ENDODONTIC EMERGENCIES INTRODUCTION EMERGENCY according to Dorlandâ€™s 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 exacerbated when the patient is under stress. These situations include: -
Acute cardiovascular emergencies. Effective management of STRESS in the dental office will
minimize the occurrence of these situations.
Other life threatening situations that occur with greater frequency in dental practice are those reactions associated with the administration of DRUGS. The most frequently observed reactions are those associated with administration of local anesthetics. Others are: -
Drug allergy. Most dental emergencies are unscheduled intrusions into the
routine of daily practice. Nevertheless the dentist must provide speedy and effective relief because such care is essential part of daily practice. The reason for endodontic emergency treatment is PAIN and at times SWELLING ensuing from pulpoperiapical pathosis. Because dental pain has many causes, the adept clinician must diagnose the origin of pain as quickly as possible to render rapid and effective relief. â€œKnowing what to do and when to do it are as important as knowing how to do itâ€?. DIAGNOSIS In an ACUTE pain emergency, the PHYSICAL as well as the EMOTIONAL state of the patient should be considered. The doctors 2
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 taking followed by a thorough but quick clinical examination. According to Grossman â€“ The diagnostic methods available to clinicians are: I.
SUBJECTIVE SYMPTOMS : Which is the chief complaint of patient eliciting either:
1) Pain 2) Swelling 3) Lack of function 4) Esthetics
OBJECTIVE SYMPTOMS Which are determined by tests and observations performed by clinicians.
The tests are as follows: 1. Visual and Tactile Inspection. 2. Percussion. 3. Palpation. 4. Mobility and Depressibility. 5. Radiographs. 6. Electric pulp test 7. Thermal tests
- Hot - Cold
8. Anesthetic test 9. Test cavity
CLASSIFICATION OF ENDODONTIC EMERGENCIES (A)
According to WALTON a)
According to GROSSMAN 1)
Acute Conditions 1. Reversible pulpitis 4
2. Irreversible pulpitis. 3. Alveolar abscess. 4. Periodontal abscess 2)
Emergencies During Treatment
Fractures Crown Root
(C) According to GUTTMAN I] TREATMENT OF VITAL PULP -
Acute reversible pulpitis
Cracked tooth syndrome.
II] TREATMENT OF NON-VITAL PULP -
Acute apical periodontitis.
Acute alveolar abscess.
Acute irreversible pulpitis
- Localized. - Non-localized
III] AESTHETIC EMERGENCY -
Fracture of crown.
Fracture of root.
Coming to the PRE-TREATMENT EMERGENCIES
ACUTE PULPITIS ACUTE REVERSIBLE PULPITIS [HYPEREMIA] Definition: Reversible
condition of the pulp caused by noxious stimuli in which the pulp is capable of returning to the uninflamed state following removal of the stimuli. Symptoms: A.R.P. is characterized by: 1. Sharp pain lasting for a moment. 2. Shooting pain lasting for short-duration. 3. Pain brought on by cold beverages and sweets. 4. Clinically â€“ the patient can identify the tooth by pointing to it.
Causes and Treatment Caries Lesion which are close to pulp can cause mild
to moderate sensitivity to patients. Treatment Caries excavation and placing a sedative cement like dycal and zinc oxide eugenol (IPC). Recent restoration which has a premature contact
Treatment Recontouring or removal of high points. 3)
Persistent pain and severe sensitivity after cavity preparation Suggesting chemical leakage. Treatment Removal of restoration and placing sedative cement like ZOE.
Recurrent caries -> under an old restorations. Treatment Remove all caries and replace with a sedative cement.
Thermal shock from preparing a cavity with a dull bur or keeping the bur in contact with the tooth for a long time can cause acute reversible pulpitis which exaggerates on placing a metallic restoration over the tooth.
Treatment ďƒ Removal of metallic restoration and palliative treatment by placing the cement. Because 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: Irreversible pulpitis is a persistent inflammatory condition of the pulp, caused by a noxious stimuli. As opposed to that of reversible pulpitis, irreversible pulpitis is caused by both hot / or cold stimuli. Therefore, the difference between reversible and irreversible pulpitis is distinguished by the duration of pain experienced by the patient.
Pain lasts for minutes to hours.
It is spontaneous.
It often continuous even when the cause is removed.
Pain is present even on bending over.
Patient complains of disturbed sleep.
Pain is experienced on sudden temperature change.
On taking sweets or acidic foodstuff.
From packing of food into cavity/food impaction.
Causes: 1. The most common cause of irreversible pulpitis is bacterial involvement of pulp through caries. 2. Reversible pulpitis may also deteriorate into irreversible pulpitis. In irreversible pulpitis the pulp may be
Vital pulp According to Grossman, the preferable emergency treatment is
â€˜PULPECTOMYâ€™ i.e. complete removal of the pulp and placement of an intracanal medicament to act as a disinfectant or obtundent. According to many authors like Weine, Walton and Grossman, in posterior teeth, where time is a factor, PULPOTOMY 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. Procedure: -
After administration of local anaesthesia.
Access cavity is prepared.
With a spoon excavator and round bur the coronal pulp is removed.
A cotton pellet moistened with formocresol is placed in the cavity and it is sealed with ZnOE cement. After removal of the tissue the site of inflammation precipitating
a painful response is gone. The formocresol fixes the non-inflammed tissues in the canal until the subsequent treatment of endodontics is followed. The tooth involved is then relieved out of occlusion.
Non-Vital Pulp Necrotic 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. Radiographically: A) If a lesion is seen â€“ ACUTE APICAL ABSCESS. B) If no lesion is seen â€“ ACUTE APICAL PERIODONTITIS ACUTE ALVEOLAR ABSCESS Also called as: -
Acute periapical abscess.
Acute apical pericementitis
Definition: Is defined as a localized collection of pus in the alveolar bone at the root apex of the tooth following death of pulp with extension of infection through the apical foramen into the periapical tissue.
Causes (Non-vital pulp) a) Bacterial involvement. b) H/O trauma. c) Mechanical or chemical irritation. The acute episode may result from: 1)
PULPITIS that progressively developed into pulp necrosis affecting the periapical tissues.
ACUTE EXACERBATION of a chronic periapical lesion
ENDO-PERIO lesion when the periodontal abscess secondarily affects the pulp through the lateral canals or deep infrabony pockets.
SYMPTOMS There are local reactions like: -
Tenderness of tooth.
Severe throbbing pain.
Systemic reactions are: -
Lack of sleep.
TREATMENT The main treatment is biphasic in nature i.e. I – Debridement of canals. II – Drainage of abscess. The emergency treatment of acute alveolar abscess differs from acute irreversible pulpitis, as the pulp is necrotic, local anaesthesia is not required and frequently CONTRAINDICATED. Forcing anaesthetic solution into an acutely infected and swollen area may increase pain and may spread infection. “BLOCK MAY BE USED IN SUCH CASES” Most of the pain that occurs during access cavity preparation is caused by tooth movement resulting from vibration of the bur therefore one should stabilize tooth with finger pressure so that the pain is reduced.
Treatment procedure follows as: 1) Access cavity preparation. 2) Profuse irrigation avoiding forcing of any solution or debris into the periapical tissue. 3) In most cases PURULENT EXUDATE escapes into the chamber and indicates that root canal is patent and draining. 4) If drainage does not occur, the apical constriction is purposefully violated and enlarged to a minimum of 20/25 No. instrument to allow for exudate to drain because in most cases the apical constriction may prevent the drainage.
According to GROSSMAN & COHEN leaving the tooth OPEN for drainage reduces the possibility of continued pain and swelling. Open root canals permit drainage and frequently eliminate the need for surgical incision as well as routine administration of oral antibiotics and analgesics. According to WALTON, after copious irrigation, the canals are dried with paper points and a medicated temporary cotton pellet is kept â€“ in other words â€“ open dressing is given. Some 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 AUGUST found that only 3% out of 311 abscessed teeth which had been left open reacted adversely. Therefore, the decision to keep the canal patent or closed must be made depending on the amount of drainage and size of swelling. SWELLINGS ASSOCIATED 1) If it is slight and localized it will disappear 24 to 48 hours after drainage. 2) If it is extensive, soft and fluctuant an incision through soft tissue is a must. 3) If swelling is hard â€“ it can be converted to soft fluctuant state by rinsing with hot saline solution 3-5 minutes at a time repeated every hour. ACUTE PERIODONTAL ABSCESS It is often mistaken for an acute alveolar abscess. Cause It can occur with either
Vital pulp Necrotic pulp
1) Its origin usually is an ACUTE EXACERBATION of infection with pus formation in an existing deep infrabony pocket. If the pulp is VITAL Treatment Consists of curettage, debridement and establishment of drainage of the infrabony pocket through sulcus. If the pulp is NECROTIC Treatment – extirpation and pulpectomy, similar to acute alveolar abscess. If the pulp is ABNORMAL and VITAL. Treatment is same as acute alveolar abscess. In any case, emergency periodontal treatment must be done simultaneously otherwise the patient will not be relieved of pain and swelling. EMERGENCIES DURING TREATMENT Endodontic 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. According to Grossman The emergencies can be due to: 1) Instrumentation beyond the root apex causing trauma to periradicular tissue. 2) When debris and microorganisms are pushed beyond the apical foramen which can cause an infectious reaction. 3) Chemical irritants like
- Irrigating solution. - Intracanal medicament
4) Incomplete debridement of all root canals. 5) Lost or depressed access cavity seals leading to recontamination. 6) Overfilled root canals with subsequent periapical inflammation.
The inflammation in the peri-radicular tissue is induced as a result of release of substances such as vasoactive amines, kinins and arachadonic acid metabolites. This interappointment emergency as classified by WALTON is referred to as â€œFLARE-UPâ€?.
WALTON has suggested the possible factors related as discussed before as: 1) Irritants within the pulp system. 2) Operator controlled or iatrogenic factors. 3) Host factors. 4) General systemic factors which are related to Flare-up.
Patients can accept that pain may continue to a lesser extent when they come to the dental office for emergency treatment. What is difficult for patients to comprehend is when they enter the office having little or no pain before therapy but then encounter an explosive flare-up after the treatment is done. Therefore PREVENTION OF FLARE-UPS Can be done by: 1) 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. 2) Using long acting anaesthetic solution. 3) Complete cleaning and shaping of root canals.
analgesics before next appointment reduces the incidence of discomfort and flare-ups. HYPOCHLORITE ACCIDENT Another very important but rare emergency is due to expelling of an irrigant such as NaOCl beyond the apex. This happens only by locking the needle of the irrigating syringe in the canal and forcefully injecting the irrigant. • Within minutes the patient feels SUDDEN EXTREME PAIN. • SWELLING within minutes. • Profuse, prolonged BLEEDING through the root canal. This bleeding is the body’s reaction to the irrigant. Remove the toxic fluid with high volume evacuation to encourage further drainage from periradicular tissue.
Treatment: 1) Allow the bleeding to continue. If the body rids itself of toxic fluid healing may be faster. 2) If the treated tooth is pulpless consider prescribing an antibiotic and an analgesic for 5 and 3 days respectively. 19
3) Since this may be hypersensitive reaction consider prescribing an antihistaminic. TRAUMATIC & ESTHETIC EMERGENCY It can be broadly classified as: 1) Crown fracture. 2) Root fracture. 3) Tooth avulsion. A traumatic injury to a tooth can cause a:
- Cracked crown - Fracture crown. - Fracture root
And all this results in pain. Coming to â€˜CRACKED TOOTH SYNDROMEâ€™ Causes: 1) Intact tooth that has an opposing plunger cusp occluding centrically against a marginal ridge. 2) Biting unexpectedly on a hard object like stone. 3) Trauma / blow. Symptoms: 1. Sharp, piercing pain during mastication. 2. Fleeting pain on thermal changes. 3. Hypersensitivity.
DETECTION ďƒ is made by: 1) Dental history. 2) Transillumination. 3) Placing a disc and making the patient bite, the disc acts like a wedge on the cracked tooth and causes pain. 4) Dye. 5) When a visible crack 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 1) Immediate treatment is covering the exposed dentin with a sedative cement like ZnOE and cementing a stainless steel band. 2) If a green stick fracture of the crown is present and the crown segment does not shear off under pressure, one should cement stainless steel band. 3) If the pulp is exposed, a band should be placed and cemented and a pulpectomy should be performed. 4) This should be immediately followed by relieving of occlusion by grinding the cusps of the tooth.
Because 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. It is wiser to assume that pulp is vital as vital pulp in the root canal of fractured tooth can enhance the prognosis of healing. CROWN FRACTURES Crown fractures can be divided into 4 major groups: 1) Only enamel. 2) Enamel and dentine without pulp exposure. 3) Enamel and dentin with pulp exposure. 4) Untreatable. ONLY ENAMEL Can be treated by composite restoration. ENAMEL AND DENTINE WITHOUT PULP EXPOSURE Can be treated by early placement of restoration with pulpal protection like sandwich technique.
ENAMEL AND DENTINE WITH PULP EXPOSURE These fall into two categories
Developing apex Open apex
It apex is developed pulpectomy. If apex is open pulpotomy – patient is checked for apical closure after every 3 months and then routine endodontic treatment. UNTREATABLE These imply to crown fracture in which an aesthetic and periodontally healthy condition is impossible. ROOT FRACTURE Can be divided as : - Vertical - Horizontal • Coronal third. • Middle third • Apical third. Vertical fractures have hopeless prognosis because it is not possible to either stabilize the fragments or remove one part surgically and leave the other in situ.
Horizontal fractures Above alveolar crest excellent prognosis. The closer the root fractures to the apex the more favourable the prognosis as sufficient root length is seen if fracture fragment is to be removed. Treatment stabilize by ligation to adjacent teeth. Check pulp vitality after 6 weeks as the pulp will be in a “stunned” state. If the fracture is at mid root or below the alveolar crest poor prognosis. If remaining root portion is left post and core can be given. TOOTH AVULSION The avulsed or luxated tooth is both a dental and an emotional problem. Cause: Result of trauma to an anterior tooth of a young adult or child. The longer the luxated tooth is out of its socket, the less likely it will remain in a healthy, functional state after replantation.
The instruction to the patients are: 1) To carry the avulsed tooth in a moist vehicle preferably in the patients mouth i.e. saliva to maintain the viability of periodontal ligament. Others are milk, saline etc. The tooth should not be dried. The extra-oral time for a tooth should not exceed 30 minutes. Procedure The tooth is placed in the socket Ligated. Stabilised and disoccluded. Radiograph to verify the position should be taken. This procedure was first given by ANDREASON
REFERRED PAIN Although the most frequent cause of pain is pulpoperiapical pathosis, the clinician knows that the pain can originate from many other sources. According to Hurwitz dental pain can have its origin in: -
Atypical facial neuralgia. 25
Temporomandibular arthrosis. Sinusitis or cold may refer to maxillary posterior teeth.
Pain arising from periodontal problems: -
Bruxism and clenching.
Pericoronitis may be confused as pulpoperiapical pain. Spicer reported pain referred to a lower molar from a basilar
artery aneurysm that produces pressure in the trigeminal nerve. Verbin and colleagues described odontalgia in a maxillary lateral incisor due to herpes zoster of trigeminal nerve. Sanubai and Richardson described vascular neck pain referred to mandibular posterior teeth. Otitis 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 exercising.
Other causes of referred or unusual pain are: -
Malaria, typhoid, influenza.
Some malignant diseases and tumors. Thus, the role of diagnosing a true endo emergency cannot be
ANALGESICS AND ANTIBIOTICS The use of analgesics and antibiotics is important in endodontic emergency treatment. Every clinician should be familiar with their: -
Mode of action.
Interactions with other drugs.
Route of administration.
ANALGESICS Analgesics are pain relievers NARCOTIC analgesics are used to relieve acute, severe pain. NON-NECROTIC or mild analgesics are used to relieve slight to moderate pain.
The most frequently used non-narcotic analgesics are: -
ASPIRIN alone or in compound is used most often in the dosage of 600mg. Aspirin should be taken 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. ACETAMINOPHEN,
analgesics is effective for mild-to-moderate. It has lower incidence of
side effects than aspirin. It lacks anti-inflammatory effect of aspirin. It is recommended for children and is available in liquid form. IBUPROFEN a proprionic acid derivative prescribed in doses of 300-400mg 4 times daily is more effective for severe pain relief than aspirin. But it should not be used in patients with h/o peptic ulcer or aspirin intolerance. NARCOTIC ANALGESICS like morphine, codine 30mg neperidine, hydrocone 5mg with acetaminophen 500mg etc are generally not used or are used with caution as it may depress the C.N.S. 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 adjunctive treatment for acute periapical and periodontal infections. Ideally, 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 likely resistant the microorganisms will develop to it.
The most effective antibiotics for use in endodontic emergencies is PENICILLIN. Penicillin acts by inhibiting the cell wall synthesis during multiplication of microorganisms and are effective against gm+ve cocci, viridans strains, many anaerobes which are involved in endodontic infections. The standard regime for dental procedures is penicillin V, 2.0gm 1 hr before treatment and 1.0gm 6 hourly later. This is quite feasible according to the European standards owing to their larger physique and body wt and higher BMR, but according to Indian Standards this regime works 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 250mg to 500mg tid. In case of PENICILLIN ALLERGY, ERYTHROMYCIN may be prescribed which acts by inhibiting proteins synthesis. The dosage in 250mg-500mg 6 hourly. Other antibiotics useful for treating endo-emergencies are: -
Cephalexin – 250-500mg 6 hourly.
Clindamycin phosphate – 150-30mg 6 hourly.
Tetracycline Hcl – 250-300mg 6 hourly. 30
Tetracycline is the least effective of all antibiotics for endo emergencies. CONCLUSIONS A satisfying and rewarding experience is to successfully manage a distraught patient who initially presented with severe pain for an emergency appointment. Proper 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 : -
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