NaOCl Extrusion and intra-canal medicaments Flashcards
common symptoms of NaOCl extrusion (6)
- pain
- swelling
- ecchymosis
- haemorrhage
- neurological complications
- airway obstructions
example of classic NaOCl accident
Ecchymosis in a classic NaOCl accident manifests along the course of superficial venous vasculature
Rare (less than 50 cases in the literature published between 1974–2013) - despite millions of RCTs performed annually
risk factors for NaOCl extrusion (6)
- Excessive pressure during irrigation risk NaOCl in PDL
- Needle locked within canal risk NaOCl in PDL
- Loss of control of working length
- Larger apical diameters/constriction
- Anatomical factors/proximity to sinus
- Higher NaOCl concentration?
pressure in NaOCl extrusion
- Patent apical foramen
- Facilitated by anatomy of facial venous drainage
- Pressure generated by positive-pressure irrigation delivery systems at the periapex have to exceed the venous pressure in the superficial veins of the neck
- Flow rate is important 1mL/15 secs
large apical diameters/constrictors can be due to
- Root resorption
- Immature teeth
- Developmental anomalies
management of NaOCl extrusion into tissues
ALL treatment must STOP
Keep calm and try not to alarm your patient
Advise the patient of what has happened and reassure them regarding the immediate management
Where pain is present consider administration of local anaesthesia via a block of the affected region.
If profuse bleeding through the root canal is occurring, allow this to continue until haemostasis is observed
A steroid-containing intracanal medicament (e.g. Odontopaste) should be place in the root canal, ensuring no pressure is used during application
Do not obturate the tooth at this visit, but seal to coronal access cavity.
Priority must be given to pain relief, reduction of the swelling, and prevention of secondary infection
- Cold compresses during the first few days
- Warm compresses for resolution of the soft tissue swelling and elimination of the hematoma
- Analgesics (Ibuprofen 400-600mg QDS/Paracetamol 1000mg QDS)
- Review within 24 hr
- Prescription of antibiotics (case specific)
- Refer if severe
guidelines for use of NaOCl
- Careful pre-operative radiographic assessment is essential – be vigilant of open apices and perforations and discuss with senior staff if either is suspected prior to commencing treatment.
- It is important that the pre-endodontic restorative state of the tooth is assessed. A pre-endodontic build-up is necessary if isolation is likely to be compromised.
- Ensure the patient is provided with a disposable bib to protect clothing. This must adequately cover clothing. If necessary use two bibs overlapping.
- Provide patient with protective eyewear.
- Always use dental dam to isolate the tooth requiring RCT and ensure this is sealed well with OrasealTM. The oral seal should be “moulded” to the tooth contours with a damp cotton wool pledget. Placing the clamp prior to dam placement can facilitate visualisation. Ensure floss is used to secure the clamp during placement and removed after dam is seated.
- Test the dental dam seal by irrigating with chlorhexidine first to ensure no leakage.
- Dam placement must be checked by the supervising clinician.
- Ensure that all syringes are clearly labelled with adhesive labels.
- Always use a side-vented needle for irrigation of the root canal.
- Always use a Luer-Lok 27G needle and ensure this is securely attached to a 3mL syringe – test this before use.
- Fill syringe less – approximately 3/4s full to aid control.
- Always use a silicone stop on the needle and set to 2mm short of working length.
- Always pass the endodontic syringe behind the patient’s head and never over the patient’s face.
- The irrigating needle should not bind in the root canal at any time.
- Whilst irrigating, depress the plunger with index finger rather than thumb to reduce the pressure.
- Report any irrigation/endodontic incident to senior staff immediately.
- If you have any concerns about the clinical handling of the Sodium Hypochlorite by the operator, then you should raise your concerns with the individual or a senior member of NHS/University staff if necessary.
pre-op radiographs for NaOCl
Careful pre-operative radiographic assessment is essential – be vigilant of open apices and perforations and discuss with senior staff if either is suspected prior to commencing treatment.
pre-endo restorative state of tooth is assessed
important
pre-endodontic build-up is necessary if isolation is likely to be compromised
pt needs to wear protective clothing
disposable bib
This must adequately cover clothing. If necessary use two bibs overlapping.
pt eyes
cover with protective eyewear
how to isolate tooth needing RCT
Always use dental dam to isolate the tooth requiring RCT and ensure this is sealed well with OrasealTM. The oral seal should be “moulded” to the tooth contours with a damp cotton wool pledget. Placing the clamp prior to dam placement can facilitate visualisation. Ensure floss is used to secure the clamp during placement and removed after dam is seated.
how to test dental dam seal
irrigating with chlorhexidine first to ensure no leakage.
who checks dental dam placement
supervising clinician
syringes
all syringes are clearly labelled with adhesive labels
needles should be
- side-vented needle for irrigation of the root canal
- Luer-Lok 27G needle and ensure this is securely attached to a 3mL syringe – test this before use
how full should syringes be
3/4s to aid control
silicone stop
always on needle
2mm short of working length
where to pass the syringe
always pass the endodontic syringe behind the patient’s head and never over the patient’s face.
irrigating needle should
never biind to root canal
how to depress the plunger when irrigating
depress the plunger with index finger rather than thumb to reduce pressure
when to report any irrgating/endodontic accidents
immediately
single Vs multi visitendo Tx
Agreement is lacking
- Vital cases often suitable for single visits but must be decided on a case-by-case basis
- Non-vital cases are more complex with greater resistance to endodontic treatment – inter-appointment dressing may be important
intra-canal medicaments use
- Placed inside root canal between treatment appointments in an attempt to destroy microorganisms and prevent re-infection
- Proper and careful canal preparation will minimize or eliminate the number of bacteria left within the root canal system
- It is important to use a medicament between visits which will reduce and prevent multiplication of any bacteria that do remain
- Reduce inflammation and exudate
- Control of root resorption
antimicrobial paste
- Paste containing corticosteroid and tetracycline
- Used during management of “hot pulps”
- Can aid in reduction of pulpal inflammation
- Can facilitate follow-up treatment
- Effective for 5-7 days
non setting CaOH
- pH 12.5
- High pH contributes to antibacterial activity
- Numerous studies demonstrate bacterial reduction after inter-appointment dressing
- Prolonged anti-bacterial activity
- Hydrolysis of Lipopolysaccharide thus reducing its inflammatory potential
- Effective in rem oving tissue debris
- Treatment for 7 days
- Combination with NaOCl improved cleaning ability
inter appointment disinfection
Canal should be completely filled with calcium hydroxide paste
- Must come into direct contact with bacterial cell wall to be effective
Placed by injection through a small disposable syringe tip (Ultracal, Optident
interappointment termporary dressings
Must effectively seal the root canal from contamination between visits – fail – significant risk bacteria will re-enter
- Cavit
- IRM
- Glass ionomer cements
failure of temporary restoration can be due to (3)
- inadequate thickness of material
- improper placement of the material
- failure to evaluate occlusion after placement
basic sequence of RCT
- RCS space filled with CaOH
- Pledget cotton wool
- Coltisol – provisional restorative material, not hard enough for longevity in oral cavity so need GI on top, but prevents really thick layer of GI that would need to broken and could damage RC if broken excessively
- GI on top (3mm to prevent displacement)
Want to be stable and consider occlusion
UltraCal Xs
- Acqueous
- Syringe delivered
- Radiopaque CaOH
- pH 12.5
- 29 gauge navi deliver tip - precisely place
- Cotton pledget on top, temporay cement seal on top, then GI (matching product)
- Can be removed – ultraden citric acid, navitip FX tip – chemical delivery and scrubbing effect
