Endodontic Emergencies

1. Endodontic Emergencies By Dr. MunaMarashdeh M.ScEndodontics

2. LETURE OUTLINE • DEFINITION • CATEGORIES • PAIN PERCEPTION AND PAIN REACTION • SYSTEM OF DIAGNOSIS • TREATMENT PLANNING • PRETREATMENT EMERGENCIES • INTERAPPOINTMENT EMERGENCIES • POSTOBTURATION EMERGENCIES

3. DEFINITION • By definition, endodontic emergencies are usually associated with pain and/or swelling and require immediate diagnosis and treatment. • These emergencies are caused by pathoses in the pulp or periradicular tissues. • Emergencies also include severe traumatic injuries that result in luxation, avulsion, or fractures of the hard tissues

4. CATEGORIES • Pretreatment Emergency A pretreatment emergency is a situation in which the patient is seen initially with severe pain and swelling. Problems occur with both diagnosis and treatment.

5. Interappointment and Postobturation Emergency The interappointment and postobturation emergency, also referred to as the “flare-up,” occurs after an endodontic appointment. It is easier to manage because the offending tooth has already been identified and a diagnosis has been previously established. Also, the clinician has knowledge of the prior procedure and will be better able to correct the problem.

6. Differentiation of Emergency and Urgency • It is important to differentiate between a true emergency and the less critical urgency. • A true emergency is a condition requiring an unscheduled office visit with diagnosis and treatment. • Urgency indicates a less severe problem, thus a visit may be scheduled Key questions to determine severity include the following: 1. Does the problem disturb your sleeping, eating, working, concentrating, or other daily activities? 2. How long has this problem been bothering you? (A true emergency has rarely been severe for more than a few hours to 2 days.) 3. Have you taken any pain medication? Was the medication ineffective? (Analgesics do not relieve the pain of a true emergency.)

7. A rule of the true emergency is one tooth is the offender, that is, the source of pain. • In the excitement of the moment, the patient might believe that the severe pain is emanating from more than a single tooth.

8. PAIN PERCEPTION AND PAIN REACTION • Pain is a complex physiologic and psychologic phenomenon. • Pain perception levels are not constant; pain thresholds, as well as reactions to pain, change significantly under various circumstances. • The pain reaction threshold is significantly altered by past experiences and by present anxiety levels and emotional status

9. Psychologic management of the patient is the most important factor in emergency treatment

10. SYSTEM OF DIAGNOSIS • Patients in pain often provide information and responses that are exaggerated and inaccurate. • After accurate information regarding the medical and dental histories is obtained, both subjective questioning and objective examination are performed carefully

11. Diagnosis Sequence 1. Obtain pertinent information about the patient’s medical and dental histories. 2. Ask pointed subjective questions about the patient’s pain: history, location, severity, duration, character, and eliciting stimuli. 3. Perform an extraoral examination. 4. Perform an intraoral examination. 5. Perform pulp testing as appropriate. 6. Use palpation and percussion sensitivity tests to determine periapical status. 7. Interpret appropriate radiographs. 8. Identify the offending tooth and tissue (pulp or periapex). 9. Establish a pulpal and periapical diagnosis. 10. Design a treatment plan (both emergency and definitive).

12. Medical and Dental Histories • Medical and dental histories should be reviewed first. If the patient is the dentist’s own, the medical history is briefly reviewed and updated. • If the patient is new, a standard, complete history is taken. An important medical complication may be easily overlooked in an emergency situation. • Either a short or a complete dental history is taken. This includes recalling dental procedures, the chronology of symptoms, or an earlier relevant comment by a dentist

13. Subjective Examination • Questions relating to the cause or stimulus that elicits or relieves the pain help select appropriate objective tests to arrive at a final diagnosis. • Pain that is elicited by thermal stimuli or pain that is referred is likely to originate from the pulp. • Pain that occurs on mastication or tooth contact and is well localized is probably apical. • The three important factors constituting the quality and quantity of pain are its spontaneity, intensity, and duration • If the patient reports any of these symptoms (and assuming that the patient is not exaggerating), significant pathosisis likely to be present.

14. Stimuli that elicit and relieve pain

15. Objective Examination • It is important in identifying the offending tooth to repeat tests that mimic what the patient reports subjectively. • In addition, objective tests include extraoral and intraoral examination such as observation for swelling and use mirror and explorer examination to note the presence of defective restorations, discolored crowns, recurrent caries, and fractures. • Cold, heat, electricity, and direct dentin stimulation also indicate the pulp status (vital or necrotic). • Periradiculartests include: (1) palpation over the apex, (2) digital pressure on teeth , (3) light percussion with the end of the mirror handle, and (4) selective biting on an object such as a cotton swab or Tooth Slooth.

16. Pulp test • Peri apical test (tooth slooth)

17. Periodontal Examination • A periodontal examination is always necessary. Probing helps in differentiating endodontic from periodontal disease. a periodontal abscess can simulate an acute apical abscess • However, with a localized periodontal abscess, the pulp is usually vital . In contrast, an acute apical abscess is related to an unresponsive (necrotic) pulp. • These abscesses occasionally communicate with the sulcus and have a deep probing defect.

18. Periodontal abscess. Radiographic appearance Acute apical abscess.

19. Radiographic Examination • Radiographs are helpful but have limitations. There is a tendency to rely too much on radiographs, often with unfortunate consequences. • Periapical and bitewing radiography may detect the presence of interproximal and recurrent caries, possible pulpal exposure, internal or external resorption, and periradicularpathosis, among other entities, but it is important to understand that diagnosis should not be based on radiographs alone

20. Bitewing , periapical x-ray should be taken

21. Diagnostic Outcome • After carefully working through the previously described sequence, the clinician should have identified the offending tooth and the tissue (pulpal or periradicular) that is the source of pain and should have recorded a pulpal or periapical diagnosis. • For many reasons, all or none of these conclusions may be clear. This may not be a true emergency or the problem may be beyond the capability of the generalist and the patient should be referred . If the diagnosis is clear, however, treatment planning follows

22. TREATMENT PLANNING • Inflammation and its consequences (i.e., increased tissue pressure and release of chemical mediators in the pulp or periradicular tissues) are the major causes of painful dental emergencies. • Therefore reducing the irritant, by releasing pressure or removing the inflamed pulp or periradicular tissue, should be the immediate goal, which usually results in pain relief.

23. PRETREATMENT EMERGENCIES • Pretreatment emergencies require a diagnosis and treatment sequencing. • Patient Management • Patient management is always the most critical factor. The frightened patient who is in pain must have confidence that his or her problem is being properly managed. • Profound Anesthesia • Obtaining profound anesthesia of inflamed painful tissue is a challenge.

24. PRETREATMENT EMERGENCIES • Irreversible Pulpitis • Without Symptomatic Apical Periodontitis • With Symptomatic Apical Periodontitis • Pulp Necrosis with Apical Pathosis • With out swelling • With localized swelling • With diffused swelling

25. Management of Painful Irreversible Pulpitis Because the pain is the result of inflammation, removal of the inflamed tissue will usually reduce the pain Irreversible Pulpitis could be • Without Symptomatic Apical Periodontitis • With Symptomatic Apical Periodontitis

26. Irreversible Pulpitis Without Symptomatic Apical Periodontitis • Complete cleaning and shaping of the root canals is the preferred treatment, if time permits. • With limited time, most pulpal tissue is extirpated with a broach (partial pulpectomy) in single-rooted teeth. • In molars, a partial pulpectomy is performed on the largest canals (palatal or distal root). Also, pulpotomy is usually effective in molars when minimal time is available • After irrigation of the chamber or canals with sodium hypochlorite, a dry cotton pellet is placed and the access is sealed temporarily • NSAIDs • Antibiotics, are definitely not indicated in cases of irreversible pulpitis

27. Removal of coronal pulp. Pulpotomyresult in relief of pain from irreversiblepulpitis.

28. Irreversible Pulpitis With Symptomatic Apical Periodontitis • In patients with extreme tenderness on percussion, a partial or total pulpectomy (as previously described) is appropriate. • Reducing the occlusion to eliminate contact has been shown to aid in relief of symptoms. • Trephination (artificial fistulation) by creating an opening through mucosa and bone is not useful and is contraindicated • NSAIDs • Antibiotics, are definitely not indicated in cases of irreversible pulpitis

29. Management of Pulp Necrosis with Apical Pathosis • The pain of pulp necrosis is related to periradicular inflammation, which results from potent irritants in the necrotic tissue in the pulp space. • Treatment now is biphasic: • remove or reduce the pulp irritants and • relieve the apical fluid pressure (when possible). • The diagnosis may be symptomatic apical periodontitis (no significant periradicularresorption) or acute apical abscess with or without swelling. • Therefore with pain and pulp necrosis there may be: (1) no swelling, (2) localized swelling, or (3) diffuse, more extensive swelling (cellulitis).

30. Pulp Necrosis without Swelling • In pulp necrosis without swelling, the teeth may contain vital inflamed tissues in the apical canal and have inflamed painful periradiculartissues (symptomatic apical periodontitis). • Alternatively, the lesion may have expanded and formed an abscess that is confined to bone. These are often painful, primarily because of fluid pressure in a noncompliant environment. • The aim is to reduce the canal irritants and to try to encourage some drainage through the tooth. • After determining the corrected working length, complete canal débridement is the treatment of choice. If time is limited, partial débridement at the estimated working length is performed

31. Canals are not enlarged without knowledge of the working length. • During cleaning, canals are flooded and flushed with copious amounts of sodium hypochlorite. • Finally, canals are irrigated with the same solution, dried with paper points, filled with calcium hydroxide paste (if the preparation is large enough), and sealed with a dry cotton pellet and a temporary filling. • NSAIDS • Antibiotics are not indicated. • The patient is told that there will still be some pain (the inflamed, sensitive periradicular tissues are still present) and that the pain should subside during the next 2 or 3 days, as the inflammation decreases.

32. Pulp Necrosis with Localized Swelling • The abscess has now invaded regional soft tissues and at • Radiographic findings range from no periapical change (seldom) to a large radiolucency. • Again, treatment is biphasic: • First and most important is débridement (complete cleaning and shaping if time permits) of the canal or canals. • Second in importance is drainage. Localized swelling should be incised • Drainage accomplishes two things: (1) relief of pressure and pain and (2) removal of a very potent irritant

33. A Localized swelling. B Incision for drainage after cleaning and shaping offending incisor • A • B

34. In teeth that drain readily after opening, instrumentation should be confined to the root canal system • In patients with a periradicular abscess but no drainage through the canal, penetration of the apical foramen with small files (up to 25) may initiate drainage and release of pressure

35. After opening into the root canal and establishment of drainage, instrumentation should be confined to the root canal system. Releaseof purulence removes a potent irritant (pus) and relieves pressure

36. Copious irrigation with sodium hypochlorite is performed throughout instrumentation to reduce amounts of necrotic tissue and bacteria. • The canals are then dried with paper points and filled with calcium hydroxide paste. After placement of a dry cotton pellet, the access is sealed temporarily. • These teeth should not be left open to drain, although leaving teeth open has been a common procedure • In acute apical abscess with localized swelling, the use of systemic antibiotics is not necessary, having been shown to be of no benefit

37. Pulp Necrosis with Diffuse Swelling • Rapidly progressive and spreading swellings, commonly referred to as cellulitis, are not localized and may have dissected into the fascial spaces . • Fortunately, these serious infections seldom occur. • Occasionally, there is elevated temperature or other systemic signs indicating a more serious infection. • These patients should be referred to a specialist.

38. An acute apical abscess has rapidly spread into the buccal and submandibular spaces and is localizingextraorally and subcutaneously, requiring extraoral incision for drainage

39. Most important is removal of the irritant by canal débridement (cleaning and shaping is completed, if possible) or by extraction. • The apical foramen may be gently penetrated with a file to hopefully permit a flow of exudate • although drainage often does not occur. At this time, swelling may be incised and a rubber drain inserted for 1 or 2 days. • Occasionally, the abscess may spread to multiple spaces. This requires hospitalization and aggressive treatment, including • intravenous antibiotics, incision, and placement of several drains

40. Rubber drain

41. After placing calcium hydroxide paste and a dry pellet, the access is closed with a temporary filling. • Systemic antibiotics are indicated • penicillin VK remains a good, inexpensive first choice for those patients who are not allergic.Initialtherapy should begin with a loading dose of 1000 mg, followed by 500 mg every 6 hours for 7 days. For patients whose symptoms do not improve after adequate local therapy and penicillin VK, 500 mg of metronidazole may be added to the existing penicillin regimen. • For patients allergic to penicillin, clindamycin is an alternative, given as a 300 mg loading dose, followed by 150 to 300 mg every 6 hours for 7 days

42. Postoperative Instructions • Patients must be informed of their responsibilities and of what to expect. • The pain and swelling will take time to resolve • proper nutrition and adequate intake of fluids are important, and medications must be taken as prescribed. The problem may recur or worsen (flare-up), requiring another emergency visit. • Communication after the visit is very important. Calling the patient the day after the appointment has been shown to reduce pain perception and analgesic needs

43. INTERAPPOINTMENT EMERGENCIES • Despite careful treatment procedures, complications, such as pain, swelling, or both, may occur. • As with emergencies occurring before root canal therapy, these interappointmentemergencies are undesirable and disruptive events and should be resolved quickly.

44. Causative Factors • No definite risk factor, these factors generally can be categorized as • Patient factors (including pulpal and periapicaldiagnosis, pt gender) • F>M • uncommon in teeth with vital pulps. More often, flare-ups occur in teeth with necrotic pulps and especially in those with a periapicaldiagnosis of symptomatic apical periodontitis or acute apical abscess. • more likely to have presented with significant preoperative pain and/or swelling • Treatment procedure • Although it would seem that certain procedures, such as over instrumentation, pushing debris out the apex, or completing the endodontic therapy in one visit, may increase the incidence of flare-ups, no definitive treatment risk factors have been identified

45. Prevention • Procedures • Use of long-acting anesthetic solutions, complete cleaning and shaping of the root canal system (possibly), analgesics, and psychologicpreparation of patients (particularly those with preoperative pain) will decrease interappointment symptoms in the mild to moderate levels. • Use NSAIDs • There are, however, no demonstrated treatment or therapeutic measures that will reduce the number of interappointment flare-ups.

46. Diagnosis • The same basic procedure is followed as for pretreatment emergencies • The problem has been diagnosed initially, so the operator has an advantage. • However, a step-by-step approach to diagnose the existing condition reduces confusion and error

47. Treatment of Flare-ups • Reassurance (the “Big R”) is the most important aspect of treatment • restoring the patient’s comfort and breaking the pain cycle • Interappointment emergencies are divided into patients with an initial diagnosis of a vital or a necrotic pulp and with or without swelling

48. Previously Vital Pulps with Complete Débridement • is unlikely to be a true flare-up, and patient reassurance and the prescription of a mild to moderate analgesic often will suffice. • Generally, nothing is to be gained by opening these teeth; the pain will usually regress spontaneously • check that the temporary restoration is not in traumatic occlusion

49. Previously Vital Pulps with Incomplete Débridement • It is likely that tissue remnants have become inflamed and are now a major irritant. • The working length should be rechecked, and the canal(s) should be carefully cleaned with copious irrigation of sodium hypochlorite. • A dry cotton pellet is then placed, followed by a temporary filling, and a mild to moderate analgesic is prescribed .

50. Previously Necrotic Pulps with No Swelling • Occasionally, these teeth develop an acute apical abscess (flare-up) after the appointment. • The abscess is confined to bone and can be very painful. • The tooth is opened and the canal is gently recleaned and irrigated with sodium hypochlorite. Drainage should be established if possible. • If there is active drainage from the tooth after opening, the canal should be recleanedand irrigated with sodium hypochlorite. Then, the canals are dried, calcium hydroxide paste is placed, and the access is sealed. • If there is no drainage the symptoms usually subside but do so more slowly than if drainage was present. • antibiotics are not indicated