Endodontic emergency



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ENDODONTIC EMERGENCY

Most individuals seeking emergency dental treatment are suffering from pain originating from the pulp or periapical area. (Periodontal and non-dental origin 10%)


* Diagnosis

Correct diagnosis of the emergency patient’s orofacial signs and symptoms is a prerequisite for their proper management.


* There are 3 roles in management of pain in emergency:

  1. Do not over treat until you are certain from the diagnosis.

  2. It is better to provide no treatment than to provide wrong treatment.

  3. When you are in doubt refer the case out.


Differential Diagnosis

Because orofacial signs and symptoms may arise from non-odentogenous etiologies, and because such pathologic entities may co-exist with confirmed endodontic and periodontal abnormalities, differential diagnosis of non-dental origin should always be considered whenever the dentist evaluates symptoms for probable cause.


Non-odentogenous causes of orofacial symptoms can be classified into several categories:

  1. Organic

  2. Functional

  3. Vascular

  4. Neuralgic

  5. Psychogenic

It should be emphasized that the main purpose of categorizing the various non-dento alveolar conditions is to facilitate the eventual referral of the patient to the appropriate medical of dental specialist.




  1. Organic disorder/alteration in the structure Of body organ adapted to specific function.

e.g.: Non-dental mandibular parasthesia is most suggestive of an impinging tumor.

    • Maxillary and facial paresthesia not attributable to dental origin is probably due to maxillary sinus disease.

    • Pathologic conditions involving the maxillary sinus (e.g. inflam., cysts, tumors, trauma) are the most common non-dental organic causes of odontic symptoms. The fact that the alveolar process of the max. post. teeth also forms the inferior portion of max. sinus help to explain this observation.




  1. Functional Disorder

Functional disorders affect the normal performance of an organ or tissue without apparent organic or structural changes.

e.g.: (MPD) myofacial pain-dysfunction syndrome involving TMJ region.

The following components are associated with this syndrome:


    1. Severe emotional stress

    2. Clenching and bruxism

    3. Occlusal disharmonies

Orofacial pain is probable result of masticatory muscle spasm. Such pain may radiate to the teeth, tongue, palate, TMJ, ear, head or neck.

Prevalence: Women more than men

Diagnosis  Clinical finding and x-ray TMJ
3. Vascular Pain Syndromes

e.g.: Migraine  due to dilation of extra cranial arteries and is usually evoked by psychologic factors characterized by post ocular pain, nausea, vomiting.


4. Neuralgic Disorder

e.g.: Trigominal neuralgia, is of a primary significance to the dentist because it involves the 5th cranial nerve.

The pain of trigeminal neuralgia is distinctly perceived as a sharp, shooting or stabbing attack similar to an electro shock.

Episodes are characterized by their sudden recurrence, extreme intensity and short duration.

The main feature of T.N. is the presence of a trigger zone around the mouth, face or throat provoking stimuli may include light touch, talking, chewing, swallowing, washing the face and blowing the nose.
The differential diagnosis of symptoms involving sharp radiating pain should include dental disorders (e.g. irreversible pulpitis, cracked tooth).

5. Psychogenic Disorder

e.g.: Psychogenic facial pain and headache may result from states of dejection and

mental depression.


If the chief complaint has been positively identified as an endodontic problem and the location has been precisely determined, the dentist should inform the patient regarding pertinent examination finding (e.g.: pre-existing periodontal condition, pulpal status, extent of alveolar involvement, restorative considerations) recommended treatment plan, alternative approaches, risks and prognosis.
Treatment According to Symptoms of Dental Pain

Pain can be thermal, percussion, or spontaneous.

I- Thermal Pain


When patient’s acute symptoms involve thermal pain, the usual nature of the complaint is moderate – severe discomfort lasting for a few seconds or lingering when the tooth is contacted by thermal stimulus.
There are 3 general categories within which the patient may have such pain.

Before endo treatment

If pain is a symptom before endo. therapy, its source must be determined.

If the pain due to thermal changes  reversible pulpitis


  • The pain is of very short duration once the stimulus removed the pain disappear (cold stimuli).

  • The pain may be diffucult to localize.

  • The tooth not tender to percussion

  • The tooth may give an exaggerated response to vitality test.

  • Radiograph presents a normal appearance and there is no apparent widening of PDL.


Treatment:  remove caries and temporize the tooth.
If the patient got a recent filling and that filling sensitive to thermal changes  remove the filling and temporize the cavity. After several weeks the sedative restoration can be replaced with a well-based final restoration.
When the signs, symptoms and the dental history indicate irreversible pulpitis

  • Spontaneous pain lasting from few seconds up to several hours.

  • Painful response to heat stimulus.

  • Ice – water relief the pain in the case of late stage.

  • Initially pain radiating, throbbing and diffuse, but once the PDL involved, the patient able to locate the tooth

  • The tooth becomes tender to percussion

  • Widening PDL

  • Pain ↑ when patient lay down in sleep


Treatment:

- pulp should be removed immediately (intra ligamentary injection to supplement convential

local anesthesia)

- Take the tooth out of occlusion → to avoid pressure in the inflamed tissue.

After initiation of endo tx. But before canal obturation
Always expect another tooth (disbelieving).

After canal obturation

Expect another tooth.


II- Percussion pain

Pain with chewing → inflam. involving PDL



Before endo. Tx

If percussion causes pain  vitality of the pulp must be verified

- If the pulp is vital  vital acute apical periodontitis

Treatment  articulating paper  occlusal premature  adjust occlusion

This is common following recent placement of restoration in posterior teeth after spots

reduction advised patient to do all chewing on the other side for several days  PDL.


- If the pulp is non-vital Necrosis with periapical extension as in early acute apical abscess or

phoenix abscess  endo.tx.


After initiation of endo. tx. but before obturation
look to the history of the tooth, if the tooth initially vital, naturally some temporary inflammation of PDL can be anticipated. This should be clearly explained to patient before treatment. The potential of inflammation can be minimized if the occlusion has been relieved prior to initiating endo therapy.
-Treatment is based on the degree of discomfort

- If the tooth is only slightly tender to percussion and if all canals have been thoroughly debrided  Reassure the patient.

- If the tooth moderate-extremely tender to percussion  Rubber dam + L.A.  examine canals for exudate  if there is exudates  irrigation reconfirms the working length, cleaning + shaping repeated (ventilation of canals).
Before sealing the tooth, be sure that the canals are completely dried  dry cotton pellet  cavit  check occlusion.

Advise patient to chew on the other side for several days.



- If the tooth initially non-vital (determining factor is presence or absence of exudate)

- Treatment is basically the same as vital tooth.

- Rubber dam  L.A.  Examine carefully for any exudates  if nothing  dry cotton pellet + cavit + check occlusion.

- If there is exudate, record the type + volume (slight hemorrhagic exudate, considerable purulent exudate)  irrigation  dry 

- If exudate persist after cleaning for more than 5 mins, leave the tooth open for one day, place a small cotton pellet in pulp chamber and ask the patient to return the following day to have the canals disinfected and the tooth closed.


- Advise patient to do all his chewing on the other side and to use v. warm rinses frequently and to brush often and thoroughly.
- If cannot be emphasized too strongly  close tooth.

*After canal obturation


Mild tenderness to biting or chewing is fairly common after canal obturation.

Should inform patient you will probably feel tender to biting for several days   anxiety


-Use articulating paper to re-check occlusion

- Mild analgesic and warm H2O rinses.

- If the pain to percussion is strong or lasts more than a few days, re-examine the post operative radiograph

- GP under extended  retreat the canals

- GP over extended  well condensed  periapical surgery

- GP long – not well condensed  retreatment


III. Spontaneous Discomfort
Before endo

If the patient presents with pain of endo origin as chief complain

The diagnosis must be:
-symptomatic irreversible pulpitis

-partial necrosis

-necrosis with periapical involvement

90% of emergency cases  pain of pulpal origin


Best relief for pain  debride the root canal regardless the extent of pulpal inflammation

or necrosis. Some patients with this kind of pain may have not sleep or eaten for long

time  exhausted, fasting, they may be difficult to manage  you have to be patient.

Treatment

-When the diagnosis has been made  L.A., adjust the tooth out of occlusion  rubber dam  remove the pulp or its remnants  cleaning + shaping

- Moderate analgesic (just in case)

- Rest + frequent warm rinses

- Full meals to help the patient regain strength


After initiation of endo but before obturation
1. Incomplete extirpation of the pulp (remaining tissue in the canal)

2. You missed extra-canal


upper molar, distal of lower molar, mandibular incisors + premolar
When it has been verified that the source of pain is the tooth under treatment 

- L.A. to stop the pain  rubber dam  Remove temporary restoration  examine each canal with a fine paper point to determine whether there is any exudate.


-check radiograph for extra canal. Serious or hemorrhagic exudate may be the result of residual

pulp tissue OR extension of instrumentation beyond the apical foramen


- Exudate  cleaning + shaping  dry the canal (it should be easy to dry if pain due to pulp remnants)
- If source of pain is of periapical origin  exudate may continue regardless of how often cleaning and shaping steps are repeated  Ca(OH)2 paste for 2 weeks
After canal obturation
exclude that the pain come from the neighaboring or opposite tooth or non-dental condition
Reasons: - over instrumentation

- filling beyond the apex



Treatment

- If the canal filled well and there is no evident material impinging on the periapical tissue

 anti inflammatory analgesic


-If the canal under filled by more than 1 mm  refilled
-If the filling is slightly extended beyond the apex + well condensed  reassure the patient +

analgesic


-If filling is impinging on the periapical tissue and pain persists more than few days  surgery –
- Overfilling + poorly condensed  refilling
- A symptomatic + overfilled  follow-up.

Swelling


Before endo. treatment


The nature, location and extent of swelling along with determination of pulp vitality, will indicate the type of the clinical treatment.

After examination + radiograph  swelling is

1. of dental origin + tooth vital  Diagnosis > lateral periodontal abscess

Treatment probing the associated periodontal pocket may allow the drainage to occur through the sulcus

2. If the tooth is not vital  acute apical abscess (phoenix) , palpation and visual examination will indicate whether the swelling is soft + flctuant or firm and indurated

- If swelling is soft + fluctuant don’t incise and drain because some swelling might appear soft, but one we open it, the drainage is hemorrhagic. This of course provides little immediate benefit for the patient, and may even complicate the presenting acute condition.

So, we have to go through needle aspiration technique 27- gauge needle attached to an aspirating syringe  placed beneath the swollen mucosa  express two or three drops of anesthetic and then aspirate.

*If you get pus in the suringe I + D

*If you get hemorrhagic exudate  not suitable for I + D

You have to ask the patient to rinse frequently with very warm water and return back when the swelling becomes larger or feel softer.

Whether or not I + D can be performed, the tooth or teeth that are the source of the swelling should be treated immediately.

Treatment

- L.A. (if possible)

- Rubber dam isolation +relived the tooth out of the occlusion

- Access cavity + unroof the pulp chamber if no exudate  negotiating the canal with file  open the canals

- If the drainage is occurring through the root canals, it should be allowed to continue for several minutes  in most cases, it will stop shortly. If the exudate does not stop within 5-10 min  the tooth can be left open to drain until next day.

- No need for strong analgesic, but sometimes you might describe Ab. after sensitivity test

After endo treatment but before obturation

The main situations that predispose to this type are:

1. chronic apical periodontitis without a sinus tract

2. re-treating and “old” root canal

3. incomplete debridement of necrotic teeth

4. over irrigation with (NaoCl)

In the first three situations, the reason for swelling appears to be a disturbance of the dynamic equilibrium between the microorganisms, toxins, and necrotic debris within the root canal system and the chronic inflammatory cells surrounding the apex. So, once we shape the canal, we push microorganism to the apex.

Treatment

The dentist has to check first:

1. The vitality of the adjacent teeth, because by coincidence an adjacent tooth is the source of the swelling.


2. Check the periodontium, because there is always also the possibility that by coincidence, a lateral periodontal abscess has developed around the tooth receiving endodontic treatment.
Treatment  cleaning + shaping
When endodontic emergencies are clinically managed in this way, the patient will often experience significant relief within a matter of minutes.
- While the patient is sitting in dental chair (rare), he may experience the following symptoms:

(while irrigating)


1. sudden extreme pain

2. swelling within minutes

3. profuse, prolonged hemorrhage through the root canal
The cause is evidently locking of the irrigating needle in the root canal while the irrigant is being expressed. This causes the irrigant to be forced beyond the canal into the periapical tissues.
Managing these rare events requires the following:
1. Maintain self control. Don’t panic.
2. Summon some type of assistance if more people are needed to keep the patient seated so you can administer regional block anaesthesia to help to attenuate the pain. An IM injection of a sedative and analgesic would be beneficial.
3. Allow the bleeding to continue. The body is attempting to dilute and rid itself of the toxic fluid. Continue high volume aspiration until the bleeding begins to subside.
Depending on the amount, concentration and temperature of irrigant forced post the apex. This may take anywhere from 5-20 mins.
4. Administer an appropriate strong Ab. intramuscularly (preferred or orally).
5. Refer the patient to an oral surgeon or endodontist immediately for continued management.
Of course, this type of emergency is completely avoidable if two simple rules are followed during irrigation:
1. Do not lock the needle in the canal.

2. Express the irrigant slowly.

After canal obturation
These most common factors may precipitate this situation include:
1. over instrumentation

2. over filling


Treatment
1. Depends on the firmness of the swelling, the location of the swelling and the quality and 2. Extension of the canal filling.

Firmness + location
- If the swelling is mild and localized Encouraging the patient to rinse frequently with

warm water rinses to allow the body to resolve the swelling without need for any further

treatment or systemic medication.
-If the swelling persists for more than a few days or gets larger or becomes soft and fluctuant 

needle aspiration to check the nature of exudate. Many clinicians will prescribe Ab. at this time

especially if the swelling area seems to be increasing in size, just as precaution.
-Assessment of the filling of the root canal can strongly influence treatment planning.

If the canal is filled well + extending to the apical foramen  surgical intervention may be avoidable.


- If it is not well condensed or gross over extension  non surgical retreatment or surgical intervention may be the only way to resolve the problem.


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