An endodontic emergency is defined as pain and/or swelling caused by inflammation or infection of the pulp and/or periradicular tissues requiring immediate treatment. Common causes are pulpal pathologies and traumatic injuries. Pain results from chemical mediators and increased fluid pressure causing stimulation of pain receptors. Accurate diagnosis involves dental history, clinical examination including vitality testing and radiographs to determine the source and rapidly provide effective treatment.
Cracked tooth syndrome is an incomplete fracture of tooth structure causing sharp pain on biting. Risk factors include excessive forces, weakened tooth structure, dental materials or rare events. Symptoms are biting pain and sensitivity. Diagnosis involves visual inspection, transillumination, dyes or bands to detect the crack
Introduction
Classification of endodontic emergency
According to P Carrotte
According to Walton and Torabinejad
According to Weine
Importance of diagnosis in endodontic emergency
Types of diagnostic Aids needed
Emergency treatment of pulp and periapical related diseases
Acute pulpitis
Acute pulpitis with apical periodontitis
Pulp necrosis
Acute periapical abscess
Emergency treatment of traumatic injuries
Crown fracture
Root fracture
Avulsion
Andreasen’s criteria
Summer’s criteria
Emergency therapy for intratreatment pain
Endodontic emergency after treatment
Medication in endodontic emergency
Conclusion
References
A detailed description about endo perio interrelationship, including introduction, development and etiology, historical aspects, definition, classification, diagnosis, differential diagnosis, management, special consideration in management,controversies prognosis, conclusion.
The document discusses various endodontic mishaps that can occur during root canal treatment. It describes mishaps related to access preparation, instrumentation, and obturation. Access-related mishaps include treating the wrong tooth, missing canals, damaging existing restorations, perforating the access cavity, and crown fractures. Instrumentation mishaps include ledge formation, perforating the root, and separated instruments. Obturation mishaps include overfilling or underfilling the canal. The document provides details on the causes, recognition, correction, prevention and prognosis of several common endodontic mishaps.
Flareups during root canal treatment can be caused by mechanical, chemical or microbial factors. They typically present as pain and swelling within hours or days after a procedure. Preventing flareups involves minimizing debris extrusion, completing treatment in one visit, using intracanal medications, maintaining asepsis and not leaving teeth open between appointments. Management includes incision and drainage if abscess is present, along with analgesics, antibiotics and potential occlusal reduction.
CONSIST OF INDTRODUCTION, PAIN DEFINITION , MECHANISM OF PAIN, THEORIES OF PAIN, PATHOPHYSIOLOGY OF PAIN, THORIES OF DENTIN HYPERSENSTIVITY , TREATMENT
The document discusses the relationship between pulpal and periodontal diseases. It states that diseases of the pulp or periodontium can lead to secondary diseases in the other via the apical foramen, lateral canals, or dentinal tubules. Both endodontic and periodontal examinations are important to diagnose the origin of lesions. Treatment should focus first on the primary disease, but both may need treatment if the secondary disease is established.
This document discusses endodontic retreatment. It defines retreatment as removing root canal filling materials from a tooth to clean, shape, and re-obturate the canals. Reasons for retreatment include persistent or reinroduced intraradicular microorganisms, extraradicular infection, foreign body reaction, or true cysts. Evaluation involves clinical examination, radiographs, and assessing for symptoms like pain, swelling or sinus tracts. Success is defined as resolution of symptoms and periapical radiolucency, while failure is persistence or worsening of these signs.
Introduction
Classification of endodontic emergency
According to P Carrotte
According to Walton and Torabinejad
According to Weine
Importance of diagnosis in endodontic emergency
Types of diagnostic Aids needed
Emergency treatment of pulp and periapical related diseases
Acute pulpitis
Acute pulpitis with apical periodontitis
Pulp necrosis
Acute periapical abscess
Emergency treatment of traumatic injuries
Crown fracture
Root fracture
Avulsion
Andreasen’s criteria
Summer’s criteria
Emergency therapy for intratreatment pain
Endodontic emergency after treatment
Medication in endodontic emergency
Conclusion
References
A detailed description about endo perio interrelationship, including introduction, development and etiology, historical aspects, definition, classification, diagnosis, differential diagnosis, management, special consideration in management,controversies prognosis, conclusion.
The document discusses various endodontic mishaps that can occur during root canal treatment. It describes mishaps related to access preparation, instrumentation, and obturation. Access-related mishaps include treating the wrong tooth, missing canals, damaging existing restorations, perforating the access cavity, and crown fractures. Instrumentation mishaps include ledge formation, perforating the root, and separated instruments. Obturation mishaps include overfilling or underfilling the canal. The document provides details on the causes, recognition, correction, prevention and prognosis of several common endodontic mishaps.
Flareups during root canal treatment can be caused by mechanical, chemical or microbial factors. They typically present as pain and swelling within hours or days after a procedure. Preventing flareups involves minimizing debris extrusion, completing treatment in one visit, using intracanal medications, maintaining asepsis and not leaving teeth open between appointments. Management includes incision and drainage if abscess is present, along with analgesics, antibiotics and potential occlusal reduction.
CONSIST OF INDTRODUCTION, PAIN DEFINITION , MECHANISM OF PAIN, THEORIES OF PAIN, PATHOPHYSIOLOGY OF PAIN, THORIES OF DENTIN HYPERSENSTIVITY , TREATMENT
The document discusses the relationship between pulpal and periodontal diseases. It states that diseases of the pulp or periodontium can lead to secondary diseases in the other via the apical foramen, lateral canals, or dentinal tubules. Both endodontic and periodontal examinations are important to diagnose the origin of lesions. Treatment should focus first on the primary disease, but both may need treatment if the secondary disease is established.
This document discusses endodontic retreatment. It defines retreatment as removing root canal filling materials from a tooth to clean, shape, and re-obturate the canals. Reasons for retreatment include persistent or reinroduced intraradicular microorganisms, extraradicular infection, foreign body reaction, or true cysts. Evaluation involves clinical examination, radiographs, and assessing for symptoms like pain, swelling or sinus tracts. Success is defined as resolution of symptoms and periapical radiolucency, while failure is persistence or worsening of these signs.
This document discusses various endodontic emergencies including pre-treatment emergencies like cracked tooth syndrome and acute irreversible pulpitis, mid-treatment flare-ups, and post-treatment emergencies. It defines endodontic emergencies and classifies them according to different authors. It also describes the management of various emergencies through accurate diagnosis, effective pain relief treatments, and addressing the underlying causes. Key procedures discussed include pulpectomy, apical trephination, incision and drainage, and irrigation with appropriate solutions.
Endodontic emergencies include pain and swelling that can occur before, during, or after root canal treatment. Common causes are pulpal and periapical pathosis or traumatic injury. A flare-up during root canal therapy results from irritants left in the root canal system and causes pain, swelling, or both. Management depends on the specific clinical condition but generally involves re-establishing drainage, debriding and irrigating the root canal, and prescribing medications.
This document discusses various types of dental emergencies that may occur during or after endodontic treatment. It describes three types of pre-treatment, intra-appointment, and post-obturation emergencies. Specific emergencies discussed in detail include acute reversible and irreversible pulpitis, acute apical periodontitis, acute periapical abscess, flare-ups during treatment, instrument separation beyond the apex, and overfilling of the root canal. The document provides descriptions of symptoms, causes, and recommended treatment approaches for resolving each emergency.
The document discusses the endodontic-periodontal interrelationship. It begins by introducing how Simring and Goldberg first described this relationship in 1964. It then discusses the classifications of endodontic and periodontal lesions put forth by various studies. The document covers the anatomical considerations between the pulp and periodontium like apical foramina, lateral canals, and dentinal tubules which allow communication between the two tissues. It also discusses the etiological factors involved like bacteria, fungi, and viruses that can lead to endodontic or periodontal diseases.
pulpotomy procedures in primary dentitionParth Thakkar
A pulpotomy involves removing the inflamed coronal pulp while leaving the healthy radicular pulp intact. The aim is to relieve pain and allow for root development. Formocresol pulpotomy is commonly used and involves applying formocresol to the exposed pulp stump to fix tissues and eliminate microorganisms. It is performed using either a single-stage or two-stage technique. Other materials used include calcium hydroxide, glutaraldehyde and ferric sulfate. Success rates depend on strict case selection and technique.
Endodontic surgery is a procedure performed to remove or correct causes of dental disease and restore tissues to health. It is often a last resort to save a tooth and requires great skill. Indications include inability to eliminate pathology with root canal treatment, inability to fully clean and fill the root canal, or iatrogenic problems like instrument breakage. Contraindications include resolved pathology, health issues, anatomic constraints, or periodontal disease. Preparation includes referral data, radiographs, diagnosis, and informed consent. Common flap designs are triangular, rectangular, or submarginal. Types of endodontic surgery include incision and drainage, trephination, periapical surgery like apicoectomy, repair of perforations,
- Endodontic instruments have evolved over time to have standardized sizes and tapers. Ingle and LeVine suggested standardizing diameters that increase by 0.05mm while maintaining a constant taper.
- Instruments are now numbered 6-140 based on tip diameter in hundredths of a millimeter. The diameter increases 0.32mm over the first 16mm of the instrument.
- Instruments can be hand operated, low-speed, engine-driven, or ultrasonic/sonic and are used for cleaning and shaping root canals.
The document discusses various aspects of root canal obturation including definitions, purposes, techniques, and materials. Obturation involves filling and sealing the cleaned and shaped root canal using gutta-percha and a sealer. The goals are to achieve a fluid-tight seal, prevent microleakage and reinfection. Common techniques include cold lateral compaction, warm vertical compaction using heat carriers, continuous wave compaction, and thermoplasticized gutta-percha injection. Carrier-based techniques like Thermafil and SimpliFill are also described. Key factors for treatment success include absence of preoperative lesions, void-free fillings, obturation within 2mm of the apex, and adequate coronal restoration
This document discusses interappointment flare-ups following root canal treatment. It begins with definitions of flare-ups and discusses the typical incidence rate, which ranges from 1.5-5.5%. Patient risk factors like pulpal necrosis, acute apical abscesses, and larger periapical lesions are associated with higher flare-up rates. Treatment factors like retreatment versus initial treatment and single versus multiple visits have been studied but no strong conclusions exist on their impact on flare-up risk. Managing flare-ups involves understanding their causes and addressing patient pain and swelling when they occur.
This document discusses various strategies for managing endodontic pain. It begins by noting that root canals are often perceived as more painful than they actually are based on surveys. It then examines diagnostic considerations for determining the origin and type of pain. Several clinical strategies are outlined for relieving endodontic pain such as pulpotomy, pulpectomy, trephination, incision and drainage, occlusal reduction, and achieving profound anesthesia. Effective pain management involves diagnosing and treating the underlying cause, using a flexible analgesic prescription, pretreating with NSAIDs, and ensuring profound anesthesia. Anxiety management techniques like relaxation therapy, flooding/implosion, and cognitive behavioral therapy are also discussed.
This document provides an overview of single visit endodontics. It discusses the history and increased acceptance of single visit root canals due to advances in technology. The document outlines indications and contraindications for single visit root canals and notes the practice management, patient, and clinician advantages which include reduced stress, cost and number of visits. Guidelines for performing single visit root canals including case selection criteria and pain control methods are also summarized.
Non-carious cervical lesions are caused by a combination of erosion, abrasion, and abfraction and affect half the population. Erosion is chemical wear from acids like those in citrus fruits and drinks. Abrasion is mechanical wear, like from overly vigorous brushing. Abfraction is stress-related wear from forces like clenching. These lesions are diagnosed through history, examination, and radiographs. Treatment depends on the severity but may include desensitization, restorations using composites or glass ionomers, endodontics, or periodontal procedures.
Endodontic diagnosis could be a difficult task in most occasions, but with clinical assessment and careful history taking this task would be easier and clearer.
This lecture assembled by Osama Asadi, B.D.S, concentrating at the basic science of diagnosing pulpal and periapical diseases and their differential diagnosis and treatment plan. also endodontic case sheet and review-cases attached to the lecture at the end to help proper understanding of the subject.
Anatomy of root apex and its significance newDilu Davis
The document discusses the anatomy and morphology of the apical third of teeth roots. It notes that this region is the most complex part of teeth and is important prognostically for endodontic procedures. The apical third can display variations like accessory canals, isthmuses, additional root canals and foramen, and curved or ribbon-shaped canal systems. These anatomical variations make cleaning, shaping, filling and surgery in this region challenging for endodontists. Proper instrumentation techniques and materials are required to navigate the complex apical third anatomy.
This document summarizes different techniques for pulp capping including direct and indirect pulp capping. It discusses the history of various materials used for pulp capping such as calcium hydroxide and mineral trioxide aggregate. Key points covered include the indications and contraindications for pulp capping, the ideal properties of capping materials, and the histological response after pulp capping including zone formation. The document provides an overview of pulp capping procedures and factors influencing their success.
The document discusses the management of endodontic pain. It defines pain and describes the various causes of pre-treatment, during treatment, and post-treatment endodontic pain. It outlines strategies for diagnosing the source of pain and discusses both pharmacological and non-pharmacological options for managing different types of endodontic pain, including the use of analgesics, local anesthetics, antibiotics, and steroids. Challenges in achieving pulpal anesthesia for teeth with irreversible pulpitis ("hot tooth") are also covered, along with strategies for improving anesthesia success.
This document discusses endo-perio lesions, which involve both endodontic and periodontal tissues. It defines endo-perio lesions as involving pulpal disease and destruction of the attachment apparatus from the gingival sulcus to the apex. There are anatomical and non-anatomical pathways connecting the tissues. Lesions are classified based on whether the primary involvement is endodontic or periodontal. Diagnostic procedures and appropriate treatment depend on accurately distinguishing the primary pathology. Treatment may involve endodontic therapy, periodontal therapy, or both depending on the classification and extent of disease.
This document discusses endo-perio lesions, which are lesions involving both the pulp and periodontium of a tooth. It begins by describing the pathways of communication between the pulp and periodontium, including developmental canals. Factors that can contribute to or cause endo-perio lesions are then discussed. The document outlines how pulpal disease can influence the periodontium and vice versa. It also provides classifications for different types of endo-perio lesions and describes their clinical signs and diagnosis. The final sections discuss management, including treatment and prognosis, of various endo-perio lesions.
Tooth infarction, also known as cracked tooth syndrome, refers to an incomplete tooth fracture extending partially through the tooth. It can occur in the crown, originating from the pulp towards the dentinoenamel junction or propagating apically in the root. Symptoms include pain upon chewing or with temperature changes. Diagnosis involves visual examination, transillumination, staining with methylene blue dye, biting tests, and occasionally radiography. Treatment depends on factors like fracture location and pulp involvement.
This document discusses endodontic emergencies and their management. It defines endodontic emergencies as unscheduled visits requiring immediate treatment for pain or swelling from pulp or periapical inflammation or infection. Various classifications of endodontic emergencies are presented. Management strategies for different emergencies arising before, during, or after treatment are covered, including pulpectomy or pulpotomy for vital pulps and root canal treatment for non-vital pulps. Clinical challenges in accurately diagnosing the tooth and pulp condition causing a patient's symptoms are also addressed.
This document discusses various endodontic emergencies including pre-treatment emergencies like cracked tooth syndrome and acute irreversible pulpitis, mid-treatment flare-ups, and post-treatment emergencies. It defines endodontic emergencies and classifies them according to different authors. It also describes the management of various emergencies through accurate diagnosis, effective pain relief treatments, and addressing the underlying causes. Key procedures discussed include pulpectomy, apical trephination, incision and drainage, and irrigation with appropriate solutions.
Endodontic emergencies include pain and swelling that can occur before, during, or after root canal treatment. Common causes are pulpal and periapical pathosis or traumatic injury. A flare-up during root canal therapy results from irritants left in the root canal system and causes pain, swelling, or both. Management depends on the specific clinical condition but generally involves re-establishing drainage, debriding and irrigating the root canal, and prescribing medications.
This document discusses various types of dental emergencies that may occur during or after endodontic treatment. It describes three types of pre-treatment, intra-appointment, and post-obturation emergencies. Specific emergencies discussed in detail include acute reversible and irreversible pulpitis, acute apical periodontitis, acute periapical abscess, flare-ups during treatment, instrument separation beyond the apex, and overfilling of the root canal. The document provides descriptions of symptoms, causes, and recommended treatment approaches for resolving each emergency.
The document discusses the endodontic-periodontal interrelationship. It begins by introducing how Simring and Goldberg first described this relationship in 1964. It then discusses the classifications of endodontic and periodontal lesions put forth by various studies. The document covers the anatomical considerations between the pulp and periodontium like apical foramina, lateral canals, and dentinal tubules which allow communication between the two tissues. It also discusses the etiological factors involved like bacteria, fungi, and viruses that can lead to endodontic or periodontal diseases.
pulpotomy procedures in primary dentitionParth Thakkar
A pulpotomy involves removing the inflamed coronal pulp while leaving the healthy radicular pulp intact. The aim is to relieve pain and allow for root development. Formocresol pulpotomy is commonly used and involves applying formocresol to the exposed pulp stump to fix tissues and eliminate microorganisms. It is performed using either a single-stage or two-stage technique. Other materials used include calcium hydroxide, glutaraldehyde and ferric sulfate. Success rates depend on strict case selection and technique.
Endodontic surgery is a procedure performed to remove or correct causes of dental disease and restore tissues to health. It is often a last resort to save a tooth and requires great skill. Indications include inability to eliminate pathology with root canal treatment, inability to fully clean and fill the root canal, or iatrogenic problems like instrument breakage. Contraindications include resolved pathology, health issues, anatomic constraints, or periodontal disease. Preparation includes referral data, radiographs, diagnosis, and informed consent. Common flap designs are triangular, rectangular, or submarginal. Types of endodontic surgery include incision and drainage, trephination, periapical surgery like apicoectomy, repair of perforations,
- Endodontic instruments have evolved over time to have standardized sizes and tapers. Ingle and LeVine suggested standardizing diameters that increase by 0.05mm while maintaining a constant taper.
- Instruments are now numbered 6-140 based on tip diameter in hundredths of a millimeter. The diameter increases 0.32mm over the first 16mm of the instrument.
- Instruments can be hand operated, low-speed, engine-driven, or ultrasonic/sonic and are used for cleaning and shaping root canals.
The document discusses various aspects of root canal obturation including definitions, purposes, techniques, and materials. Obturation involves filling and sealing the cleaned and shaped root canal using gutta-percha and a sealer. The goals are to achieve a fluid-tight seal, prevent microleakage and reinfection. Common techniques include cold lateral compaction, warm vertical compaction using heat carriers, continuous wave compaction, and thermoplasticized gutta-percha injection. Carrier-based techniques like Thermafil and SimpliFill are also described. Key factors for treatment success include absence of preoperative lesions, void-free fillings, obturation within 2mm of the apex, and adequate coronal restoration
This document discusses interappointment flare-ups following root canal treatment. It begins with definitions of flare-ups and discusses the typical incidence rate, which ranges from 1.5-5.5%. Patient risk factors like pulpal necrosis, acute apical abscesses, and larger periapical lesions are associated with higher flare-up rates. Treatment factors like retreatment versus initial treatment and single versus multiple visits have been studied but no strong conclusions exist on their impact on flare-up risk. Managing flare-ups involves understanding their causes and addressing patient pain and swelling when they occur.
This document discusses various strategies for managing endodontic pain. It begins by noting that root canals are often perceived as more painful than they actually are based on surveys. It then examines diagnostic considerations for determining the origin and type of pain. Several clinical strategies are outlined for relieving endodontic pain such as pulpotomy, pulpectomy, trephination, incision and drainage, occlusal reduction, and achieving profound anesthesia. Effective pain management involves diagnosing and treating the underlying cause, using a flexible analgesic prescription, pretreating with NSAIDs, and ensuring profound anesthesia. Anxiety management techniques like relaxation therapy, flooding/implosion, and cognitive behavioral therapy are also discussed.
This document provides an overview of single visit endodontics. It discusses the history and increased acceptance of single visit root canals due to advances in technology. The document outlines indications and contraindications for single visit root canals and notes the practice management, patient, and clinician advantages which include reduced stress, cost and number of visits. Guidelines for performing single visit root canals including case selection criteria and pain control methods are also summarized.
Non-carious cervical lesions are caused by a combination of erosion, abrasion, and abfraction and affect half the population. Erosion is chemical wear from acids like those in citrus fruits and drinks. Abrasion is mechanical wear, like from overly vigorous brushing. Abfraction is stress-related wear from forces like clenching. These lesions are diagnosed through history, examination, and radiographs. Treatment depends on the severity but may include desensitization, restorations using composites or glass ionomers, endodontics, or periodontal procedures.
Endodontic diagnosis could be a difficult task in most occasions, but with clinical assessment and careful history taking this task would be easier and clearer.
This lecture assembled by Osama Asadi, B.D.S, concentrating at the basic science of diagnosing pulpal and periapical diseases and their differential diagnosis and treatment plan. also endodontic case sheet and review-cases attached to the lecture at the end to help proper understanding of the subject.
Anatomy of root apex and its significance newDilu Davis
The document discusses the anatomy and morphology of the apical third of teeth roots. It notes that this region is the most complex part of teeth and is important prognostically for endodontic procedures. The apical third can display variations like accessory canals, isthmuses, additional root canals and foramen, and curved or ribbon-shaped canal systems. These anatomical variations make cleaning, shaping, filling and surgery in this region challenging for endodontists. Proper instrumentation techniques and materials are required to navigate the complex apical third anatomy.
This document summarizes different techniques for pulp capping including direct and indirect pulp capping. It discusses the history of various materials used for pulp capping such as calcium hydroxide and mineral trioxide aggregate. Key points covered include the indications and contraindications for pulp capping, the ideal properties of capping materials, and the histological response after pulp capping including zone formation. The document provides an overview of pulp capping procedures and factors influencing their success.
The document discusses the management of endodontic pain. It defines pain and describes the various causes of pre-treatment, during treatment, and post-treatment endodontic pain. It outlines strategies for diagnosing the source of pain and discusses both pharmacological and non-pharmacological options for managing different types of endodontic pain, including the use of analgesics, local anesthetics, antibiotics, and steroids. Challenges in achieving pulpal anesthesia for teeth with irreversible pulpitis ("hot tooth") are also covered, along with strategies for improving anesthesia success.
This document discusses endo-perio lesions, which involve both endodontic and periodontal tissues. It defines endo-perio lesions as involving pulpal disease and destruction of the attachment apparatus from the gingival sulcus to the apex. There are anatomical and non-anatomical pathways connecting the tissues. Lesions are classified based on whether the primary involvement is endodontic or periodontal. Diagnostic procedures and appropriate treatment depend on accurately distinguishing the primary pathology. Treatment may involve endodontic therapy, periodontal therapy, or both depending on the classification and extent of disease.
This document discusses endo-perio lesions, which are lesions involving both the pulp and periodontium of a tooth. It begins by describing the pathways of communication between the pulp and periodontium, including developmental canals. Factors that can contribute to or cause endo-perio lesions are then discussed. The document outlines how pulpal disease can influence the periodontium and vice versa. It also provides classifications for different types of endo-perio lesions and describes their clinical signs and diagnosis. The final sections discuss management, including treatment and prognosis, of various endo-perio lesions.
Tooth infarction, also known as cracked tooth syndrome, refers to an incomplete tooth fracture extending partially through the tooth. It can occur in the crown, originating from the pulp towards the dentinoenamel junction or propagating apically in the root. Symptoms include pain upon chewing or with temperature changes. Diagnosis involves visual examination, transillumination, staining with methylene blue dye, biting tests, and occasionally radiography. Treatment depends on factors like fracture location and pulp involvement.
This document discusses endodontic emergencies and their management. It defines endodontic emergencies as unscheduled visits requiring immediate treatment for pain or swelling from pulp or periapical inflammation or infection. Various classifications of endodontic emergencies are presented. Management strategies for different emergencies arising before, during, or after treatment are covered, including pulpectomy or pulpotomy for vital pulps and root canal treatment for non-vital pulps. Clinical challenges in accurately diagnosing the tooth and pulp condition causing a patient's symptoms are also addressed.
Pulp therapy for primary and young teethSaeed Bajafar
The document discusses various pulp therapy techniques for primary and young permanent teeth, including indirect and direct pulp capping, pulpotomy, and apexogenesis. It provides indications and contraindications for each technique, as well as descriptions of techniques such as using calcium hydroxide or zinc oxide-eugenol to cover exposed pulp tissue. The goal of pulp therapy is to maintain the health of the teeth and surrounding tissues through various treatments aimed at preserving pulp vitality.
In this brief lecture I will discuss most common endodontic emergencies that occur while practicing endodontics. The lecture is directed to the mind of undergraduate level.
I hope you enjoy it.
This document discusses the classification and treatment of various types of dental injuries resulting from trauma. It describes 8 classes of dentofacial injuries involving fractures of the crown, root, or whole tooth. It also discusses the WHO classification system for traumatic dental injuries. The types of injuries covered include enamel fractures, dentin fractures, complicated crown fractures involving the pulp, root fractures, crown root fractures, luxation injuries such as concussion, subluxation, and lateral luxation. The document outlines the diagnosis, treatment approaches including pulpotomy, pulp capping, apexification, and restoration, as well as the prognosis, for each type of injury.
Description :
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
This document discusses acute apical abscess, which is a severe localized inflammatory condition characterized by the formation of pus around the apex of a tooth. The most common cause is bacterial invasion of the dental pulp from tooth decay. Clinically, it presents as acute pain that is worsened by pressure, percussion or palpation. Diagnosis involves a dental examination and x-rays. Emergency management involves establishing drainage to relieve pain, either through root canals or surgical drainage. After drainage is achieved, root canal treatment should be performed to thoroughly clean and disinfect the canals and remove the source of infection. Antibiotics may be prescribed in some cases but are generally not needed if adequate drainage is established.
1. Dental pain, also called orofacial pain, refers to uncomfortable sensations in the mouth that can range from annoying to debilitating. It is caused by activation of the nervous system and may feel sharp, dull, throbbing, or sore.
2. Acute dental pain is characterized by its location, type, frequency, onset, exacerbating/remitting factors, and severity. Short, sharp, shooting pain may be due to fluid movement in dentin tubules, initial pulp inflammation, cavities, cracked teeth, or sensitivity from gum recession or tooth wear.
3. Treatment for acute dental pain involves reducing inflammation, typically through restorations, root canals, reducing occlusion
This document outlines learning objectives and content about disorders of the oral cavity, teeth, jaw, and salivary glands. The learning objectives cover using the nursing process to care for patients with these conditions, describing relationships to nutrition, managing abnormalities, cancers, and surgeries. The content sections define dental plaque, caries, tooth disorders, malocclusion, temporomandibular disorders, parotitis, sialadenitis and their prevention, manifestations, assessment, and nursing management.
Post insertion complaints in cd patients/ oral surgery courses Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
Bruxism is the habitual grinding or clenching of teeth during sleep or while awake. It can cause physical injuries to teeth like fractures, cracked tooth syndrome, and tooth ankylosis. Fractures of teeth are commonly caused by trauma, large dental restorations, or internal resorption. Cracked tooth syndrome involves an incomplete crack in the tooth that causes sharp fleeting pains. Tooth ankylosis is a fusion between the tooth and bone caused by root resorption and repair with cementum or bone. Treatments depend on the specific injury but may include splints, crowns, endodontic treatment, or extraction.
The document discusses 10 common patient complaints following partial denture insertion and their potential causes: 1) pain or discomfort from the soft tissues or ridge, which may be due to nodules, damage, uneven contact, excessive displacement during impression, or high vertical dimension; 2) difficulties with mastication from neuromuscular changes, food type/amount, lack of sharpness, unbalanced articulation, or food lodgment; 3) denture movement during function from improper clasp adjustment, occlusal defects, over-extended peripheries, or improper tooth positioning. Potential solutions are provided for examining and addressing each complaint.
The document summarizes key aspects of patient assessment and clinical examination in dentistry. It discusses performing an infection control review, collecting the patient's chief complaint, medical history, and dental history. The clinical examination involves an extraoral examination of the head and neck and an intraoral examination of the soft tissues and teeth. The intraoral examination assesses the soft tissues, examines teeth for issues like caries, fractures, restorations, and performs pulp tests to evaluate vitality.
This document provides information on the management and treatment of traumatic dental injuries in children. It discusses the diagnosis process, which involves taking a medical and dental history, performing a clinical examination, conducting sensitivity tests, and getting radiographs. The clinical exam evaluates soft tissues, hard tissues, tooth displacement, mobility, fractures, and color changes. Treatment depends on the specific injury and may include protecting soft tissues, monitoring concussed teeth, splinting subluxated teeth, restoring tooth fractures with calcium hydroxide, crowns, or composite resins, and reattaching tooth fragments when possible. The goal is to restore function and aesthetics while protecting the pulp.
This document discusses various types of dental emergencies that may occur during or after endodontic treatment. It describes three types of pre-treatment, intra-appointment, and post-obturation emergencies. Specific emergencies discussed in detail include acute reversible and irreversible pulpitis, acute apical periodontitis, acute periapical abscess, flare-ups during treatment, instrument separation beyond the apex, and overfilling of the root canal. The document emphasizes the importance of adequate pain management, prevention of complications, and proper treatment protocols for resolving endodontic emergencies.
The document discusses oro-facial pain and its management. It describes various types of dental pain, including short, sharp shooting pain which can be caused by conditions that expose dentin like caries, fractures, or gum recession. Tests that can help diagnose dental pain are discussed, like pulp sensitivity tests, percussion, probing, mobility and palpation. Radiographs may also reveal issues like recurrent decay or bone loss. The goal of acute pain management is to inhibit tissue damage signaling, block nerve impulses, and activate endogenous analgesia.
This document discusses various endodontic emergencies, including:
- Hot tooth caused by irreversible pulpitis, which requires immediate pain relief. Bupivacaine is recommended for injection.
- Dentin hypersensitivity caused by exposed dentin, which can be treated by plugging dentinal tubules or desensitizing nerves.
- Acute apical periodontitis presenting with tooth discomfort on biting, which is usually treated with symptomatic relief for vital teeth or root canal treatment for non-vital teeth.
- Acute periapical abscess seen as swelling and pain, sometimes requiring incision and drainage along with root canal treatment and antibiotics.
This document discusses endodontic diagnosis and treatment planning. It begins with an introduction to endodontics and causes of pulpitis. Signs and symptoms of pulpitis are then outlined. The diagnostic process involves subjective history, objective examination, and tests like percussion, palpation, thermal sensitivity, electric pulp testing, and radiographs. Based on the diagnosis, a treatment plan is formulated which may involve root canal treatment, referral, or extraction. The document provides details on diagnosing and treating different pulpal and periapical conditions like reversible/irreversible pulpitis, abscesses, cysts, and necrosis.
Co-Chairs, Val J. Lowe, MD, and Cyrus A. Raji, MD, PhD, prepared useful Practice Aids pertaining to Alzheimer’s disease for this CME/AAPA activity titled “Alzheimer’s Disease Case Conference: Gearing Up for the Expanding Role of Neuroradiology in Diagnosis and Treatment.” For the full presentation, downloadable Practice Aids, and complete CME/AAPA information, and to apply for credit, please visit us at https://bit.ly/3PvVY25. CME/AAPA credit will be available until June 28, 2025.
10 Benefits an EPCR Software should Bring to EMS Organizations Traumasoft LLC
The benefits of an ePCR solution should extend to the whole EMS organization, not just certain groups of people or certain departments. It should provide more than just a form for entering and a database for storing information. It should also include a workflow of how information is communicated, used and stored across the entire organization.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Lecture 6 -- Memory 2015.pptlearning occurs when a stimulus (unconditioned st...AyushGadhvi1
learning occurs when a stimulus (unconditioned stimulus) eliciting a response (unconditioned response) • is paired with another stimulus (conditioned stimulus)
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdfrightmanforbloodline
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
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Dental implants are the most common type of method for replacing the missing tooth. Unlike dentures or bridges, implants are surgically placed in the jawbone. In layman’s terms, a dental implant is similar to the natural root of the tooth. It offers a stable foundation for the artificial tooth giving it the look, feel, and function similar to the natural tooth.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
low birth weight presentation. Low birth weight (LBW) infant is defined as the one whose birth weight is less than 2500g irrespective of their gestational age. Premature birth and low birth weight(LBW) is still a serious problem in newborn. Causing high morbidity and mortality rate worldwide. The nursing care provide to low birth weight babies is crucial in promoting their overall health and development. Through careful assessment, diagnosis,, planning, and evaluation plays a vital role in ensuring these vulnerable infants receive the specialize care they need. In India every third of the infant weight less than 2500g.
Birth period, socioeconomical status, nutritional and intrauterine environment are the factors influencing low birth weight
2. INTRODUCTION
• Endodontic emergencies infringe on a tight,
planned schedule of a dentist as well as that of
the patient and tend to upset the day for
everyone including the patient, dentist and staff.
• Endodontic emergency is a condition associated
with pain and/or swelling that requires
immediate diagnosis and treatment.
• Pulpal pathologies and traumatic injuries are the
two most common causes for these emergencies.
Pain can originate from the pulp or the
periradicular area.
Cohen 11th edition
3. • Pain in endodontic emergencies is mainly
related to two factors, namely, chemical
mediators and pressure.
• Chemical mediators cause pain directly by
lowering the pain threshold of sensory nerve
fibers or by increasing vascular permeability
and producing edema.
• Increased fluid pressure resulting from edema
also stimulates the pain receptors.
4. DEFINITION
• An endodontic emergency is defined as pain
and/or swelling caused by inflammation or
infection of the pulp and/or periradicular
tissues necessitating an emergency visit to the
dentist for immediate treatment.(Grossman’s
endodontic practice 13th edition)
• An endodontic emergency is defined as pain
or swelling caused by various stages of
inflammation or infection of the pulpal or
periapical tissues. (Cohen 11th edition)
5. • 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
pulpal/periapical disease and thus are candidates for
endodontic therapy.
Cohen 11th edition
7. MANAGEMENT OF ENDODONTIC
EMERGENCIES
• Management can be divided into the
following steps:
Proper attitude
Make an accurate diagnosis
Render prompt and effective treatment
8. Proper attitude: A calm
and confident
professionalism should
be displayed. A positive
attitude to the patient’s
problem can make the
individual aware that an
efficient and effective
treatment will be done
9. Make an accurate diagnosis:
• acute pain or swelling needs
immediate relief, the essential
diagnosis should be rapid and
accurate.
• Attaining pertinent medical and
dental history to avoid
important medical
complications or allergic
reactions or make modifications
in the treatment.
10. • Subjective examination
Questions relating to history, location, severity, duration
character, stimuli eliciting/ relieving pain should be asked.
• Objective examination
Visual examination of face, oral and hard and 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 elicit
/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.
11. Radiographic examination: helps in detecting recurrent / inter
proximal caries, possible pulpal exposures, resorptions, periapical
pathosis etc.
A differential diagnosis should be done to consider or rule out
even nonodontogenic sources of pain which mimic odontogenic
pain quite closely.
After diagnosis, a prompt and effective treatment plan should be
made while keeping in mind about the prognosis.
Periodontal prognosis Restorability
13. CRACKED TOOTH SYNDROME
• DEFINITION: Cracked tooth is
defined as an incomplete fracture
of the dentine in a vital posterior
tooth that involves the dentine and
occasionally extends into the pulp.
• The term “cracked tooth
syndrome” (CTS) was first
introduced by Cameron in 1964.
• History of pain on release of biting
on a particular tooth, often
occurring with food having small,
harder particles in them.
A Review of the Diagnosis and Management of the Cracked Tooth
14. Predisposing factors
Excessive forces on a healthy tooth:
A Review of the Diagnosis and Management of the Cracked Tooth
•A large proportion of the cracked teeth are seen in unrestored or
minimally restored teeth.
•Masticatory accidents, such as chewing on an unexpectedly hard
food particle, can result in a high concentration of force over a small
area.
•A fall or a blow to the face is a form of excessive trauma
•Parafunctional activities.
•Sport is another common cause of tooth fracture.
15. Normal forces on a weakened tooth structure:
A Review of the Diagnosis and Management of the Cracked Tooth
•Intra-coronal restorations have been significantly
associated with cracked teeth. For instance, teeth with
Class II restorations are seen with cracks
approximately three times more frequently than teeth
with a Class I restoration.
•Endodontic treatment has also been implicated as a
risk factor for CTS.
•Pins or posts that have been placed in teeth for
additional means of retention will almost always result
in additional tooth structure being removed, and this
has been suggested as a precipitating factor for tooth
and root fractures.
16. Dental materials:
A Review of the Diagnosis and Management of the Cracked Tooth
•Water contamination of amalgam, before the advent of high
copper/low gamma-2 phase alloys, resulted in a dimensional
expansion.
•it has been suggested that the curing of a large increment of
composite can result in excessive shrinkage.
•It is the associated stresses caused by the inappropriate
handling of these materials which can result in a cracked
tooth.
•„
Finishing a restoration so that it is ‘high in the bite’, either
with a plastic restoration, such as amalgam, or a cast
restoration, such as an inlay, may also lead to a fractured
tooth due to the wedging effect of the restoration.
•The forces generated during lateral condensation of gutta
percha can be excessive and lead to fracture of the apical
portion of the root.
17. Rare events:
Pain mechanism:
• The short, sharp pain on biting experienced
with CTS is explained by the fluid movements
in the dentinal tubules when the fracture
fragments separate during the application of
pressure.
A Review of the Diagnosis and Management of the Cracked Tooth
•The modern trend for the piercing of body parts has led
to reports of CTS associated with piercing of the tongue.
• A rare cause of a cracked tooth is as a result of loss of
tooth substance due to internal resorption.
18. • This is due to the stimulation of the
mechanoreceptors in close proximity to the
odontoblastic cell body.
• These then activate the quick acting A-delta
fibres in the pulp.
• Bacterial ingression down the crack may also
result in pulpal inflammation, which causes
the release of neuropeptides, lowering the
pain threshold of the unmyelinated C-type
pain fibres in the pulp chamber.
• This explains the dull ache associated with the
hypersensitivity to cold and, occasionally, hot
stimuli associated with cracked teeth.
A Review of the Diagnosis and Management of the Cracked Tooth
19. SYMPTOMS
•The patient will often complain of pain on biting or on eating,
especially certain types of food that have small hard particles in
them, for example muesli and seeded bread.
• Occasionally, the pain is felt on release of biting. The pain is brief,
sharp.
•There may be an increase in sensitivity to hot and cold, and sweet,
depending on how far the crack has extended into the dentine.
DIAGNOSIS
•Superficial cracks or crazing in the enamel are often seen in teeth
but this enamel crazing is superficial and asymptomatic.
•The tip of a sharp probe can be used to run along the tooth surface
and may catch on the line of the crack.
•The probe can also be used in the fissures or in between the margins
of the tooth and the restoration to open up the crack.
•Magnification, a bright light and a dry field of vision will make it
easier to see a crack.
21. • Magnifying loupes
• Dyes-methylene blue
• Tooth sloth- more
reliable.
• Orthodontic bands
22. Management
• The emergency and definitive treatment will be dictated by: „
Pulpal status; and „
The restorability of the tooth.
Pulpal status:
• A tooth exhibiting reversible pulpitis, with an incomplete
fracture that is suspected of communicating with the pulp,
may still be treated conservatively, as preservation of pulpal
health will depend largely on the degree of bacterial
contamination.
• It can be difficult to determine the pulpal status. A short,
sharp pain due to pressure only might be indicative of an
uninfected pulp, while a more lingering ache on hot and cold
stimulation could indicate a greater degree of inflammation
due to bacterial infection. Teeth with this type of pain should
be treated urgently to prevent further movement across the
crack.
• If the pulpal status is uncertain, the tooth should be
stabilized and reassessed before a definitive restoration is
placed.
A Review of the Diagnosis and Management of the Cracked Tooth
23. Restorability:
• The extent of the crack is not usually a factor
where the fracture is incomplete and not
displaced.
• Complete or displaced fractures require the
fragment to be removed and will normally
require the restoration to be placed over the
fracture margins.
• Where the fracture margins are more than 2 mm
below the gingival margin, crown lengthening
may be required. Teeth with a lack of coronal
tooth structure have a poorer prognosis.
• In case if crack is vertical - involving the entire
root – extraction is preferred.
A Review of the Diagnosis and Management of the Cracked Tooth
24. Emergency treatment:
• The aim of emergency treatment is to relieve pain, to
make the mouth comfortable and to improve function.
• The treatment depends on the diagnosis of the pulpal
status, the extent and the position of the crack. The
tooth should be stabilized to prevent further
propagation of the crack and damage to the tooth.
Relieving pain:
• Teeth with the symptoms of a reversible pulpitis and
an incomplete fracture are treated with stabilization of
the crack. An irreversible pulpitis or pulpal necrosis
requires an extirpation of the pulp in addition to
stabilization.
• Extraction of the tooth is indicated if the tooth is
unrestorable.
A Review of the Diagnosis and Management of the Cracked Tooth
25. Acute Reversible Pulpitis
• 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 uninflammed state following
removal of stimuli.
Clinical characteristics
Quick, sharp, shooting momentary tooth pain suggesting involvement
of A-delta fibers.
Pain is always specific to a stimulus.
Pain is instantly relieved on removal of the stimulus.
It is more often brought on by cold than hot food or beverages .
Pulpitis: A review (IOSR Journal of Dental and
Medical Sciences)
26. Causative factors
•Trauma, as from a blow or from a disturbed Occlusal
relationship
•Thermal shock, as from preparing a cavity with a dull bur or
keeping the bur in contact with the tooth for too long, or as
from overheating during polishing a filling
•Excessive dehydration of a cavity or irritation of exposed
dentin at the neck of a tooth
•Placement of a fresh amalgam filling in contact with, or
occluding, a cast restoration.
•Chemical stimulus, as from sweet or sour foodstuffs or from
irritation of a filling; or bacteria, as from caries
Pulpitis: A review (IOSR Journal of Dental
and Medical Sciences)
27. DIAGNOSIS
• 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 restorations,
exposed dentin.
• Pulp vitality tests: Thermal tests: helps to locate the
offending tooth. Cold test is preferable, because the pulp is
sensitive to temperature changes, particularly cold.
Electric pulp test, using less current than on the control
tooth, is an excellent corroborating test.
• Percussion, palpation and radiographs give normal status.
Pulpitis: A review (IOSR Journal of Dental and Medical Sciences)
28. TREATMENT
•Periodic care to prevent the development of caries,
•early insertion of a filling if a cavity has developed,
•desensitization of the necks of teeth where gingival recession is
marked,
•use of a cavity varnish or cement base before insertion of a
filling, and
•care in cavity preparation and polishing are recommended to
prevent pulpitis.
•When reversible pulpitis is present, removal of the noxious
stimuli will usually bring the pulp back to a healthy state.
•Once the symptoms have subsided, the tooth should be tested
for vitality to make sure that pulpal necrosis has not occurred.
•When pain persists despite proper treatment, the pulpal
inflammation should be regarded as irreversible, the treatment
for which is pulp extirpation.
29. Hypersensitive Dentin
• It is characterized by short, sharp pain arising from
exposed dentin in response to stimuli – thermal,
tactile, osmotic or chemical and which cannot be
ascribed to any other form of dental defect or
pathology.
Etiological factors
Exposed dentinal tubules due to :
Periodontal surgery
Tooth abrasion
Erosion
Abfraction
Attrition
Cohen 11th edition
30. • The mechanisms underlying dentin sensitivity have
been a subject of interest in recent years.
• Converging evidence indicates that movement of fluid
in the dentinal tubules is the basic event in the arousal
of dentinal pain.
• It now appears that pain-producing stimuli, such as
heat, cold, air blasts, and probing with the tip of an
explorer, have in common the ability to displace fluid in
the tubules.
• This is referred to as the hydrodynamic mechanism of
dentin sensitivity.
• The hydrodynamic theory suggests that dentinal pain
associated with stimulation of a sensitive tooth
ultimately involves mechanotransduction.
• Recently, classical mechanotransducers have been
recognized on pulpal afferents, providing a mechanistic
support to this theory.
31. • Thus fluid movement in the dentinal
tubules is translated into electric signals
by receptors located in the axon
terminals innervating dentinal tubules.
• Indeed, there is a positive correlation
between rate of fluid flow in the tubules
and discharge evoked in intradental
nerves, with outward fluid movements
producing a much stronger nerve
response than inward movements.
• Presumably, heat expands the fluid
within the tubules faster than it expands
dentin, causing the fluid to flow toward
the pulp, whereas cold causes the fluid
to contract more rapidly than dentin,
producing an outward flow.
32. Treatment
• Treatment modality includes chemical or physical blockage of the
patients dentinal tubules to prevent fluid movements from within.
Cohen 11th edition
33. Differential Diagnosis
Conditions that produce symptoms namely those of
dentinal hypersensitivity are:
cracked tooth syndrome
fractured restorations
chipped teeth
Dental caries
post restorative sensitivity
teeth in acute hyper function
palatogingival groove
Cohen 11th edition
34. Acute Irreversible Pulpitis
• It is essential that this condition should
be distinguished from acute reversible
pulpitis which has many similar
symptoms because the emergency
procedure for each is different.
• Clinically manifested by spontaneous
pain that is exacerbated by in
particular by hot stimuli, never cold. In
fact cold very often brings relief to the
patient.
It is a persistent inflammatory condition of the
pulp, symptomatic/ non-symptomatic, caused by
noxious stimuli with the pulp becoming incapable of healing
Pulpitis: A review (IOSR Journal of Dental and Medical Sciences)
35. • If a patient describes pain that lasts for
minutes to hours, or is spontaneous or
disturbs sleep or occurs when bending
over, then patient will require pulpectomy
rather than palliative treatment.
• Symptoms can be localized or non-
localized. The non-localized pulpitis poses
one of the most difficult and challenging
problem to the practitioner since the
patient cannot identify the offending tooth.
• Based on the patient’s history that the pain
is provoked by the hot foods or beverages,
the application of heat in a controlled
sequential manner to the individual teeth is
undoubtedly helpful in localizing the
diseased tooth.
Pulpitis: A review (IOSR Journal of Dental and Medical Sciences)
36. • Heat by causing dilation of blood vessels, tissues and
gaseous products of proteolysis, the pressure increases,
thus increases the pain.
• In contrast, cold has a contractile effect on the remaining
functional vascular bed, reducing the intra pulp pressure
below the pain threshold of the pain receptors.
• Treatment :
Pulpectomy followed by insertion of a medicated cotton
pellet, moistened with an obtundent such as eugenol into
the pulp chamber.
Place a temporary filling.
Prescribe analgesics if necessary. Premedications or post
medication with antibiotic is indicated if the patient is
medically compromised.
If there is no sufficient time for pulpectomy, pulpotomy is
indicated.
Pulpitis: A review (IOSR Journal of Dental and Medical Sciences)
37. Acute Apical Periodontitis/ Symptomatic Apical
periodontitis
• There is a complain of the tooth
feeling elevated in the socket or
inability to chew on the particular
tooth.
• Diagnosis is usually simple, the tooth
is tender on percussion.
• A radiograph of the tooth may appear
normal or exhibit a thickening of the
periodontal ligament space or show a
small periapical radiolucency
•An acute condition that occurs before alveolar bone is resorbed.
•One of the most difficult emergency condition to treat is acute
pulpitis with apical periodontitis due to difficulty in achieving
required depth of anesthesia in such cases.
Grossman’s endodontic practice 13th edition
38. Causative factors
In vital tooth that has experienced Occlusal trauma by:
Abnormal occlusal contacts.
Recently inserted restorations extending beyond occlusal
plane.
Wedging of a foreign object between the teeth, such as a
toothpick or food.
Traumatic blow to the teeth.
In nonvital tooth it may be caused by:
Sequelae of pulpal disease.
Iatrogenic causes such as:
oRoot canal instrumentation forcing bacteria or debris
beyond the apical foramen.
oOverinstrumentation.
oForcing irrigants and medicaments through the apical
foramen.
oExtension of the obturating material beyond the foramen.
Grossman’s endodontic practice 13th edition
39. • Treatment
Removal of causative factors.
Occlusion should be relieved.
Adjustment of high points in cases of hyperocclusion.
Removals of irritants in case of non vital infected pulp and
initiate endodontic therapy .
Prescribe analgesics and anti-inflammatory drugs.
Prognosis for tooth is generally favourable.
Grossman’s endodontic practice 13th edition
40. Pulp Necrosis
Treatment
The proper treatment for pulp
necrosis is pulpectomy and
obturation of root canals.
No anesthetic is necessary in most
instances but in some cases there are
still enough pain receptors to cause
discomfort during the procedure.
Ensure removal of all necrotic tissue
and thorough irrigation of the canals
is required.
Rarely causes an emergency procedure.
However, the patient may notice a swelling
and request emergency treatment.
Grossman’s endodontic practice 13th edition
41. Acute Exacerbation of Asymptomatic
Apical Periodontitis (Phoenix Abscess)
• Causes: When chronic periradicular diseases, such as
asymptomatic apical periodontitis, are in a state of
equilibrium, the periradicular tissues are asymptomatic.
Sometimes, noxious stimulus from a diseased pulp can
cause acute inflammatory response in these dormant
lesions. Lowering of body’s defenses due to influx of
bacterial toxins from the root canal or irritation during
root canal instrumentation may also trigger acute
inflammatory response.
Definition: This condition is an acute inflammatory
reaction superimposed on an existing asymptomatic
apical periodontitis.
Grossman’s endodontic practice 13th edition
42. Symptoms:
• tooth may be tender on palpation.
• As inflammation progresses, the tooth gets elevated from
its socket and becomes sensitive.
• The mucosa over the radicular area may appear red and
swollen and is sensitive to palpation.
Diagnosis:
• most commonly associated with the initiation of root canal
therapy in a completely asymptomatic tooth.
• The radiograph shows a well-defined periradicular lesion.
• The patient gives a history of trauma that lead to
discoloring of the tooth over a period of time or a
postoperative pain that had subsided until then.
• Lack of response to vitality tests diagnoses a necrotic pulp.
Grossman’s endodontic practice 13th edition
43. •Š
A phoenix abscess is an acute symptomatic
abscess with distinct periradicular radiographic
changes.
•Š
Š
It can be differentiated from an acute alveolar
abscess in which widening of the periodontal
ligament space is the only radiographic change
seen.
Treatment
The treatment of acute exacerbation of a chronic
lesion is the same as that of an acute alveolar
abscess.
Grossman’s endodontic practice 13th edition
44. Acute Alveolar Abscess: (Acute
periapical abscess )
Microbiology and Treatment of Acute Apical
Abscesses : Clinical Microbiology Reviews
45. Symptoms
• Local symptom
Tenderness of the tooth.
Patient has throbbing
severe pain with swelling
of the overlying soft
tissue with or without
tooth mobility.
When swelling become
extensive, it result into
cellulitis and the patients
facial changes.
• Systemic symptom
Fever, Irritation, etc
Microbiology and Treatment of Acute Apical
Abscesses : Clinical Microbiology Reviews
46. Where to expect swelling from which
tooth???
Microbiology and Treatment of Acute Apical
Abscesses : Clinical Microbiology Reviews
47. Ludwig's angina
• Potentially life-threatening
cellulitis or connective tissue
infection, of the floor of the
mouth, usually occurring in
adults with concomitant dental
infections.
• usually develops in
immunocompromised persons
• bilateral involvement of the
submandibular, sublingual and
submental spaces
Treatment involves appropriate antibiotic medications, monitoring and
protection of the airway in severe cases, and, where appropriate, urgent
ENT surgery, maxillo-facial surgery and/or dental consultation to incise and
drain the collections. The antibiotic of choice is from the penicillin group.
48. The acute episode may result from :
Microbiology and Treatment of Acute Apical
Abscesses : Clinical Microbiology Reviews
49. Treatment
• Infiltration anesthesia contraindicated
forcing anesthetic
solution into an
Acutely inflammed
and swollen area
localized acidic
pH
•block anesthesia may be administered
•test cavity tests for any remaining, vital pulp that could
require anesthesia and initiates emergency quickly, without
waiting for anesthesia to take effect.
Microbiology and Treatment of Acute Apical
Abscesses : Clinical Microbiology Reviews
50. Procedure
• access opening stabilize the tooth with finger
pressure or impression compound (high speed)
• Irrigate profusely
• Instrument within 1 mm of the root apex.
Frequently, a purulent exudate escapes into the chamber and indicates that
the root canal is patent and draining.
(dry canal due to the apical contriction preventing the inflammatory
products from draining through the tooth)
To relieve this problem, a procedure called ‘apical trephination’ is
followed.
Microbiology and Treatment of Acute Apical
Abscesses : Clinical Microbiology Reviews
51. • Aspiration using any mild suction devices such as
a wide gauge needle placed in the saliva ejector
will give sufficient negative pressure which aids in
establishing drainage through the canal.
• Leave the tooth open. Current evidence suggests
that leaving teeth open between appointments
(open dressing) is not recommended as it impairs
the prognosis.
• Advice the patient to use warm saline rinses for 3
minutes each hour.
• Prescribe analgesics or antibiotics if indicated and
necessary.
Microbiology and Treatment of Acute Apical
Abscesses : Clinical Microbiology Reviews
52. Gutmann describes various modalities of treatment for localized or
diffuse swellings associated with acute alveolar abscess.
Microbiology and Treatment of Acute Apical
Abscesses : Clinical Microbiology Reviews
56. Technique
• The clinician should first dry the mucosa
over the affected area and then spray the
tissue with a refrigerant topical anesthetic.
• Some clinicians prefer to anesthetize the
area with conduction anesthesia
(mandibular or infraorbital block), or
peripheral infiltration around but not in the
swollen tissues, prior to incision.
• More often, a topical anesthetic solution is
sprayed over the swollen area immediately
preceding the incision.
• Although a topical anesthetic is minimally
effective, it usually suffices for the quick,
sharp thrust of the No. 11 scalpel through
the center of the soft, fluctuant mass down
to the solid cortical bone plate.
57. Fluctuant swellings: When the swelling “points,” i.e., it
localizes into a soft, fluctuant, palpable mass, it should
be incised and drained, a procedure that dramatically
reduces the swelling and pain.
Indurated swellings: If the swelling remains hard or
indurated, then the swollen tissue should be bathed in
warm saline rinses for 5 minutes every hour until it
becomes soft, fluctuant, and ready for incision.
• Some clinicians advocate incising even hard tissue
whenever pain is present; they suggest that the tissues
will drain eventually and the pain will disappear
sooner.
• Antibiotics and analgesics can be prescribed as needed.
Finally, the tooth should be disoccluded slightly if it is
extruded from its socket.
58. Rationale for I & D
• Decreases number of
bacteria
• Reduces tissue pressure
• Alleviates pain/trismus
• Improves circulation
• Prevents spread of
infection
• Accelerates healing
Microbiology and Treatment of Acute Apical
Abscesses : Clinical Microbiology Reviews
59. Trephination – Apical and surgical
Microbiology and Treatment of Acute Apical
Abscesses : Clinical Microbiology Reviews
60. Surgical
Rarely indicated.
However it is a reliable procedure to manage
pain when all other methods have failed.
Indicated when the severe pain is due to
increase in intracortical pressure in the
periradicular tissues, when apical trephination
has failed.
Microbiology and Treatment of Acute Apical
Abscesses : Clinical Microbiology Reviews
Needle tip used in an impression material
gun was modified and sutured into place
as a drain in the palatal tissue.
Trephination and Decompression
61. Acute Periodontal Abscess
• It is often mistaken for an acute alveolar abscess
as periodontal abscess causes
• pain and swelling.
Etiology
• It is usually an exacerbation of infection with pus
formation in an existing deep infrabony pocket.
62. Treatment
• Vital pulp periodontal therapy
• When the pulp is abnormal and vital, the tooth is
treated as if for acute irreversible pulpitis.
• If the pulp is necrotic, treat as if for acute alveolar
abscess.
• In any case, emergency periodontal treatment
must be done simultaneously; otherwise, the
patient will not be relieved of the pain and
swelling.
63.
64. TRAUMATIC INJURIES
• Endodontic treatment may be required as a
result of traumatic injury.
• Most common endodontic emergencies are:
a) Fracture of teeth and alveolar bone
b) Avulsion
65. Fracture of teeth and alveolar bone
• C++, clinical and radiographic examination;
• S+, splint removal;
• S++, splint removal in cervical third fractures.
• 1 For crown-fractured teeth with concomitant
luxation injury, use the luxation follow-up
schedule.
• 2 Whenever there is evidence of external
inflammatory root resorption, root canal therapy
should be initiated immediately, with the use of
calcium hydroxide as an intra-canal medication
IADT guidelines for the management of
traumatic dental injuries
66.
67.
68.
69.
70.
71.
72.
73.
74.
75. Avulsion
• Avulsion of permanent teeth
is one of the most serious
dental injuries, and a prompt
and correct emergency
management is very
important for the prognosis.
• Incidence – 3% of all dental
injuries
• True dental emergency –
timely attention to
replantation could save the
tooth.
• Sports and automobile
accidents --- frequent causes.
IADT guidelines for avulsed permanent teeth
76. • First aid for avulsed teeth at the place of accident: If a tooth is avulsed,
make sure it is a permanent tooth (primary teeth should not be
replanted).
Keep the patient calm.
Find the tooth and pick it up by the crown (the white part). Avoid touching
the root.
If the tooth is dirty, wash it briefly (max 10 s) under cold running water
and reposition it. Try to encourage the patient/guardian to replant the
tooth. Once the tooth is back in place, bite on a handkerchief to hold it in
position.
If this is not possible, or for other reasons when replantation of the
avulsed tooth is not possible (e.g., an unconscious patient), place the
tooth in a glass of milk or another suitable storage medium and bring with
the patient to the emergency clinic. The tooth can also be transported in
the mouth, keeping it inside the lip or cheek if the patient is conscious. If
the patient is very young, he/she could swallow the tooth – therefore it is
advisable to get the patient to spit in a container and place the tooth in it.
Avoid storage in water!
Seek emergency dental treatment immediately.
81. HOT TOOTH
• The term "hot" tooth generally refers to a pulp
that has been diagnosed with irreversible pulpitis,
with spontaneous, moderate-to-severe pain.
• A classic example of one type of hot tooth is a
patient who is sitting in the waiting room, sipping
on a large glass of ice water to help control the
pain.
• The inferior alveolar nerve (IAN) block is
associated with a failure rate of 15% in patients
with normal tissue, whereas IAN fails 44-81% of
the time in patients with irreversible pulpitis.
Similarly, it has been reported that the failure
rate of a maxillary infiltration injection is as high
as 30% in teeth with irreversible pulpitis.
Hot tooth – A challenge to endodontists-
International Journal of Biomedical Research
( Review article)
82. Most common sites of occurrence:
• Primary and permanent teeth
• Sites of recent or defective restorations
•Sites of recent trauma
• Mandibular molars are more challenging to anesthetize.
• Patients with anxiety about dental treatment or patients
who have been in pain for several days usually require a more
sophisticated approach.
Signs
• Deep restorations or caries.
• Coronal fracture lines.
• Increased tooth mobility .
• Thickening of periodontal ligament.
Hot tooth – A challenge to endodontists-
International Journal of Biomedical Research ( Review article)
83. Symptoms
Pain when biting and in response to percussion test.
Increased sensitivity to temperature extremes.
Earlier presentation: often intense, lingering pain in
response to cold.
Later presentation: intense pain in response to heat;
relieved by cold water. Pain may be spontaneous and
poorly localized (e.g., entire left side is painful), often
radiating from ear to temple for maxillary teeth.
Pain may wander to opposing arch but never over the
midline
Hot tooth – A challenge to endodontists-
International Journal of Biomedical Research
( Review article)
84. Hypotheses to explain the inability to
anesthetize hot tooth
1) Ion trapping : Low pH is responsible for ion trapping of local
anesthetic. According to this hyphothesis, low tissue pH shall
be responsible for a greater proportion of the local
anesthetic being trapped in the charged acid form of the
molecule and thus unable to cross cell membrane. However
ion trapping is for infiltration injections only, block injections
are likely to involve acidotic tissues.
2) Altered Membrane excitability of peripheral nociceptors :
Nerves from inflamed tissue shows decreased excitability
threshold and altered resting potential. Studies show that
lower excitability thresholds are responsible for transmission
of impulses even with action of local anesthetic.
85. 3) Tetrodoxin resistant channels: It is confirmed that, Tetrodoxin
resistant channels (TTXr), a class of sodium channels resist the
action of local anesthesia. Increased expressions of sodium
channels in pulp are responsible for anesthetic failures in hot
tooth. TTX r channels are resistant to lidocaine, thereby
causing incomplete anesthesia.
4) The Central core theory : This theory states that the nerve
situated outside of the nerve bundle supply molar teeth while
the nerve situated inside the nerve bundle supplies the
anterior teeth. The anesthetic solution may not diffuse into
the nerve trunk to reach all the nerves to produce an
adequate block even if deposited at the correct site. This
theory may only be applicable for the higher failure rates in
the anterior teeth with IANB and not for the posterior teeth.
86. • 5) Central sensitization : Central sensitization
may contribute to local anesthetic failures.
Increased Sensitization may amplify incoming
signals from sensory nerves. In central
sensitization, there is an increased response to
peripheral stimuli and because of this, the IANB
may permit for sufficient enough signaling to
occur thereby leading to the perception of pain.
6) Psychological factors: Patient anxiety is one of
the factor for local anesthetic failure. It is
understood that apprehensive patients have a
reduced pain threshold and more likely to
complain pain during the time of endodontic
treatment.
Hot tooth – A challenge to endodontists-
International Journal of Biomedical Research
( Review article)
87. Management strategies in patients with a hot
tooth
• Even after giving a proper anesthesia, if the patient responds
pain, two treatment strategies could be considered:
I) Supplemental Injections
II) Change in the Anesthetic solution.
I)Supplemental injections : There are several alternative
supplemental injection techniques available in the field of
dentistry.
A. Intraligamentary(Periodontal ligament) Injection
B. Intraosseous Injection
C. Intraseptal anesthesia
D. Intrapulpal Anesthesia
E. Mandibular Buccal Infiltration Injection with Articaine
Hot tooth – A challenge to endodontists-
International Journal of Biomedical Research
( Review article)
88. F. Preemptive Strategies to Improve Success of the IANB
Injection, such as:
1) Use of fast acting anti-inflammatory drugs
2) Reducing pulpal level of inflammatory mediator PGE2
3) Injectable NSAID ketorolac, when injected intraorally or
intra muscularly produce significant analgesia in patient
with severe odontogenic pain.
4) Intra-osseous injection of 40 mg methyl prednisolone in
patients with irreversible pulpitis resulted in less pain.
II. Change in anesthetic solution
a) 1.4% Articaine
Anesthetic efficiency of 4% articaine with 1:100,000
epinephrine shows higher anesthetic efficiency than using
2% lidocaine with 1:100,000 epinephrine when used as
buccal infiltration. Mechanism of action is that articaine
contains a thiophene group, which increases its lipid
solubility.
Hot tooth – A challenge to endodontists-
International Journal of Biomedical Research
( Review article)
89. b) Mandibular Buccal infiltration with articaine
Mandibular buccal infiltration with 4%
articaine could be considered as a
supplemental injection technique. Studies
shows that buccal infiltration of 4% articaine
shows higher anesthetic efficiency as
compared to 2% lidocaine solution.
c) 0.5 M Mannitol
Combination of 0.5 M Mannitol and lidocaine
with epinephrine in Inferior Alveolar Nerve
block shows higher anesthetic efficiency
compared to lidocaine and epinephrine alone.
Hot tooth – A challenge to endodontists-
International Journal of Biomedical Research ( Review article)
90. ENDODONTIC FLARE – UPS
• An acute exacerbation of peri radicular
pathosis after initiation or continuation
of root canal treatment.
• Inter-appointment flare-up is
characterized by the development of
pain, swelling or both, following
endodontic intervention.
• The causative factors of inter
appointment pain comprise mechanical,
chemical, and/or microbial injury to the
pulp or periradicular tissues, which are
induced during root canal treatment.
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91. • Regardless of the type of injury, the intensity of
the inflammatory response is directly
proportional to the intensity of tissue injury.
• The frequency of inter appointment pain has
been reported to be significantly higher in teeth
with periradicular lesions as compared to teeth
with vital pulps and normal periradicular tissues.
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92. Cause of Interappointment Pain
Microbial causes:
• There are some special circumstances in which
microorganisms can cause interappointment pain as a result
of imbalance in host–bacteria relationship induced by
intracanal procedures.
• Development of pain precipitated by infectious agents can be
dependent on several factors. These factors are as follows:
Presence of pathogenic bacteria:
• The bacterial species can be associated with symptomatic
periradicular lesions. These include Porphyromonas
endodontalis, Porphyromonas gingivalis, and Prevotella
species.
• A recent study revealed that F. nucleatum, Prevotella species,
and Porphyromonas species were frequently isolated from
flare-up cases.
93. Presence of virulent clonal types
• Presence of virulent clones of
endodontic pathogens in the root
canal may be a predisposing factor
for interappointment pain, provided
that conditions are created for them
to exert their pathogenicity.
Microbial synergism or additism:
• Most of the endodontic pathogens
show virulence when they are in
association with other species.
Number of microbial cells:
• If the host is faced with a higher
number of microbial cells than it is
used to an acute exacerbation of the
periradicular lesion can occur.
Journal of Pharmacy and Bioallied Sciences Vol 4 August
2012 Supplement 2 - Part 3; Harikaran, et al.: Flare-up review
94. Environmental cues:
• Studies have demonstrated that
environmental changes can influence the
behavior of some putative oral (and
endodontic) pathogens, including P. gingivalis,
F. nucleatum, Prevotella intermedia, and oral
treponemes.
• If the root canal environmental conditions are
altered by intracanal procedures and become
conducive, microbial virulence can be
enhanced and interappointment pain can
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95. Host resistance:
• Individuals who have reduced ability to cope with
infections are more prone to develop clinical symptoms
after endodontic procedures in infected root canals.
• Herpes viruses have the ability to diminish the host
resistance to infection.
There are some situations during the endodontic
treatment that can facilitate microorganisms to cause
interappointment pain. These include:
(a) apical extrusion of debris;
(b) incomplete instrumentation leading to changes in
the endodontic microbiota or in environmental
conditions; and
(c) secondary intraradicular infections.
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96. Apical extrusion of debris:
• Extrusion of infected debris to the periradicular tissues
during chemomechanical preparation is one of the
principal causes of postoperative pain.
• Forcing microorganisms and their products into the
periradicular tissues can generate an acute
inflammatory response, the intensity of which will
depend on the quantitative (number) and qualitative
(virulence) nature of the extruded microorganisms.
• Iatrogenic overinstrumentation promotes the
enlargement of apical foramen, which may permit an
increased influx of exudate and blood into the root
canal.[18] This will enhance the nutrient supply to the
remaining bacteria within the root canal, which can
then proliferate and cause exacerbation of a chronic
periradicular lesion.
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97. • Steps to prevent the apical extrusion of debris,
crown-down techniques, irrespective of
whether hand- or engine-driven instruments
are used, which extrudes less debris and
should be selected for the instrumentation of
infected root canals. Therefore, the
quantitative factor is more likely to be under
the control of the practitioner. The qualitative
factor is more difficult to be controlled.
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98. Incomplete chemomechanical preparation leading to the
following:
1. Changes in the endodontic microbiota
• incomplete chemomechanical preparation can disrupt the
balance within the microbial community by eliminating
some inhibitory species and leaving behind other
previously inhibited species, which can then overgrow.
• If overgrown strains are virulent and reach sufficient
numbers, damage to the periradicular tissues can be
intensified. This results in exacerbation of the lesion.
2. Increase of the oxidation–reduction potential
• Another form of environmental change induced by
endodontic intervention refers to the entrance of oxygen in
the root canal. It has been suggested that this can alter the
oxidation–reduction potential (Eh) in the root canal and, as
a consequence, acute exacerbation can occur.
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99. • This theory is based on the fact that the increase in Eh
would induce microbial growth pattern to change from
anaerobic to aerobic.
• Energy yield of facultative anaerobe is more marked in
the presence of oxygen than under anaerobic condition
and a faster growth rate is expected with consequent
overgrowth of facultative anaerobic bacteria.
Secondary intraradicular infections:
• Secondary intraradicular infections are caused by
microorganisms that were not present in the primary
infection and have gained entry into the root canal
system during treatment, between appointments, or
even after the conclusion of the endodontic
treatment,the most common being a breach of the
aseptic chain during treatment.
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100. Non-microbial causes
• The intensity of pain will depend on several aspects,
including intensity of the injury, intensity of tissue
damage, and intensity of the inflammatory response.
All these three phenomena are interconnected, as one
is directly dependent on the other.
• Mechanical irritation causing periradicular
inflammation includes mainly overinstrumentation and
overextended filling materials.
• Chemical irritation includes apical extrusion of irrigants
or intracanal medications. Most irrigants and
medications are cytotoxic to the host tissues.
• The larger the amount of overextended material, the
greater is the intensity of damage to the periradicular
tissues.
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101. Treatment of interappointment pain
Re-instrumentation:
• Definitive treatment may involve re-entering the
symptomatic tooth. The access cavity should then
be opened.
• Working lengths should be reconfirmed, patency
to the apical foramen obtained and a thorough
debridement with copious irrigation performed.
• Drainage will allow for the exudative components
to be released from the periradicular tissues, thus
reducing localized tissue pressure.
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102. Cortical trephination:
• Cortical trephination is defined as the surgical
perforation of the alveolar bone in an attempt
to release accumulated periradicular tissue
exudates.
• Chestner et al.reported pain relief in patients
with severe and recalcitrant periradicular pain
when cortical trephination was performed.
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103. Incision and drainage (I and D)
• The rationale for an I and D procedure is to facilitate
the evacuation of pus, microorganisms, and toxic
products from the periradicular tissues.
• Moreover, it allows for the decompression of the
associated increased periradicular tissue pressure and
provides significant pain relief.
• If the abscess occurs after the obturation of the root
canal system, incision of the fluctuant tissue is perhaps
the only reasonable emergency treatment, provided
the root canal filling is adequate.
• Antibiotics are usually not indicated in cases of a
localized abscess, but they can be used to supplement
clinical procedures in cases where there is poor
drainage and if the patient has a concomitant trismus,
cellulitis, fever, or lymphadenopathy.
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104. Intracanal medicaments:
• Clinical studies have demonstrated that post-treatment
pain is neither prevented nor relieved by medicaments
such as formocresol, camphorated
paramonochlorophenol, eugenol, iodine potassium
iodide, Ledermix, or calcium hydroxide.
• However, the use of intracanal steroids, nonsteriodal
anti-inflammatory drugs (NSAIDs), or a corticosteroid–
antibiotic compound has been shown to reduce post-
treatment pain.
• In a study conducted by Walton et al. steroids and
NSAIDs, when placed within the root canal system after
debridement procedures, can reduce or prevent post-
treatment pain.
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105. Occlusal reduction:
• There appears to be minimal agreement in the
dental literature as to the benefit of reducing the
occlusion to prevent postendodontic pain.
• Rosenburg et al. demonstrated that in teeth with
pain upon biting, occlusal reduction was effective
in reducing postoperative pain.
• Sensitivity to biting and chewing is perhaps due
to increased levels of inflammatory mediators
that stimulate periradicular nociceptors. Occlusal
reduction may therefore alleviate the continued
mechanical stimulation of the sensitized
nociceptors.
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107. VERTICAL ROOT FRACTURE (VRF)
• Vertical root fractures are longitudinal fractures that
originate in the roots of teeth and with few exceptions,
these fractures occur almost exclusively in
endodontically treated teeth.
• The diagnosis is often difficult to establish by
radiograph, percussion, or other means.
• In most cases, the patient complains of discomfort and
may or may not be able to locate the affected tooth.
• In the early stage, when hairline fracture is present and
before separation of the fragments is evident, no
radiographic changes are visible either in the tooth or
in the adjacent bone.
• At times, asking the patient to chew on a tooth slooth,
cotton applicator, or rubber polishing wheel helps in
identifying the tooth.
108. Etiology
•Root anatomy, amount of remaining sound tooth structure,
loss of moisture in dentin, amount of bony support, pre-
existing cracks, and biochemical properties of root dentin are
predisposing etiological factors
•Traumatic occlusion
•Excessive load on an endodontically treated tooth
•Bruxism
FIG: The vertical root fracture line can
be clearly seen on an extracted tooth.
109. Clinical Features
•Dull spontaneous pain,
mastication pain, tooth
mobility, periodontal-type
abscesses, and bony
radiolucencies
•Deep osseous defects: The
typical bone loss pattern in
teeth with vertical root
fractures is the loss of alveolar
bone, specifically in relation to
the fracture area
•Sinus tract located near the
cervical area
110. Radiographic Features
•Separation of root segments
associated with a radiolucency
surrounding the bone between the
roots.
•Hairline fracture–like radiolucency
•Halo appearance—a combined
periapical and periradicular
radiolucency on one or both sides
of the involved root a characteristic J-shaped radiolucent
lesion seen in this radiograph
indicative of a vertical root fracture.
111. Management
•When a longitudinal fracture of a root
occurs, the prognosis for that root is usually
hopeless.
•Endodontically treated teeth have to be
extracted if they cannot be restored. Hence,
extraction of such teeth is the recommended
treatment of choice.
•In multirooted teeth, hemisection or
radisectomy may be indicated.
112. HIGH RESTORATION
• Once obturation of the root canal space has
been completed, restoration of the rest of the
tooth should be carried out.
• The occlusion should be checked for
interferences and managed by occlusal
rehabilitation to avoid apical periodontitis or
worse, a fractured tooth.
113. OVERFILLING
• The most likely cause of pain following obturation of
the root canal space is the presence of infected
material in the periapical region.
• Over filling cause pain more as a result of over
instrumentation and trauma to apical periodontium.
• Management:
- Prescription of analgesics and antibiotics
(infection is present).
- Removal of the root filling and repreparation of
the canal.
- Periradicular surgery and apicectomy, in case
retrieval of the extruded filling is not possible to be
considered only in case of gross extrusion or
persistence of infection due to improper apical seal.
114. UNDERFILLING
• Underfilling cause pain due to inadequate
debridement.
Management:
• Removal of the root filling and repreparation
of the canal.
116. Endodontic emergencies: Due to
some medications
• Formaldehyde-containing medications, various compounds
containing arsenic and paraformaldehyde used as pulp
devitalizers.
• Such agents have some clinical benefit, although local soft
and hard tissue necrosis occurs if they are not confined to the
pulp.
• case report describes tissue degeneration and swelling in a
patient treated with formocresol during root canal treatment.
117. Hypochlorite accident
• A hypochlorite accident refers to
any event in which sodium
hypochlorite extruded beyond
the apex of a tooth and the
patient immediately manifests a
combination of some of the
following symptoms:
• Severe immediate pain
• swelling
• Profuse bleeding both
interstitially and through the
tooth.
118. Causes :
• Forceful injection of NaOCl due to wedging of the
irrigating needle into the root canal.
• Irrigating a tooth with a large apical foramen,
apical resorption or an immature apex.
Features:
• Edema and ecchymosis, accompanied by tissue
necrosis, paraesthesia and secondary infection.
• Although most patients recover within 1-2 weeks.
Long-term paraesthesia and scarring have been
reported.
119. Management:
• Immediate aspiration and continuous irrigation with
normal saline.
• Cold pack over the affected area.
• Regional block anesthesia administered. Pain
management difficult because symptoms from distant
anatomic structures will continue to cause discomfort.
• Monitor tooth for the next half hour. Blood exudation
extended from canal denotes the bodies reaction to
the irritant. Remove the fluid with high volume suction
to encourage further drainage. If drainage is persistent
consider leaving the tooth open.
• Antibiotic coverage to prevent secondary infection.
120. • Analgesics prescribed. Because of possible
bleeding complication with aspirin and NSAIDs
an acetaminophen-narcotic combination may
be more appropriate.
• Corticosteroids – inflammatory process
• Home care instructions: Cold compress to
minimize pain and swelling.
• Subsequently warm compresses to encourage
healing.
121. Prevention :
• Bend the irrigating needle at centre to confine
the tip of the needle to higher/coronal levels of
root canal.
• Never bind the needle in the canal
• Oscillate the needle in and out to ensure that the
tip is free to express the irrigant with out
resistance
• express the irrigant slowly and gently.
122. Hydrogen peroxide as a cause of
iatrogenic subcutaneous cervicofacial
emphysema:
• The use of hydrogen peroxide 3% as an irrigant to
newly operated tissue plans may cause
emphysema.
• facial swelling, tenderness and crepitation
• Radiographs will be normal
• paranasal computed tomography (PNCT) – detect
the presence of air within the tissue spaces.
• prophylactic antimicrobial therapy
• Emphysema will recover on its own within a
week.
123. Air emphysema
• Air introduced into periapical tissues during
invasive root canal treatment --- potential to do
great harm.
• Although rare occurance – but has a risk
• In a study done on pigs – significant pressures
during air drying beyond the apex of the roots
with apical diameters larger than size #20
• Compressed air should never be component in
drying of a root canal that is open to periapical
tissues.
124. ASPIRATION / INGESTION OF
ENDODONTIC INSTRUMENTS
• Aspiration of endodontic hand instruments
happens only when rubber dam is not in place.
• Grossman had aptly stated (1955) that if an
instrument is swallowed by the patient , the
dentist is likely to be confronted lawsuite.
• High power suction along with rubber dam help
in prevention of aspiration of instruments.
• Aspiration of endodontic instruments can be a
clinical disaster ending up in life threatening
situations or ending up in the need of major
surgery to remove instrument.
126. Š
Analgesics
•Preoperative NSAID can enhance the effect and
depth of the local anesthetic.
•Š
Š
The first line of management is always restricted
to the use of a non-narcotic analgesic.
•Š
Š
Opioid analgesics are more potent and effective
in pain relief; however, they exhibit adverse side
effects including nausea and drowsiness.
•Š
Š
In acute emergencies, a combination of NSAID
and opioids is preferable.
130. Antibiotics
• Antibiotics are substances that are produced in very
low concentrations by microorganisms to suppress or
to kill other microorganisms.
• These drugs attack cell structure and metabolic
pathways of bacteria, but not human cells, and play a
key role in controlling bacterial infections.
• The common antibiotics used in endodontic
emergencies are as follows:
Penicillin G
Cephalosporins
Metronidazole
Erythromycin
Clindamycin
131. Indications for Antibiotic
Therapy
• Systemic involvement
• Compromised host resistance
• Fascial space involvement
• Inadequate surgical drainage
Guidelines for Antibiotic Therapy:
• Select antibiotics with anaerobic
spectrum
• Use a larger dose for a shorter
period of time (“hard and fast” rule)
132.
133. CONCLUSION
• KNOWING WHAT TO DO AND WHEN TO DO ARE AS
IMPORTANT AS HOW TO DO
• More than 80% of pts who reports to dental , clinic are with
emergency symptoms with endodontically related pain.
Therefore the knowledge, skill for the treatment of these
endodontic emergencies is highly required for every clinician.
• An accurate diagnosis and effective treatment of acute
situations are an important responsibility and priviledge of
dental practice.
• Effective caring and management of endodontic emergencies
not only represents a service to the public, which the dentist
can be proud of but also enhances the positive image of
dentistry.