BDS 11135 Emergency Treatment PDF

Emergency Treatment BDS 11135 Date : xx / xx / xxxx Aims: The educational aims of this lecture are: 1. 2. 3. 4. To explain types and diagnosis of pulpal and periapical pain To explain how to manage symptomatic pulpitis in an emergency appointment To explain how to manage symptomatic apical perio...

Emergency Treatment BDS 11135 Date : xx / xx / xxxx Aims: The educational aims of this lecture are: 1. 2. 3. 4. To explain types and diagnosis of pulpal and periapical pain To explain how to manage symptomatic pulpitis in an emergency appointment To explain how to manage symptomatic apical periodontitis in an emergency appointment To explain how to manage non-odontogenic pain Objectives: On completion of this lecture, the student should have: An understanding of how to manage in an emergency appointment a patient who is in pain caused by a vital/ non-vital tooth or non-odontogenic pain. • An endodontic emergency is defined as pain or swelling caused by various stages of inflammation or infection of the pulpal or periapical tissues. • 85% of all dental emergencies arise as a result of pulpal or periapical disease • In an emergency situation an accurate diagnosis must be established. History Clinical examination RG examination Special tests Final diagnosis An emergency treatment consists of applying one or more of these basic principles: 1- Remove the cause of pain 2- Provide drainage if fluid exudate is present 3- Prescribe analgesics if required 4- Adjust the occlusion if indicated. Endodontic emergency Pretreatment Vital Non-vital Inter-appointment Post-appointment I- Pretreatment emergency A- Emergency treatment of vital teeth 1- Dental Hypersensitivity: ➢ Due to dentin exposure, usually in the cervical area of the tooth. ➢ Immediate relief is achieved by blocking the exposed dentinal tubules by topical applications of desensitizing agents and the use of certain dentifrices. ➢ The most reliable long-term results have been obtained by: 1- good oral hygiene. 2- meticulous local plaque control. 3- use of fluoride preparations. 2- Crown fractures: ➢ Leads to symptoms because of dentin exposure. ➢ The symptoms are controlled by restoring the tooth or simply covering the exposed dentin surface. ➢ For more extensive injuries follow the trauma guidelines 3- Reversible Pulpitis: • Induced by: 1- Caries 2- Exposed dentin 3- Recent dental treatment 4- Defective restorations • Treatment: 1- Conservative removal of caries 2- Protection of dentin 3- Proper restoration will resolve the symptoms 4- Irreversible Pulpitis: ➢ The ideal emergency treatment is to remove the diseased pulp completely and and prepare the root canal system (pulpectomy) ➢ If time does not allow this, removal of pulp tissue from the pulp chamber is often effective (pulpotomy) ➢ In multirooted teeth, a pulpotomy (removal of the coronal pulp) and removal of tissues from the widest canal ➢ The use of corticosteroid preparations in vital root canals has been advocated in situations where complete instrumentation is inconvenient or impossible because profound anesthesia cannot be secured Irreversible Pulpitis Pulpotomy or Pulpectomy 50–75% reduction in the severity of the pain within one day Dressing in the pulp chamber corticosteroid preparations or eugenol cotton and temporary restoration Systemic medication Analgesics are a useful adjunct to manage the residual pain & antibiotics are contraindicated 5- Acute Pulpitis with apical periodontitis: ➢ Considered the most difficult condition to be treated as depth of anesthesia is a common problem. ➢ Emergency treatment consists of: 1- removal of all pulp tissue (pulpectomy) from the root canals 2- irrigation of the canal system with sodium hypochlorite 3- drying the canals, antibacterial dressing such as calcium hydroxide & closure of the access cavity 5- Acute Pulpitis with apical periodontitis: Pain on percussion can be relieved by occlusal reduction If instrumentation of the root canal is not possible, usually because of extreme tenderness of the tooth, the placement of a medicament (eugenol) in the pulp chamber before sealing the access cavity will bring relief in about 70% of these patients. I- Pretreatment emergency B- Emergency treatment of non-vital teeth 1-Acute periapical abscess: • Anesthesia → nerve block or ring block • Infiltration anesthesia into the abscess is contraindicated because of: - pain - dissemination of microorganisms - dilution of anesthetic solution into the pus 1-Acute periapical abscess: ➢ Relief of pain can be obtained speedily by obtaining drainage and adjusting the occlusion of the causative tooth. ➢ Drainage of pus: First choice → Through the canal Second choice → Incision & drainage (I & D) 1-Acute periapical abscess: Drainage Enough time Lack of time or copious exudate Access cavity Drainage No drainage Violate the apical constriction No drainage 1-Acute periapical abscess: Drainage Enough time 1- tooth allowed to drain until discharge stops 2- canals irrigated gently with sodium hypochlorite & cleaned of debris 3- Prepared fully, dressed and sealed Lack of time or copious discharge it is permissible to leave the tooth on open drainage for no longer than 24 hours leaving the canal open for longer periods → flare-ups Pattern of drainage Yellowish white, or greenish white in color Pus mixed with blood (bloody tinged) Blood Clear serum exudate Irrigation during drainage First: warm saline or distilled water, NaOCl has tendency to clump the pus Second: NaOCl (from 0.5% to 5.25%) or alternate use of H2O2 & NaOCl 1-Acute periapical abscess: Drainage Enough time Lack of time or copious exudate Access cavity Drainage No drainage Violate the apical constriction No drainage 1-Acute periapical abscess: No darainage Violate the apical constriction (apical trephination) Pushing the instruments out of the apical foramen for a distance 2 -3 mm only up to file #30 No Drainage Drainage 1-Swelling I&D 2-No Swelling Artifistulation Cortical trephination 1-Acute periapical abscess: Incision and drainage (I&D) 1- Swelling A stab incision is made below the most dependent point of the fluctuant swelling 1-Acute periapical abscess: Artificial fistulation (artifistulation) 2-No Swelling Cortical trephination Cortical trephination ➢ It is the surgical perforation of the alveolar cortical plate to release, from between the cortical plates, the accumulated inflammatory and infective tissue exudate that causes pain ➢ Made in the absence of swelling, severe pain and failure of apical trephination to allow for pus drainage. ➢ Involves an engine-driven perforator entering through the cortical bone and into the cancellous bone. ➢ Extreme care must be taken when carrying out a trephination procedure to avoid irreversible injury to the tooth root or surrounding structures Emergency management of cellulitis ➢ Drainage and prescription of antibiotics are indicated to provide significant pain relief ➢ Patients with cellulitis should be followed on a daily basis to ensure that the infection is resolving ➢ None responding cellulitis that appears to begin to involve the floor of the mouth and upper neck or towards the cavernous sinus, must involve 1- prompt referral to a hospital for emergency care 2- immediate drainage of the relevant tissue compartments, 3- tooth extraction if necessary and intravenous antibiotics Antibiotics and pain control ➢ If good drainage has been established → no antibiotics ➢ If a patient’s general health is influenced by the periapical inflammation, or if a patient’s medical status is poor → antibiotics ➢ Antibiotics in conjunction with appropriate endodontic treatment are recommended for progressive or persistent infections with systemic signs and symptoms such as fever ➢ Analgesics with an anti-inflammatory effect, like ibuprofen, have proven to be effective ➢ If patient fear or anxiety presents a problem, a tranquilizer like diazepam should be used 2-Pulp necrosis: • Necrosis is not an emergency, yet it may create an emergency so: 1- Debridement of the root canal system must be done carefully to avoid pushing of necrotic material & bacteria to periapical area. 2- An intracanal medication may be beneficial between visits II- Inter-appointment Causes of inter-appointment emergencies: 1- Mis-diagnosis 2- Missed canal 3- Incomplete removal of pulp tissue 4- Overinstrumentation 5- Method of irrigation 6- Intracanal medicaments 7- High occlusion 5- Method of irrigation → Hypochlorite accidents Factors that can contribute to this are: 1- Overpreparation of the apical foramen 2- Pre-existing open apex 3- Poor working length control 4- Irrigation under pressure Signs & symptoms: 1- Acute pain 2- Swelling 3- Bruising or even paraesthesia 4- A life threatening airway obstruction has also been reported Hypochlorite accidents Management: 1- Clinician should stay calm and reassure the patient 2- Further irrigation with sterile saline or water 3- Antibiotics and painkillers. 4- Other treatment modalities have been suggested include local anesthesia and antihistamines 5- Cold compresses for the first 6 hours will help to reduce pain and swelling, followed by warm compresses will help to encourage healthy healing. Inter-appointment emergencies are: 1- Secondary Apical Periodontitis 2- Incomplete Removal Of Pulp Tissue 3- Phoenix Abscess 1- Secondary Apical Periodontitis Causes: - overinstrumentation - overmedication - forcing debris into the periapical tissue Diagnosis of overinstrumentation: Confirmed by inserting a thin sterile paper point into the canal First: paper point will extend easily past the apical foramen Second: on withdrawal the tip will disclose a reddish color indicating inflamed periapical tissue & absence of apical stop Management: Intracanal medication and sealing with temporary filling for few days 2- Incomplete removal of pulp tissue Diagnosis: A sterile paper point is inserted into the canal short of the working length On withdrawal the tip of the point will display a brownish discoloration indicative of presence of inflamed seeping tissues. Management: Determine the correct working length and remove the remnants of the pulp tissues 3- Phoenix abscess It is an acute exacerbation of a chronic lesion Causes: - Pushing new strains of microorganisms into the periapex - Pushing or forcing necrotic debris - Overinstrumentation Management: Same as acute periapical abscess III- Post appointment • Patients may experience pain after canal preparation and cleaning or following obturation • It is a normal finding in almost half of all patients • This can take 3–4 days to subside but will be maximal over the first 24–48 hours • Causes: 1- irritation by obturation materials 3- extrusion of sealer periapically 2-overfilling 4- high occlusion Post appointment Adequate & acceptable root canal filling Pain only Reassurance & analgesics Inadequate & unacceptable root canal filling Pain & swelling Correctable In correctable I&D& antibiotics Retreatment Surgical intervention Emergency treatment of non-odontogenic pain ➢ Referred pain can complicate a dental diagnosis, the clinician must be sure to make an accurate diagnosis to protect the patient from unnecessary dental or medical treatment ➢ If after all the testing procedures are complete and it is determined that the pain is not of odontogenic origin, then the patient should be referred to an orofacial pain clinic for further testing ➢ The dental practitioner also has the opportunity to refer the patient for a second opinion at any time, particularly where the diagnosis continues to remain unclear ➢ The referring dentist should convey appropriate information to the specialist 1- Definition of an endodontic emergency 2- Endodontic Emergency TTT Pretreatment Vital 1- Hypersenstivity 2- Crown fracture 3- Reversible pulpitis 4- Irreversible pulpitis 5- Acute pulpitis with apical periodontitis Inter-appointment Post appointment Non-vital 1- Acute periapical abscess 2- Pulp necrosis 1- 2ry apical periodontitis 2- Incomplete removal of pulp tissue 3- Phoenix abscess 3- Emergency treatment of non-odontogenic pain Aims: The educational aims of this lecture are: 1. 2. 3. 4. To explain types and diagnosis of pulpal and periapical pain To explain how to manage symptomatic pulpitis in an emergency appointment To explain how to manage symptomatic apical periodontitis in an emergency appointment To explain how to manage non-odontogenic pain Objectives: On completion of this lecture, the student should have: An understanding of how to manage in an emergency appointment a patient who is in pain caused by a vital/ non-vital tooth or non-odontogenic pain. Reading material: Students are advised to read details at: 1. Cohen`s pathways of the pulp, 11th edition, 2016, Kenneth M. Hargreaves and Louis H. Berman. 2. Endodontic science (two volumes), 2nd edition, 2009, Carlos Estrela. 3. Problems in endodontics, Etiology, diagnosis and treatment, 2009, Michael Hulsmann and Edgar Schafer. 4. Endodontology, an integrated biological and clinical view, 2013, Domenico Ricucci and Jose F. Siqueira Jr. 5. Clinical endodontics, 3rd edition, 2009, Leif Tronstad. Thank You