ENDODONTIC EMERGENCIES CONTENTS INTRODUCTION DEFINITION MANAGEMENT PRE-TREATMENT EMERGENCIES o ACUTE REVERSIBLE PULPITIS o ACUTE IRREVERSIBLE PULPITIS o ACUTE APICAL PERIODONTITIS o PULP NECROSIS WITH PERIAPICAL ABSCESS o ACUTE PERIODONTAL ABSCESS o TRAUMATIC INJURIES . CRACKED TOOTH SYNDROME . CROWN FRACTURE . ROOT FRACTURE . AVULSION MID-TREATMENT FLARE-UPS o APICAL PERIODONTITIS SECONDARY TO TREATMENT o PHOENIX ABSCESS o RECURRENT PERIAPICAL ABSCESS o CAUSES o MICROBIOLOGY o PREVENTION AND TREATMENT o HYPOCHLORITE ACCIDENT POST-TREATMENT EMERGENCIES o CAUSES AND TREATMENT REFERRED PAIN ROLE OF DRUGS CONCLUSION Page 1 ENDODONTIC EMERGENCIES INTRODUCTION One time when our hours of learning are put into true practical test is when we get a frantic call or an unscheduled visit from a patient in distress, and that is when we know we know we are facing an endodontic emergency. An endodontic emergency is defined as an “An unscheduled visit associated with pain or swelling ensuing from pulpoperiapical pathosis requiring immediate diagnosis and treatment.” The fact that is associated with words like unscheduled and immediate, imply the emergency of the situation. Pain is the most common factor that motivates the patient to seek dental treatment. Approximately 90% of patients requesting dental treatment for the relief of pain have pulpul periapical disease and thus are candidates for endodontic therapy.Hence the alleviation of dental pain is one of the prime objectives of dental profession. MANAGEMENT OF ENDODONTIC EMERGENCIES: The management of endodontic emergencies can be summarized into the 3 P’s “Prompt, precise and polite” Polite: the dentist’s reaction to the patient is important for both pain and patient management. The clinician should understand the patients needs, fears about the immediate problem and defenses for coping with the situation. building a rapport with the patient goes a long way not only in treating but also preventing endodontic emergencies like flare ups. Precise :”Heed to the needs of the patient” Page 2 ENDODONTIC EMERGENCIES The main focus of the clinician should be on the chief complaint of the patient that drove him to the clinic. After a review of subjective and objective symptoms and determining a diagnosis, treatment of the tooth should be initiated first. Prompt: an emergency often requires the dentist to be prompt in his action so as to relieve the suffering patient. This may also be of particular significance in severe traumatic cases where the time elapsed has a strong impact on the prognosis of the tooth. We shall divide our management into the following steps: • Proper attitude • Make an accurate diagnosis • Provide profound anesthesia • Render prompt and effective treatment 1. Proper attitude: A calm and confident professionalism should be displayed . a positive attitude to the patients problem can make the individual aware that an efficient and effective treatment will be done. 2. Make an accurate diagnosis: In the instance of dental emergency when a patient is suffering acute pain or swelling and needs immediate relief, the essential diagnosis should be rapid and accurate. The patient’s emotional status as well as physical condition such as limited mouth opening or associated injuries can further complicate diagnosis. The step-by step approach for proper initial diagnosis and identifying the culprit behind the pain include: • Attaining pertinent medical and dental histories to avoid important medical complications or allergic reactions or make modifications in the treatment. • Subjective examination: questions relating to history, location, severity, duration character, stimuli eliciting/ relieving pain should be asked. The spontaneity, Page 3 ENDODONTIC EMERGENCIES intensity and duration of pain should be enquired. An astute clinician can arrive at a tentative diagnosis by thorough subjective examination alone. • Objective examination: includes- : • Visual examination of face, oral and hard soft tissues. Dental examination should follow to note presence of defective restoration, discolored teeth, recurrent caries, fractures etc. • Perform vitality testing to note pulpal status. Thermal tests are more useful as they mimic the stimuli which elecit /relieve the pain. • Periradicular tests including palpation over apex and light digital pressure/ percussion should be done to identify periapical inflammation as the source of pain. • Periodontal examination to check for pockets should be done. Probing helps in differentiating endodontic from periodontal diseases. Radiographic examination: helps in detecting recurrent / inter proximal caries, possible pulpal exposures, resorptions, periapical pathosis etc. Remember radiographs are an aid to diagnosis. Learn to use them and not abuse them. A differential diagnosis should be done to consider or rule out even non- odontogenic sources of pain which mimic odontogenic pain quite closely. Periodontal prognosis: All the above should be done quickly but correctly. Once the offending tooth and the tissue i.e pulp/ periradicular has been identified it is critical to determine the prognosis of the tooth. If the tooth is periodontally very weak with excessive pockets/bone loss Restorability: if the restorability of the tooth is questionable, then extraction is the best choice. The patient himself may not want treatment at times. 3. Provide profound anesthesisa: Attaining profound anesthesia in rendering emergency treatment can be difficult even for an experienced clinician. This is because: • The presence of an acidic environment due to inflammatory prcesses , the anesthetic molecule is prevented from disassociating into ionic fom and cation is unable to penetrate through neural sheath. Page 4 ENDODONTIC EMERGENCIES • In the presence of swelling an dinfection , local infiltration is contraindicated due to the pain caused to the patient and chances of spread of infection. • Conduction/block anesthesia is generally made use of. However inflamed nerve fibres are morphologically and biochemically altered through out the length by neurochemicals like neuropeptides(GRP). Therefore nerve blocks at a site distant frm the inflamed tooth are rendered less effective. To avoid this problem, the clinician should • Select alternative and supplementary sites of injection e.g. intraligamentary, and a few drops of intrapulpul injection. When the pulp is exposed these are effective adjuncts. • Consideration should be given to the type and amount of anesthetic used. Hot tooth: • It is the tooth that is difficult to anesthetize • scientists have shown that there is a special class of sodium channels on C fibres known as tetrodotoxin resistant (TTXr) . • these are five times more resistant to anesthetic then TTX sensitive channels. • Additional anesthetic or supplemental injections are required to achieve profound anesthesia. • Importantly bupivacaine was found to be more potent than lignocaine in blocking TTX channels CLASSIFICATION: Endodontic emergencies can be classified according to the time when they occur as: I: Pre treatment emergencies II: During Rx emergencies/ inter appointment ‘flare ups’ III: After Root canal Rx / post-obturation emergencies Page 5 ENDODONTIC EMERGENCIES Pre treatment emergencies 1. Acute reversible pulpits 2. Acute irreversible pulpits • Without apical periodontitis • With apical periodontitis 3. Acute apical periodontis 4. Pulp necrosis with acute periapical abscess • Without swelling • With swelling : - localized - diffuse 5. Acute periodontal abscess 6. Traumatic Injuries • Cracked tooth syndrome • Fracture a. Crown Enamel Enamel and Dentin Enamel and Dentin with pulp exposure b. Root Horizontal Vertical • Luxated teeth • Avulsed tooth Acute reversible pulpitis / hyperemia Page 6 ENDODONTIC EMERGENCIES Definition: It is a mild to moderate inflammatory condition of the pulp caused by noxious stimuli in which the pulp is capable of returning to the uniflammed state following removal of stimuli Cause: : Trauma from a blow /disturbed occlusion : Thermal shock: cavity preparation / polishing : Excessive dehydration : Galvanic shock : Chemical stimulus: food /cements : Caries : Systemic conditions: circulatory disturbances, sinusitis Diagnosis: is by patients’ symptoms and clinical tests. Subjective symptoms: The patient reports of a pain which is sharp, lasts a few seconds and disappears on removal of stimulus such as cold, sweet or sour foods. It does not occur spontaneously. Although the paroxysms of pain are of short duration they may continue for months . Dental examination may reveal caries, large restorations, fracture and deep wear facets ,recently placed restrations, exposed dentin Pulp vitality tests: o Thermal tests: helps to locate the offending tooth. Cold test is preferable. Percussion, palpation and radiographs give normal status. o Electric pulp test may give a slightly early response Radiographic examination are normal Treatment: removal of noxious stimuli normally suffices. If a recent restoration ahs a high point, recontouring the high spot will relieve the pain. If persistent painful episodes occur following cavity preparation , chemical cleansing of the cavity or leakage of the restoration , one should remove the restoration and place a sedative dressing sucha s zinc oxide eugenol. Page 7 ENDODONTIC EMERGENCIES If symptoms donot subside then pulpul inflammation should be regarded irreversible and pulpectomy should be done. Acute irreversible pulpitis Definition: It is a persistent inflammatory condition