Endo Fall 2017 Sr. Seminar Flashcards
What is external resorption?
External Resorption: physiologic and pathologic process resulting in the loss of dentin or cementum which initial begins in the periodontium and affects the external surfaces of the tooth
Types of external resorption
External -Surface resorption -Replacement resorption (ankyloses) -Inflammatory resorption -Invasive cervical resorption Internal
Radiographic Features of Internal resorption
Sharp, clearly defined outlines/borders Walls of lesion appear to balloon out Lesion is usually symmetrical Lesion does not shift on angled films Canal or pulp chamber cannot be visualized within the defect
Radiographic Features of External resorption
Margins of the radiolucent lesion will appear ragged and irregular
Lesion is usually asymmetrical
Lesion shifts with angled films
Canal space is visible throughout the root and can be followed unaltered to the apex
Clinical and Histopathologic Features of ICR
Normal / vital response
Often asymptomatic
Resorption typically initiates cervically
“pink spot” mistaken for internal resorption
small opening in cementum
opaque outline of pulp
spreads and surrounds pulp seen in lesion
resistant predentin layer
Natural Barriers to Resorption are…
PDL, cementum, predentin, then reaches pulp
Classifications of External Cervical Resorption
Class 1 = shallow penetration into dentin near cervical area
Class 2 = well-defined lesion close to coronal pulp without extension into radicular dentin
Class 3 = lesion extends into coronal 1/3 of root
Class 4 = lesion extends beyond coronal 1/3 of root
Distribution of Predisposing Factors for resorption
Orthodontics: 24.1% Idiopathic: 16.4% Trauma: 15.1% Surgery near CEJ: 5.1% Non-Vital Bleaching: 2.9% (---> increases to 9.7% when other factors combined) Related to heat and supercool 7% incidence resported in post bleaching ICR avoid by: placement of a sound base (>= 2mm) ramp base cervically no heat sodium perborate and water instead of superoxol
Causes of Root resorption
Periodical disease Excess ortho movement, Trauma, Internal resorption, Ectopic eruption, Tumors or metastatic disease, idiopathic
Tx options and prognosis for resorption
External / Surgical Approach Supra Osseous Defects Pulp maintains vitality Mini flap access Infra Osseous Defects Resorption may extend to canal space Crown lengthening needed Repair may result in periodontal defect Lesion may recur
Restorative materials
Amalgam RMGI Resin Ionomer (best perio healing) -Geristore or Dyract -Clinical and histologic evidence of epithelial and CT adherence
Invasive Cervical Resorption Treatment Success Rates
% Success after 3 years/% Requiring NS Endodontics
Class 1: 100/0
Class 2:100/66.7
Class 3:77.8/95.2
Class4:12.5/100
Summary for Resorption
Summary
-External cervical resorption is not rare
-Occurs in areas often not covered by BWXR’s
-Detected during exam, PSR probing
-Diagnose using angled radiographs, ancillary images
-Treatment planning is critical
-What’s the strategic value of the tooth, how extensive
is the lesion, what are the possible periodontal
outcomes, repair with internal or external approach or
both?
What is surgical endodontics?
- “Surgical endodontics is the treatment of choice when teeth cannot be treated appropriately by nonsurgical means.”
- Endodontic surgery is nota substitute for NS RCT or careless NS RCT
Nonsurgical Retreatment Rationale–
Bergenholtzet al., ScandJ Dent Res, 1979
•Conclusion–Retreatment is the method of choice whenever possible
Indications for retreatment
- Failure to heal after nonsurgical treatment has failed
- Nonsurgical retreatment has been attempted or has also failed
- Anatomic considerations
- Extreme root curvature
- Root resorption
- Iatrogenic Considerations
- Impassable ledges
- Separated instruments
- Gross overfill
- Establish drainage (incision and drainage)
NSRCT not practical due to….
Irretrievable posts or cast crowns
Contraindications to retreatment
•Patient –Psychological condition –Medical condition •MI within last 6 months •Uncontrolled high BP •Bleeding disorders •Brittle diabetes •Dialysis and immunocompromised patients
Local Factors Poor crown: root ratio Periodontal disease Nonrestorable tooth Anatomy Bone thickness Mandibular 2nd and 3rd molars External oblique ridge Zygoma Surgical Inaccessibility
Pre-operative instructions for Surgical Endodontics•
Chlorhexidinegluconate(Peridex)
•Reduces introduced oral flora into site
•Beginning 1 day before surgery
•Continue until suture removal
–Pre-load analgesics before surgery
•Ibuprofen reduces onset and severity of post-op pain (400 –600mg q6hrs)
•Acetaminophen in addition can be synergistic (325mg q6hrs)
Local Anesthesia and Hemostasis for surgical endodontics
•Local anesthesia 1) 2% lidocaine with 1:100k epinephrine •Block anesthesia 2) 2% lidocaine with 1:50k epinephrine •Hemostasis 3) 0.5% marcaine with 1:200k epinephrine •Pain relief
Reactive Hyperemia
Clinical implications
“opening of the flood gates”
usually impossible to re-establish hemostasis
post-surgical hemorrhage and hemotoma
Factors Affecting Flap Design
Amount of attached gingiva present Number of teeth involved Presence and depth of perio pockets Length of roots involved Amount of access needed Presence and size of apical pathosis Esthetic considerations Other anatomical factors (neurovascular bundle and frenum)
Principles of Flap Design
Maintain maximum blood supply to reflected and adjacent tissue
Place incisions over sound bone
Insure flap is of adequate size
Avoid sharp corners (reduced potential for necrosis)
Avoid incisions over bony eminences
Tissue is more friable, tends to pull away and heals by secondary intention
Retract and handle soft tissue with care
Analyze periodontal condition carefully
Incisions Should be Based On
Supraperiosteal blood vessels
They are vertically oriented
Course parallel to long axes of teeth
Vessels which supply alveolar mucosa also supply gingival tissue
Triangular flap design
Triangular Single vertical releasing incision Horizontal intrasulcular incision Recommended for maxillary incisors, maxillary posteriors, and mand posteriors Advantages Good access and visualization Enhanced rapid wound healing by primary intention Minimal blood supply disruption Ease of wound closure Minimal postsurgical sequelae Disadvantages Surgical access may be limited somewhat by single releasing incision Retraction more difficult Gingival attachment disturbed Loss of soft tissue attachment level Potential loss of crestal bone height
Rectangular flap design
Advantage Enhanced surgical access Disadvantages Wound closure is more difficult Great potential for flap dislodgement
Limited Mucoperiosteal Flaps
Submarginal curved (semilumar)
-Single curved incision
-No primary advantages
-Archaic design == no place in modern surgical endodontics
Submarginal rectangular (luebke-ochsenbein)
-Scalloped horizontal incision in attached gingiva (2mm —
-AG must remain intact)
Advantages
-Marginal interdental gingiva not involved
-Crestal bone not exposed
-Adequate surgical access
Disadvantages
-Limited apical orientation
-Incision may cross bony defect (possible fenestration/dehiscence)
-Cannot visualize entire root
-Disruption of blood supply
-Difficult wound closure
-Increased post-op swelling and pain
-Flap shrinkage and scarring
-Delayed healing due to secondary intention
Periradicular Surgery
Intact cortical bone
Remove bone until root is exposed (aim to apical third of root)
Localize apex (determine MD and BL boundaries)
Periradicular Curettage
Indications: to remove contaminated reactive tissues from the alveolar bone surrounding the root
To create access to the root apex
To provide a biopsy specimen
Root-End Resection
Indications
To remove pathological processes (root tips, contaminated apices, resorption)
Remove operator errors (ledges, zips, perfs, separated instruments)
Remove anatomical variations (accessory canals, apical deltas, severe curves)
Technique:
Expose 3mm of root end and remove
Continue resection until a positive apical exit is identified
Maxillary molar Mb root—must resect more than 3mm because MB2 ends short of MB
Evaluate resected root anatomy
Complete circumferential resection (methylene blue dye is useful)
Check for additional foramina, anastomoses between foramina, and fracture lines
Hemorrhage control
cotton pellets soaked in anesthesia, gelfoam, surgical, ferric sulfate, collagen, calcium sulfate, racellets (does have a cardiovascular effect)
Root End Preparation
Stay in canal and prepare canal 3mm from new apex to coronal portion
Minimize reduction of sound root structure
REQUIREMENTS OF ROOT END FILLING MATERIALS
biocompatible, nonresorable, impervious to breakdown, capable of being well adapted
EXAMPLE OF Root-End Filling Materials
–Gutta-percha
–Amalgam
–Zinc oxide-eugenol
•IRM
•Super EBA cement
-Hydraulic Calcium Silicate Cements
-MTA
-Hazardzous ingredients (MSDS)
-Supersealing ability and less cytotoxic
-Endosequence root repair material
-Produces CaOH2 surface that leads to HYAP formation and cemental growthSurgical Site Closure
- Reapproximation
- Compression
- Stabilization
Reapproximation–Repositioning tissue •Replacement in the original position •Flap design eases reapproximation –Full thickness flaps are better •Flaps resisting reapproximationrequire more sutures
•Compression –Accomplished twice (3-5 min each time) •Initially after reapproximation –Enhances intravascular clotting •After stabilization with sutures –Thins out fibrin clot in wound site –Prevents formation of thick clot or coagulum
Post Surgical Management
Diet Hygiene -No brushing 1st day (use cotton swab and mouthwash) -Brush other than surgical area 2nd day -Continue CHX rinse until suture removal Activity restriction Suture removal 3-10 days Pain -Usually minimal and of short duration -Maximum on day of surgery
What are endodontic mishaps?
Endodontic mishaps or procedural accidents
are those unfortunate occurrences that happen
during treatment, some owing to inattention to
detail, others totally unpredictable.
Steps on managing endodontic mishaps
Recognition:
-Radiographic, clinical observation or as a result of a patient complaint.
- Correction:
-Depending on the type and extent of procedural accident.
-Unfortunately, in some instances, the mishap
causes such extensive damage to the tooth that it may have to be extracted.
- Re-evaluation:
-Re-evaluation of the prognosis of the tooth
involved in an endodontic mishap is necessary and
important.
-This may affect the entire treatment plan and
may involve dentolegal consequences.
-Dental standard of care requires that patients
be informed about any procedural accident.
Establishing Good Patient Communication following mishaps
- Inform patient before treatment about possible risks (fracture of full porcelain crowns)
- When a procedural accident occurs, explain to the patient the nature of the mishap, what can be done to correct it, and what effect the mishap may have on the tooth prognosis and on the entire treatment plan
- Referral to a specialist and be liable for the correction fee
Treating Wrong Tooth
Recognition
Continued symptoms after treatment
Isolated wrong tooth—evident after removal of rubber
dam
Correction
Inform patient
Appropriate treatment of both teeth (one incorrectly
accessed and one with original problem)
Prevention
If cannot reproduce symptoms for a specific tooth
(common in irreversible pulpitis), allow signs and
symptoms to become more specific before initiating
treatment
Mark the tooth before applying rubber dam
Missed Canals
Recognition: - Recognition of a missed canal can occur during or after treatment. - During treatment, an instrument or filling material may not be exactly centered in the root, indicating that another canal is present. (Cone-beam CT increases the chances of locating extra canals) - After treatment, sealer may be identified in missed canal. Correction: - Re-treatment is appropriate and should be attempted before recommending surgical correction. Prognosis: - A missed canal decreases the prognosis and will most likely result in treatment failure. - In some teeth with multicanal roots, two canals may have a common apical exit. As long as the apical seal adequately seals both canals, it is possible that the bacterial content in a missed canal may not affect the outcome for some time. Prevention: - Knowledge of root canal anatomy and morphology. - Adequate coronal access allows the opportunity to find all canal orifices. - Shift shots taken from mesial and/or distal angles. - Assuming at the outset that certain teeth have roots with multiple canals, and diligently searching for those canals.
Damage to Existing Restoration
In preparing an access cavity through a porcelain or porcelain bonded crown, the porcelain will sometimes chip even when the most careful approach using water cooled burs is followed
Correction:
Minor porcelain chips may be repaired by bonded resin composite to the crown
However, the longevity of such repairs is unpredictable
Prevention
Do not place a rubber dam clamp on the margin of a
porcelain crown
An alternative to prevent damage to an existing permanent cemented crown is to remove it before treatment by using special devises such as metalift crown and bridge removal system
Access Cavity Preparations
Undesirable communication between pulp space and the external surface
May occur during preparation of the access cavity, root canal space or post space
Recognition:
If perk above PDL, first sign is leakage of saliva into the cavity and NaOCl into the mouth
When the crown is perforated into the PDL, bleeding into the access cavity is often first sign
To confirm, place a small file through the opening and take a radiograph
Correction:
Above the alveolar crest may be repaired intracoronally without the need for surgical intervention
Into the PDL should be repaired as soon as possible to minimax injury
Materials used for repair should provide a good seal and not cause further tissue damage (MTA)
CaOH palced in the area of perforation and left for a few days will leave the area dry and allow inspection of performation
MTA may be placed in presence of blood since it requires moisture to be present to cure
Prognosis
Generally compromised
Depends on size, location, time accessibility, seal, and existing perio conditions
The sooner the repair is done, the better chance of success
Surgical corrections may be necessary in refractory cases
Prevention
Align axis of access bur with longitudinal axis of tooth
Identify calcification of chamber on preop radiograph
Follow principles of access
Thorough knowledge of pulpal anatomy
Crown Fractures
- Crown fractures may happen when the patient
chews on the tooth weakened additionally by an access preparation.
- Recognition of such fractures is usually by direct observation.
Treatment:
- Extraction unless fracture is of a “chisel type”,
in which only the cusp or part of the crown is
involved. In such cases, the loose segment
may be removed and treatment completed.
Prognosis:
- Less favorable than intact tooth. Outcome is unpredictable.
- Cracks may spread to the roots, leading to vertical root fractures.
Prevention:
- Orthodontic bands and temporary crowns may be
applied before root canal treatment.
- Reduce occlusion after root canal treatment.
- In addition to preventing this mishap, it also will aid
in reducing discomfort after root canal treatment.
Types of instrument related mishaps
- Instrumentation Related
- Ledge formation
- Perf
- Seperated and foreign objects
- canal blockage - Obturation related
- under or over-extended root filings
- nerve parathesia
- vertical root fracture
Instrument Related Mishaps: Ledge formation
Ledge formation
Causes
Incorrect assessment of the root canal direction
Inadequate access
Erroneous root canal length determination
Forcing and driving the instrument into the canal
Using a noncurved stainless steel instrument that is too large for a curved canal
Failing to use the instruments in sequential order
Packing debris in the apical portion of the canal during instrumentation
Correction
Using a small file, with a distinct curve at the tip to explore the canal to the apex
The curved tip should be pointed toward the wall opposite the ledge
Do not force instruments
Prevention
The best solution is prevention
Accurate interpretation of diagnostic radiographs should be completed before the first instrument is placed in the canal
Awareness of canal morphology is imperative throughout the instrumentation procedure
Use of flexible NiTi with non-cutting tip
Precurving and not forcing instruments
Instrument Related Mishaps: Perforations
Perforations
Cervical
Most often during widening the canal orifice or inappropriate use of GG
Recognition by the sudden appearance of blood
Can be managed by repairing with MTA or its analogs
Fair prognosis if sealed properly
MidRoot
Occurs mostly in curved canals
Repair is challenging due to limited access
Prognosis is guarded and may lead to fractures and microleakage due to inadequate seal
Prevention by anti-curvature filing and use of flexible instruments
Apical
Sudden pain during treatment
Tactile resistance of the confines of the canal space is lost
Correction:
Consider new perf site a new apical opening and obturate as such
Apical surgery in case of periapical lesion and extensive damage
Re-establish new working length
Creating an apical plug using MTA
Prognosis is better than coronal and midroot perforations
Instrument Related Mishaps: Seperate and foreign objects
Separate Instruments and Foreign Objects Objects Endo files and reamers (most common) GG drills Lentulo spirals Fragments of amalgam fillings Tooth picks Pencil leads Pins Tomato seeds Causes: Applying excessive force Extremely curved or constricted canals Fatigued and stressed instruments Failure to establish a smooth glide path Correction Retrieve Bypass Leave behind Apicoectomy Prevention Establish straight line access Do not force instrument Establish glide path Do not skip sizes Do not use fatigued or stressed instruments Use copious irrigation Use canal lubricant
Instrument Related Mishaps: Canal blockage
Recognition When the confirmed working length is no longer attained Correction: Recapitulation Copious irrigation Use of lubricants
Obturation Related Mishaps: Under or over extension
Over or Under Extended Root Fillings
The apical termination of filling material should be just short of the radiographic apex (1mm)
If extruded beyond apical limit = overextension
If shorter than apical limit = under extension
Over-Extension
Causes
Apical perforation
Too much compaction force
Natural/pathological loss of apical constriction (open apex due to resorption)
May result in treatment failure by
Irritation from filling material
Leakage
Compression of neurovascular bundle and neurotoxicity
Under-extension
Causes
Incorrect working length
Failure to fit master cone up to working length
Improper canal preparation
Particularly in the apical third of the canal space
Improper canal obturation technique
May result in treatment failure by
Persistent infection
Reinfection and apical percolation of tissue fluids
Recognition
By post-treatment radiograph
Correction
Retreatment
Periapical surgery
Replantation
Prevention
Accurate working length
Modification of obturating techniques
Creation of apical plug using MTA
Taking radiograph during initial phases of obturation to allow for corrections
Obturation Related Mishaps: Nerve Parathesia
Nerve Paresthesia Causes Over instrumentation Over extension of CaOH2 dressing Over extension of obturating material Nerve injury by formaldehyde containing pastes (N2, sargenti paste)
Obturation Related Mishaps: Vertical root fractures
Vertical Root Fractures
May occur during all phases due to application of extensive apical and lateral forces and thin/weak canals walls
Recognized suddenly crunchy sound, deep localized periodontal pocket, J shaped radiolucency
Misc Mishaps: Post space perforation
Post Space Perforation
Causes: misdirected drilles/burs in post space preparation
Recognition by bleeding and via radiograph
Corrected by sealing and repair
Prevention via radiograph to determine canal anatomy and removal of GP with hot instrument instead of drills
Misc Mishaps: Irrigant Related Mishaps
Irrigant Related Mishaps
Sodium hypochlorite accident: most common
Immediate swelling, pain, ecchymosis
4 class es of symptoms based on type, amount, concentration, toxicity
1) edema without ecchymosis
2) ecchymosis involving periorbital region and angle of mouth
3) ecchymosis involving 2 and extending into neck
4) ecchymosis involving 3 and extending into mediastinum
treatment
symptomatic treatment with analgesics, antibiotics, and corticosteroids
ice pack application followed by warm saline soaks
in severe cases, hospitalization and decompression of tissue spaces
prognosis
mostly favorable if treatment immediately
otherwise paresthesia, scarring, and muscle weakness may occur
prevention
do not force irrigant
irrigating needle should not bind to canal
use side vented needles or apical negative pressure delivery system
Misc Mishaps: Tissue Emphysema
Tissue Emphysema
Collection of gas/air in subcutaneous periradicular tissues
Compressed air being forced into the tissue spaces during canal preparation or surgical procedures
Recognition by rapid swelling, erythema, and crepitus
Treatment: palliative care and observation
Prevention: do not blow air into canal during shaping (just use air from handpiece)
Misc Mishaps: Instrument Aspiration and Ingestion
Instrument Aspiration and Ingestion
Due to failure to use rubber dam
Recognition: patient symptoms, chest and abdomen xrays
Management: hospitalize immediately
Prevention: always use rubber dam and attach floss to clamps, files, and reamers
Mishaps pictures
See phone
Modes of Failure (Pretreatment
-Anatomy
Do not retreat the radiograph
If a patient is not having symptoms and no radiographic signs of pathoses, even if the radiograph does not look like ideal endo, it is not necessarily a failure
-Restorative
Coronal leakage is a major cause of endo failure
Many studies have found that the quality of the restorative is more important than the endo
-Breaks
Teeth break, especially compromised teeth
Occlusion is a critical component
Maintaining dentin during endo and restorative is one of the keys to long-term success
Breaks are catastrophic failures
Fractures are responsible for 47% of post-root canal treatment extractions
Post-treatment fractures are frequently attributed to pronounced loss of dental tissues
Options for retreatment
-Retreatment
Retreatment is our primary option if:
Tooth has good restorative prognosis
Problem with RCT can be corrected endodontically
Patient wants to save the tooth
Should be performed by a microscope-competent endodontist
Cases with missed anatomy and working restorative are easy decisions to do retreatment
Predictability
Literature: 60-90%
Experience: very predictable if done well and in the right situation
Not all failing RCT are created equal
-Apical Surgery
Fewer indications for surgery with microscopes and our ability to fix things nonsurgically
I often recommend implants instead of surgery especially in molars
Surgery is still a great option for certain situations (mostly anterior teeth and occasionally PMs)
-Extraction
Restorative prognosis trumps endo prognosis
Patient expectations
Root-fractured teeth require an extraction
But you do not know theres a crack/fracture unless you can see it
Summary for retreatment
-Endodontic Failures
Anatomy failures can usually be fixed with retreatment
Restorative failures can sometimes be fixed with retreatment
Breaks need to be extracted
-Failure Options
Restorative prognosis trumps endo prognosis
Missed anatomy cases should have retreatment, not apical surgery
Most apical surgery these days is on anterior or PM
Cracked teeth are extractions but are tough to diagnose (cant say its cracked unless you see it)
-Retreatment
Better to do endo right the first time (only treat cases within your capabilities)
Retreatment should only be done by a microscope-competent endodontist
Best: immediately restore teeth following retreatment
Not all retreatments have the same prognosis (exam on a case by case basis)
Anatomic Relationship between Pulp and Periodontium
Anatomic Relationship between Pulp and Periodontium
Major connection: apical foramen (either single or apical delta)
Lateral, secondary, and accessory canals
17% apical third
9% middle third
1.5% coronal portion
Furcation canals (accessory canals in the furcation area)
Dentinal tubules in the absence of cementum
Young cementum is more permeable than older
Cemental defects may occur 5-10%
Cementum may be variably mineralized
May be subject to resorption
Root Grooves
palatalogingival grooves in max lateral incisors- up to 4.6%
Root Fracture
Vertical
Narrow pockets that extend to middle root
Coronal sinus tract
Prior RCT
Lateral radiolucency
Definitive diagnosis required direct visualization
Performations
Overinsturmentation, internal and external resorption, caries, iatrogenic
Endodontic and Periodontal Disease
Endo –> Perio
Infection from the canal may spread to the periodontal tissues
Bacterial products and toxins may also spread to the periodontal tissues causing alveolar bone loss
Periapical abscess may drain through the periodontium to the gingival sulcus or perio pocket
Perio –> Endo
Infection from a periodontal pocket may spread to the pulp through lateral/accessory canals
Bacterial products and toxins may also gain access to the pulp through exposed dentinal tubules
Apical blood supply may be affected by sever periodontitis leading to pulp necrosis
Periodontal Disease
Slowly progressing disease that only affects the dental pulp in later stages of the disease
Moderate periodontitis= lateral canals
Severe periodontitis = apice
Treatment
Short term: vigorous SRP may accelerate pulpal inflammation
Long term: repeated SRP in maintenance patients
Primary Endodontic Lesions
Inflammatory changes
Resorption of bone apically and laterally
Inflammatory process in the periodontium as a result of a root canal infection
Sinus tract along the periodontal ligament space
Endodontic tests: necrotic pulp
Treatment: NSRCT
Primary Endodontic Lesion with Secondary Perio Involvement
Lesion of endo origin not treated
Drainage persists, accumulation of plaque and calculus
Periodontal disease with apical migration of the attachment
Diagnosis is difficult
Prognosis and treatment altered
Necrotic root canal and plaque or calculus
Xray: generalized periodontal disease
Treatment: endo and perio
Primary Periodontal Lesion
Plaque and calculus produce inflammation causing loss of surrounding alveolar bone and supporting perio soft tissue
Loss of clinical attachment and formation of a periodontal abscess
Tooth mobility and pulp test positive
Bony lesion is widespread and more generalized than a lesion of endo origin
Treatment: periodontal therapy
Prognosis: outcome of perio therapy and patient compliance
Primary Periodontal Lesion with Secondary Endo Involvement
It differs from endo perio only by temporal sequence of disease process
Deep pocketing, history of perio disease
Apical progression of periodontal disease open and expose the pulp to the oral environment
Pulp involved: clinical signs of pulp disease
Xray: indistinguishable from primary endo lesions with secondary perio involvement
Treatment: perio and endo
Prognosis: periodontal treatment subsequence to endo therapy
True Combined Lesions
Pulp and periodontal disease occur independently or concomitantly in the same tooth
Necrotic pulp, or failing endo treatment, plaque, calculus, and periodontitis
Treatment: endo and perio therapy
Prognosis: perio disease determines
Diagnostic dilemmas
Non-Odontogenic pain & lesions Pathology/metastasis Resorption Referred pain/persistent pain Difficult dx!
3 D’s of Pain Control
Diagnosis
Definitive dental treatment
Drugs
Treatment of Symptomatic Irreversible Pulpitis
Pulpal debridement
Radiographs
2 at different angles
determine morphology
identify pathology
estimate working length
Anesthesia
Volume
Speed of injection
Type of anesthetic
Alternate injection locations
Supplemental anesthesia (intraosseous- pdl, stabident, xtip and intrapulpal)
To ensure anesthesia
Cold test with endo-ice
Do not use cotton tip application, use pellet
Negative response to cold –> 80% less likely to experience pain during RCT
Pulp extirpation
Removal of all coronal and radicular pulpal tissues
Access
Working length
Remove pulpal tissues via K files and rotary files—at least to 25 k file
Irrigation with NaOcl and side vented needles
Intracanal medicament
Usually CaOH2 or CHX gel
Use lentulo spiral for most complete placement
Prescribe analgesics
Symptomatic Irreversible Pulpitis
Intermittent or spontaneous pain •Exposure to extreme temperatures •Prolonged periods of pain •Pain remains after removal of stimulus •Inflammation and stimulation of nociceptive C-Fibers •Treatment by pulpal debridement
Supplemental Anesthesia PDL Injection
Needle wedged between root and bone •Bevel towards root •Must have good back pressure •Advantages •Quick to provide •Rapid Onset •Disadvantages •May cause tooth extrusion •Not effective for mandibular anterior •Unpredictable duration •Discomfort
Supplemental Anesthesia: • X-tip/ Stabident
• X-tip/ Stabident • Direct delivery of LA into cancellous bone • Introduced after unsuccessful conventional techniques • Rapid onset • Duration: 30 minutes • Improves success rate of profound anesthesia – Symptomatic: 82 – 91% – Asymptomatic: 95 - 98%
Intrapulpal Injection
- Absolute last resort
- Good back pressure needed
- Anesthesia by pressure not anesthetic
- Advantages
- Quick onset
- Disadvantages
- Traumatic
- Decreased confidence in practitioner
Hsaiu Wu study and cold
- Cold test with endo-ice
- Do not use cotton tipped-applicator
- Use #2 Cotton Pellet
- Negative response to cold 80% less likely to experience pain during RCT
ENSURES RCT
Acute apical absess
AAE Definition: An inflammatory reaction to pulpal infection and necrosis characterized by rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus formation, and swelling of associated tissues.
Acute Apical Abscess
Abscess
- Localized
- Small
- Fluctuant
- Purulence
Cellulitis
- Generalized
- Large
- Diffuse borders
- Firm
- Serious
Incision & Drainage- Indications
Swelling
•Abscess
•Cellulitis
Contraindications for NSAIDS
- Asthma
- Ulcers
- Ulcerative colitis
- Uncontrolled HTN
- Kidney disease
- Blood thinners/Aspirin
- Third trimester
Combination pain relief in endo
- Greater peak analgesia
- More consistent analgesia
- 200-400mg Ibuprofen + 500-1000mg Tylenol
Common adult Rx regimens
Ibuprofen: (Max 3200 mg/day)
•Take 400-600 mg every 4-6 hours for 72 hours
•Take 800 mg every 8 hours for 72 hours
Acetaminophen: (Max 3000 mg/day)
•Take 650 mg every 6 hours for 72 hours
•Take 1000 mg every 8 hours for 72 hours
Tylenol #3 (Acetaminophen 300 mg + codeine 30 mg): (Max 10 tabs/day)
•Take 1-2 tabs every 4-6 hours for 72 hours (No alcohol, driving, or major decisions)
Percocet (Acetaminophen 325 mg + Oxycodone 5 mg): (Max 9 tabs/day)
•Take 1-2 tabs every 4-6 hours for 72 hours (No alcohol, driving, or major decisions)
Common adult Rx regimens
Indications for antibiotics
Indications:
•Systemic involvement: febrile (>100˚F), lymphadenopathy, trismus, malaise
•Progressive infection: increased swelling or cellulitis
•Immunocompromised patient
The first antibiotic of choice for odontogenic infections
PenVK
Pen VK
- The first antibiotic of choice for odontogenic infections
- Narrow spectrum; GM+,GM- aerobic cocci; anaerobic rods
- Dose
- 1000 mg loading dose
- 500 mg q6h x 7 days
Antibiotics: Metronidazole (Flagyl)
- Inactive against most aerobic bacteria; use in conjunction with other antibiotics
- Add to penicillin regimen after 48 hrs. without improvement
- Anaerobic GM- rods and GM+ cocci
- Dose
- 1000 mg loading dose
- 500 mg q6h x 7 days
- Antabuse effect
Antibiotics: Clindamycin
Second antibiotic of choice •Primary, if allergic to penicillin •GM- anaerobic rods, GM+ aerobic strep •Dose •600 mg loading dose •300 mg q6h x 7 days •Psuedomembranous colitis
T or F: Never prescribe antibiotics as definitive treatment
True
Tx decisions should always be based on what?
based on laboratory, biological and clinical studies (in vitro and then in vivo in animals, then humans)
Instrumentation in Endo
Nickel-Titanium 1988 Walia, Brantley, Gerstein
Increased flexibility
Superior fracture resistance
Improved torsional properties
Heat Treating
•Martensite
•Decreased elasticity = pre-curve file and it holds shape
Controlled Memory HyFlex
300% more resistant to separation
Minimal transportation of canal because high flexibility and no rebound
Regains shape during sterilization
Dentin Preservation
TruShape
•Remove 36% less dentin while contacting up to 75% of canal walls
•Better disruption of microbial biofilms = less bacteria
Self-adjusting File
•Hollow file –NiTilattice = compressable
•Adapts to canal anatomy
•Continuous irrigation through center
Modes of dentin preservation
Dentin Preservation
TruShape
•Remove 36% less dentin while contacting up to 75% of canal walls
•Better disruption of microbial biofilms = less bacteria
Self-adjusting File
•Hollow file –NiTilattice = compressable
•Adapts to canal anatomy
•Continuous irrigation through center
Final Irrigation Alternatives
EDTA, Chlorhexidine, detergent (Qu mix)
Benefits: Chlorhexidineadds substantivity to antimicrobial action, detergent increases surface gettability of solution, decreased time
Disadvantages: High cost, possible salt/precipitate formation
EndoVac
Negative-pressure system
Eliminates risk of apical extrusion of irrigant
Eliminates vapor lock
Potential for significantly better infection control within canals
EndoActivator
Acoustic streaming
•Activated irrigantspromote disinfection and tissue removal from lateral canals, fins, deltas, and anastomoses
•Facilitates 3-D obturation–C-shaped canals
SonendoGentle Wave
Closed-loop, multisoniccleaning unit
•Delivers precise concentrations of irrigants
•Self-contained = collects tissue and waste fluids
•Potential for apical extrusion of fluid/debris
Endosequence BC Sealer and Points
- Calcium silicate bioceramiccement
- Antibacterial during setting due to high pH
- Zero shinkage
- Biocompatible
- Mono-block
EndosequenceBC Root Repair Material
Calcium silicate cement –same as the sealer but higher viscosity •Antibacterial •Biocompatible •Osteogenic •More resistant to wash-out than MTA
CBCT and endo
It is recommended to use the smallest possible FOV, the smallest voxel size, the lowest mA setting (depending on the patient’s size) and the shortest exposure time in conjunction with a pulsed exposure-mode of acquisition
Adv Focused Field of View CBCT
Higher resolution and diagnostic potential Focused on anatomy of interest Less radiation exposure Less time required to read the image Smaller area of responsibility
Endodontic Application of CBCT
Diagnosis, canal morphology, evaluation of root fractures and trauma, analysis of root resorption, presurgical planning, intra-operative treatment, assessment of pathosis of endodontic origin
Bucker and radiograph study
CBCT found all 14 furcations, PA found 1/14
Root Fractures and CBCT
Retrospective comparison of CBCT and conventional PA for 20 patients with suspected root fractures
CBCT detected fractures in 90%
Pas detected fractures in 30-40% of cases
Bernard’s et al.
Regeneration
Changing diseased state back to vital, maturing state
•Remove infection
•Tissue engineering
•Continued development
Primary Goal: The elimination of symptoms and the evidence of bony healing
Secondary Goal: Increased root wall thickness and/or increased root length (desirable, but perhaps not essential)
Tertiary Goal: Positive response to vitality testing (evidence of more organized, vital pulp tissue)
Goals of regeneration
Primary Goal: The elimination of symptoms and the evidence of bony healing
Secondary Goal: Increased root wall thickness and/or increased root length (desirable, but perhaps not essential)
Tertiary Goal: Positive response to vitality testing (evidence of more organized, vital pulp tissue)
3 key elements of regeneration
Three Key Elements
- Stem Cells
- SCAP - Scaffold
- Blood clot or platelet-rich plasma - Growth Factors
- BMP, TGF-beta, fibroblastic growth factor
OBJECTIVES OF CANAL OBTURATION
Three dimensional fill
•Prevent apical and coronal microleakage
•Create favorable environment for periradicular healing
•Sealing with dimensionally stable, inert, biologically compatible material
DIFFICULTIES OF CANAL OBTURATION
No obturation technique can:
•succeed without proper debridement of the canal system
•produce a completely impervious seal
•Apical control of fill is hardest aspect of endodontics
TERMINATION OF OBTURATION AND SUCCESS
> 2mm (68%), 0-2 (94%), extruded (76%)
Sjogren, study
Tamse and obturation
- Regardless of the technique, gutta percha is not impervious to fluid penetration
- Many “Endo”failures may actually be restorative failures due to microleakage, up to 50%-Tamse
ROOT CANAL SEALERS
Sealers are used between dentin and core materials (guttapercha) to fill spaces due to inabilities of core materials to fill all areas of the canal.
•Types include: ZOE, CaOH2, resin, GI cements, MTA based.
IDEAL ROOT CANAL FILLING MATERIAL
- Easy to manipulate and adequate working time
- Dimensional stability, but easily removed
- Adapt to various canal shapes
- Not irritate periapical tissues
- Impervious to moisture (non-porous)
- Unaffected by and not soluble in tissue fluids
- Bacteriostatic and easily sterilized
- Radiopaque but will not discolor teeth
Gutta Percha
Advantages
Compatible, adaptable, can be softened, inert, tissue tolerant, non-allergic, does not stain teeth, radiopaque, dimensionally stable, easily removed if necessary
Disadvantages
Lacks adhesive quality (need sealer) easily displaced by pressure (adequate apical stop required)
Slight shrinkage after heating (need sealer)
HISTORICAL OBTURATIONMATERIALS
SargentiPaste
•Silver Points
•Resilon
-Sargenti Paste (N2)Also called N2, N2 Universal, RC2B, RC2W
Contains formaldehyde which is toxic and potentially carcinogenic
Denied approval by FDA in 1993
-Silver Point Poor seal due to poor fit Corrosion products toxic Irritation to periapical tissues Lacks dissolvability
-Resilon
Synthetic based polycaprolactone polymer
Used with epiphany resin sealer
Attempts to form adhesive bond between core polymer, canal wall, and sealer to create monoblock
Handles similar to BP
Softened with heat or dissolved with solvents like chloroform
Extremely challenging to obtain perfect bonds especially within root canal system
Degradation of product in canal after obturation by bacteria and salivary enzymes
Use of silver points
AAE is against using these
PROBLEMS WITH RESILON
Extremely challenging to obtain perfect bonds especially within root canal system
Degradation of product in canal after obturation by bacteria and salivary enzymes
TAY
Conventional Obturation Techniques
-Cold lateral Condensation
Formerly most popular technique
Simple armamentarium
Standard to which other techniques are compared
Good:
Long track record, replicates well, seals well, inexpensive, requires little armamentarium
Bad:
Moderately time consuming
Can leave vertical voids
Can split roots (vertical root fractures)
Warm Vertical Compaction (downpack and backfill) aka Continuous Wave
Gold standard of obturation today (since 1967) (Schider)
Precise heated tip of pluggers employed by system B
Thermafil
THERMAFIL SYSTEM “GP ON A STICK”
•Developed by Dr. Ben Johnson in 1978
•Alpha phase GP on metal or plastic carrier
•Heat carriers in special heater
THERMAFIL TECHNIQUE
- Instrument canal with tapering preparation
- Select Thermafil corresponding to largest file, passively fit size verifier at working length
- Lightly coat walls of canal with sealer
- Heat thermafilobturatorin Thermaprepoven
- Insert and push the Thermafil obturator to WL without rotation
- Stabilize handle and immediately sever shaft with bur
ADVANTAGES OF THERMAFIL(ACCORDING TO MANUFACTURER)
- Three-dimensional obturation
- Apical control
- Simple and predictable
- Very rapid technique
- Eliminates iatrogenic root fractures
DISADVANTAGES OF THERMAFIL
Cost: $425 for oven and $7+ per obturator
•Technique sensitive
•Difficult retreatment
•Gutta-percha may be stripped from carrier at orifice during insertion
•Large carrier may not follow canal curvature
WHAT IS GUTTACORE?
Cross-linked GP core (carrier) with GP coating
ADVANTAGES OF MECHANICAL COMPACTION
Three-dimensional obturation
•Creates a well compacted mass of GP in canal
DISADVANTAGES OF MECHANICAL COMPACTION
- Many steps
- Compactor may remain in the mass of GP (broken)
- Void formation possible
- High initial cost
- Obturate entire canal system prior to removing GP for post preparation
THERMOPLASTIC BACK-FILLING
Inject small amount, then vertically condense
•Inject GP in remainder of canal
•Apical control is difficult (need GOOD APICAL STOP)
HOW DO WE MANAGE OPEN ROOT APICES?
Large/Blunderbuss
Immature (>1mm)
Resorbed apex
MASTER APICAL IMPRESSION TECHNIQUE
Master cone is fitted 1-2mm short of the working length
Chemically soften by dipping apical 4-5 mm of Master Cone in chloroform (solvent)
Master cone forms apical impression (working time 1-2 minutes
Canal COMPLETLEY filled to WL with MTA
ADVANTAGES OF MTA
Excellent sealing properties •Set up in moisture conditions (hydrophilic) •Bioactive •Biocompatibility •Antibacterial
DISADVANTAGES OF MTA
- Extremely expensive
- Long setting time
- Can discolor teeth (older formulations)
- Difficult to handle within canal
- Resorbable apical barrier sometimes needed
TAKE HOME MESSAGE with latest innovations
Beware of the “latest and greatest product” marketing
•Long-term success studies are the TRUE test
•DO NO HARM!!!
•When in doubt…. Refer!
Who Gets Hurt?
- 1/3 boys
- 1/4 girls
- mostly chipped teeth
- mostly maxillary centrals
Pupils and damage
Fixed, pinpoint: pons damage
Fixed, dilated: medullary damage
History of the AccidentHow
- Blow to lips and anteriors could cause crown, root, or bone fractures to the anterior.
- Blow to chin could cause any tooth fracture
- Padded blow: root fracture
- Hard blow: crown fracture
Rhinorrhea Otorrhea
“Discharge of clear cerebrospinal fluid through the nose or external auditory meatus may be a sequela of severe trauma with associated fracture of craniofacial osseous structures.”
Cranial nerve testing
Cranial Nerve Testing
1 Olfactory: smell
2 Optic: normal sight without blurriness or diplopia
3 Oculomotor: adduct eye, downward gaze, elevate eye
4 Trochlear: motor to superior oblique, inward, downward, lateral movements
5 Trigeminal: gently rub explorer on surface of skin
6 Abducens: motor to lateral rectus, abducts eye
7 Facial: symmetry of facial contractions
8 Auditory: hear the tick of watch, postural balance without tinnitus or vertigo
9 Glossopharyngeal: speak normally without hoarseness, swallow normally
10 Vagus: normal speech, swallowing, and able to elevate soft palate
11: Spinal Accessory: turn the neck
12 Hypoglossal: protrude the tongue
SUMMARY of CRANIAL NERVE TESTING
- Eye movement III, IV, VI Sight II
- Sound VIII
- Taste VII, IX Move the tongue XII
- Smell I
- Feel V
- Speak IX, X
- Turn the neck XI
Eye movement CN
3, 4, 6
Sight Cn
2
Taste CN
7,9
Move the tongue cn
12
smell cn
1
Feel cn
5
Speak vcn
9, 10
Turn the neck CN
11
Uncomplicated Crown Fracture
Fracture of the enamel only or enamel and dentin without pulp exposure
Approximately 1/3 of all dental injuries
Smooth the sharp edges. Use bonded composite resin if necessary for aesthetics
Enamel/Dentin Fracture
- CaOH2 over exposed tubules
- Bonded resin
- Account for the fractured tooth fragment
Complicated Crown Fracture
Fracture involving the enamel and dentin with pulp exposure
Treatment OptionsComplicated Crown Fracture
- Vital Pulp therapy
·pulp cap
·pulpotomy - Pulpectomy
Apexogenesis:
A vital pulp therapy procedure performed to encourage continued physiological development and formation of the root end.
Time elapsed since trauma
After 24 hours, chances of direct bacterial contamination of the pulp increase and the zone of inflammation progresses apically (Cvek M, JOE, 1982). Thus as time progresses, the chance of success of maintaining a healthy pulp decreases.
Periodontal injury
A periodontal injury compromises the nutritional supply of the pulp. This is important in mature teeth, where the chance of pulp survival is not as good as for immature teeth (Andreasen JO, 1970).
Apexification-
a method of inducing a calcified barrier in a root with an open apex or the continued apical development of an incompletely formed root in teeth with necrotic pulp.
INDICATIONS FOR APEXIFICATION
Indications-teeth with open apices in which standard instrumentation techniques cannot create an apical stop to facilitate effective obturation of the canal.
fracture of cementum, dentin, and pulp
- fracture of cementum, dentin, and pulp
- < 3% of all dental injuries
- usually oblique facial to palatal
Classification of root fractures
•Shallow coronal third (a) •Deep middle third (b) apical third (c)
Pulpal Necrosis
- Apical Segment-rare
* Coronal Segment-25% (Andreasen FM, Andreasen JO, Endo Dent Trau 1988)
Treatment of Deep Root Fracture
•Reposition
•Rigid Splint (3 months)
•Monitor vitality at 1 week, 1 and 3 months (25% of coronal segment will undergo necrosis)
•Rigid splint if fracture is apical to the level of the crestal bone
•Poor prognosis if the fracture is at or coronal to level of crestal bone
extract the coronal fragment
extrude apical fragment
What are the two most important things to do in treatment of root fractures?
Immediate reposition and fixation
Four Responses to Root Fractures
1 Healing with Calcified Tissue
2 Healing with Interposition of Connective Tissue
3 Healing with Interposition of Bone and Connective Tissue
4 Interposition of Inflammatory Tissue Without Healing
Lateral Luxation
- Lateral displacement (M,D,F,L)-often crown palatal and apex facial
- Extreme percussion sensitivity
Extrusive Luxation
(displacement in a coronal direction) •Reposition •Splint (1 to 3 m) •Observe for symptoms of pulp necrosis •Often mistaken for an avulsion •Extensive trauma to PDL and cementum
Intrusive LuxationTreatment Options
- Orthodontic extrusion
- Surgical repositioning
- Transplantation of an avulsed tooth
Prognosis of Luxation Injuries
•Pulp necrosis: common subluxation: 12 -20% lateral or extrusive: >50% •Canal obliteration: common •Root resorption: 5-15%
Biological Consequences OF REPLANTING TOOTH
•Damage to the attachment apparatus (PDL, cemental layer).
Time increases PDL damage.
•The apical neuro-vascular supply to the pulp is severed (always pulp necrosis).
Revascularization possible in immature teeth.
Primary Teeth and replantation
Andreasen JO, Andreasen FM 1994:
Replantation of primary teeth is not justified due to the risk of pulp necrosis and possible interference with the development of the permanent successors.
Immature ToothDelayed Replantation
•Bjorvatn, Massler 1971: 1% stannous fluoride soak for 5 minutes •Barb akow, Austin 1978: 10% stannous fluoride soak is detrimental to the pulp, PDL, alveolar bone •CaOH2 apexification •Splint Immature ToothDelayed Replantation
Mature Tooth Rapid Replantation
- Replant
- Splint
- Pulpectomy (CaOH2) in 1-2 weeks
- Obturate 1-2 weeks later
To Splint or Not to Splint?
•Andreasen JO, Andreasen FM. 1994
Semirigid (7 t0 10 d)
•Berude, Hicks. JOE, 1998
•In 9 monkeys 27 teeth were extracted, replanted and splinted. No significant difference was found in the PDL healing pattern of physiologically splinted, rigidly splinted, or nonsplinted replanted teeth.
Abscess
A swelling containing pus as a result of inflammation
Localized collection of pus surrounded by infected tissue
Cellulitis
Acute spreading bacterial infection below the surface of the skin characterized by redness, warmth, swelling, pain
Can also cause fever, chills, enlarged LN
Clinical diagnosis based on spreading involvement of skin and subcutaneous tissues with erythema, swelling, and local tenderness, accompanied by fever and malaise
Diffuse spreading skin infection
Factors Influencing Infection
Virulence of bacterial organisms
Compromised host
Predisposing local factors
Factors enhancing infection
Bacteremia
Presence of bacteria in blood (reversible)
Septicemia
bacteria multiplying in blood (irreversible)
Particular Space Infections Related to Teeth
Maxillary Centrals: apices closer to the labial
Maxillary Laterals: apices closer to labial or palatal
Maxillary Canine: apex is closer to labial
Maxillary Premolars: apex to labial (except for palatal apex of 1stPM)
Apices well below buccinators so vestibular swelling
Maxillary Molars: apex towards buccal
Buccinators attachment determines vestibular or buccal space
Mandibular Centrals and Laterals: exudate usually perforates buccal, mentalis muscle determined intra or extraoral
Mandibular Canine: exudate perforates buccal above muscles
Mandibular Premolars: exudate perforates buccal, above muscles so vestibular swelling
Designations of pulp
•Normal •Reversible pulpitis •Irreversible pulpitis Symptomatic Asymptomatic •Necrotic •Previously treated •Previously initiated
How many bacteria in oral cavity?
300
Factors influencing infection
- Virulence of bacterial organism
- Compromised Host resistance
- Predisposing local factors (poor oral hygiene, hematoma)
- Factors Enhancing Infection (Uncontrolled Metabolic Diseases, Alcoholism, malnutrition)
Factors that help to limit the spread of
dental infection
- Lamina dura
- Periosteum
- Muscle
attachment
vein communication
Facial vOphthalmic vCS
Facial vPterygoid PlexusCS
Max vPterygoid PlexusCS
Cavernous Sinus
- Abducens n: difficulty in moving the eye.
- Ophthalmic n: headache, burning and tingling of the forehead.
- Signs of toxemia (fever, malaise).
Buccal Space
Medial: buccinator m. Lateral: skin of cheek Anterior: labial musculature Posterior: pterygomandibular raphe Superior: zygomatic arch Inferior: lower border of mandible Contents: Stenson’s duct; facial artery
Mentalis Space
Superior: mentalis m. and depressor labii inferioris m.
Inferior: platysma m.
Medial: mandible
Lateral: skin of the cheek
Submental Space
Superior: mylohyoid m.
Inferior: platysma m.
Lateral: digastric m.
Posterior: submandibular space
Sublingual/Submandibular Space
Sublingual/Submandibular Space
1st molar: usually above mylohyoid
2nd molar: 50/50
Sublingual Space
Superior: mucosa of floor of mouth
Inferior: mylohyoid m.
Lateral: lingual of mandible
Contents: sublingual gl., submandibular duct, lingual n., hypoglossal n.
Potential Spread of Sublingual Space Infection
- Posterior-inferiorly into the submandibular space.
* Posterior-laterallyinto the parapharyngeal spaces.
Submandibular Space
Superior: mylohyoid m.
Lateral: body of mandible, platysma
Medial: mylohyoid m., hypoglossus m.
Contents: submandibular gl and nodes, facial artery and vein
Potential Spread of Submandibular Space Infection
- Posteriorly
into the sublingual, parapharyngeal, or pterygomandibular space - Laterallyinto the opposite submandibular space
- Inferiorlyinto the fascial planes of neck
Ludwig’s Angina
A massive, bilateral cellulitis
•Spaces: sublingual, submandibular, submittal, often pharyngeal
-•Swelling can displace the tongue upward and backward blocking the pharyngeal airway
•Edema of the glottis (late complication)
The Role of Antibiotics
- An adjunct; not treatment.
- Will not evacuate pus.
- Indicated for moderate and severe infections when drainage is inadequate.
- Penicillin is the drug of choice (unless cultures show otherwise).
- Clindamycin if allergic to penicillin
Antibiotic Indications
- Systemic involvement
- Rapidly progressive swelling
- Diffuse swelling
- Compromised host defenses
- Involvement of fascial spaces
- Severe pericoronitis
- Osteomyelitis
RULE OF THUMB FOR ANTIBIOTICS
The rule of thumb is that antibiotic coverage should last for at least 48 hours after complete remission of clinical symptoms.
