endodontic emergencies

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INTRODUCTION Pain in endodontic emergencies are related to two factors Chemical mediators  lowers pain threshold increase vascular permeability edema Pressure  edema

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Definition Occurrence of severe pain & or swelling following an endodontic treatment ,requiring an unscheduled visit and active treatment (Watson& Foud 1992)

emegency /urgency:

emegency /urgency True emergency  Requires unscheduled visit with diagnosis &treatment at that time Less critical urgency  Less severe problem

System of diagnosis:

System of diagnosis Medical and dental histories Subjective examination Objective examination Periodontal examination Radiographic examination

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Categorized into 3 types Pretreatment Intra appointment Post obturation Emergencies related to trauma

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Classification of endodontic emergencies (P Carrotte ) Pretreatment Dentin hypersensitivity Pain of pulpal origin Reversible pulpitis Irreversible pulpitis Acute apical periodontitis Acute periapical abscess Traumatic injury Cracked tooth syndrome

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Patients under treatment Mid treatment flare- ups Exposure of pulp Fracture of teeth Recently placed restoration Periodontal treatment

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Post endodontic treatment Over instrumentation Over extended filling Under filling Fracture of root High restoration

Pre-treatment emergencies:

Pre-treatment emergencies Obtaining profound anesthesia Intra- pulpal anesthesia Supplemental intraosseous injection Anesthetic efficacy of the supplemental inraosseous injection in patients with irreversible pulpitis . ( John nusstiein et al. Joe 2003

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Hypersensitive dentin Defined as sharp short pain arising from exposed dentin in response to stimuli typically thermal, chemical, osmotic or tactile &cannot be ascribed to any other form of dental defect or pathology Cause Exposed dentinal tubules due to Gingival recession Periodontal surgery Loss of enamel due to abrasion &erosion

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Treatment Desensitize the nerve potassium nitrate corticosteroids Cover the dentinal tubule preventing fluid flow  chemical / physical blockage a-plugging the dentinal tubule b-dentin sealers c-periodontal soft tissue grafting d-lasers e- propolis

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Cracked tooth syndrome Incomplete fracture of tooth with vital pulp


etiology Masticatory / Accidental trauma Morphologic factors: -Deep occlusal grooves -Steep cusp- fossa relationship - Mandibular molars -Bifurcation

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Iatrogenic factors: -Tooth cutting- Silvestri -Wedging effect- metal inlays -Amalgam filling -Endodontic treatment -Pins -Posts Other factors: -Excessive temp. fluctuations - Parafunction - Hiatt -Malocclusion

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Special tests The bite test Sensibility/vitality tests Transillumination Staining Radiographs


treatment Depends on location & extent Extent- difficult to determine Endodontic treatment & full crown

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Management The emergency and definitive treatment will be dictated by: Pulpal status & The restorability of the tooth The aim of emergency treatment -to relieve pain, to make the mouth comfortable to improve function.

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Urgent care immediate reduction of its occlusal contact by selective grinding

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Definitive treatment depend on: The extent of the crack; The loss of any tooth structure subgingivally ; The restorative material to be used; The patient’s preference for a particular type of treatment.

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Extent and position of the crack Full coverage crown if fracture involves crown portion Endodontic treatment & restorationif fracture involves root canal system Extraction if fracture of root extends below alveolar crest


ABSCESS & CELLULITIS Abscess  localised collection of pus within a tissue / confined space Cellulitis symptomatic edematous inflammatory process that spread diffusely through connective tissue &facial planes Severity related to virulence host resistance

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Facial planes – potential spaces bet anatomic structures of head &neck Spread of infection into facial planes life threatening

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Anatomic space involved in infection Mandibular buccal vestibule Sub mental space Sub lingual space Sub mandibular space Pharyngeal &cervical space Ludwings angina – infection of Sub mental space, Sub lingual space,Sub mandibular space

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Maxillary buccal vestibule Buccal space both maxillary & mandibular Sub masseteric space Deep temporal space Pterygomandibular space Bilateral parapharyngeal space Retropharyngeal space

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Anatomic space involved in midface swelling Palate Base of upper lip Infra orbital /canine space Periorbital spaces May result in cavernous sinus thrombosis

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Management of space infection Prompt diagnosis Removal of reservoir of infection by drainage of infectious material through tooth, soft tissue alveolus Surgical method for drainage I&D Needle aspiration Trephination

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Antibiotics in endodontics Conditions not requiring adjunctive antibiotics Pain without signs &symptoms of infection 1-symptomatic reversible pulpitis 2-symptomatic apical periodontitis Teeth with necrotic pulps & radiolucency Teeth with sinus tract (chronic apical abscess Localized fluctuant swelling)

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Conditions requiring adjunctive antibiotics 1 - systemic involvement fever>100ºF malaise lymphadenopathy trismus 2- progressive infection increased swelling cellulitis osteomylitis 3- persistant infection

Acute reversible pulpitis:

Acute reversible pulpitis Localized inflammation of pulp Lowering of threshold stimulation for A-delta fibers Exaggerated ,non lingering response to stimuli

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Management Removal of cause Recontouring of recently placed restoration Removal of restoration &replace with sedative dressing Relieve the occlusion Apply fluoride varnish to sensitive dentin

ACUTE irreversible pulpitis:

ACUTE irreversible pulpitis With /Without acute apical periodonitis H/O spontaneous pain Exaggerated response to hot or cold that lingers Presence of extensive restoration /caries May be responsive to electrical or thermal test

Without acute apical periodontitis:

Without acute apical periodontitis Complete cleaning and shaping Partial pulpectomy pulpotomy

Acute pulpitis with apical periodontitis:

Acute pulpitis with apical periodontitis Teeth elevated out of its socket Discomfort to biting or chewing Sensitivity to percussion Management Heavy dose of L.A needed Placement of intra canal medicament Pulpectomy / RCT

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Signs &symptoms of reversible /irreversible pulpitis Signs/symptoms Reversible pulpitis Irreversible pulpitis Duration of pain after stimulus Short but not linger Lasts for few sec –hrs Lingers after removal of stimulus Localization of pain difficult Radiates initially Response to vitality exaggerated Aggrevates pain on application of heat/cold .cold relieve pain Tenderness on percussion absent May be present at a later stage radiograph normal Widened PDL space in later stages

Acute periapical abscess:

Acute periapical abscess Swelling &pain Feeling of teeth elevated in its socket May not have radiographic evidence of tooth destruction Fever &malaise Mobility may or may not present

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Biphasic treatment Pulp debridement Incision &drainage Access cavity preparation Local infiltration should not be given Do not leave tooth open bet appointments Culturing the exudate Thorough irrigation In case of systemic features antibiotics should be given Relieve tooth out of occlusion NSAID – to relieve post operative pain Culturing exudate

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Irrigants used in treating acute abscess Distilled water or saline –emergency appt Alternate use of NaOCl & Hydrogen peroxide

Cracked Tooth:

Cracked Tooth

Sodium Hypochlorite Accident:

Sodium Hypochlorite Accident

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