal mode of endodontic treatment pursuant of the stimulus is removed. to the diagnosis. Treatment may vary depending on the pulpal In 1977,22,23 187 board-certified endodontists responded to or periapical status, the intensity and duration of pain, and a survey to determine how they would manage various end- whether there is diffuse or fluctuant swelling. Paradoxically, as odontic emergencies. Ten years later, 314 board-certified endo- discussed later, the mode of therapy that we tend to choose dontists responded to the same questionnaire in order to has been directed more from surveys of practicing endodon- determine whether there had been any changes in how these tists rather than from controlled clinical studies or research emergencies were managed.31 The clinical management of investigations. emergency treatment of a tooth with irreversible pulpitis with or without a normal periapex seemed to be fairly similar by Teeth with Vital Pulps removing the inflamed pulp tissue either by pulpotomy or As described in Chapter 1, teeth with vital pulps can have one complete instrumentation.75 In a similar survey conducted in of the following presentations: 2009,63 most respondents stated that they cleaned to the level ◆ Normal. The teeth are asymptomatic with no objective of the “apex,” as confirmed with an electronic apex locator; pathoses. this suggests a change in the management of endodontic cases ◆ Reversible pulpitis. There is a reversible sensitivity to cold based on the advent of a more contemporary armamentarium. or osmotic changes (i.e., sweet, salty, and sour). In general, the most current survey indicates that there ◆ Irreversible pulpitis. The sensitivity to temperature changes is a trend toward more cleaning and shaping of the canal is more intense and with a longer duration. when irreversible pulpitis presents with a normal periapex, 708 PART II The Advanced Science of Endodontics compared with performing just pulpectomies as described in To assist the clinician in assessing the level of difficulty of the 1977 survey. None of the individuals surveyed in the 1990 a given endodontic case, the American Association of Endo- or 2009 poll stated that they would manage these emergencies dontists (Chicago, IL) has developed the “AAE Endodontic by establishing any type of drainage by trephinating the apex, Case Difficulty Assessment Form and Guidelines” (Fig. 18-2). making an incision, or leaving the tooth open for an extended This form is intended to make case selection more efficient, period of time. more consistent, and easier to document, as well as to provide In addition, for vital teeth, the 1977 survey did not even a more objective ability to determine when it may be necessary broach the concept of completing the endodontics in one visit, to refer the patient to another clinician who may be better able whereas in the 1988 study about one third of the respondents to manage the complexities of the case. indicated that they would complete these vital cases in a single visit and the
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