2. Cons. lec. 9 : Endodontic Emergencies
Part 1 , done by : Ala’a AlSmadi.
We will talk about: The management of endodontic emergencies
categories , system of diagnosis , treatment planning , pre-treatment
emergencies ,inter-appointment emergencies , post-obturation
emergencies
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Definition of endodontic emergency:
By definition, Endodontic emergency is usually associated with pain
or/and swelling, it means that the patient comes to you with
swelling or sever pain or both.
The cause of the pain: the pulp or the periradicular tissue.
Emergencies also include sever traumatic Injuries, such as: luxation,
avulsion or fracture { we will not talk about them in this luc.}
But also traumatic injury is considered endodontic emergencies.
Categories of endodontic emergencies:
Pre-treatment emergency.
Inter-appointment emergency
Post-obturation emergency
Pre-treatment emergency:
This is the first time you see the patient, you did not do for whom
anything, so you Have a problem in diagnosis and treatment; you
don’t know the offending tooth, you don’t know if it endodontic
treatment or not; this is the first time that you see the patient
3. Inter-appointment and post-obturation emergency “flare-up”:
either you treat the patient ,but you didn’t do obturation, or after
obturation , here the diagnosis is easier , because you know the
tooth already and you know what you did for the patient , so
you can manage the case ,it’s easier for diagnosis and for
treatment inter-appointment and post-obturation emergencies .
So we have 3 types of emergencies:
1- PRE-TREATMENT
2- INTER-APPOINTMENT
3- POST-OBTURATION
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How to differentiate between emergency and urgency??
True emergency : you have to see the patient now , he can’t wait ,
so you have to ask the patient many questions to check that it’s
true emergency case, you should ask him if the pain disturb his
daily activity ,if he can sleep , can eat , ask about his
concentration ,or other daily activities , you have to ask him:
if he can’t sleep or eat so it’s really a true emergency .
how long have this pain disturbing him, so if it last more than 1
week it will not be a true emergency , so how he can tolerate
sever pain more than 1 week? So it should be few hours to 2
days – maximally, To consider it sever pain and true emergency
have you taken any medication ? if he said yes , and the pain
stop ,then this is not true emergency , because true emergency
doesn’t improve with pain killers.
in the true emergency 1 tooth is the offending , it can’t be related
to more than 1 tooth ; so you have to find 1 tooth only .
Sometimes the patient because he is in severe pain, he think that
4. he has many painful teeth, but if he can’t find 1 tooth then , it will
not be true emergency .
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Pain perception and pain reaction:
The pain is a complex physiologic and psychologic phenomenon, if
the patient is under stress or he is anxious He will exaggerate the
pain, and the threshold of the pain will be lower, so you have to
manage the patient and reassure him, and this is the most important
thing in the emergency.
psychological management of the patient is the most important
factor in the emergency treatment.
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System of diagnosis:
You have to make system of diagnosis to diagnose the endodontic
emergency.
Patient in pain often provide information and responses that are
exaggerated and inaccurate.
You have to take from him full medical history and dental history
and do subjective and objective examination before you start the
treatment.
Don’t depend on what the patient tell you, because he is in pain, he
is under stress, so he may exaggerate the problem.
the diagnosis sequence (slide 11),
1. Obtain pertinent information about the patient’s medical and
dental histories.
5. 2. Ask pointed subjective questions about the patient’s pain: history,
location, severity, duration, character, and eliciting stimuli.
3. Perform an extraoral examination.
4. Perform an intraoral examination.
5. Perform pulp testing as appropriate.
6. Use palpation and percussion sensitivity tests to determine
periapical status.
7. Interpret appropriate radiographs.
8. Identify the offending tooth and tissue (pulp or periapex).
9. Establish a pulpal and periapical diagnosis.
10. Design a treatment plan (both emergency and definitive).
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Medical and dental history :
If the patient is yours, and you saw him before, then re-check the
medical history quickly, but if this is the first time to see him then
you have to take full medical examination , because it is maybe that
the patient has Medical problems in an emergency situation.
the patient may concentrate on his pain and his tooth and he is
overlooked large medical problem.
The dental history is less important and you can take brief dental
history; about previous treatment, previous restoration, then you
have to ask him some questions to describe his pain; subjective
examination, You have to ask him about the stimulus elicit and relief
the pain .
6. ## Pain that is elicited by thermal stimuli or pain that is referred is
likely to originate from pulp, for example: the patient said that he
has pain on cold and hot this is mainly from pulp not from the
periradicular tissue. and also he can’t determine the tooth this is
from the pulp.
## If it’s from periradicular tissue then he can point to the tooth that
causes the problem.
for example , if the patient said : I have pain in the lower area or in
the upper area , then this is from the pulp , he can’t point to exact
tooth, but if he say : I have pain in mastication (or tooth contact) ,
this means that the problem is the periradicular tissue.
So pain on mastication , pain on biting , pain on tooth contact is
from periradicular tissue.
The most important 3 things you should ask about:
The intensity of the pain ,
The duration of the pain
The spontaneity, Is The pain continues or not?
If he has long duration pain then there will be significant pathosis ,
also if the pain is intense and continuous this means that there is a
significant pathosis.
So the most important 3 things is to ask the patient about the
continuity and intensity and the duration.
We have to ask him about the stimuli that elicit and relief pain:
- Pain on eating
7. - Pain on cold
- Pain on hot
Then in an objective examination you have to repeat tests that
mimic the patient’s pain, if he said I have:
## Pain on cold, you should make for him cold test.
##pain on biting, you should make him bite on tooth sloth or cotton
roll.
You have to repeat the patient pain.
Cold, heat, electricity: can tell you about the pulp status; is it vital or
necrotic?
Thermal examination and electricity test: you can test the pulp, is it
vital or necrotic.
Periradicular test include:
1- Palpitation over the apex : you can palpate to see if there is a
swilling
2- Digital pressure on teeth: by your finger you can press the tooth
to see if it’s painful.
3- light percussion by the end of the mirror handle: if he has pain
on percussion ,then this is from periradicular tissue
4- selective biting on an object ,such as : a cotton swab or tooth
slooth ,this is to mimic the patient pain , that he told you about
when he came .
slide 16:
-Pulp test : this is the endoice ,electric test .
-Periapical test : by cotton roll or swab , or tooth slooth , you should
ask the patient to bite to see if he has pain.
8. Periodontal examination
You have to do also periradicular examination, to differentiate
between abscess from pulpal origin or periodontal origin (when you
look clinically they look the same , sometimes they really look the
same) so you have to do periodontal examination by periodontal
probe to check for probing defects ; if he has deep pocket and the
tooth vital , then it will be a periodontal abscess not a periapical
abscess , you can take an x-ray , do probing and vitality test.
usually the periodontal abscess is related to a vital tooth and – of
course- periapical abscess is related to necrotic /non-vital tooth. So
you have to do????? also probing with periodontal probe .
slide 18:
### 1st
photo is periodontal abscess, in the x-ray there is severe
bone resorption, large vertical defect, and when you do probing, the
pocket depth will be more 3 mm.
###2nd
photo: acute apical abscess, you do vitality test and you do
periapical x-ray , to see periapical radiolucensy. Also you have to do
radiographic examination, but don’t depend only on the
radiographs. In the clinic you take the radiograph and you set the
diagnosis , you can’t depend only on the radiograph so you have to
do always clinical , objective , subjective examination .
Although the radiographs helps you a lot, but don’t depend on
radiographs only.
You have to take both bitewings and periapical radiographs;
- Bitewings to see the proximity of caries to the pulp , because
periapical can’t tell
9. - Periapical radiographs to see root resorption, radiolucency
around the apex. PA tells you more about the root.
So you have to take periapical and bitewing x-rays.
Question from a student and this is the answer >> it’s impossible
to have vital tooth and periapical lesion at the same time ,and
even if we detect radiolucency on the radiograph ,it won’t be
periapical radiolucency it might be : mental foramen or defect ,
but not periapical lesion , if the tooth is partially necrotic
(especially in multi-rooted teeth )then the tooth will be sensitive ,
put still we don’t reach to clear radiolucency on the periapical
region , but if we have big and clear radiolucency on the x-ray
then for sure the tooth is necrotic , so maybe something is wrong
in the x-ray or in the examination so it’s impossible to have
periapical lesion and vital tooth at the same time , maybe we have
widening in the lamina dura and the tooth is vital , it’s possible
,but to have periapical lesion with vital tooth , it’s impossible .
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Diagnostic outcome:
We did subjective, objective, periodontal, radiographic
examination , then you have to go to the diagnosis , is this really
endodontic emergency or no? and if it endodontic emergency
what’s the case? Vital or non-vital tooth/necrotic, with swilling,
without swilling? Then you have to make an exact diagnosis so
you can make a good treatment planning and a good treatment.
after carefully working through the previously described
sequence, the clinician should have identified the offending tooth
( as we said only 1 tooth for the emergency and you have to know
10. the cause either pulpal or periradicular tissue), that the source of
the pain.
for many reasons, all or none of these conclusions maybe clear. as
we said you may done the whole examination but you can’t find a
single tooth, this may be not true emergency or maybe the
problem is beyond the capability of generalist and the patient
should be referred , so if you can’t give a diagnosis don’t treat the
patient; refer him. So don’t try to open teeth without definite
diagnosis.
Question > what is the management of the patient if he has more
than 1 painful tooth ??
It’s possible to have more than 1 tooth need an RCT, but here
we’re talking about “emergency” , for example when you see the
patient without an appointment , in an emergency case so it’s
inacceptable to have 5 painful teeth, for example {with the
exception of the trauma , because we may have more than 1
painful tooth as an emergency in case of trauma } so , we talk
about carious root canal , how the patient will have 3 or 4 painful
emergency teeth at the same time?!.
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Treatment planning:
After the diagnosis you have to make treatment planning.
the cause of the pain is the inflamed tissue. Inflammation and its
Consequences (increase the tissue pressure and release of chemical
mediators on pulp and periradicular tissue) is the major cause of
painful dental emergencies.
11. therefore reducing the irritant, by releasing the pressure or
removing the inflamed pulp or periradicular tissue, should be the
immediate goal which usually result in pain relief.
The cause of the pain is the pressure of the inflammation, so you
have to release the pressure, this will result in pain relief.
Pre-treatment emergencies:
Pre-Treatment emergencies : this is the first time that you see the
patient , maybe he is your patient , but this is the first time you see
him with emergency , you did not treat him . pre-treatment
emergencies required diagnosis and treatment ,so you have problem
you don’t know the tooth , we have to do a good diagnosis and a
good treatment , you have to do patient management , and as we
said patient management is the most important factor in endodontic
emergencies , you have to reassure the patient because he is under
stress , the patient must be confident that his problem will be
properly managed .
You have to give him profound anesthesia, in most cases of
endodontic emergencies you will need supplemental anesthesia.
after you did the examination you will have a diagnosis, either of
reversible pulpitis or necrotic tooth.
irreversible pulpitis it could be:
- Without symptomatic periapical periodontitis (confined only to
pulpal tissue)
- With symptomatic periapical periodontitis.
We have pulp necrosis with apical pathosis , if the pulp is necrotic it
will not cause pain without apical pathosis.
12. It could be apical pathosis
1-without swilling or
2-with localized swilling or
3-with diffused swilling.
now we will take about how to manage each one .
So the diagnosis is either irreversible pulpitis or pulp
necrosis with apical pathosis . irreversible pulpitis
either with symptomatic apical periodontitis or without
symptomatic apical periodontitis.. Pulp necrosis either
without swilling or with localized swilling or with
diffused swilling {cellulitis}.
Now we will take about irreversible pulpitis,
Because the inflammation is the result of the pain, removal of
inflamed tissue will usually reduce the pain . Irreversible pulpitis is
either
1-with apical periodontitis or
2-without apical periodontitis.
if we reach a diagnosis that the case is irreversible pulpitis without
symptomatic apical periodontitis ,then the treatment choice is to do
pulp extirpation , in :
the anterior teeth you do(pulpectomy) extirpation for the canal
pulpal tissue which is most of time 1 canal.
posterior teeth either if you have time do pulpectomy (coronal
pulputomy and extirpation of the largest root canal < distal in
the lower and the palatal in the upper >)
13. If you don’t have time pulputomy of the coronal pulp tissue is
enough. If you have time; do complete debridement for both the
anterior and the posterior teeth.
Notes:
-Don’t use the Barbed broach in the small canals, only in large ones.
-Pulputomy : the removal of the pulp tissue from the pulp chamber
/removal of coronal pulpal tissue.
END OF PART 1 > DONE BY : ALA’A ALSMADI.
14. Cons lec # 9 , Endodontic Emergencies continue..
part 2
Done By : Bayan Al-sheikh
: I advise you to read the slides while studying this partHint
~~ doctor said it's an important lecture in order to be able to make correct diagnosis.
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the patient has pain on biting & has acute apical periodontitis so here we do
not pulpetomy for posterior teeth & for anterior teeth withpulpectomy
occulosal reduction because we have pain on biting .
don't forget the tooth is vital so there is no need for antibiotic you can give
him only pain killer (NSAI is the best choice )
The feel of pulp necrosis is related to periradicular inflammation which
result from potent irritant in the necrotic tissue in the pulp space
PRETREATMENT EMERGENCIES
Irreversible Pulpitis
1)Without Symptomatic
Apical Periodontitis
2) With Symptomatic
Apical Periodontitis
Pulp Necrosis with
Apical Pathosis
1) Without swelling
2) With localized
swelling
3)With diffused
swelling
Irreversible pulpitis with symptomatic apical
Periodontitis
Pulp necrosis with apical pathosis
15. as we said if the pulp is necrotic & no apical pathosis the patient will not feel
pain ,but if there is apical pathosis he will start feeling pain.
-- So the treatment is biphasic :
1) remove or reduce the pulp irritants and
2) relieve the apical fluid pressure (when possible )
-- The diagnosis may be:
1 - symptomatic apical periodontitis as irreversible pulpitis ,no
abscess still partially necrotic , or
2- acute apical abscess with or without swelling
- Therefore with pain and pulp necrosis there may be:
(1) No swelling
(2) localized swelling
(3) Diffuse, more extensive swelling (cellulites).
- means the pulp is necrotic with no obvious intraoral swelling
In pulp necrosis without swelling, the teeth may contain vital inflamed
tissues ,as we said partially necrotic in the apical canal and have inflamed
painful periradicular tissue (symptomatic apical periodontitis ) ..No pus, Or
- the lesion may have expanded and formed an abscess that is confined to
bone.
These are often painful, primarily because of fluid pressure in a
noncompliant environment.
Pulp necrosis without swelling
16. - The aim of treatment is to reduce the canal irritants and to try to
encourage some drainage through the tooth (release the pressure).
- After determining the corrected working length, the best is complete
canal débridement to the corrected working length is the treatment of
choice (in necrotic teeth we do not have pulp extirpation )
-If time is limited, partial débridement at the estimated working length is
performed.
Note in case of pulp necrosis you have to find the corrected working
length before start the treatment.
Canals are not enlarged without knowledge of the working
length.
You have to do a good irrigation with sodium hypochlorite
in irreversible pulpitis we don't do instrumentation only pulp
extirpation you can do of coarse irrigation
dry cotton pellet & temporary filling.
But ( Pulp Necrosis without Swelling)you have to do a good
irrigation , instrumentation & you have to put non setting calcium
hydroxide .
Remember !
In irreversible pulpitis (vital tooth) we do pulp extirpation
with barbed broach is enough, we don't do
instrumentation if you don't have time we closed the
tooth with dry cotton pellet & temporary filling)
17. -you can't leave the canal empty ! because we do instrumentation &
it's wide & necrotic so you have to do an intracanal medicament ,
then dry cotton pellet , temporary filling
No need for antibiotics only pain killer because the patient doesn't
have systematic symptoms.
The patient is told that there will still be some pain not like
irreversible pulpitis.
--in irreversible pulpitis , patient will be comfort & there will be large
improvement .
--but, in pulp necrosis the patient will be in pain because
inflammation still there, it needs time from 2-3 days
-we have localized intraoral swelling
-The abscess has now invaded regional soft tissues not confined to
the bone
treatment :
First and most important is débridement (complete cleaning
and shaping to the corrected working length , if time permits)
of the canal or canals.
Second in importance is drainage. Localized swelling should
be incised
Drainage accomplishes two things:
(1) relief of pressure and pain and
(2) removal of a very potent irritant
Pulp Necrosis with Localized Swelling
18. -radio graphically most of the time we will find large radiolucensy
Sometimes after opening the abscess will drain heavily, in this
case you shouldn't exceed the apical foramen , you should confine
your instrumentation to the corrected working length so , if you
open the tooth & you find pus no need to go beyond the apex.
In patients with a periradicular abscess but no drainage through
the canal you have to do over instrumentation but with small file
not larger than 25 ,when you reach 25 ,you complete your
instrumentation to the corrected working length.
19. Copious irrigation with sodium hypochlorite then non setting calcium
hydroxide, dry cotton pellet , temporary filling .
Be careful don't leave the tooth open to drain the case will worsen.
In old technique which consider a disaster they left the abscess open to
drain!
Also here don't use antibiotic because it's localized swelling .
Rapidly progressive and spreading swellings, commonly referred to as
cellulites, are not localized and may have dissected into the fascial
spaces .
These serious infections seldom occur.
There is elevated temperature or other systemic signs indicating a more
serious infection
These patients should be referred to a specialist.
If you are a general practitioner don't deal with these cases.
Pulp Necrosis with Diffuse Swelling (cellulites)
This patient with submental cellulites here surgeon did
an extra oral excision & drainage & he put rubber
drain to leave the inside area open to drain.
20. -as dentist Most important is removal of the irritant by canal debridement
-incision & drainage are done by surgeon, you can't do it .
ž -After placing calcium hydroxide paste and a dry pellet, the access is
closed with a temporary filling.
In this case you have to give the patient antibiotic, the first choice penicillin
vk , if the patient didn't improved after 7 days you have to add
metronidazole, for allergic patient use clindamycin instead of penicillin
Patients must be informed of their responsibilities and of what to
expect.
The pain and swelling will take time to resolve
proper nutrition and adequate intake of fluids are important, and
medications must be taken as prescribed.
-This is rubber drain after incision &
drainage
-also u can use rubber drain in the
localized swelling in the intraoral abscess
Postoperative Instructions
21. Communication after the visit is very important. Calling the patient the
day after the appointment has been shown to reduce pain perception and
analgesic needs
Despite careful treatment procedures, complications, such as pain,
swelling, or both, may occur.
you should be confident if you
As with emergencies occurring before root canal therapy, these
interappointment emergencies are undesirable and disruptive events and
should be resolved quickly.
you have to report as pretreatment emergencies , bring the patient
quickly & treat him .
no known causative factor for interapointment emergencies but there are
some suspected causes :
1 ) Patient factors (including pulpal and periapical diagnosis, pt
gender)
-incidence more common in female than male
-vital teeth have less interapponintment flare-ups than necrotic
teeth .
-preoperative pain is significant factor in determinaning the
incidence of flare-ups (if the patient comes to you at first time with
severe, pain he is more likely to develop flare-up )
2 ) Treatment procedure
Although it would seem that certain procedures, such as over
instrumentation, pushing debris out the apex, or completing the
endodontic therapy in one visit, may increase the incidence of
flare-ups, no definitive treatment risk factors have been identified .
( they didn't find significant relation between treatment
procedure & flare-up)
INTERAPPOINTMENT EMERGENCIES
(between the visits)
22.
Use of long-acting anesthetic solutions, complete cleaning and shaping
of the root canal system (possibly), analgesics, and psychologic
preparation of patients (particularly those with preoperative pain) will
decrease (not prevent) interappointment symptoms in the mild to
moderate levels.
Use painkiller NSAIDs
There are, however, no demonstrated treatment or therapeutic measures
that will reduce the number of interappointment flare-ups.
The same basic procedure is followed as for pretreatment emergencies ,
you have to make system of diagnosis
you have to deal with The problem which has been diagnosed initially, so
the operator has an advantage.
However, a step-by-step approach to diagnose the existing condition
reduces confusion and error
The most important thing if the patient came to you for the first time is the
status of the pulp vital or necrotic .
if he came previously with vital pulp and you have already done
complete debridement , you have nothing to do here , you only check the
temporary filling
Treatment of Flare-ups
Prevention of flare-up
Diagnosis
23. If you did partial debridement, in inter appointment flare-up do complete
debridement
If the patient came previously with necrotic pulp without swelling
sometimes they develop acute apical abscess so you have to do complete
debridement & drainage of the abscess, then good flushing of sodium
hypochlorite , inter canal medicament , dry cotton pellet & temporary
filling .
if the patient came with localized swelling you have to do incision &
drainage , complete canal debridement to the corrected working length ,
flushing of sodium hypochlorite inter canal medicament , dry cotton
pellet & temporary filling
you have to follow your patients , communicate with them asking them
to visit the clinic in case of emergency issues
True emergencies postobturation are rare, if you did everything in a good
way from beginning , mild postobturation pain is common and resolve
spontaneously.
Causative Factors:
Little is known about the etiologic factors involved in postoperative pain
after obturation. Pain tends to occur in the first 24 hours.
There is a correlation between the level of obturation and pain incidence,
with overextension associated with the highest incidence of discomfort.
Follow-up Care
POSTOBTURATION EMERGENCIES
24. Postobturation pain also relates to preobturation pains .(means if you did
the obturatin & the patient already has pain ,he will develop
postobturation pain )
Treatment
if you did everything in a good way there is no treatment only you have
to wait .
But if there is procedure that you can't correct sometimes you need
surgery or extraction or referral to specialist .
Good luck everyone in next term
