5 Emergency in Endodontics PDF

EMERGENCY CONDITIONS AND TREATMENT APPROACHES IN ENDODONTICS  Endodontic Emergency; 1. Traumatic injuries 2. Inflammatory conditions of the pulp and periapical tissues  What are the emergencies in endodontics? Endodontic emergency; It describes con...

EMERGENCY CONDITIONS AND TREATMENT APPROACHES IN ENDODONTICS  Endodontic Emergency; 1. Traumatic injuries 2. Inflammatory conditions of the pulp and periapical tissues  What are the emergencies in endodontics? Endodontic emergency; It describes conditions in which there is pain and/or swelling caused by various stages of infection or inflammation of pulpal and/or periapical tissues, requiring prompt diagnosis and treatment.  Real emergencies: A) It is impossible for the patient to wait, even for a short time. B) The pain is very severe !!!Analgesics are generally ineffective. o The patient's sleep, eating, daily activities are affected, analgesics are not effective. Clinical conditions considered as endodontic emergencies (1977-2009): Pathways of the pulp, Cohen S.  Teeth with irreversible pulpitis with normal periapex  Teeth with irreversible pulpitis and acute apical periodontitis  Teeth with necrotic pulp without swelling, with acute apical periodontitis  Teeth with necrotic pulp with fluctuant swelling with drainage  Teeth with necrotic pulp with fluctuant swelling without drainage  Teeth with necrotic pulp with diffuse facial swelling with drainage through the canal  Teeth with necrotic pulp without drainage and diffuse facial swelling  Management of endodontic emergencies Psychological approach Correct diagnosis;  Finding out the main complaint  Review of the medical history  Application of objective and subjective diagnostic protocols Informing the patient The patient and the physician should agree on the treatment.  Emergencies in Endodontics; Emergencies in a tooth that has not been treated before (Before treatment) Emergencies that occur in a tooth whose endodontic treatment has been started (acute exacerbation=flare up) Emergencies that occur later in a tooth whose endodontic treatment has been completed  Painful conditions before treatment; Conditions that can be seen in teeth with vital pulp; A-) Reversible pulpitis B-) Irreversible pulpitis  Reversible pulpitis  They are NOT real emergencies.  It causes cold, hot, sweet, sour pain.  Causes: Caries, exposed dentin, recent dental treatment, damaged restorations, occlusal trauma.  Treatment: Removal of irritant, application of desensitizing agents, appropriate restoration.  Symptomatic (painful) Irreversible Pulpitis It requires urgent treatment!  The pain is very severe.  Pain is spontaneous.  There is night pain.  Response to thermal tests is painful. Pain persists after the stimulus is removed.  There is referred pain.  Symptomatic (painful) Irreversible Pulpitis Treatment:  Root canal treatment or extraction  CARIES must be thoroughly cleaned to avoid recontamination of the root canal system  Pulp is removed  Chemomechanical preparation is complete  If there is percussion sensitivity, Ca(OH)2 medicament is applied.  NSAID analgesic can be given to the patient  Antibiotics are not recommended!!!!  Acute apical periodontitis: Cause: Infected pulp, tissue damage (due to chemomechanical preparation) or occlusal trauma, food impaction, high restoration  There is sensitivity to percussion (+), pain when biting and chewing.  Mobility due to edema in the periodontal ligament and elevation of the alveolar socket of the tooth may be seen.  The tooth can be vital or devital.  A tooth with symptomatic irreversible pulpitis may be accompanied by acute apical periodontitis. Treatment: It is directed towards the cause. NSAI analgesics may be given. Importance of maintaining apical constriction: 13 Apical extrusion of debris!!! Emergencies that can be seen in teeth with necrotic pulp:  Teeth with necrotic pulp without swelling  Teeth with necrotic pulp, acute apical abscess with swelling  Teeth with necrotic pulp without swelling Chemomechanical preparation Calcium hydroxide medication Be careful not to push necrotic debris from the apex !!!!!  Teeth with necrotic pulp (acute apical abscess) with swelling:  The swelling may be localized or diffuse, fluctuant or firm.  In the presence of swelling, the treatment principle is to provide drainage and remove the source of infection. Antibiotics should be given in the presence of diffuse swelling.  When swelling is localized; The access cavity is opened. Drainage is provided through the root canal. The root canal system is completely cleaned. The access cavity should be closed. There is no need to use antibiotics. Acute apical abscess with localized swelling;  Apical Trephination???  In conditions where drainage does not occur, the #15 K-file is extruded 1-3 mm from the determined working length to achieve this.  Disadvantages: Loss of apical constriction zone Zip formation in curved canals  Reader and Beck (2001) reported that trepination could not significantly reduce pain and swelling. Therefore, investigators did not recommend trephination as a traditional procedure for the treatment of teeth with symptomatic necrotic pulp with periapical lesions. In localized soft tissue swellings, incisional drainage may be required when there is no dental drainage and fluctuation is obtained from adjacent areas. In cases where an incision is considered, the evacuation and shaping processes in the canals should be finished before and the tooth should be closed. Abscess drainage when there is no dental drainage in localized soft tissue swellings Palatinal apse  When the swelling is diffuse;  Urgent use of antibiotics is required. (+NSAI Analgesic)  The patient should be followed closely.  When the patient is provided with sufficient mouth opening for treatment, the necrotic material in the root canal system is immediately cleaned and root canal treatment is started. Tissue swelling is fluctuant-There is drainage through the root canal  The access cavity is opened, drainage is provided, ample irrigation is done, and the cavity is closed.  Drainage can be achieved without incision. Tissue swelling fluctuant-No drainage through root canal  Access cavity is opened, if there is no drainage; The canal is washed and the cavity is closed.  Drainage is provided by incision. Tissue swelling non-fluctuant-There is drainage through the root canal  The access cavity is opened, drainage is provided, ample irrigation is done, and the cavity is closed.  Rinse with warm-warm physiological saline.  Antibiotics are given.  No incision is made.  Tissue swelling non-fluctuant-No drainage through root canal  Access cavity is opened, if there is no drainage; the canal is washed, cleaned and the cavity is closed.  Rinse with warm physiological saline.  Antibiotics are given.  No incision is made.  Leaving the tooth open??????  It is not recommended to leave the tooth uncovered between appointments.  In cases where there is drainage through the root canal, the patient is kept in the chair for a while, waiting for the drainage to be interrupted, and the access cavity is closed.  The basic principles of incision for drainage:  Drainage is indicated when swelling is fluctuant.  The incision is made where the swelling is most fluctuant.  After appropriate anesthesia, a horizontal incision is made in the center of the swelling.  It is tried to drain the abscess as much as possible by using a hemostat through the incision.  Trephination:  In acute abscessed teeth, when there is no soft tissue swelling, trepination is the surgical puncture of the alveolar cortical layer and the release of tissue exudate that accumulates in the cortical layer and causes pain. It is rarely required when diagnosis and treatment are handled with the right approaches. It is not a method applied in practice!!!!! Trepination is the perforation of the cortical bone in moderate to severe painful conditions caused by pressure from the accumulation of exudate in the alveolar bone, without intraoral or extraoral swelling. There are only two reported clinical applications. In these studies, the effectiveness of trepination as a prophylactic in the canal filling phase of lesioned teeth was evaluated and it was reported to be effective in reducing postoperative pain (24,25). 24. Peters DD. Evaluation of prophylactic alveolar trephination to avoid pain. J Endod 1980;6:518. 25. Elliott JA, Holcomb JB. Evaluation of a minimally traumatic alveolar trephination procedure to avoid pain. J Endod 1988;14:405 32  TANIM Cracked tooth syndrome (CTS); Its depth and progression in tooth structure are precisely unknown, up to pulp or periodontal ligament.It is a dental pathology defined as an elongated fracture line. (Ellis, 2001)  Cracked or broken teeth: (Split tooth = Split tooth)  There is a small crack in the initial stage, it has not reached the pulp.  The stresses caused by chewing cause sharp pain at the crack line with the dentinoblastic tear process. The patient can feel complete relief during periods of not chewing.  When the crown parts move, the underlying dentin is momentarily exposed and the patient feels pain.  As a result, the crack progresses in the apical direction and reaches the pulp cavity and infection occurs with bacterial invasion.  If the crack progresses deeper, the tooth fragments can be completely separated without any dentin connection (split tooth).  ÇDS’DA TEŞHİS_ dental hikaye  Prolonged cracks in vital teeth may lead to pulpitis/pulp necrosis, resulting in spontaneous pain along the 5th cranial nerve.  InWhich teeth it can be seen????  It can be seen in teeth with large restorations, or sometimes in teeth with very small restorations or even in non-carious teeth that have not undergone any treatment.  It is especially seen in posterior group teeth (upper premolars, molars, lower molars).  Cracked or broken teeth: (Split tooth) Clinical signs:  There is pain in certain chewing positions.  The pain is variable, it can be a short-term, sharp pain or a spontaneous, long-lasting pain. Diagnosis;  If symptoms and clinical tests show pulpal pathology in posterior teeth and no dental caries or restoration is seen on the radiograph, this may often be a sign of progressive crack.  Since the crack is mostly parallel to the film, it cannot be seen radiographically, but cracks in the buccolingual plane can be observed.  A wooden stick or rubber cloth can be bitten into the suspected tooth.  Removal of filling material in a restored tooth, some staining solutions such as methylene blue, tincture diode after opening the cavity may help in the diagnosis. 39 Prognosis;  Endodontic treatment can be applied for cracked teeth due to symptoms.  Although pulpal pain disappears with treatment, the tooth remains sensitive to percussion.  The extension of the fracture line determines the prognosis of the tooth, if a vertical fracture has occurred, it is decided to extract the tooth.  If the fracture line is above the alveolar crest and is horizontal or diagonal, the prognosis may be better. Text book of Endodontlogy  NATURAL FACTORS ETİYOLOJİ Differences in the anatomical structure of the teeth, bruxism, teeth grinding, pipe smoking, pen biting Bite nails tooth wear, ANATOMIC FACTORS  Deep occlusal grooves  Prominent root grooves  bifurcations  Wide pulp cavity  Lingual inclinations of the lingual cusps of mandibular molars  Upright cusp-fossa relationship of maxillary premolars  steep cusp slope  Deep cusp-fossa relationships  Visual inspection is often insufficient Painting method  Methylene blue  iodine  food dyes  ÇDS’DA TEŞHİS_ klinik muayene Semptomlar çatlağın yeri ve derinliğine göre değişebilir (Geurtsen 2003). Proprioseptif lifler olmadığıdan hasta ağrıyan dişini ayırdedemez. Vertikal çatlaklar okluzal yüzey boyunca mesio-distal yönde ilerler; bir ya da her iki marjinal sınırı içerir tarzda olabilirler (Liu ve Sidhu 1995). Çok uzun süre asemptomatik bir evre geçirilebilir. Hastalar hassas bölgeyle çiğneme yapmaktan kaçınarak aylarca ağrıyla yaşayabilir. Tamamen kırık oluştuktan sonra ağrı ortadan kalkar ya da karakteri değişir ki bu dişlerin tanısında çok fazla sorun yaşanmaz (Rosen 1982). Geçmişte ÇDS tecrübe etmiş bireyler durumun tanısını kendileri ÇDS’DA TEŞHİS_ klinik muayene transiluminasyon  ÇDS’D TEŞHİS_ klinik muayene bite test Consent of the patient RISK OF CUSP FRACTURE Orangewood sticks, cotton rolls, rubber plungers of anesthetic cartridges, some abrasive rubber discs (Lynch 2002). The sticks are placed on a certain muscle and the patient is asked to bite. With this procedure, the fracture can be detected. bite test ÇDS’DA TEŞHİS_ klinik muayene ‘Tooth Slooth II’ (Professional Results Inc. Laguna Niguel, California, USA) ‘Fracfinder’ (Denbur, OakBrook, IL, USA) Advantage: More sensitive and precise results in diagnosis compared to tree sticks (Ehrmann ve Tyas 1990).  ÇDS’DA TEŞHİS_ klinik muayene Biting pain that goes away when the pressure is relieved When the diagnosis cannot be made by direct methods;  copper rings,  Stainless steel orthodontic bands  acrylic temporary crowns  If the pain disappears 2-4 weeks after applying these indirect methods, a diagnosis of CTS can be made (Mathew, 2012).  Surgical opening of the area  Case: Patient complaint: Pain in certain chewing positions in tooth no. 24 Diagnosis: Cracked tooth Treatment: Composite resin restoration Dt. Amirreza Ebrahimi Prof.Dr. Meltem Öztan 17.05.2019 Case: Vertical root fracture Case: The patient complains of pain during chewing.  ÇDS’DA TEŞHİS Vertical Fracture 58 II. Emergencies with pain and swelling in a tooth whose endodontic treatment has been started (Acute exacerbation=Flare up) Incidence; 1.4%-16% (Siquera 2002) Endodontic acute exacerbation cases;  Symptomatic apical periodontitis after endodontic treatment  Insufficient removal of pulp tissue in root canals (presence of vital pulp tissue in the canal)  Acute exacerbation of chronic apical periodontitis (Phoenix abscess)  Recurrent periapical abscess Predisposing factors in the etiology of flare up;  Age (in young individuals)  Gender (Female)  Tooth type (in molars)  Condition of the pulp (Necrotic pulp)  Presence of preoperative pain  allergy  treatment  sinus tract  Individuals using systemic steroids Flare up causes;  Flare up causes; Chemical causes; Microbial causes; Mechanical causes;  Irrigation solutions  Over instrumentation  Overflow of canal filling  Intra-canal material medicaments  Incorrect measurement  canal filling of working length material  Insufficient removal of pulp  Prevention of flare up; 1. Choosing instrumentation techniques that cause the least extrusion of debris from the apex (Crown down) 2. Completion of the chemo-mechanical procedure in the same session 3. Use of intra-canal antimicrobial medicaments 4. Not leaving the root canal system of the tooth open to the oral environment 5. Working in aseptic conditions during root canal treatment procedures  Symptomatic apical periodontitis after endodontic treatment Reasons: Over instrumentation Extrusion of any medications Pushing debris into periapical tissues Validation test: After rubber dam is applied, the temporary filling in the access cavity is removed and sterile paper point with a marked working length is placed in the canal. If inadvertently over instrumentation was performed, the paper cone will go beyond the working length with no apical resistance felt. Red or brown blood will be seen on the tip of the paper point.  Insufficient removal of pulp tissue from root canals Validation test: When the rubber dam is applied, the temporary filling in the access cavity is removed and the sterile paper point is placed in the canal, the patient feels pain when it is shorter than the working length and red-brown discoloration is observed at the tip of the subject due to bleeding. Acute exacerbation of chronic apical periodontitis (Phoenix Abscess):  This occurs in asymptomatic teeth with necrotic pulp and periapical lesions. Exacerbation occurs in the previously asymptomatic periradicular lesion. The reason for this event is thought to activate the bacterial flora by changing the internal environment in the root canal cavity during instrumentation.  Recurrent periapical abscess:  It is the recurrence of acute symptoms in a tooth with an acute periapical abscess relieved by emergency treatment. In some cases, abscess recurs due to high virulence of microorganisms or low host resistance.  Etiology of acute flare-ups:  Inadequate cleaning of the root canal system  Over instrumentation  Pushing debris into the periapical region  Over filling  Presence of periapical lesion !!!!!!!!  Re-treatment cases  Host factors  Microbiology and Immunology of Acute Exacerbations: Flare-ups in endodontics: I. Etiological factors S Seltzer, I J Naidorf, J Endod, 1985 Nov;11(11):472-8  Change of local adaptation syndrome  Changes in periapical tissue pressure  Microbial factors  Effect of chemical mediators  Changes in cyclic nucleotides  immunological response  psychological factor  Change of local adaptation syndrome Inflammation occurs in the connective tissue decomposed by any irritant, and if it continues for a long time, chronic inflammation occurs (local adaptation syndrome). In chronic pulp disease, the periapical inflammatory lesion adapts to irritants, but a new irritant (over instrumentation, infected debris, irrigant, medicament) reaching the lesion during root canal treatment may cause flare-up.  Changes in periapical tissue pressure Endodontic treatment causes pressure changes in the periapical region. In teeth with increased periapical pressure, excessive exudate causes pain by pressing on the nerve endings. In this case, when the root canals are opened, the exudate is expected to come out. Conversely, if the atmospheric pressure is greater than the periapical pressure, microorganisms and other irritants may be drawn towards the periapical area, causing an inflammatory response and severe pain. In such cases, when the root canal is opened, there is no drainage.  Microbial factors Bacteria are the main cause of pulpal and periapical diseases. (obligate anaerobic bacteria) Microbial products, virulence factors, endotoxins (LPS; lipopolysaccharide) and enzymes are important in the pathogenesis of the periapical region. endotoxin; A lipopolysaccharide found in the cell wall of Gram- negative bacteria, associated with pathogenicity, and toxic to the host, which occurs when the bacteria are degraded or during growth. Gram (-) microorganism species are known to induce pain and inflammation.  Microbial factors Necrotic tissue forms a medium for obligate anaerobes. Porphyromonas species are associated with symptomatic periradicular lesions. Prevotella, Porhyromonas, Peptostreptococcus species are present in cases with percussion pain. Gram (-) anaerobic bacteria are present in symptomatic lesions.  Effect of chemical mediators Chemical mediators can be in the form of cell mediators, plasma mediators, and neutrophil products. Cell mediators: Histamine, serotonin, prostaglandin, platelet activating factor and lysosomal components. Plasma mediators circulate in the form of inactive precursors and are activated upon contact with the irritant. For example, the Hageman factor is activated when it comes into contact with an irritant, platelet aggregation occurs and forms plasmin, activating the complement system. Activation of the complement system results in tissue lysis. In instrumentation of root canals, the acute inflammatory response begins with polymorphonuclear leukocyte infiltration, then releases collagenase, peroxidase, amylase, lipase, and other lytic enzymes, resulting in severe pain and swelling.  Changes in cyclic nucleotides While the increase in cAMP level inhibits the degranulation of mast cells and helps to reduce the pain, the increase in cGMP level stimulates the degranulation of mast cells and results in an increase in pain. Studies have revealed that the cGMP level is higher than the cAMP concentration in flare-up cases.  immunological response The presence of macrophages and lymphocytes in chronic pulpitis and periapical diseases indicates a cellular and humoral response. Despite its protective role, immunological mechanisms also play a role in the destructive phase of inflammation.  Psychological factor Anxiety, fear, psychosis, previous traumatic dental experiences can trigger painful attacks and increase their intensity. As a result of anxiety, there is an increase in the amount of corticosteroids in the circulation, which may affect the body's neuroimmune modulation system and may pave the way for the spread and proliferation of microorganisms. Diagnosis and Treatment of Flare-up Cases:  Flare-up treatment is evaluated according to whether the pulp is vital or necrotic, and whether there is swelling in the initial diagnosis of the treated tooth. Pain is controlled. Teeth with vital pulp at the beginning of treatment and in which the root canal system has not been completely cleaned  Working length is rechecked  Canals are washed profusely with NaOCl  Chemo-mechanical preparation of canals is completed  A sterile dry cotton pellet is placed on the orifice of the canal and the tooth is closed with a temporary filling.  The patient is given analgesics.  Teeth with necrotic pulp without swelling  The incidence of flare-up in teeth with necrotic pulp is higher than in vital teeth.  The correct working length is determined, instrumentation of the root canals is completed.  If there is drainage from the canal when the tooth is opened, the canal should be carefully cleaned by washing it abundantly with NaOCl.  Wait until the drainage is cut off. After irrigating and drying the canal, calcium hydroxide is placed and closed with a temporary filling. Teeth with necrotic pulp and swelling:  Antibiotics and analgesics are given.  Incision and drainage are made when appropriate condition is provided.  The canal is opened again and cleaned and washed abundantly with NaOCl.  Calcium hydroxide is placed in the canal and the tooth is closed with a temporary filling. III. Emergencies after endodontic treatment is completed: Etiology;  Over instrumentation  Over-filling  Persistent periapical inflammation  Presence of untreated canals (Missed canals)  Crown-root or root fracture  hyperocclusion  Poor coronal coverage The patient complains of spontaneous pain and night pain, root canal treatment has been started, but the pain continues. Diagnosis: Presence of missed canal 6-canals mandibular 1st molar Root fracture in tooth with excessive condensation force Temporary or permanent restoration should be checked for hyper- occlusion.  Flare up treatment;  Correct diagnosis  Accurate determination of working length  Complete removal of pulp  Effective and adequate irrigation  Application of intra-canal medicament  Giving Analgesic+Antibiotic (In necessary cases) In cases with swelling;  Drainage through the canal  Incision and drainage  Intra-canal medicament application  Giving Analgesic+Antibiotic (In necessary cases)