This is a short presentation elaborating on Hot tooth and its management. It is a type of pre-treatment endodontic emergency. Most common failure for anaesthesia. Supplementary anaesthetic techniques are also briefed .

1. PRESENTED BY
ABIRAMI VETRISELVAN

2. 
 The term "hot" tooth generally refers to a pulp that has been
diagnosed with irreversible pulpitis, with spontaneous,
moderate-to-severe pain.
 Clinically, Hot tooth is a term given to a tooth that is difficult
to anaesthetize.
What is iT?

3. 
 Common sites
 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.
Where ??

4. Hypotheses
for failure of
LA !

5. 
 Tetrodoxin resistant channels (TTXr), a class of sodium
channels resist the action of local anesthesia.
 They are sensitized by prostaglandins and are increased in
inflammed dental pulp thereby stimulating C-fibres for pain
conduction.
 They are 4 to 5 times resistant to blockade by lidocaine.
1.Tetrodoxin resistant channels

7. 
 Nerves from inflamed tissue shows decreased excitability
threshold and altered resting potential. Studies show that
lowered excitability thresholds are responsible for
transmission of impulses even with action of local
anesthetic.
2.Altered Membrane excitability

9. 
3. Ion trapping
 According to this hyphothesis, low tissue pH is responsible for
local anesthetic to being trapped in the charged acid form of
the molecule and thus decreasing its membrane permeability.
DRAWBACK :
 Ion trapping is for infiltration injections only, block injections
are likely to involve acidotic tissues.

11. 
 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.
4. Psychological factors

12.  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 or on biting often radiating from
ear to temple for maxillary teeth.
 Increased sensitivity to temperature extremes.
Symptoms

13. 
 Deep restorations or caries
 Tenderness on percussion
 Coronal fracture lines
 Thickening of the periodontal ligament
 Failure of LA
Signs

14. Management

15.  Most of traditional injections might not work every time,
so the clinician should go for alternative supplemental
injection for managing pain.
 Intraligamentary(Periodontal ligament) Injection
 Intraosseous Injection
 Intraseptal anesthesia
 Intrapulpal Anesthesia
I. Supplemental injections

16. 
 Periodontal ligament (PDL) injection has been reported
showing 50-96% of cases with successful anesthesia for
endodontic procedures .
 But, most of the times, a re-injection is advisable for good
result .
 The duration of pulpal anesthesia to be around 15 min for
single rooted teeth and rather less for lower molar
Intraligamentary
Injection

17. 
 In about 5-10% of mandibular posterior teeth with irreversible
pulpitis, supplement injections even when repeated do not
produce profound anesthesia. When Pain persists when pulp
is entered. This is an indication for an intrapulpal injection.
Intrapulpal Anaesthesia

18. 
Intra-osseous
Intra-osseous Injections
 The onset of intra-osseous anesthesia is rapid. The onset of
anesthesia ranged from 10 s to 120 sand lasts an hour.
 The LA is injected deep into the cancellous bone adjacent to the
tooth.

19. 
Other common injections

20. 
 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.
 Bupivacaine is a better alternative in case of TTX-r conditions.
II. Change in anesthetic solution

21. 
 Use of NSAID as an adjunct 1 hour before the
procedure inhibits the action of prostaglandins that
are the key factor for pain transmission.
III. NSAID

22. 
 Anti-anxiety agents like diazepam or lorazepam can
be given to the patient the previous day of procedure
or 2 hrs before to calm the patient .
IV.Anxiolytics