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Transcript of Endodontics
- Rana Hazem
- Radhwa Refaat
- Reem Ahmed Hany
- Shymaa hassan elsharkawy
What is endodontic emergency?
PROPER DIAGNOSIS IS VERY IMPORTANT TO TREAT THE CASE.
THE IMMEDIATE GOAL OF THE TREATMENT SHOULD BE THE REDUCTION OF PRESSURE OR REMOVAL OF THE INFLAMED PULP OR PERIRADICULAR TISSUE.
Endodontic emergency is a unschedualed case that requires immediate intervention. Present with pain , with or without swelling and require immediate diagnosis and treatment. The cause maybe pulpal or periapical. Traumatic injuries are consider as endodontic emergency. Urgency is a less severe problem, as most patients exaggerate their pain so the problem may be urgent not an emergency.
How to differentiate between emergency and urgency?
1. History of the patient : You need to ask the patient. How long the tooth was painful ? If it's true emergency, it is rarely more than 1 day.
2.True emergencies are not relieved by analgesics .
The aim of emergency endodontic treatment is to relieve pain and control any inflammation or infection that may be present
3- Objective examination
1-OBTAIN MEDICAL & DENTAL HISTORIES
The most important step is QUESTIONING ...
Ask about the pain [spontanousity, intensity, and duration of pulpal or periapical symptom ]:
1. If the patient can localize pain then we are mostly talking about periodontal involvement.
2. Pulpal pain is sensitive to thermal stimuli,sweet,osmotic but in periapical involvement,there is pressure on biting.
3. PAIN CAUSED BY THERMAL CHANGES IS OF PULPAL ORIGIN . PAIN CAUSED BY PRESSURE IS OF PERIRADICULAR ORIGIN .
Questions relating to precipitating factors (Cold,hot, air , biting) and relieving factors help select appropriate objective tests to arrive at a final diagnosis.
Initial diagnosis is reached after this subjective question.
OBJECTIVE TESTS & RADIOGRAPHICAL EXAMINATION ARE USED FOR CONFIRMATION.
Intra oral examination
Extra oral examination
(cc) photo by theaucitron on Flickr
(cc) photo by theaucitron on Flickr
Soft tissue lesion
Of course, don’t over rely on radiograph and don’t diagnose from radiograph. Radiograph helps you in diagnosis. Its 2D representation of 3D object.
2.Records and radiographs should first be checked for any relevant information such as deep caries, pinned restorations, and the appearance of the periodontal ligament space.
cold spray , hot gutta percha , Ice sticks & hot water
Vitality tests can be misleading, as various factors have to be taken into account .
Thermal and electrical pulp testers are used to differentiate between VITAL and NON-VITAL pulp cases .
Extra oral sinus tract
Tooth mobiltity test
It is important to differentiate a periodontal emergency and endodontic emergency.
Sometimes, in simple case, we have periodontal abscess. It mimics an endodontic abscess.
PERIODONTAL ABCESS CAN STIMULATE THE SYMPTOMS OF ACUTE APICAL ABCESS BUT THE PULP HERE IS VITAL & POCKETS ARE PROBED.
Pharmacological steps to relief the pain
Aspirin has been used as an analgesic for more than 100 years.
Its analgesic and antipyretic effects are equal to those of acetaminophen, and its antiinflammatory effect is more potent.
However, aspirin’s side effects include epigastric distress,nausea, and gastrointestinal ulceration. In addition, its analgesic effect is inferior to that of ibuprofen.
When NSAIDs and aspirin are contraindicated, such as in patients for whom gastrointestinal problems are a concern, acetaminophen is the preferred nonprescription analgesic.
For moderate to severe pain relief, ibuprofen, an NSAID, has been found to be superior to aspirin (650 mg) and acetaminophen (600 mg) with or without codeine (60 mg).
Because of their anti- inflammatory effect, NSAIDs can suppress swelling to a certain degree after surgical procedures.
Anti- inflammatory benefit make NSAIDs, especially ibuprofen,the drug of choice for acute dental pain in the absence of any contraindication to their use.
If the NSAID alone does not have a satisfactory effect in controlling pain, then the addition of an opioid may provide additional analgesia. However, in addition to other possible side effects,opioids may cause nausea, constipation, lethargy, dizziness, and disorientation.
The prescription of antibiotics should be adjunctive to appropriate clinical treatment .
Because of potential risk factors such as allergies, drug interactions, and systemic complications, antibiotics should be prescribed judicially.
They are indicated when signs and symptoms suggest systemic involvement such as high fever, malaise, cellulitis, unexplained trismus, and persistent and progressive infections, and for patients who are immunologically compromised.
The objective is to aid in the elimination of infection from the tissue spaces. The use of antibiotics alone, without properly addressing the source of the endodontic infection, is not appropriate treatment
FIRST STEP IN TREATMNT IS PROFOUND ANESSTHESIA TO GAIN PATIENT’S CONFIDENCE & COOPERATION
UPPER JAW : INFILTRATION OR BLOCK
LOWER JAW: INFERIOR ALVEOLAR BLOCK.( LINGUAL & LONG BUCCAL BLOCK MAY BE HELPFUL)
SOMETIMES : PERIODONTAL,INTRAPULPAL OR INTRAOSSEOUS INJECTIONS MAY BE NEEDED
Vital pulp disease
It is a persistent inflammatory condition of the pulp , caused by a noxious stimulus. Acute Irreversible pulpitis exhibits pain usually caused by hot or cold stimulus .
The pain is sharp, excruciating , throbbing or shooting and it is generally severe.
Abnormally responsive to heat and cold .
Pain occurs spontaneously .
Pain is referred / diffuse due to absence of pressure receptors (proprioceptors ) .
Pain lasts for several minutes to hours and lingers even after removal of stimulus .
Nocturnal pain , pain on bending or lying down position.
The procedure is as follows:
Access cavity prepared and canals located .
Extirpate the canals ( Remove the entire Pulp tissues ) .
Cleaning and shaping with the use of irrigating solution like Naocl. Pain persists if inflamed pulp remains in root canal because inflammatory process will extend into peri radicular tissues .
Place dry cotton pellet in the pulp chamber & temporary filling .
Non Vital necrotic pulp disease
ACUTE APICAL PERIODONTITIS
It is a painful inflammation of periodontium as a result of trauma, irritation or infection through root canal .
Pulp is Necrotic giving -ve response to vitality tests , But In early stages , The Pulp may still have residual viable nerve fibers , so may give +ve response ..
ACUTE ALVEOLAR ABSCESS
It is a localized collection of pus in the alveolar bone at the root apex following pulp death with extension of infection through apical foramen into periapical tissues .
Severe Throbbing Pain , Tooth felt elongated with tenderness to biting .
Tenderness to percussion .
Radiographically : Ranges from widening of lamina dura to periapical Radiolucency .
It is accompanied by a severe local reaction and at times general reaction of systemic toxicity such as elevated temperature, dizziness , malaise , nausea, lack of sleep, headache etc.
Patient may present with no swelling , with intra oral sinus OR with swelling [facial asymmetry ] .
ANESTHESIA IS BLOCK ANESTHESIA OR RING ANESTHESIA . INFILTRATION SHOULD NOT BE ADMINISTRATED .
FIRST: Correct Access cavity is prepared using high speed hand piece to minimize vibration ( painful )
SECOND : DRAINAGE OF PUS , in order to :
1-RELEASE OF PRESSURE
2-REMOVAL OF THE VERY POTENET IRRITANT ( THE PUS)
PULP NECROSIS WITH DEFFUSE SWELLING
THESE LESIONS ARE RAPIDELY PROGRESSIVE & SPREADING PRODUCING A SWELLING THAT HAS DISSECTED INTO TISSUE SPACES .
THESE PATIENTS OCCASIONALLY HAVE AN ELEVATED TEMPRATURE & SYSTEMIC SIGNS .
SPREADING OF INFECTIONS INTO FACIAL SPACES IS A VERY DANGEROUS SITUATION .
SYSTEMIC MANIFESTATION ARE PRESENT , EYE CLOSURE IF ASSOCIATED WITH UPPER TEETH & TRISMUS IF ASSOCIATED WITH LOWER TEETH .
DRAINAGE IS VERY IMPORTANT IF THERE IS FLUCTUATION & PUS.
EXTRAORAL INCISION WITH DRAIN MAY BE NEEDED (ORAL SYRGEON)
REMOVAL OF IRRITANTS BY DEBRIDMENT OF CANALS OR EXTRACTION OF INFECTED TOOTH .
STRONG ANTIBIOTIC (I.V.) & ANALGESIC .
MAY NEED HOSPITALIZATION.
PULP NECROSIS WITHOUT SWELLING
TOOTH NOT AFFECTED BY THERMAL STIMULUS .
Vitality : -VE
PERIAPICAL RADIOLUCENT LESION MAY BE SEEN .
Pain & tenderness on percussion .
Sometimes the tooth may be extruded.
Pain is Localized .
Radiocraphically : normal or slight widening of lamina dura
ANESTHESIA : INFLAMED PULP REMENETS IN THE APICAL CANALS OR THE INFLAMED PERIRADICULAR TISSUE
COMPLETE DEBRIDMENT IS THE TREATMENT OF CHOICE
Also known as [ Post treatment emergencies ]
After obturation the patient may complain of pain &/or swelling
Factors generally can be categorized as
Related to the patient (including pulpal and periapical diagnosis)
Preparation beyond the apical terminus( over instrumentation )
overextension of root canal filling material
chemical irritants (such as irrigants, intracanal medicaments, and sealers) hyperocclusion
1. 2ry apical
Signs and Symptoms
removal of the pulp
Although pulpotomy in the initial appointment may relieve the pain , but the pain ( sensitivity to hot and cold ) may be experienced due to incomplete removal of the pulp ...
3. Recrudescene of chronic periapical lesion
Acute exacerbation of a chronic lesion
Low percentage of chronic lesions becomes acute after the first endodontic appointment The condition is referred to as RECRUDESCENE ( breaking out a new ) or a PHOENIX ( rebirth ) abscess
Cracked tooth syndrome (posterior teeth)
Crazing of the enamel surface is a common finding on teeth as a consequence of function, but on occasion it may indicate a cracked tooth. If the crack runs deep into dentine and is therefore a fracture, chewing may be painful. Initially, this may not be of sufficient intensity for the patient to seek treatment. However, once the fracture line communicates with the pulp, pulpitis will occur . A period of several months may follow before any further symptoms develop. The patient may present with a whole range of bizarre symptoms, many of which are similar to those of irreversible pulpitis .
Pain on chewing.
Sensitivity to hot and cold fluids.
Pain which is difficult to localize.
Pain referred .
Acute pulpal pain.
Signs & Symptoms
Diagnosis can be difficult and much depends on the plane of the fracture line and its site on the tooth.
Radiographs are unlikely to reveal a fracture unless it runs in a buccolingual plane.
A fiber-optic light is a useful aid as it will often reveal the position of the fracture.
One diagnostic test is to ask the patient to bite on a piece of folded rubber dam. Care must be exercised as this test may extend the fracture line. The extent of the fracture line and its site will decide whether the tooth can be saved or not. If it is a vertical fracture, involves the root canal system and extends below the level of the alveolar crest, then the prognosis is poor and extraction is indicated
Another method for diagnosis of fracture line is methylene blue test
However, if the fracture line is horizontal or diagonal and superficial to the alveolar crest, then the prognosis may be better.
If the tooth substance is strong enough, it should be tied together on either side of the crack to prevent propagation of the crack, microleakage and hydrodynamic pressure in the dentinal tubules.
The most common mode of treatment utilized by the author is the overlaying of the offending cusp with amalgam
Gold and porcelain inlays may also be used in a similar way to tie the cusps together.
Widdop14 described the use of cross-pinning, where pins are placed on either side of the crack and the restorative material is packed around them .
Ehrmann and Tyas13 suggested the use of a stainless steel orthodontic band which is cemented around the cracked tooth, binding the 3 cusps together. This has the advantage of allowing time to see if the symptoms are reversible .
Chipped or Fractured Teeth
Most chipped or fractured tooth crowns can be repaired either by reattaching the broken piece or by placing a tooth-colored filling. If a significant portion of the tooth crown is broken off, an artificial crown or “cap” may be needed to restore the tooth.
If the pulp is exposed or damaged after a crown fracture, root canal treatment may be needed. These injuries require special attention. If breathing through your mouth or drinking cold fluids is painful, bite on clean, moist gauze or cloth to help relieve symptoms until reaching your dentist’s office. Never use topical oral pain medications (such as Anbesol®) or ointments, or place aspirin on the affected areas to eliminate pain symptoms.
Injuries in the back teeth often include fractured cusps, cracked teeth and the more serious split tooth. If cracks extend into the root, root canal treatment and a full coverage crown may be needed to restore function to the tooth. Split teeth may require extraction.
Dislodged (Luxated) Teeth
During an injury, a tooth may be pushed sideways, out of or into its socket. Your endodontist or general dentist will reposition and stabilize your tooth. Root canal treatment is usually needed for permanent teeth that have been dislodged and should be started a few days following the injury. Medication such as calcium hydroxide may be put inside the tooth as part of the root canal treatment. A permanent root canal filling will be placed at a later date.
Children between seven and 12 years old may not need root canal treatment since their teeth are still developing. For those patients, an endodontist or dentist will monitor the healing carefully and intervene immediately if any unfavorable changes appear. Therefore, multiple follow-up appointments are likely to be needed. New research indicates that stem cells present in the pulps of young people can be stimulated to complete root growth and heal the pulp following injuries or infection.
Knocked-Out (Avulsed) Teeth
If a tooth is completely knocked out of your mouth, time is of the essence. The tooth should be handled very gently, avoiding touching the root surface itself. If it is dirty, quickly and gently rinse it in water. Do not use soap or any other cleaning agent, and never scrape or brush the tooth. If possible, the tooth should be placed back into its socket as soon as possible. The less time the tooth is out of its socket, the better the chance for saving it. Call a dentist immediately!
Once the tooth has been put back in its socket, your dentist will evaluate it and will check for any other dental and facial injuries. If the tooth has not been placed back into its socket, your dentist will clean it carefully and replace it. A stabilizing splint will be placed for a few weeks. Depending on the stage of root development, your dentist or endodontist may start root canal treatment a week or two later. A medication may be placed inside the tooth followed by a permanent root canal filling at a later date.
If you cannot put the tooth back in its socket, it needs to be kept moist in special solutions that are available at many local drugstores (such as Save-A-Tooth). If those solutions are unavailable, you should put the tooth in milk. Doing this will keep the root cells in your tooth moist and alive for a few hours. Another option is to simply put the tooth in your mouth between your gum and cheek. Do not place the tooth in regular tap water because the root surface cells do not tolerate it.
The length of time the tooth was out of the mouth and the way the tooth was stored before reaching the dentist influence the chances of saving the tooth. Again, immediate treatment is essential. Taking all these factors into account, your dentist or endodontist may discuss other treatment options with you.
A traumatic injury to the tooth may also result in a horizontal root fracture. The location of the fracture determines the long-term health of the tooth. If the fracture is close to the root tip, the chances for success are much better. However, the closer the fracture is to the gum line, the poorer the long-term success rate. Sometimes, stabilization with a splint is required for a period of time.
Do traumatic dental injuries differ in children?
Chipped primary (or “baby”) teeth can be esthetically restored. Dislodged primary teeth can, in rare cases, be repositioned. However, primary teeth that have been knocked out typically should not be replanted. This is because the replantation of a knocked-out primary tooth may cause further and permanent damage to the underlying permanent tooth that is growing inside the bone.
Children’s permanent teeth that are not fully developed at the time of the injury need special attention and careful follow up, but not all of them will need root canal treatment. In an immature permanent tooth, the blood supply to the tooth and the presence of stem cells in the region may enable your dentist or endodontist to stimulate continued root growth.
Endodontists have the knowledge and skill to treat incompletely formed roots in children so that, in some instances, the roots can continue to develop. Endodontists will do all that is possible to save the natural tooth. These specialists are the logical source of information and expertise for children who are victims of dental trauma.
PAINFUL ACUTE PULPITIS WITH APICAL PERIODONTITIS
Acute Pulpitis associated with an inflammatory response of periapical tissues .
The same Signs & Symptoms as acute pulpitis , but with slight to severe Pain on biting & eating ..
1. Anesthesia : severe inflammation will prevent anesthesia from attaining full effectivness. to over come this problem :
a. heavy dose of local anesthesia
b. another supplemental anesthesia
2. Correct access is prepared under copious coolent and complete deroofing is done
3. TOTAL PULPECTOMY
4. Access is closed with sterile cotton pellet and temporary filling
5. Anti-inflammatory can prescribed
6. RELIEF OF OCCLUSION .
Because The periodontal Ligament is affected Leading to Pain on Percussion due to Presence of Proprioceptive receptors ...
ROOT CANAL TREATMENT
Remove the coronal part of the pulp by sharp spoon excavator or large round bur at low speed .
Pulp in the roots is relatively vital & formcresol fixes the non inflamed tissue in the root canal ..
Don't use formocresol in case of pulpectomy as it is caustic & irritant material , when reaching the periapical tissue Severe Infection
Two stages :
The patient feels elongation of the teeth due to VD of blood vessels in periapical area .
Biting on the tooth relief the pain because biting will push the blood away from the dialted blood vessels in the periapical area decrease intra periapical pressure & relief pain .
Advanced stage :
Biting on the tooth will increase Pain due to fluid accumaltion in the periapical area & increase the intra periapical pressure biting will intensify pressure & pain .
Occurs immediately on removal of pulp chamber and Pus will be discharged through the access .
HEAVY IRRIGATION WITH WARM DISTILLED WATER OR SALINE ( preferred irrigant in initial stage ) .
It is advicable NOT to use SODIUM HYPOCHLORIDE WITH THE PRESENCE OF PUS because it has tendency to clump the exudates & causes plugging of the apical constriction & prevent drainage .
The preferred irrigation mechanism : Alternating use of NAOCL & HYDROGEN PEROXIDE
will cause foaming & aid in bubbling out of of any debris that may be packed
in the canal ( but making the final irrigant NAOCL )
If not through Access Cavity
Because the Apical Constriction prevent dainage through the tooth
HOW TO SOLVE IT ????
Apical Constriction is enlarged & violated by 2-3 mm with file size #25 to allow drainage .
Trephination is the surgical perforation of alveolar cortical plate [over the root end] to release the accumulated tissue exudate
that is causing pain.
A small vertical incision is made adjacent to the tooth, the mucosa is retracted and No.6 round bur is used to penetrate cortical plate forming holes on the periphery of circle of 1cm in diameter .
Then Use fissure bur th connect these holes & remove the disc of bone of 1cm in diameter , and then drainage occurs ..
Apical bone is probed with endodontic explorer to locate perforation , which may be enlarged with spoon excavator or endodontic file .
The incision is left open to allow further drainage .A strip of rubber dam is cut to resemble H or T & disinfected , one half is placed underneath the tissue .
Suture is placed .
Antibiotics given & patient is given appointement
after 4-7 days .
PUS DRAINAGE OCCUR
NO PUS DRAINAGE
enlarge to #30 & don't exceed as it won't be effective
THE ONLY CASE IN WHICH WE UNDERGO OVER-INSTRUMENTATION INTENTIONALLY ...
Don’t leave these teeth open for drainage , But If the drainage through the canal is not stopped, the access may be left opened for further drainage BUT NOT MORE THAN 24 HRs .
Leaving the tooth on “open drainage”should be avoided if possible, but if absolutely necessary , for less than 24 hrs , as after this time further contamination of root canal by anaerobic bacteria makes subsequent RCT very difficult .
In case of open Access , IF U FILE , DON'T CLOSE ...... IF U CLOSE DON'T FILE
The FIRST CHOICE
If No Time
THE BEST TTT FOR THIS CONDITION IS COMPLETE PULPECTOMY :
Vitality : respond at low current .
Percussion & palpation : No tenderness
Normal Radiograph .
Visual examination : Caries or Deep Filling .
Missed Canal :
Prognosis : Decreased ... but better in case of Type II .
Prevention : 1. Proper Access Preparation
2. knowledge about root canal anatomy
3. Treat teeth with high incidence of extra canals
unless proven otherwise .
Incomplete removal of pulp tissue :
Improper Working Length
Irrigation Accident :
Forcing NAOCL beyond the apical foramen Severe pain & irritation to periapical tissues .
H2O2 Cause Emphysema .
Prevention : Care should be taken during delivery of irrigant into the canal + The needle should be in up & down motion & not under Pressure .
Intracanal Medications :
Overmedicating a canal Acute Pain , Tissue Irritation & initiate Inflammation .
Use of intracanal antibiotics risks the induction of hypersensitivity & development of resistant strains of Micro orgs .
Ca(OH)2 is the recommended intracanal medication now .
Open versus Close Access Cavity :
The Tooth is recommended to be left OPEN only in the following cases :
Tooth exhibiting excessive discharge ( weeping canal ) & drainage of the pus never stops , but the tooth should be closed as soon as the drainage stops .
Acute Infection with diffuse swelling or cellulitis , however at first sign of resolution of infection & when the patient is still under ABs , tooth should be closed .
Flare- Up persists or takes place in the Periapical area .
Over - instrumentation
INCISION & DRAINAGE
when the Pus passes through the cortical bone & becomes accumulated under soft tissues
( According to the DIRECTION OF THE MOST DEVELOPING FLUCTUANT POINT in the Abscess )
. The Principle Indication is the presence of a collection of pus which POINTS from a FLUCTUANT abscess in the soft tissues .
a. Treating the wrong tooth
b. Pain not due to pulpal cause
same as acute apical periodontitis :
1. Throbbing , gnawing and pounding pain
2. Tenderness on eating and chewing
3. Pain is localized
4. Tooth is slightly elongated
5. Vitality test : -ve
1. Over instrumentation
3. pushing debris or microorganism to the periapical region
Sterile paper point
1. Tooth is opened and W.L is readjusted
2. Canals are re-cleaned and irrigated with NAOCL
3. Canal is dried and medicated with Ca(OH)2
4. Strong analgesic is prescribed to the patient
To give symptomatic relief corticosteroid antibiotic medication is used
1. Access is re-opened after L.A and rubber dam
2. paper point is placed in the canal short of the apical foramen , on withdrawal the point will display BROWNISH DISCOLORATION indicating inflammed seeping tissue
1. Remaining pulp tissue is removed
2. A sterile cotton pellet is placed and access sealed with temporary filling
1. Change in the environment with the root canal
2. Over instrumentation or forcing necrotic debris through the apex with area of low resistance present
Signs and Symptoms
Same as acute periapical abscess excpet :
1. All vitality tests are -ve as it follows a chronic lesion
2. Well defined radiolucent area
3. Definite tooth mobility
same as acute periapical abscess
acceptable R.C filling:
If pain only
Patient reassurance and analgesics prescription
If pain and swelling
Incision and drainage and antibiotics
2. Inadequate unacceptable R.C filling
Retreatment : Remove gutta percha & retreatment for relief of pain and swelling
e.g : 1. Short incomplete obturation
2. missed canal
Can't remove gutta percha flap to drain the fluid apically , apicectomy and retrograde filling for proper seal
e.g : 1. Broken instrument
2. Calcified canal
3. severly curved canal
Severe tenderness on Percussion , and the tooth may be felt slightly elongated .
Radiographically : Normal or slight widening of the Lamina Dura may be seen around the apex .
Vitality test : respond at low current
DRY THE CANALS WITH PAPER POINTS .
MEDICAMENTS : THEN CLOSE WITH GOOD TEMPORARY FILLING
MILD ANALGESIC & ANTIBIOTIC ARE NEEDED
Make sure that there is no pus in the canals before you close .
Debridement of the canal till the coronal 2/3 to decrease M.O population .
Preparation of the apical 1/3 is done to avoid pushing necrotic tissues to the periapical region Periapical Periodontitis & flare-ups .
HEAVY IRRIGATION WITH COPIOUS AMOUNT OF SODIUM HYPOCHLORITE
DRY THE CANALS WITH PAPER POINTS
FILL THE CANALS WITH NON SETTING CALCIUM HYDROXIDE.
CLOSE IT WITH STERILE COTTON PELLET & WITH TEMPORARY FILLING .
MILD ANALGESIC IS NEEDED(ANTIBIOTIC IS RARELY NEEDED)
Vitality Tests :
1. Early Stage : Pain caused by heat & cold .
2. Advanced : Heat produces pain
Cold relieves Pain
3. Late Stage : Both Heat & cold cause Persistant Pain .
SWELLING IS EITHER :
Absent with Severe Pain ( Early Stage )
Localized or diffuse with less pain ( Late Stage )
NOT EMERGENCY BUT MAY INDUCE EMERGENCY WHEN ?
Necrotic remnants extend to periapical tissues
Pushed by the operator to pass the apical foramen into periapical area .