Lecture 9 - Simplifying Endodontics with Hussain Al-Huwaizi PDF

Endodontics Lecture 9 ‫حسين فيصل الحويزي‬.‫د‬.‫أ‬ Endodontic Emergency Treatment Emergency conditions in endodontics induce infection which is expressed as pain and/or swelling. Any irritation to the tissues results in inflammation and release of chemical mediators which with pressure induce pain. C...

Endodontics Lecture 9 ‫حسين فيصل الحويزي‬.‫د‬.‫أ‬ Endodontic Emergency Treatment Emergency conditions in endodontics induce infection which is expressed as pain and/or swelling. Any irritation to the tissues results in inflammation and release of chemical mediators which with pressure induce pain. Chemical mediators cause pain by lowering pain threshold of the sensory nerve fibers or by increasing vascular permeability and producing edema. Increased fluid pressure resulting from edema directly stimulates the pain receptors. The classification of endodontic emergencies includes (Walton): APretreatment 1Dentin hypersensitivity 2Pain of pulpal origin a) Reversible pulpitis b) Irreversible pulpiis 3Acute apical periodontitis 4Acute apical abscess 5Traumatic injury 6Cracked tooth syndrome BPatients under treatment 1Mid treatment flare-up. 2Exposure of pulp 3Fracture of tooth 4Recently placed restoration 5Periodontal treatment CPost endodontic treatment 1Overinstrumentation 2Overextended obturation 3Underfilling 4Fracture of root 5High restoration Irreversible acute pulpitis The diagnosis of irreversible pulpitis can be subcategorized as: 1Asymptomatic. Asymptomatic irreversible pulpitis means a tooth that has no symptoms, but with deep caries or tooth structure loss that, if left untreated, will cause the tooth to become symptomatic or nonvital. 2Symptomatic. Pain from symptomatic irreversible pulpitis is often an emergency condition that requires immediate treatment. These teeth exhibit intermittent or spontaneous pain, whereby exposure to extreme temperatures will elicit intense and prolonged episodes of pain, even after the source of the stimulus is removed. Teeth with irreversible pulpitis with definite periapical inflammatory extension, occlusal reduction is recommended. Antibiotics are not recommended for the emergency management of irreversible pulpitis. Steps of treatment a) Clean the root canal(s) to the working length. b) Place a suitable medicament in the pulp canal and chamber (ex. Calcium hydroxide). c) Close the access opening with a temporary filling. d) Check occlusion of the tooth. e) Prescribe a pain analgesic. Acute apical periodontitis It is inflammation of the apical periodontal tissue caused from extension of pulpal infection periapically. It is characterized by the following features: 1Elevated tooth from its socket because of build up in fluid pressure in the periodontal ligament. 2Discomfort on biting. 3Sensitivity to percussion. Steps of management 1Access opening preparation. 2Total pulp extirpation. 3Cleaning the root canal. 4Thorough irrigation and dryness. 5Placement of intracanal medicament as Calcium hydroxide. 6Close the tooth with a temporary filling material. 7Relieve occlusion. 8Prescribe analgesics. Acute periapical abscess Extrusion of bacteria from the root canal to the periapical area induces infection ending in formation of a collection of pus. Acute periapical abscess is characterized by the following features: 1Clinically a swelling is evident with pain and a sensation of tooth elevation. 2Radiographic evidence varies in size of lesion. 3Systemic fever. Steps of management 1Pulp debridement of its contents. 2Incision and drainage (if swelling is present) 3If pus is oozing the tooth may be left open for 1 day for drainage. 456- Antibiotics may be prescribed only if systemic features are present as fever. Relieve the tooth out of occlusion. Analgesics should be prescribed. Local anaesthetic is contraindicated to be used because: 1Pain caused by injection in distended area. 2Chance of spread of microorganisms. 3Ineffectiveness of local anaesthetics. Cracked tooth syndrome It is incomplete fracture of a tooth with vital pulp. It is commonly seen with teeth with large restorations. Pain is experienced when the patient chews laterally a cotton roll. Steps of treatment 1Immediately reduce the occlusal contact with the cracked area. 2Analyze the extent of the crack to preserve the pulpal health. 3If the pulp is involved and the crack is superfacial to the alveolar bone endodontic treatment is necessary. 4If the crack is below the alveolar bone extraction of the tooth is necessary. Intratreatment flare-up Flare-up is the occurrence of pain, swelling or both during the course of root canal treatment. Risk factors contributing to flare-ups: 1Overinstrumentation and overobturation. 2Inadequate debridement. 3Periapical extrusion of debris. 4Preoperative pain, percussion sensitivity and swelling. 5One visit endodontics in cases of acute apical periodontitis. 6Retreatment. 7Apprehension. 8History of allergies. Steps of management 1Reassurance of the patient 2Complete debridement of the root canal with no overinstrumentation or extrusion of debris. 3Establishment of drainage if pus is present. 4Relief of occlusion 5Calcium hydroxide intracanal medication. 6Analgesic and antibiotic prescription. Overextended treatment beyond the apex. Any extension of an instrument or filling material induces acute inflammation and with the presence of extruded debris will cause infection. Pain is magnified because of the limited area between the bone and the tooth. Steps of treatment 1- Care should be taken in consideration not to extend instrumentation beyond the apex. 2- Reinstrumentation to the exact working length should be done o insure a apical stop area to prevent extrusion of gutta percha. 3- If gutta percha is extended beyond the apex then retreatment should be performed by special retreatment kits as ProTaper retreatment and D-Race systems. 4- Analgesic should be prescribed. Fracture of tooth During the course of treatment or after it the tooth may be subjected to force and it might fracture. The treatment depends on the extent of the fractured area (in crown or including root). The steps of treatment resemble that of the cracked tooth syndrome.