Endodontics Emergencies

Conservative lec No. 10 3.12.2008

Today we are going to talk about endodontic emergencies, it’s something that the patient complain of, has to be either pain or swelling that would required an unscheduled visit (extra visit) for management, so it may be pain or swelling or both, but you need to see the patient immediately in a visit and manage him, usually it’s caused by a pathosis either in the pulp or in the pulp and periapical tissue and the diagnosis will be irreversible pulpitis or apical periodontitis in addition to that.

Endodontic emergencies can be classified into:

1) Pretreatment : it means before you see the pt, he come to you as an emergency. So he is a new patient and that is the first time you see him.

2) Interappointment : you treat the patient and the next day he will come back complaining of swelling and pain that wasn’t before your treatment and he will blame you.

3) Postobturation : everything is good and when you finish the obturation he will get a flare-up, he will get sever pain and swelling.

System of diagnosis :

1) Medical and dental history : if a new patient came to you and you see him for the first time, then you should take medical and dental history, you ask about previous treatment if present. The second thing you must take into consideration is the history of pain, if it’s spontaneous or stimulated by something, disturbing the sleep or not, if it’s relieved by analgesic or not, localized to a tooth or not.

2) Examination (subjective and objective) : palpation, percussion, radiographs, vitality test.

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3) Periodontal examination: you should do periodontal examination to the teeth and check the PD, sometimes there is a tooth with a PD equals 1-2 mm and suddenly become 7 mm in a certain area on the tooth (buccaly or lingualy), this tooth either cracked or has vertical root fracture that need extraction.

4) Radiographic examination : you should see if there is any caries because some of them can’t be seen clinically like class II caries(interproximal).

Cold Test :

The most reliable one is the CO2 test because it have the lowest degree (-78°) , but we don’t have it in our clinics. The one that we use in the clinics is the DichloroDifluoroMethan (DDM) that has -50° boiling point, we apply it on a cotton and put it on the tooth surface, the normal response will be sharp and short pain that relieved by removing the stimulus and will appear within a 15 sec, delayed response is very rare but happened in elderly due to pulp shrinkage after secondary dentine formation, if the pain remained for 30 sec then that is a clue for RCT to this tooth. If the tooth is crowned you will test it palataly or lingual if there is exposed structure of the tooth, if not then you retract the gingiva and test on cementum.

Mechanism of the cold test:

Cold test will do disturbance in dentinal fluids and cause an outflow for it, which will stimulate the mechanoreceptors in Aδ fibers, this is what called the HYDRODYNAMIC THEORY.

So, the cold doesn’t reach the nerves directly, it only cause a fluid movement.

**The hot has an action similar to the cold .

In each response (+ve or –ve) we may have false results, sometimes we may reach false –ve like in atrophic pulp (due to aging) which will give a delayed response, or false +ve like when you fail to dry the tooth completely before applying the cotton, that will make the saliva transfer the response through the gingiva to the adjacent tooth or in multi roots teeth.

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CASE I :

Page 2 slide 8 .

20 years female complains of severe pain in upper left premolars for 3 days, the pain was continuously there and she complained from sensitivity on hot.

Here we can do hot test (we rarely do it), we isolate the tooth with rubber dam and apply hot water on the tooth, the tooth which is sensitive to hot mostly will be sensitive to the cold, but not necessarily. If hot test isn’t the test you want to do, so you must do radiographs. In this case, we took a periapical radiograph for the tooth, it had a class I cavity, then recurrent caries happened and became a class II that make exposure to the pulp. It’s an easy case for diagnosis, you can never miss that this tooth need an endodontic treatment although this tooth is periapicaly sound.

CASE II :

Page 2 slide 9

53 years old male complains of a very severe pain on lower left premolars, he hasn’t slept for two days with disturbing daily activities, that indicate and irreversibly inflamed pulp. When radiographs was taken, the lower premolar

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are already treated, root canal looks fine, there is a periapical radiolucent area but this won’t be a cause of a pain from irreversible pulpitis, in this tooth there is no pulp, so the pt won’t feel pain, the pain may happen when the patient bite.

In these pictures in, 34 and 35 are obturated and have no problems, 25 also obturated and 24 has DO cavity with cracked line on the mesial marginal ridge and extremely sensitive in cold, so the patient reported pain in the lower jaw, but the test show problem in the upper teeth, and that what we call REFERRED PAIN .

** So pain in the upper teeth sometimes referred in the lower teeth and vice versa.

**Note: if you are suspecting a problem in a tooth that has a pain and you gave anesthesia and the pain disappeared, so your suspicion is true.

In this case we do:

1. Rubber dam.2. Access.3. Extirpation.

If the tooth was vital we do extirpation to the estimated working length and irrigation with sodium hypochlorite (do as much as you can instrumentation, barbed broaches files to the estimated working length).You put dressing and close it and relieve the occlusion by reducing the cusps or at least functional cusps (In the upper the palatal cusp including with the buccal of the lower). Reduce the palatal cusp by 1mm.If the lower need post crown you can reduce

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it by 2mm, this is(relieve from the occlusion) effective in reducing interappointment pain .

Referred pain:

1. The inflammation remains confined within the pulp.2. Histology: liquifaction necrosis with an increase in intrapulpal pressure

and primarily involves C-fibers.3. Anterior teeth don’t refer to posterior teeth.4. Posterior teeth don’t refer to anterior teeth.5. Usually doesn’t cross the midline.6. Upper premolar often refer to lower premolar7. Upper molar often refer to lower molar.

There is some teeth don’t refer pain, the tooth must be inflamed virgin to refer pain. But tooth with previous endodontic treatment, tooth with sinus tracts, tooth with periodontitis or tooth undergoing endodontic treatment will not refer pain, the pain will be in the same area of the tooth.

Other sources of referral of pain:

1. TMJ diseases: patient came to you complaining of pain in the tooth and he has Phantom tooth syndrome or atypical facial pain which is psychological, he has muscle pain and say to you this tooth is harming me, you do class I , class II, endodontic treatment , extraction and the pain remains, this is Phantom tooth syndrome, any muscle pain (temporalis , lateral pterygoid , medial pterygoid) can cause pain in the upper teeth.

2. Heart- myocardial infarction, thrombosis, angina pectoris.3. Lower molar refers to ear.4. Upper molar refers to sinus.

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If patient complain of a pain and you took this radiograph, the cause is the first premolar has a big restoration and periapical changes.

In the pictures below, you can see a patient which has swelling in the palate, you can see the crown, remember that you should do periodontal examination before the diagnosis, notice the probe has entered 7mm, this is an isolated pocket ,so we expect that this tooth has crack or root fracture. By the way, this tooth was treated by a good endodontic treatment and there was crack then become a sinus tract. The solution for this tooth is extraction, it is a hopeless tooth.

Student question: can we drill a cavity through the crown?

If the crown has good margins with good adaptation then you can drill the access cavity through the crown as a normal tooth and do endodontic

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treatment, it is more difficult and the vision isn’t clear, but if the crown is old and a bad one you remove the crown, do endodontic treatment and temporary cement until you replace it with a new crown. Not every crowned tooth should have an endodontic treatment.

**Sometimes it is class I cavity, from the heat of preparation and because there is no sufficient cooling, there is no enough water with the high speed you will cook the pulp, it will become irreversibly inflamed then dies, when you come to do cementation the patient will complain from pain so you should drill the crown that you prepared.

Detecting cracks

The patient complain of pain on release of a pressure (when he bites and opens), this pain is a diagnostic for a cracked tooth. How we can decide that? We have to reproduce the patient pain by tooth slot, not found in the clinic, so you can use the handle of the mirror, put it on the tooth that the patient complain from, then the patient should bite and open, during biting there is no pain but after he opens the pain starts, this is a diagnostic for cracked tooth. May be you can’t see the crack, but there is certain managements that we will study it later on.

That treatment for a cracked tooth is orthodontic band, which we put around the cracked tooth and do cementation (splinting the crack) so the pain will disappear, after that we do a crown or an overlay .The crack usually found mesiodistally .

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When can we doubt in a cracked tooth?

When the tooth looks sound and it’s vital on the cold test and on the radiograph you can’t detect anything, there is no other diagnostic features for pulpal involvement and the pain found on release of pressure(when open mouth from bite).

You can notice in the picture below that there is a crack started at the buccal pit and then continued downward, and here there is sinus, this tooth has been crack because it was treated by endodontic, the temporary restoration wasn’t removed and no crown has been done for this tooth, teeth with temporary restoration will get crack within 5 years. The tooth which treated by endodontic if not crowned finally it will break.

In intraoral examination in this picture below, you can see sinus tract, it looks like an ulcer, sometimes it can be sever to be present as an ulcer, this patient was infected with hepatitis C, so he had low immunity and had external swelling and internal ulcer, this isn’t the first visit, it is the third visit after it’s improved( it was bigger than what we can see here in the picture).

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After we took the history, the possible diagnosis is:

1. Irreversible pulpitis.2. Acute apical periodontitis.3. Acute apical abscess(swelling with pus).

After examination and diagnosis, our goal now is to reduce the irritant and reduce the pressure by removing the inflamed tissue and you can achieve a profound anesthesia.

A-Pretreatment emergencies

1.Irreversible pulpitis:

As we said in irreversible pulpitis we do complete pulp extirpation by a barbed broach, files to estimated working length, sometimes the patient in severe pain so we do pulpatomy, it might be enough and this is called in physiology “Axotomy”.

Pain perception starts in the receptors and periapical nerve, after that to the nuclei and CNS, if you cut the periapical nerve you will cut the receptors of pain, so we expect to reduce the pain, but what remains is the prostaglandin pain mediator in the brain, so the patient may be still feels pain.

But at least if the patient complains of a severe pain and you gave him intrapulpal anasthesia and he still in pain, then you can do pulpotomy.

Pulpotomy: it means removing the pulp chamber alone, not necessarily to reach the canals, we must remove as much as possible from the pulp chamber with a big round bur, then you apply chemical medicament in the chamber like formocresol or a dry cotton pellet alone (it’s as effective as relieving the pain with a pellet that is moistened with formocresol).

This treatment is temporary not definitive, you have to complete pulp extirpation after a few days because the ideal is to proceed all the way to

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estimated working length, and reduce the tooth from occlusion if there is any apical periodontits.

**don’t give the patient any antibiotics (this is a misuse), give him analgesics.

2. Pulp necrosis :

In case of pulp necrosis it will be either acute periapical periodontitis without swellings (only tenderness to percussion), or it will be acute apical abscess. If there are no swellings so there is no pulp, you should take the corrected working length and enlarge the canals if you can from the 1st visit, but if you can’t so you do to the estimated.

We have localized swelling or diffuse swelling, if it’s localized you have to open the tooth and try to do drainage through the tooth to drain the pus, in this case the pus may go out or maybe not.

This is a rubber dam and this is an access, notice the bloody discharge (blood with pus), and if you tried to dry the canal with a paper point you will notice that it will be wet completely.

Sometimes it might be oozing, in this case we can do intracanal drainage (not found in our clinic), we put this tip on the ordinary suction and like the non-setting CaOH, and we insert it inside the canal and suction the pus.

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If the patient came with a pain and sinus that found close to 5 or 6, we can’t say that this sinus is for the 5 or the 6, you should always trace the sinus, it’s may be from the adjacent tooth.

So, how can we do tracing??

We insert a gutta percha (35 or 40) inside the sinus tract and take a radiograph to see where is the cone pointing, sometimes you have to penetrate the sinus with a probe or a local anesthesia needle to insert the cone.

Sometimes the radiograph is misleading, in case where the sinus is between the 5 and 6, we do cold test, if the 6 test +ve then it’s definitely the 5, but if it had abnormal response then it’s the 6.

Another shape of the sinus tract can be found palataly. This is orthodontic band around the 4 which is broken down, here we can’t apply a rubber dam, so it’s usually recommended to build it up with a temporary material then we put the orthodontic band and then apply the rubber dam.

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Pulp necrosis either localized or diffused swelling, in the a-localized swelling you have to palpate and see if it’s fluctuant or hard, if it’s fluctuant you can do incision and drainage.

→ Never leave the canal open, although the pain disappear (because the pressure has been relieved) but the bacteria from the saliva will enter inside the canal and cause an infection further than the edno, also in the localized swelling, if it is just inside the sulcus then there is no need for antibiotics. (Antibiotics just for the systemic manifestation).

b-Diffuse swelling means swelling in the cheek, neck, face, near the eye, or outside according to the position of the tooth, ex. Infection in the canine can reach the eye and cause a swelling, and the pt will have a systemic signs like fever,malasie, or joint pain, these patient have to take analgesic and antibiotics (penicillin or mitronidazole) and the swelling will subside in 2-3 days or may reach 5 days according to the patient response. These patients will have flare-up risk, it means that you may finish the treatment and suddenly they may get another swelling.

This is a localized swelling, you check for fluctuation either by your finger, mirror head, or the suction. You must find the most dependant point which is the point that has the largest amount of pus (most accumulation of pus) and has a head.

You make an incision with a scalpel blade no. 15 or 11 (there is a way to make an incision with the least amount of harm and damage to the patient), the length of this incision is about 1 cm, as we increase this length it will be better for draining more pus and it will heal quickly, we leave it open, not suture it or we can use the hemostat (artery forceps) and widen the opening

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and then we do irrigation with saline or CHX but not with sodium hypochlorite because it will cause necrosis to the tissue.

You should give anesthesia before, either ID block but away from the swelling because this environment is acidic that will cause failure for the anesthesia, or we give posterior alveolar nerve block, or anterior and posterior to the swelling.

This is a case of cellulitis, in this case you should not think to do incision and drainage, you should refer it to a specialist (oral surgery) immediately, if the patient could open his mouth then they will do extraction, here there is a risk for an infection to occur in the spaces mostly in the upper which can reach the cavernous sinus then thrombosis will occur which may cause blindness.

In the lower spaces there is what we call “Ludwig’s angina” (swelling in the submandibular , submental and sublingual spaces) which starts suddenly and accompanied with systemic symptoms (elevated temp. , difficulty in breathing or swallowing, trismus which complicate the extraction), the specialist will give

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the patient IV antibiotics and wait 2-3 days then extract the tooth or sometimes they do extraoral drainage.

Indications for antibiotics:

Fever, malaise, cellulitis, palpable lymph nodes, or un-explained trismus.

All what we talked about before was the pretreatment emergencies, now we will talk about the interappointment emergencies (during treatment).

B-Interappointment(flare up):

1.You treat the pt and he came back with swelling and severe pain, the incidence for this to happen is 1-3% (not common).

2.Doesn’t has any relation to the age, sex, intracanal medications ,single or multiple visit , medical history.

3.Preoperative pain and pulp necrosis are predicators of a flare-ups. usually there is no flare-up in vital teeth.

4.Ledermix as an intracanal medicament (antibiotic corticosteroid mix). This is effective in cases which need vital extirpation, you put it as an intracanal medicament instead of CaOH or you mix them together with a spatula, it will reduce the pain (anti inflammatory).

5.The most important is reassurance, if you cleaned the canal very well then you have to reassure the patient that it happens.

6.Previously vital pulps with complete debridement, you give the patient analgesic. (Don’t give antibiotic unless there is a diffuse swelling).

7.If you aren’t sure that you cleaned the canal very well, then you have to reopen the tooth and debride it.

8.If the pulp is necrotic with no swelling then you have to reopen the tooth, then take the exact working length, do enlargement and widen the canal, complete your instrumentation, then do dressing and let the patient go home.

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9.If there was swelling, then you should make an incision and drainage or give antibiotics.

C-Postobturation emergency:

You treated the patient and after that he will come with swelling, this swelling because of trauma from treatment. (that is if your work was good, but if it wasn’t adequate so there may be other reasons like bacterial infection and it has to be retreated)

There is correlation with the level of obturation,if there is a gross overfilling, the patient will get flare-up(too much gutta percha or sealer outside the apex), here you need retreatment, but if there is a little overfilling the patient will complain of slight pain which relieved by analgesic. So sometimes you need retreatment and sometimes you need incision and drainage.

Analgesics:

Options:

Paracetamol (acetaminophen) or there is Revacot which is combination of paracetamol with codeine (which is not found in the market now because people get addiction), now what present is Pnadinfort which contain caffeine and codeine (low %)not like the revacort .

What are the option of analgesics that we can give to a patient that is complaining of pain ??

According to studies, Ibuprofen 800 mg(two tablets)loading dose was relieved pain in 50% of patients who have severe pain by 100%. So it’s preferred to start with Ibuprofen (400 mg), two tablets every 3-4 hours for the first two days only, no need for more.

Paracetamol alone isn’t enough, you can do a combination of Ibuprofen and paracetamol at the same time, and it’s very effective.

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Codeine with acetaminophen (revanin) isn’t efficient (57%).

In Ibuprofen 400 mg (one tablet), you can notice the % here was decrease from 100% to 56%. You have to give instructions to the patient to take the drugs with full stomach, not empty.

Codeine (60 mg) isn’t effective (15%).

Placebo is not effective (18%).

So Ibuprofen is enough. Sometimes you can give voltaren injection, it’s more rapid, and within 15 min the patient will give response.

Done by:

Shahd Qeadan….

The End

: واالصدقاء للصديقات تحية

( , , , ,) النك ) - شكرا دينا حمدان نور ريمه ابو ربى فرح أستطيع بغدرش عفانه أماني , , , , , , ,) نور مرام كتانه لينا سكينه أسعد فاطمه مديحه ميس تسكتي حاولت

, , , , , , , فاطمه, النجار نور هدى سناء زينب تيسير جمانه الصاحب عبد جمانه الرحمون, ,) ( , , , نور, أسماء كرابه عطاالله روان مخلوف أروى العمري أمل فكريه لمياء

... , , , , , زبيده, عين ايمن نور هدايو نور فائزه نور عيني نور نادية نور جيوسي) طربيزه)

, , , , , ,) ( معاذ حلحولي اياس ابوالوليد محسن كثيييييييير معي غلبتك عوضي عبدالله, , , , , ,) ( السيد انس الشمري محمد اليافعي صالح حسين رشيدان جز روح الثاني علي

( ,) .... ( , , الله العابدين زين قصيرة وفقرة ال منتصر القاضي صالح ربحي انس, ) ( , , , ,) القرنين ذو ببير سرك معله علي ادهم باسل مدلج امين هالعمله على يسامحك

. , , , , الرحمن, عبد النيرد صوالحة نعيم نازيرول محمد حليم نور انجكو

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