Endodontic Emergencies
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This presentation offers a comprehensive review of the clinical management and evidence-based approaches to endodontic emergencies. Delve into the diagnostic criteria, pathophysiology, and treatment modalities for a spectrum of endodontic conditions, including acute pulpitis, apical abscesses, and traumatic dental injuries. Utilizing the latest research and case studies, the presentation will explore key decision-making frameworks and surgical vs non-surgical interventions to optimize patient outcomes. Designed for dental professionals, postgraduate students, and researchers, this presentation aims to elevate the standard of care in the management of endodontic emergencies
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Endodontic Emergencies
- 1. Emergencies
- 3. • Introduction • Classification • Endodontic Emergencies before treatment • Endodontic Emergencies during treatment • Endodontic Emergencies after treatment • Clinical management of endodontic emergencies • Conclusion • References Contents
- 4. Introduction An endodontic emergency is defined as pain and/ or swelling caused by inflammation or infection of the pulp and/or peri-radicular tissues necessitating an emergency visit to the dentist for immediate treatment. - Dr. Louis I. Grossman Pulpal Pathologies Traumatic Injuries Chemical Mediators and Pressure PGE2 / Histamines / Substance P / Bradykinins / Interleukins / TNF-α Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd.
- 5. Definitions by Various Authors Conditions that require immediate attention to diagnose and treat pulpal and/or periradicular pain, infection, or discomfort An endodontic emergency is any condition that requires immediate diagnosis and treatment to alleviate pain, prevent further deterioration of the dental pulp, or control an active infection Endodontic emergencies are acute episodes of pain, swelling, or infection originating from the dental pulp or periapical tissues that require immediate management to alleviate symptoms and/or prevent further complications.
- 6. Differentiating between Emergency and Urgency in Endodontics EMERGENCY URGENCY IMMEDIATE DIAGNOSIS & TREATMENT CAN BE SCHEDULED LATER Does the problem disrupt daily activities or quality of life? How long has the problem been severe? Have pain medications been ineffective? CONSIDER PATIENT’S EMOTIONAL AND MENTAL STATUS Torabinejad, Mahmoud, and Richard E. Walton. 2014. Endodontics: Principles and Practice. 5th ed. Elsevier Saunders.
- 7. Classification Before Treatment During Treatment After Treatment (A) Endodontic Emergencies Presenting With Pain And/Or Swelling (i) Crown-originating fracture (COF) (ii) Symptomatic reversible pulpitis (iii) Symptomatic irreversible pulpitis (iv) Primary symptomatic apical periodontitis (v) Secondary symptomatic apical periodontitis (phoenix abscess) (vi) Symptomatic (acute) alveolar abscess (vii) Cellulitis (B) Traumatic Injuries (i) Crown/root fractures (ii) Luxation injuries (iii) Tooth avulsion (a) Hot tooth (b) Endodontic flare-ups (a) Postobturation pain (b) Vertical root fracture (VRF) Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd.
- 10. Endodontic Emergencies Presenting With Pain or Swelling 1) Crown Originating Fracture denotes an incomplete fracture of a tooth with a vital pulp. The fracture involves enamel and dentin, often involving the dental pulp. Etiology Clinical Features / Symptoms Diagnosis Pain on release of biting force Pain to Cold Stimulus Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd.
- 11. Management of Crown Originating Fractures GOAL : Prevent separation and reduce bacterial colonization between cracks Treatment option depends on : pulpal status & extent of fracture Reversible Pulpitis Diagnostic banding for 2 weeks SYMPTOMS Irreversible Pulpitis Uncomplicated Fractures Complicated Fractures Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd.
- 12. Symptomatic Reversible Pulpitis Reversible pulpitis is a mild-to-moderate inflammatory condition of the pulp caused by noxious stimuli in which the pulp is capable of returning to the uninflamed state following removal of the stimuli Cause Symptoms Treatment - Short / Sharp pain lasting for a moment - Pain is specific to a stimulus - Pain subsides on removal of stimulus - Cold Stimulus > Hot Stimulus CAUSATIVE AGENT Dull Bur Desiccation Thermal Shock Trauma Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd.
- 13. Symptomatic Irreversible Pulpitis Irreversible pulpitis is a persistent inflammatory condition of the pulp, symptomatic or asymptomatic in nature with the pulp becoming incapable of healing. Cause Symptoms Treatment - Lingering pain due to cold stimulus even after removal of stimulus - Sharp / Piercing / Shooting pain - Nocturnal and Postural pain Chemical Thermal Mechanical Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd.
- 14. Primary Symptomatic Apical Periodontitis Primary symptomatic apical periodontitis is a painful inflammation of the periodontium as a result of trauma, irritation, or infection through the root canal, regardless of whether the pulp is vital or non-vital, producing clinical symptom including painful response to biting and percussion. Cause Symptoms Treatment • Vital Tooth - Abnormal Occlusal Contacts - High points in recent restorations - Traumatic Blow to teeth • Non - Vital Tooth - Sequelae of pulpal disease - Tenderness on percussion - Extruded feeling of tooth - Pain on closure or mastication CAUSATIVE AGENT - Adjustment of high points - Removal of irritants Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd.
- 15. Secondary Symptomatic Apical Periodontitis (Phoenix Abscess) This condition is an acute inflammatory reaction superimposed on an existing asymptomatic apical periodontitis. Cause Symptoms Treatment Asymptomatic Apical Periodontitis (State of equilibrium) Noxious Stimuli from diseased pulp Acute inflammatory response (Phoenix Abscess) Initially – Tender to percussion Elevation from socket – more sensitive Mucosa around the tooth appears swollen and red Note : Distinct peri-radicular radiographic changes Access opening to be done Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd. Drainage BMP Closed Dressing Calcium Hydroxide Recall - 2 weeks
- 16. Symptomatic (Acute) Alveolar Abscess Cause Symptoms Treatment symptomatic (acute) apical abscess is an inflammatory reaction to pulpal infection and necrosis characterized by rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus formation, and eventual swelling of associated tissues. Bacterial Invasion of dead pulp tissue History of trauma Long standing infection Tenderness of tooth – alleviated by pressure on tooth Fluctuant swelling of overlying tissue Throbbing Pain Note : Local Anesthesia is contraindicated in acute abscess cases Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd. Access opening to be done Drainage BMP Closed Dressing Calcium Hydroxide Recall - 2 weeks
- 17. Achieving Drainage Through Root Canals Pain reduction in necrotic teeth with swellings LOCAL ANESTHESIA CONSIDERATIONS - Acidic Environment - Painful - May spread infection into facial spaces Conduction Anesthesia Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd.
- 18. Clinical Protocol Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd. Draining purulent exudate Draining purulent exudate Analgesics Antibiotics in systemic involvement
- 19. Clinical Protocol Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd. CLINICAL NOTES NO OPEN DRESSINGS BETWEEN APPOINTMETS STABILIZE TOOTH BEFORE ACCESS OPENING
- 20. Incision & Drainage Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd. Dull, boring, excruciating pain Pain is relieved Sinus Tract Formation Symptomatic Acute Alveolar Abscess Asymptomatic Chronic Alveolar Abscess Incision in the dependent part of the swelling Abscess 24-48 Hours
- 21. Incision & Drainage Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd. Clinical Protocol : Dry Tissue Apply Anesthetic Puncture with no. 11 surgical blade Incision to facilitate drainage Soft tissue compression Antibiotics or Analgesics if needed De-occlude the tooth Selective Occlusal Grinding
- 22. Antibiotic Regimen Removal of micro-organisms and their by products from root canal Over 700 species of micro-organisms identified Local & Systemic Use Symptomatic Apical Periodontitis Good Drainage Antibiotics - General health affected due to peri-apical inflammation - Medically Compromised patients - Abscesses on the floor of the mouth - Pain without signs and symptoms of infection - Teeth with necrotic pulps and a radiolucency - Presence of Sinus Tract - Localized fluctuant swellings Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd.
- 23. When to Prescribe Systemic Antibiotics In Endodontics? Balasubramaniam R, Jayakumar S. Antibiotics in endodontics-A concise review. IJADS. 2017;3(4):323-9.
- 24. How much to prescribe? Amoxicillin Clindamycin Ciprofloxacin Metronidazole Augmentin Dosage Effectiveness 1000mg loading dose / 500mg – 8 hourly for 5 to 7 days 250mg - 500mg / 4 times in a day 500mg / 2 times in a day 600mg loading dose / 300mg – 6 hourly for 5 to 7 days 1000mg loading dose / 500mg – 8 hourly for 5 to 7 days Gram Positive > Gram Negative Anaerobes > Aerobes Gram Negative > Gram Positive Aerobes gram-positive facultative microorganisms / anaerobes / certain gram negative organisms Balasubramaniam R, Jayakumar S. Antibiotics in endodontics-A concise review. IJADS. 2017;3(4):323-9. Gram Positive / Gram Negative
- 26. Luxation Injuries Trauma to supporting structures of periodontium Disrupts blood supply to pulp
- 27. Luxation Injuries Concussion: An injury to the tooth-supporting structures with abnormal loosening or displacement of the tooth, but with marked reaction to percussion. Subluxation: An injury to the tooth-supporting structures with abnormal loosening, but without displacement of the tooth. Intrusive luxation: Displacement of the tooth into the alveolar bone. This injury is accompanied by communition or fracture of the alveolar socket. Extrusive luxation: Partial displacement of the tooth out of its socket. Lateral luxation: Displacement of the tooth in a direction other than axially. This is accompanied by communition or fracture of the alveolar socket. Avulsion: Complete displacement of the tooth out of its socket Andreasen JO, Andreasen FM. Textbook and Color Atlas of Traumatic Injuries to the Teeth, 3rd edition, Copenhagen Munksgaard, 1994.
- 28. Luxation Injuries Immediate Management Concussion Lateral Luxation Intrusive Luxation Extrusive Luxation Subluxation The Recommended Guidelines of the American Association of Endodontists for the Treatment of Traumatic Dental Injuries, 2013 If Needed Rinse the area with Saline 2 Weeks Upto 7mm - Allow re-eruption No movement - ortho/surgical repositioning within 3 weeks More than 7mm - ortho/surgical repositioning within 3 weeks Flexible Splinting 2 Weeks 3mm / < 17 y/o - allow re-eruption - No movement in 3 weeks – reposition surgically/ortho 3-7mm - reposition ortho/surgically within 3 weeks > 7mm - reposition surgically - splint for 2 weeks or 4 weeks if extensive / suture cervically Rinse the area with Saline 2 weeks / 4 weeks
- 29. Luxation Injuries Endodontic Management Concussion Lateral Luxation Intrusive Luxation Extrusive Luxation Subluxation The Recommended Guidelines of the American Association of Endodontists for the Treatment of Traumatic Dental Injuries, 2013 Revascularization Apexification Revascularization Apexification Revascularization Apexification 2 weeks CaOH Dressing End of 4 weeks Splint Removed Repositioning Flexible Splinting 4 Weeks Repositioning Flexible Splinting 4 Weeks Repositioning Flexible Splinting 4 Weeks 2 weeks End of 4 weeks Splint Removed
- 31. Avulsion Injuries Complete displacement of the tooth out of its socket (W.H.O) INCIDENCE BIOLOGICAL CONSEQUENCES Pulp Necrosis Due to disruption of blood supply Surface Resorption Inflammatory Resorption Replacement Resorption Internal & External Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd.
- 32. Management of Avulsion Injuries Replanted Tooth Kept in medium / stored dry up-to 60 mins Extra oral dry time > 60 mins Leave tooth in place After 7-10 days CaOH – 1 Month Obturation Splint Removal 1-2 weeks After 7-10 days CaOH – 1 Month Obturation Splint Removal 1-2 weeks Carefully remove necrotic tissue from root 2% NaF CaOH 1-2 weeks The Recommended Guidelines of the American Association of Endodontists for the Treatment of Traumatic Dental Injuries, 2013 Splint Removal after 2 weeks
- 33. Management of Avulsion Injuries The Recommended Guidelines of the American Association of Endodontists for the Treatment of Traumatic Dental Injuries, 2013 Replanted Tooth Kept in medium / stored dry up-to 60 mins Extra oral dry time > 60 mins Leave tooth in place After 7-10 days CaOH – 1 Month Obturation Splint Removal 1-2 weeks Doxycycline / Minocycline (1mg per 20 ml of saline) 5 minutes Irrigate socket with saline 1-2 weeks Remove necrotic tissue using gauze Irrigate socket with saline 4 weeks
- 34. Revolutionizing Avulsed Tooth Replantation : Stem Cells New Proposed Avulsed Tooth Management Protocol : •Situation A: Extraoral time <1 hour, tooth kept wet • Immediate replantation with PRF •Situation B: Extraoral time 2-7 days, tooth kept wet • Root canal treatment (RCT), replant with PRF •Situation C: Extraoral time <7 days, tooth dry • RCT, cell-mediated therapy •Situation D: Extraoral time >7 days, tooth wet or dry • RCT, cell-based therapy •Situation E: Extraoral time >weeks, tooth wet or dry • RCT, create socket space, cell-based replantation
- 36. Hot Tooth The term "hot" tooth generally refers to a pulp that has been diagnosed with irreversible pulpitis, with spontaneous moderate-to-severe pain Seal M, Dhanya Kumar N. The Hot Tooth Dilemma. CODS J Dent 2012; 4 (2):1-4. Cause Acute Exacerbation (Due to influx of inflammatory mediators and pro-inflammatory neuropeptides) These mediators sensitize the peripheral nociceptors within the pulp of the affected tooth Pain production and neuronal excitability Note : Highest occurrence in Mandibular First Molars
- 37. Management IANB + Buccal Infiltration Inferior Alveolar Nerve Block Buccal Infiltration with 4% Articaine with 1:100,000 epinephrine Buffering Mixing the anaesthetic solution with sodium bicarbonate Supplemental Intraligamentary Injection 0.2 ml deposited in PDL space using 27 gauge needle Intra-pulpal Injection Painful Injection 27 gauge needle wedged into the chamber L.A. solution injected under pressure Seal M, Dhanya Kumar N. The Hot Tooth Dilemma. CODS J Dent 2012; 4 (2):1-4.
- 38. Endodontic Flare-Up An endodontic flare-up is an acute exacerbation of an asymptomatic pulp or periapical pathosis after the initiation or continuation of root canal treatment. PREDISPOSING FACTORS MECHANISM MANAGEMENT Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd.
- 39. Predisposing Factors Pre-operative history of pain Pulpoperiapical Status (Acute Alveolar Abscess > Vital Pulp) Overinstrumentation Underinstrumentation Apical Extrusion of debris Apical Extrusion of Irrigants Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd.
- 40. Hypochlorite Accident Inadvertent extrusion of irrigant beyond the periapex, termed sodium hypochlorite accident, may be one of the serious causes of endodontic flare-ups. Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd. SIGNS NaOCl (Hypertonic) Enters peri radicular area Blood Capillaries Swell More blood flows into the area Body’s natural reflex to dilute NaOCl
- 41. de Sermeño RF, da Silva LA, Herrera H, Herrera H, Silva RA, Leonardo MR. Tissue damage after sodium hypochlorite extrusion during root canal treatment. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2009 Jul 1;108(1):e46-9. 65 y/o 23 - RCT initiated Complex medical history 5% NaOCl used Sudden pain during irrigation Severe Facial Swelling No paresthesia Grade 2 mobility Irregular PDL space air emphysema - extravasation of sodium hypochlorite solution
- 42. Management Immediate Treatment Plan Follow Up de Sermeño RF, da Silva LA, Herrera H, Herrera H, Silva RA, Leonardo MR. Tissue damage after sodium hypochlorite extrusion during root canal treatment. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2009 Jul 1;108(1):e46-9. Tissue Dissolution Healthy / Infected Follow Up Antibiotics & Analgesics Steroids & Vitamins 24 – 48 hrs 1 week 2-3 weeks
- 43. de Sermeño RF, da Silva LA, Herrera H, Herrera H, Silva RA, Leonardo MR. Tissue damage after sodium hypochlorite extrusion during root canal treatment. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2009 Jul 1;108(1):e46-9. General Health Evaluation Discharged 48 hours later Medications Continued RCT completed 1 week later 2.5% NaOCl / 14.3% buffered EDTA CaOH dressing given, replaced 15 days later Obturation done with CaOH based sealer Ecchymosis / swelling resolved
- 44. Clinical Notes Modified technique for NaOCl irrigation Open Apex Do NOT wedge needles in canals Highest incidence in Re-treatment cases Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd.
- 45. Mechanism of Endodontic Flare-Up Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd. Microbial infection and periapical inflammation Local adaptation response (asymptomatic phase) Introduction of irritants (e.g., microbial by-products, irrigants, medicaments) Severe inflammatory response triggered Endodontic flare-up (pain, swelling, or other symptoms)
- 46. Management of Endodontic Flare-Up Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd. NSAID’s & Acetaminophen Antibiotics (if required) Long Acting Local Anestheisa Occlusal High Point Reduction Anxiety Reduction
- 48. Post Obturation Pain Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd. Pts. complain of pain post RCT Post teeth most commonly effected Etiology
- 49. Post Obturation Pain Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd. Over-Extended Obturation Under-Obturation Peri-apical inflammation – firing of proprioceptive nerve fibers in PDL Short lived results – abate in 24-28 hours No treatment required Incomplete cleaning & shaping of root canal Presence of viable pulp tissue Failure of resolution of inflammation RETREATMENT
- 50. Post Obturation Pain Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd. Persistent Pain High Occlusal Points Failure of resolution of pain Selective Occlusal Grinding Remnant pulpal tissue Retreatment Treatment
- 51. Management of Post Obturation Pain Garg, N., Garg, A. (2020). Textbook of Endodontics (4th ed.). Jaypee Brothers Medical Publishers.
- 52. Vertical Root Fracture 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. Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd. Etiology : Post Placement Condensation during obturation Traumatic Occlusion Pre-existing Cracks Excessive Load on Endodontically treated teeth Bruxism Corrosion & Expansion of metallic posts
- 53. Vertical Root Fracture Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd. Diagnosis Buccolingual Direction Proximal Surfaces Root Involvement Inconsistent Signs CBCT Imaging 2D x-rays not precise
- 54. Vertical Root Fracture Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd. Diagnosis Deep and narrow periodontal defect Sinus tract positioned more coronally in attached gingiva J – Shaped Radiolucency
- 55. Vertical Root Fracture : Management Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd. Conventional Root Removal Hemi-section for multirooted teeth Unique Suggested Calcium Hydroxide Placement Cementation with adhesive resins, epoxies, glass ionomer
- 56. Conclusion In conclusion, endodontic emergencies are critical situations that require prompt diagnosis and treatment. They encompass a range of conditions such as acute pulpitis, apical periodontitis, and abscesses. Effective management relies on proper case assessment, timely intervention, pain control, and prevention of complications. A multidisciplinary approach and collaboration with specialists further ensure successful outcomes and patient satisfaction.
- 57. References Inman, B. S., & Grossman, L. I. (2021). Grossman's Endodontic Practice (14th ed.). Wolters Kluwer India Pvt. Ltd. de Sermeño RF, da Silva LA, Herrera H, Herrera H, Silva RA, Leonardo MR. Tissue damage after sodium hypochlorite extrusion during root canal treatment. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2009 Jul 1;108(1):e46-9. Seal M, Dhanya Kumar N. The Hot Tooth Dilemma. CODS J Dent 2012; 4 (2):1-4. Torabinejad, M., & Walton, R. E. (2014). Endodontics: Principles and Practice (5th ed.). St. Louis, MO: Elsevier Saunders. Garg, N., & Garg, A. (2013). Textbook of Endodontics (2nd ed.). New Delhi, India: Jaypee Brothers Medical Publishers. Tronstad, L. (2008). Clinical Endodontics: A Textbook (3rd ed.). New York, NY: Thieme Medical Publishers. Balasubramaniam R, Jayakumar S. Antibiotics in endodontics-A concise review. IJADS. 2017;3(4):323-9. Ingle, J. I., Bakland, L. K., & Baumgartner, J. C. (2008). Ingle's Endodontics (7th ed.). Hamilton, Ontario, Canada: BC Decker Inc.
- 58. Thank You For Your Time.
Editor's Notes
- A very good morning, respected HOD, Senior professors and my dear colleagues, I'd like to start with a quote that resonates with our field: "The art of dentistry exists at the intersection of science, precision, and compassion.“ As a postgraduate dental student, I'm thrilled to present on a critical topic in dentistry: endodontic emergencies. These situations challenge our expertise and empathetic approach, as they cause significant pain and anxiety for patients. In this presentation, we'll explore endodontic emergencies, their diagnosis and management, and the latest advancements in the field. By the end, you'll be better equipped to tackle these challenges with confidence and compassion.
- Endodontic emergencies are conditions characterized by pain and/or swelling that necessitate immediate diagnosis and treatment. The primary culprits behind these emergencies are pulpal pathologies and traumatic injuries. It's important to note that pain can arise from either the pulp or the periradicular area. In endodontic emergencies, pain is primarily linked to two factors: chemical mediators and pressure. Chemical mediators directly cause pain by lowering the pain threshold of sensory nerve fibers or by increasing vascular permeability, leading to edema. The resulting increased fluid pressure from edema also stimulates pain receptors.
- Every clinician has to understand the fact that an Emergency and Urgency are not the same thing An emergency is a sudden, unexpected situation requiring immediate action to protect lives, property, or the environment, often involving potential harm or danger. Urgency indicates a less severe problem; a visit may be scheduled for mutual convenience of the patient and the dentist. Ask these 3 questions to the patient a true emergency disrupts daily quality of life true emergencies remain severe till a few hours to 2 days analgesics do not relieve the pain of a true emergency
- 1. Listening: Actively hear and acknowledge the patient's concerns, ensuring they feel valued and understood during their endodontic emergency. 2. Understanding: Empathize with the patient's pain and anxiety, considering their unique situation to better address their needs. 3. Integrating: Combine the patient's history, symptoms, and clinical findings to create a comprehensive understanding of their endodontic issue. 4. Analyzing: Evaluate the available diagnostic information to identify the most appropriate course of action for the patient's endodontic emergency. 5. Synthesizing: Develop a well-rounded treatment plan that addresses the patient's immediate needs while considering long-term oral health goals.
- Can arise due to parafunctional habits such as bruxism, nail-biting or due to iatrogenic errors like fractures caused due to instruments used or during tooth preparation or restorations clinical features of COF include cracks running in the occluso-cervical direction Characteristic symptom of COF is pain upon release of bite pressure (rebound pain) pain on application of cold stimulus Diagnosis : visual examination : fibre optic transillumination – light does not pass through the portion of tooth where the crack has propagated By using a device called tooth slooth, concave end is placed on each cusp and pt is asked to bite through magnification : using loupes or visualizing the tooth under a microscope dye staining can be used to rule out fractures – methylene blue
- If the initial diagnosis is reversible pulpitis : no lingering pain to cold stimulus / no spontaneous severe pain – a 2 week waiting period is recommended Tooth is stabilized with an orthodontic band for these 2 weeks if pt. has uncomplicated fracture invl enamel and dentin, a full crown restoration which will immobilize the fragments may be successful if the diagnosis is irreversible pulpitis, this would necessitate a RCT followed by a full coverage restoration
- Causes include injury from a blow or due to disturbed occlusal relationship thermal shock : preparing cavity with a dull bur or keeping bur in contact with the tooth for too long excessive desiccation of the cavity or irritation of the dentinal tubules at the neck of the tooth symptoms include 1) short and sharp pain lasting for a moment 2) pain is specific to a stimulus 3) pain subsides upon removal of the stimulus 4) tooth more responsive to cold stimulus rather than hot treatment modality includes removal of causative agent
- Causes: 1) Thermal: Prolonged exposure to extreme hot or cold temperatures causing pulp damage 2) Mechanical: Traumatic injury, repeated dental procedures, or excessive occlusal forces 3) Bacterial: Advanced dental caries, severe periodontal disease, or pulp exposure during restorations Symptoms: 1) Lingering pain due to cold stimulus even after removal of stimulus 2) Pain worsens with thermal stimuli, especially heat or cold 3) Difficulty pinpointing the affected tooth 4) Possible swelling or tooth sensitivity Treatment: 1) Root canal therapy or tooth extraction 2) Pain management and infection prevention 3) Appropriate tooth restoration or replacement 4) Regular dental care and follow-up
- Change of pH in the area will not allow the ionization of the molecules of the drug hence rendering the anesthetic ineffective
- Rubber dam is placed access opening is done while keeping a finger on the tooth to minimize vibrations caused due to the bur pulp chamber is irrigated profusely and debrided root canal orifices are located and the tooth is instrumented within 1mm of root apex pus discharge from within the tooth can be observed If there’s no pus discharge, 8 or 10 number file is extruded 1mm out of the apex to facilitate drainage if still there’s no discharge, canals are instrumented within 1mm of apex ICM is placed if blood and pus discharge doesn’t stop irrigate profusely and place a sterile cotton in the pulp chamber and make the patient wait for some time cotton can be removed after some time canals should be re-irrigated and ICM should be placed prescribe the patient analgesics or antibiotics if there’s systemic involvement pt is recalled after 2 weeks, the pulpoperiapical status and canals are observed, later RCT is completed
- Salivary contamination and bacterial buildup when open dressing done stabilization causes less vibrations leading to less pain while doing access openings
- - Pain in acute abscess could be periradicular or periodontal origin, assess clinically and radiographically - Excruciating pressure pain due to confined exudate - Pain relief is achieved when exudate penetrates cortical plate into : 2 scenarios when pain diminishes : natural sinus drainage / surgical incision & drainage - Importance of timely drainage for healing – Timely drainage is crucial for healing as it alleviates the built-up pressure from the exudate, reducing pain and preventing further tissue damage or infection spread. Prompt drainage also accelerates recovery and reduces the risk of complications. Swelling diminishes in 24-48 hours when its slight and localized and good drainage is established Prescribe hot saline holds and rinses : Hot saline holds and rinses provide pain relief, reduce inflammation, and offer antiseptic properties, all while promoting improved oral hygiene, making them an effective adjunct therapy for managing acute alveolar abscesses. - Extensive swelling: soft tissue incision may be necessary - perform incision at the most dependant portion of the swelling / abscess
- Dry the tissues with sterile gauze - Apply topical anesthetic spray or jelly before giving incision in the swelling [ why do we not give L.A. to a patient with abscess and swelling : 1. Inadequate anesthesia: In the presence of an active infection and inflammation, the local tissue becomes acidic. Local anesthetics are less effective in an acidic environment, which can result in inadequate pain relief during dental procedures. 2. Risk of spreading infection: Injecting local anesthesia into an inflamed and infected area may inadvertently spread the infection to adjacent tissues or introduce new bacteria, potentially worsening the condition. 3. Increased pain: Injecting local anesthesia into an already swollen and inflamed area can cause additional pain and discomfort for the patient ] - Puncture the most dependent part of the swelling with a no. 11 bp blade down to the cortical bone - Periosteal elevator is then used to dissect the incision area to facilitate drainage - Soft tissue compression is performed to facilitate drainage from the site - Disocclude the tooth if it’s in contact with the opposing tooth (eliminates pain caused by contact with teeth in the opposing arch)
- Root canal treatment is essential for addressing infections within the tooth's root canal system, which can harbor over 700 species of microorganisms and their byproducts. The goal is to thoroughly clean and disinfect the root canal, ensuring a successful outcome and preventing future complications. Striking the right balance between mechanical treatment, the use of irrigants, and the judicious prescription of antibiotics is crucial for optimal dental health, as it minimizes the risk of antibiotic resistance while effectively managing infections. ~ Antibiotics can be prescribed in medically compromised patients and patients having abscess on their floor of mouth ~ While they should not be prescribed in asymptomatic patients with no signs of infection & Teeth with necrotic pulps and radiolucency & when there’s a sinus tract associated with the particular tooth & in Localized fluctuant swellings
- In dentistry, there are various situations that may require different approaches to treatment. For example, in cases of symptomatic or asymptomatic apical periodontitis, an acute apical abscess with systemic involvement, or when treating immunosuppressed patients, the use of systemic antibiotics may be necessary in conjunction with local debridement. However, in cases of only apical abscess or cellulitis/space infection, debridement of the root canal and the use of intracanal medicaments may be sufficient without the need for systemic antibiotics. It is essential to understand these distinctions in order to provide appropriate care. In some instances, no antibiotics are required, and local debridement is sufficient. In other cases, both local debridement and systemic antibiotics are needed to effectively treat the infection. The key is to accurately assess the patient's condition and choose the most suitable treatment option to ensure successful outcomes and minimize the risk of antibiotic resistance.
- Luxation injuries cause trauma to the supporting structures of periodontium it might lead to a disruption in the apical blood supply
- Surface resorption is a process that happens in teeth, specifically in the outer layers called cementum and dentin. When there is some physical damage to these layers, the body starts a repair process. First, macrophages (a type of immune cell) come in to remove the damaged tissue. After that, other cells are recruited to rebuild and repair the area. During this process, small shallow cavities called resorption cavities form, but they are usually not a cause for concern as they are part of the natural repair process. it occurs as a result of necrotic pulp becoming infected in presence of severely damaged cementum. This infected pulp allows bacterial toxins to migrate out through the dentinal tubules into the periodontal ligament causing resorption of both root and adjacent bone This kind of resorptive process is associated with teeth with extensively damaged cementum and PDL. Avulsion injuries are classic examples of teeth showing such resorptive patterns. The loss of the PDL and cementum exposes the root surface to osteoclasts that replace the cementum and dentin with new bone resulting in the fusion of the bone and the tooth
- 🩸 PRF and tooth reimplantation: - Platelet-rich fibrin (PRF) is a blood-derived biomaterial containing growth factors and cytokines. - PRF promotes tissue regeneration, accelerates healing, and reduces inflammation. - In tooth reimplantation, PRF enhances periodontal ligament (PDL) cell migration, adhesion, and proliferation, improving root reattachment and long-term prognosis. - PRF also helps in the repair and regeneration of alveolar bone and cementum. 2) 🦷 PDL stem cells and tooth reimplantation: - PDL stem cells are multipotent cells found in the periodontal ligament. - They have the ability to differentiate into various cell types like osteoblasts, cementoblasts, and fibroblasts. - In tooth reimplantation, PDL stem cells help regenerate the periodontal ligament, alveolar bone, and cementum. - This regeneration process supports tooth stability and function, promoting a successful reimplantation outcome. 3) 📉 Resorption risk with PRF and PDL stem cells: - Using PRF and PDL stem cells in tooth reimplantation may reduce the chances of resorption. PRF's growth factors and cytokines improve healing and prevent inflammation - PDL stem cells promote the regeneration of periodontal tissues, reducing the risk of ankylosis or replacement resorption. - However, the exact risk reduction depends on various factors, including extraoral time, tooth condition, and reimplantation techniques.
- C-fibers are nerve fibers that transmit pain signals in our body. There are special sodium channels on these fibers that help control the flow of signals. These channels can be either tetrodotoxin-resistant (TTXr) or tetrodotoxin-sensitive (TTXs). During inflammation or injury, the channels change from TTXs to TTXr. This change makes the nerve fibers more sensitive and can increase pain. TTXr sodium channels are harder to block with anesthetics like lidocaine, which means it's more difficult to numb the pain in these situations. "Hot tooth" is a term that might refer to a situation where the anesthetic isn't working well because the TTXr channels are not being blocked effectively. This can result in continued pain despite the use of anesthetic.
- The reason behind this management approach is to provide better pain relief by targeting the tooth from multiple angles. Articaine is a potent local anesthetic that can penetrate inflamed tissue more effectively than other anesthetics. The epinephrine helps to constrict blood vessels, which can reduce bleeding during the procedure and also prolong the anesthetic effect by keeping it localized in the area of injection. Local anesthetics work best in a neutral or slightly alkaline environment. When the anesthetic solution is injected into inflamed tissues, the acidic environment can slow down the onset of anesthesia and reduce its effectiveness. By adding sodium bicarbonate to the anesthetic solution, the pH of the solution becomes more alkaline, which can counteract the acidic environment in the inflamed area.
- sodium hypochlorite is a strong solution that can cause tissues to swell if it comes in contact with them. When it touches the tissues around the root of a tooth, it makes the small blood vessels expand. This causes more blood to flow into the area, which is the body's natural way of trying to dilute the strong sodium hypochlorite and reduce its concentration.
- Steroids: Prednisone or Dexamethasone (consult a physician for appropriate choice and dosage) Vitamins: Vitamin C, Vitamin A, and Vitamin E (to support tissue repair, immune function, and reduce inflammation)
- General health evaluation for systemic problems (cirrhosis hepatica, diabetes mellitus, hypertension) Continued regular medications and prescribed antibiotics Discharged 48 hours later, emphysema signs and symptoms persisted One week later, endodontic treatment resumed Sodium hypochlorite extrusion symptoms still present Intraoral exam showed apical abscess and draining fistula Root canal treatment performed with proper isolation, disinfection, and irrigation Calcium hydroxide-based intracanal dressing applied, replaced after 15 days Root canal filling completed with gutta-percha cones and calcium hydroxide-based sealer Permanent restoration placed Ecchymosis and swelling resolved, normal mouth opening restored
- Be very careful while irrigating teeth with open apex as it might lead to extrusion of the irritant irrigant in Open apex cases, irrigation is done very carefully
- 1) Microbial infection and periapical inflammation: Endodontic flare-ups often begin with a microbial infection that causes inflammation at the tooth's periapical region. 2) Local adaptation response (asymptomatic phase): Initially, the body's immune system tries to adapt and control the infection, leading to an asymptomatic phase without noticeable symptoms. 3) Introduction of irritants: The situation can be exacerbated by the introduction of irritants, such as microbial byproducts, irrigants, or medicaments used during endodontic treatment. 4) Severe inflammatory response triggered: These irritants may trigger a severe inflammatory response, causing the immune system to become overwhelmed. 5) Endodontic flare-up: As a result, patients may experience endodontic flare-ups, characterized by pain, swelling, or other acute symptoms.
- Non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen: These medications can help relieve pain and reduce inflammation. NSAIDs like ibuprofen and naproxen are particularly effective in managing dental pain. Long-acting local anesthesia: Local anesthesia can be used to provide pain relief and reduce swelling. Long-acting anesthetics like bupivacaine can provide pain relief for up to several hours. Antibiotics (if required): If the flare-up is caused by a bacterial infection, antibiotics may be necessary to treat the infection. Amoxicillin is the most commonly prescribed antibiotic for endodontic infections. Anxiety reduction: Endodontic flare-ups can be stressful, and anxiety can exacerbate the symptoms. Practicing relaxation techniques like deep breathing, meditation, or yoga can help reduce anxiety and stress. Occlusal high point reduction: Occlusal high points can cause excessive pressure on the treated tooth, leading to pain and discomfort. Adjusting the occlusion can help relieve the pressure and reduce symptoms.
- Chances of experiencing postoperative discomfort increase if pain is present preoperatively. Painful episodes are caused by pressure exerted by insertion of root canal filling materials or by chemical irritation from ingredients of root canal cements and pastes 1) Overinstrumentation: Excessive filing during root canal treatment can cause post-obturation pain by irritating the periapical tissues. 2) Pulpo-periapical status: Pre-existing inflammation or infection in the pulpo-periapical region can contribute to post-obturation pain. 3) High points: Improper occlusal adjustment can lead to high points, causing discomfort and pain after obturation. 4) Overextended obturation: Extrusion of filling materials beyond the apex can cause irritation and inflammation, leading to post-obturation pain. 5) Missed canal: Failing to identify and treat all root canals can leave residual infection, causing pain after obturation. 6) Incomplete coronal seal: An inadequate seal at the tooth's crown can allow bacterial leakage, leading to re-infection and post-obturation pain. 7) Traumatic injuries of teeth: Teeth with a history of trauma may have a higher risk of post-obturation pain due to compromised pulp or periapical tissue.
- Trauma: Accidents or sports injuries can cause vertical root fractures in non-endodontically treated teeth. The impact may result in a fracture that extends longitudinally along the root. Occlusal forces: Excessive biting forces or parafunctional habits, such as bruxism (teeth grinding), can generate stress on the tooth structure, potentially leading to vertical root fractures in teeth without prior endodontic treatment. Structural anomalies: Teeth with structural abnormalities, such as developmental grooves or dilacerations, are more susceptible to vertical root fractures even without endodontic treatment. Pre-existing cracks: In some cases, teeth may have pre-existing, undetected cracks that can eventually develop into vertical root fractures due to continued stress or force. Iatrogenic causes: Dental procedures, such as crown or post preparations, may inadvertently introduce excessive forces or stress concentrations that can lead to vertical root fractures in non-endodontically treated teeth
- 1. Buccolingual direction: In diagnosing VRF, considering the buccolingual direction is vital to detect fractures that may extend from the buccal to lingual aspect of the tooth. 2. Proximal surfaces: Inspect proximal surfaces for any signs of VRF, as fractures may manifest along the mesial or distal aspects of the tooth. 3. Root involvement: Assess root involvement to determine the extent of the VRF, which impacts treatment options and prognosis. 4. Inconsistent signs: VRF diagnosis can be challenging due to inconsistent clinical signs, making it crucial to combine multiple diagnostic methods. 5. CBCT imaging: Cone-beam computed tomography (CBCT) is a valuable tool in VRF detection, providing three-dimensional views and enhanced visualization of the tooth structure. 6. Fracture size: Smaller fractures may be difficult to detect, requiring careful assessment and advanced imaging techniques to ensure accurate diagnosis. 7. Imaging artifacts: Be aware of potential imaging artifacts that can mimic VRF, leading to false-positive results and unnecessary interventions. 8. Varying specificity: Diagnostic methods have varying specificity for VRF, necessitating the use of multiple tools and clinical judgment to reach a conclusive diagnosis. 9. Surgical validation: In some cases, surgical exploration may be required to confirm the presence of a VRF, ultimately guiding appropriate treatment decisions.