Emergency endodontics Flashcards
Types of endo emergency
Pulpitis (reversible/ irreversible) Periapical infection Cracked tooth Mid & post-tx flare-ups Trauma involving the pulp Iatrogenic damage involving pulp
Types of periapical infection
Symptomatic (acute) apical periodontitis
Acute apical abscess
What is pulpitis?
Inflammation of the pulp
Need to differentiate between reversible and
irreversible pulpitis
This is a clinical diagnosis and cannot be differentiated
histologically
Signs and symptoms of reversible pulpitis
Pain brought on by hot, cold, sweet
Short duration – does not linger for long after removal of the stimulus
Can be very difficult to localise
The tooth may give an exaggerated response to
sensibility testing
Radiographs are generally of normal appearance (no PA radiolucency)
Treatment of reversible pulpitis
Removal of the causative factor e.g. caries, failed restoration etc.
Consider placing temporary restoration such as zn-ox/ eug
Monitor response to tx
Reversible pulpitis: instructions to pt
Pain will gradually decrease
Take analgesics as required
Paracetamol 2x500mg up to QDS
Ibuprofen 2x400mg up to TDS
Prescribe co-codamol (2x30/500mg QDS) only if very severe pain
Emphasise the need to complete treatment if required
Return if symptoms become more severe
Signs and symptoms of irreversible pulpitis
Spontaneous pain Pain persists (hours) Pain triggered by heat and in the later stages relieved by cold Kept awake at night Tooth can be TTP, but not always Pain can radiate
Treatment of irreversible pulpitis (if time and pain permit)
Local anaesthetic Access cavity Removal of pulp tissue (barbed broach) Coronal 2/3 opening Determine working length Complete chemo-mechanical debridement Copious irrigation Dry the canal Place CaOH into canal Place bacteria tight seal *if possible complete RCT at same apt, completing obturation and place bacteria tight seal*
Treatment of irreversible pulpitis (if time does not permit)
Local anaesthetic Access cavity Removal of pulp tissue (barbed brooch) Copious irrigation Dry pulp chamber Place a sedative dressing (eg Leadermix/ Odontopaste) Place bacteria tight seal Complete root canal instrumentation in next few days
Irreversible pulpitis: hot pulps
Sometimes, a tooth with pulpitis can be incredibly painful and difficult to anaesthetise
In this situation, try the following methods:
Regional anaesthesia
Consider additional sources of innervation (eg long buccal)
Multiple anaesthetics (eg lignocaine + articaine)
Intra-ligamentary anaesthesia
Intra-pulpal anaesthesia
Intra-osseous anaesthesia
Consider inhalational sedation
Irreversible pulpitis tx (if pain does not permit)
Attempt to remove as much pulp tissue as possible and
place a sedative dressing
If this is not possible, advise analgesics
THERE IS NO PLACE FOR ANTIBIOTICS IN THE
TREATMENT OF PULPITIS
The patient should return to continue treatment as soon
as possible
Irreversible pulpitis: instructions to pt
Pain will gradually decrease Take analgesics as required Paracetamol 2x500mg up to QDS Ibuprofen 2x400mg up to TDS Prescribe co-codamol (2x30/500mg QDS) only if very severe pain Emphasise the need to complete treatment Return if symptoms become more severe
Signs and symptoms of symptomatic apical periodontitis
Tender to percussion
Tender to palpation especially over the apices
Swelling and reddening of the mucosa
No responses to vitality testing
Pain can be severe especially in function or pressure
Can be CONSTANT and worsening
Can be present for several hours
Tx of symptomatic apical periodontitis (if time permits)
Local anaesthetic Access cavity Coronal 2/3 opening Determine working length Complete chemo-mechanical debridement Copious irrigation Dry the canal Place CaOH into canal Place bacteria tight seal
Tx of symptomatic apical periodontitis (if time does not permit)
Local anaesthetic Access cavity Coronal 2/3 opening Copious irrigation Dry the canal Place CaOH into canal Place bacteria tight seal Complete root canal instrumentation in next few days
symptomatic apical periodontitis: instructions to pt
Pain will gradually decrease Take analgesics as required Paracetamol 2x500mg up to QDS Ibuprofen 2x400mg up to TDS Prescribe co-codamol (2x30/500mg QDS) only if very severe pain Emphasise the need to complete treatment
Signs and symptoms of acute apical abscess
Swelling
Severe pain especially on pressure
Feeling of the tooth being elevated in the socket
Mobility may be present
The patient may experience fever, malaise and
lymphadenopathy
Tx for acute apical abscess
Attempt drainage through the tooth Local anaesthetic (regional?) Access cavity Drain the pus If no pus occurs immediately explore the canal/apex with a small file to encourage pus discharge) Copious irrigation Dry the canal Place CaOH into canal Place bacteria tight seal Complete root canal instrumentation when patient is able
Acute apical abscess tx: burs
Use a diamond bur to reduce vibration
Enter the pulp chamber and watch the pus flow out!
‘Palpate’ or ‘push’ the swelling to maximize discharge
Tx for acute apical abscess if no drainage through tooth (or drainage inadequate) AND fluctuant swelling is present
Local anaesthetic: spray the swelling with ethyl
chloride or place topical LA for 3 minutes (also
consider regional LA)
Incise the swelling VERTICALLY with a scalpel
Aspirate the pus
Copious irrigation
Leave to continue to drain and heal (no need for
sutures)
Complete root canal treatment when patient is able
Acute apical abscess: are abx required?
Only when Signs of spreading infection (diffuse swelling, trismus etc) Signs of systemic involvement (fever, malaise, lymphadenopathy) Certain patients who are severely medically compromised
Acute apical abscess: instructions to pt
Return to the dentist (or attend A&E) if:
The swelling progresses
Difficulty opening mouth
They start to feel unwell
Any difficulty swallowing/ breathing
Return for completion of treatment as soon as possible
following resolution of symptoms
Cracked tooth syndrome
Up to 20% of patients with odontogenic pain had a
cracked tooth (incomplete fracture) as the main cause
Causes include masticatory incidents, bruxism, thermal
cycling etc
Cracked tooth syndrome: which teeth most often affected?
Second premolars and first molars (especially those with large restorations
Symptoms of cracked tooth syndrome
pain on chewing, sensitivity to cold and hot fluids, pain which is difficult to locate
Cracked tooth syndrome fracture line
Usually from mesial to distal
Cracked tooth syndrome diagnosis
Ask the patient to bite on a cottonwool roll, wood stick, or fracture detector (tooth slooth)
Pain on release of pressure is the most reliable aid and most expressive clinical finding
Visual detection of crack
(fibreoptic, staining)
Radiographs are of little value for detection
Treatment for cracked tooth syndrome
No signs of pulpitis: stabilisation of the tooth
with an adhesive restoration or partial/full coverage crown
Consider using a copper or orthodontic band
to stabilise the tooth to aid diagnosis/provide
immediate relief/protection
Signs of irreversible pulpitis (eg symptoms
when not in function): Endodontic treatment followed by full crown
Fracture line extends below the alveolar crest:
Extraction
Cracked tooth syndrome: vertical root fractures
There will be a deep but narrow periodontal pocket which follows the
path of the root fracture
The fracture may be clinically visible, but
often hidden under a restoration and the
gingivae
Look for a ‘J’ shaped lesion on a
radiograph
Difficult to diagnose definitively on a
radiograph unless the two segments
separate
Mid and post-tx flare-ups
Define the source of the pain:
Recent restorative treatment
Recent endodontic treatment (mid-treatment, post-treatment)
Mid and post-tx flare-ups: recent restorative treatment
Risk of symptoms is related to the depth and amount of tooth
structure removed and the condition of the pulp
Need to assess the symptoms and make a diagnosis (reversible/ irreversible pulpitis)
Assess restoration – leakage, occlusion, exposed dentine etc?
Consider monitoring and recommending analgesics, adjusting the occlusion, placing a sedative dressing, desensitising agent etc.
Mid and post-tx flare-ups: endo flare-ups
Can occur either mid-treatment or post-treatment
Usually due to bacterial contamination/change in bacterial flora:
Poor rubber dam technique
Unsatisfactory temporary restoration
Inappropriate intra-canal medication
Incomplete chemo-mechanical preparation
Missed canals
Forcing debris through the apex
Overfill of root filling material
Mid and post-tx flare-ups: signs and symptoms from endo
Similar to acute apical periodontitis Tender to percussion Tender to palpation especially over the apices Swelling and reddening of the mucosa Pain can be severe especially in function or pressure Can be CONSTANT and worsening Can be present for several hours
Mid and post-tx flare-ups: ‘Pheonix abscess’
When a non-vital tooth flares-up when it has
previously been asymptomatic
Probably due to alteration in the internal environment
of the root canal space during instrumentation
Bacterial flora is altered and causes symptoms
Management of mid-tx flare-ups:
Assess the need to re-open the root canal
Is the patient able to tolerate treatment?
Is there clinical time available?
If not re-opening, provide advice regarding analgesics
etc
If re-opening:
Follow conventional procedure
Try to ascertain the reason for the flare-up
Leave the tooth with well condensed CaOH in situ
Management of mid-tx flare-ups: advice to pts
Return if symptoms significantly worsen
The symptoms are unlikely to affect the outcome of the
endodontic procedure
Take analgesics as required
Antibiotics are not indicated
Management of post-tx flare-ups
Often due to bacterial contamination at the apex or overfill of material
Difficult to treat as the root filling is in situ and often also the definitive restoration
Usually best to monitor symptoms and reassure patient that they should resolve with time
Advise appropriate analgesics
There is no indication for antibiotics unless the
previously identified criteria are present
Trauma involving the pulp
A crown fracture involving the pulp is also known as a complicated crown fracture Diagnosis is usually straight forward and based on clinical presentation A history of trauma with exposed pulp and pain will be present
Treatment for trauma involving the pulp
In young patients with open apices, it is very important to preserve pulp
vitality by pulp capping or partial pulpotomy in order to secure further root
development
This treatment is also the treatment of choice in patients with closed apices
Pulp capping should only be attempted if the injury is very recent due to
the risk of contamination
Calcium hydroxide compounds and MTA (white) are suitable materials for
such procedures
In older patients with closed apices and an associated luxation injury with displacement, endodontic treatment is usually the treatment of choice.
Additionally, if the injury is old and there are signs of pulpal necrosis, then
endodontic treatment is indicated
Trauma involving the pulp: pulp capping
Local anaesthetic
Isolate with rubber dam
Clean with water, saline or chlorhexidine
Disinfect with NaOCl
Apply pulp-capping material (either MTA, biodentine
or calcium hydroxide) over exposed pulp tissue
Seal exposed dentine with GIC or composite
Restore remaining tooth with composite
Trauma involving the pulp: partial pulpotomy
Local anaesthetic
Isolate with rubber dam
Clean with water, saline or chlorhexidine
Perform pulpotomy to a depth of 2mm with a clean, round diamond bur under water spray
Place a saline moistened cotton pellet over the pulp until
bleeding has stopped
Apply pulp-capping material (either MTA, biodentine or
calcium hydroxide) over exposed pulp tissue
Seal exposed dentine with GIC or composite
Restore remaining tooth with composite
Trauma involving the pulp: preferred treatment, follow-up and prognosis
Partial pulpotomy should normally be preferred over
pulp-capping due to slightly better long-term
outcomes
Follow-up
Clinical and radiographic follow-up at 6-8 weeks and 1
year
Prognosis
Depends on extent of initial injury, time before
intervention and stage of root development
If the tooth becomes none vital, then endodontic
treatment is indicated
If the tooth is immature, successful treatment can
result in completion of root formation (apexogenesis)
The aim of treatment in
the case of trauma where
the pulp is still vital is to
preserve the vitality of the
pulp
Iatrogenic damage involving pulp
Iatrogenic damage involving the pulp can be divided
into 2 categories
Non-carious exposure
Carious exposure
This affects the chance of the subsequent treatment
maintaining the vitality of the pulp
Extent of bacterial contamination seems to be the most important factor
Non-carious exposure
Usually occurs due to over-enthusiastic
cavity preparation or tooth preparation for an indirect restoration
Although they should ideally be avoided
with careful clinical technique, they
generally have the best prognosis
Management involves pulp capping as
previously described
Prognosis for maintaining a vital pulp is
generally very good, provided a bacteriatight restoration can be provided
Carious exposure
Depends on the extent of the caries and the patient
symptoms
If the exposure still has soft caries over it or the patient has
symptoms of pulpitis, then endodontic treatment should be undertaken
If possible, leave ‘affected dentine’ over the pulp and place a bacteria-tight restoration to prevent pulp exposure
If pulp exposure occurs, but all ‘infected dentine’ has been removed and the patient has no symptoms, attempt a pulp
cap or partial pulpotomy
Iatrogenic damage involving the pulp: Pulp-cap versus partial pulpotomy
Partial pulpotomy is preferred in this situation as it
removes the superficially and potentially infected layer of the pulp
Surrounding dentine is also removed to create a well defined space for the pulp-capping material to be placed
Follow the procedure a s described previously
It is essential to stop the bleeding from the pulp before
placing the pulp-capping material
If bleeding cannot be stopped, proceed to endodontic treatment
