Emergency Endodontics Flashcards
Types of endo emergency
Pulpitis Periapical infection Cracked tooth Mid and post-treatment flare-ups Trauma involving the pulp Iatrogenic damage involving the pulp
Pulpitis
Reversible
Irreversible
Periapical infection
Symptomatic acute apical periodontitis
Acute apical abscess
Pulpitis
Inflammation of pulp
Reversible pulpitis signs and symptoms
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)
Reversible pulpitis treatment
Remove causative factor
Consider placing temp
Monitor response
RP - instructions
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
Irreversible pulpitis - signs and symptoms
Spontaneous pain Pain persists for hours Pain triggered by heat and in later stages relieved by COLD Kept awake at night Tooth can be TTP but not always Pain can radiate
Irreversible pulpitis - treatment time permitting
If possible
LA Access cavity Remove pulp tissue Coronal 2/3 opening Determine WL Chemo mechanical debridement Copious irrigation Dry canal Place CaOH into canal Place tight seal
Complete RCT at same appt so after DRYING canal, complete obturation and place bacterial seal
Irreversible pulpitis - time not permitting
LA Access Removal of pulp tissue Copious irrigation Dry pulp chamber Place sedative dressing e.g odontopaste Place bacterial tight seal Complete RCT in next few days
Irreversible pulpitis - hot pulps
Painful and hard to anaesthetise due to infection Regional anaesthesia Additional sources of innervation Multiple anaesthetics IL IP IO Inhalational sedation
Irreversible pulpitis treatment if pain does not permit
Remove as much pulp tissue as possible and place sedative
Advise analgesics
not place for antibiotics
Irreversible pulpitis - instructions
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
Symptomatic apical periodontitis - Signs and symptoms
TTP
Tender to palpation especially over apices
Swelling and reddening of mucosa
No responses to vitality testing
Pain can be severe esp in function/pressure
CONSTANT and worsening
Several hours
Symptomatic AP - treatment 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
Symptomatic AP - treatment 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 AP - instructions
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
Acute apical abscess - signs and symptoms
Swelling Severe pain esp on pressure Feeling of elevation in socket Mobility Fever, malaise, lymphadenopathy
Acute apical abscess - treatment
Attempt drainage through tooth LA Access Drain pus via cavity - use diamond bur to reduce vibrations If no pus occurs then explore canal Copious irrigation Dry canal Place CaOH Place tight seal Complete RCT when patient able
Acute apical abscess - treatment when drainage through tooth is inadequate and fluctuant swelling present
LA - spray swelling with EC and place topical Incise swelling VERTICALLY Aspirate pus Copious irrigation Leave to continue to drain and heal Complete RCT when patient is able
Are antibiotics required?
Only when signs of spreading infection - diffuse swelling/trismus
Systemic involvement
Patient is medically compromised
Acute apical abscess - instructions to patient
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
Most commonly affects
Signs and symptoms
Fracture line usually
2nd premolars and first molars
Pain on chewing, cold sensitivity and hot sensitivity , difficult to localise pain
Mesial –> 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
Cracked tooth syndrome - treatment
If no pulpitis
If signs of irreversible pulpitis
If fracture line extends below alveolar crest
Stabilise tooth with adhesive restoration / partial or full coverage crown
Consider using copper or orthodontic band to stabilise tooth to aid diagnosis/provide immediate relief/protection
Endodontic tx followed by full crown
Extraction
Vertical root fractures - features
Deep but narrow perio pocket following path of fracture
J-shaped lesion
Mid and post treatment flare ups can be caused by
Recent restorative treatment
Recent endodontic treatment - mid/post treatment
Recent restorative treatment causing flare up - plan - what to assess
Risk of symptoms related to depth and amount of tooth structure removed and pulpal condition
Assess symptoms and diagnose
Consider monitoring and recommending analgesics, adjusting occlusion, placing sedative dressing and desensitising agent
When do endodontic flare ups occur?
Cause
Mid or post tx
Bacterial contamination/change in flora Poor RD Unsatisfactory temp Inappropriate intracanal medication Entry of debris into periodontium Missed canals Overfill of root filling
Mid and post treatment flare-ups - signs and symptoms
Similar to acute apical periodontitis
Tender to percussion
Tender to palpation especially over the apices
Swelling and reddening of the surrounding mucosa
Pain can be severe especially in function or
pressure
Can be CONSTANT and worsening
Can be present for several hours
Mid and post treatment flare ups - Phoenix 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 treatment flare ups - what to assess
Assess need to re-open root canal
Provide analgesic advice
Follow procedure and ascertain reason for flare up
Leave CaOH well condensed
Advice to patients on Mid treatment flare ups
Return if symptoms get worse
Take analgesics as required
Abs not indicated
Management of post-treatment flare ups
Is treatment possible?
What to advise patient
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 pulp can result from
Complicated crown fracture
History of trauma and exposed pulp and pain
Treatment of pulp-involving trauma
Preserve pulp vitality by pulp capping/partial pulpotomy in young people to secure root development
Endodontics for older patients with closed apices
Pulp capping indication and process
Injury recent LA Isolate Clean Disinfect CaOH over exposed area Seal exposed dentine with GIC/composite Restore with composite
Partial pulpotomy process
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
Follow up of pulp trauma
Which treatment is preferred? and why?
If tooth becomes non-vital, what is the treatment indicated?
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 non-vital, then endodontic
treatment is indicated
Iatrogenic damage involving pulp - two types
Carious
Non-carious
Affects chance of subsequent tx maintaining vitality
Iatrogenic damage involving pulp - non carious exposure
Over prepping indirect restoration
Pulp capping
Good prognosis
Iatrogenic damage involving pulp - carious exposure
Depends on extent of caries
Endo if symptoms of pulpitis exist
Leave affected dentine over pulp and place bacteria tight restoration
Attempt pulp cap or Partial pulpotomy
Pulp-cap versus partial pulpotomy
Why is pulp capping more destructive?
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
