tic Emergency- Dr Firas Elayyan

8/3/2019 tic Emergency- Dr Firas Elayyan

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ENDODONTICEMERGENCIES


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-ENDODONTIC EMERGENCIES

ARE CHALLENGE IN BOTH

DIAGNOSIS & MANAGEMENT

-EVERY CASE IS A COMPLETE

SEPARATE STORY


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-DENTIST SHOULD

INTERFER-NEVER DEPEND ON

MEDICATIONS ALONE


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DEFINITION

OF EMERGENCY

CASES ASSOCIATED

WITH PAIN &/ ORSWELLING & REQUIRE

IMMEDIATE DIAGNOSIS

& TREATMENT


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KEYS QUESTIONS TO

DETERMINE THE CASE:

1-DISTRUPTION OF

SLEEPING,WORKING &

EATING

2-DURATION3-PAIN MEDICATION


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CAUSES OF THESE

EMERGENCIES

ARE IRRITANTS THAT INDUCE

SEVERE INFLAMATION IN PULP &

PERIRADICULAR TISSUES


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THESE IRRITANTS LEAD TO

THE RELEASE OF A GROUP

OF CHEMICAL SUBSTANCESTHAT INITIATE THE

INFLAMATION


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THESE SUBSTANCES

CAUSE PAIN IN TWO

WAYS:

1-DIRECTLY : BY LOWERING THE

RESPONSE THRESHOLD OF SENSORY

NERVES

2-INDIRECTLY:BY INCREASING

VASCULAR PERMIABILITY &PRODUCING EDEMA


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THE MAIN CAUSE OF THE PAIN

IS

EDEMA RESULTS ININCREASED FLUID PRESSURE

WHICH STIMULATES PAINRECEPTORS


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THE IMMEDIATE GOAL

OF THE TREATMENT

SHOULD BE THE

REDUCTION OF

PRESSURE ORREMOVAL OF THE

INFLAMED PULP ORPERIRADICULAR

TISSUE.


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PSYCHOLOGICAL MANAGEMENT IS

THE MOST IMPORTANT:

1-CONTROL THE SITUATION2-GAIN THE CONFIDENCE OF THE

PATIENT

3-PROVIDE ATTENTION & SYMPATHY4-TREAT THE PATIENT AS AN

IMPORTANT INDIVIDUAL


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-PATIENT IN PAIN OFTEN PROVIDE

INFORMATION AND RESPONSES THAT

ARE EXAGGERATED & INACCURATE.

-ALSO HE MAY GIVE YOU FALSE

IMPRESSION.

-BE AWARE OF THE REFERRED PAIN &

SYSTEMIC CONDITION.


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PROPER DIAGNOSIS IS

VERY IMPORTANT TOTREAT THE CASE:

1-OBTAIN MEDICAL & DENTAL HISTORIES

2-SUBJECTIVE EXAMINATION

3-VISUAL EXAMINATION

4-INTRAORAL EXAMINATION5-PULP TESTING

6-PULPATION & PERCUSION

7-RADIOGRAPH


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1-OBTAIN MEDICAL &DENTAL HISTORIES


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2-SUBJECTIVE EXAMINATION

QUESTIONS:HISTORY,LOCATIONDURATION,SEVERITY,NATURE,

STIMULATING AGENTS.


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PAIN CAUSED BY THERMAL

CHANGES IS OF PULPALORIGIN.

PAIN CAUSED BY PRESSUREIS OF PERIRADICULAR

ORIGIN


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PAIN

SPONTANEITY,INTENSITY

& DURATION.


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-Initial diagnosis is reached after this

subjective question

-OBJECTIVE TESTS &RADIOGRAPHICAL EXAMINATION AREUSED FOR CONFIRMATION.


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3-OBJECTIVEEXAMINATIONS


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A-EXAMINATION OF FACE &

ORAL SOFT & HARD TISSUE.

(SWELLING,RESTORATIONS,DISCOLARATION,CARIES,

FRACTURES)


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B-PERIRADICULAR TESTS:

-PALPATION OVER THE

APEX

-DIGITAL PRESSURE ON THE

TEETH

-LIGHT PERCUSSION


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C-VITALITY TESTS OF THEPULP:

COLD,HOT,ELECTRICAL,,,,

CAVITATION.


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D-PERIODONTAL EXAMINATION

PROBING IS VERY IMPORTANT


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PERIODONTAL ABCESS CAN

SIMULATE THE SYMPTOMS

OF ACUTE APICAL ABCESS

BUT THE PULP HERE ISVITAL & POCKETS ARE

PROBED.


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4-RADIOGRAPHICEXAMINATION


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PROPER DIAGNOSIS IS

REACHED


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TREATMENT PLAN


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THE IMMEDIATE GOAL

OF THE TREATMENT

SHOULD BE THE

REDUCTION OF

PRESSURE ORREMOVAL OF THE

INFLAMED PULP ORPERIRADICULAR

TISSUE.


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FIRST STEP IN TREATMNTIS :

PROFOUND ANESSTHESIA

TO GAIN PATIENTS

CONFIDENCE & COOPERATION


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UPPER JAW:INFILTRATIONOR BLOCK

LOWER JAW: INFERIORALVEOLAR BLOCK.(

LINGUAL & LONG BUCCALBLOCK MAY BE HELPFUL)


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SOMETIMES:

PERIODONTAL,

INTRAPULPAL ORINTRAOSSEOUS INJECTIONS

MAY BE NEEDED


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EMERGENCIES

1-PRETREATMENT2-INTERAPPOINTMENT

3-POSTOBTURATION


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PRETREATMENTEMERGENCIES


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1-PAINFUL IRREVERSIBLE

PULPITIS WITHOUT

APICAL PERIODONTITIS


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DIAGNOSIS

1-PAIN ON THERMAL

STIMULI (MAINLY HOT)

2-NO PAIN ON PERCUSION3-SPONTANOUS PAIN

4-NO RADIOGRAPHICPERIAPICAL CHANGES


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TREATMENT:

-PROFOUND ANESTHESIA-COMPLETE PULP EXTIRPATION-CLEANING & SHAPING OF THE

CANALS IS DESIRABLE.-IN MOLARS ;PULPOTOMY MAY BE

ENOUGH TO RELEASE PRESSURE

-MEDICAMENTS :CAMPHOR SEALED

IN THE CANALS.

-A MILD ANALGESICS BUT NO

ANTIBIOTIC


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2-PAINFUL IRREVERSIBLE

PULPITIS WITH ACUTE

APICAL PERIODONTITIS


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-THE SAME AS ABOVE BUT

WITH SLIGHT TO SEVERE PAINON PERCUSION

-RADIOGRAPHICALLY :SLIGHT

WIDENNING OF THE LAMINA

DURA AROUND THE APEX


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THE SAME TREATMENT

BUT:

1-MAY NEED RELIEF OF

OCCLUSION2-ANTIBIOTIC IS NOT

NEEDED


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3-PULP NECROSIS

WITHOUT SWELLING


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DIAGNOSIS

-TOOTH NOT AFFECTED BY

THERMAL STIMULOUS

-PAIN ON PERCUSION

-PERIAPICAL RADIOLUCENT

LESION MAY BE SEEN


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TREATMENT

-ANESTHESIA:INFLAMED PULPREMENETS IN THE APICAL

CANALS OR THE INFLAMED

PERIRADICULAR TISSUE-COMPLETE DEBRIDMENT IS THE

TREATMENT OF CHOICE

-HEAVY IRRIGATION WITHCOPIOUS AMOUNT OF SODIUM

HYPOCHLORITE


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-DRY THE CANALS WITH PAPER

POINTS-FILL THE CANALS WITH NON

SETTING CALCIUM HYDROXIDE.

-MEDICAMENTS :CAMPHORSEALED IN THE CANALS & CLOSE

IT WITH TEMPORARY FILLING

-MILD ANALGESIC ISNEEDED(ANTIBIOTIC IS RARELY

NEEDED)


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4-PULP NECROSIS WITHLOCALIZED SWELLING

(associated with acute apical

abcess)


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-TOOTH MAY HAVE SOME

MOBILITY & VERY SINSITIVE TOBITTING

-THERE MAY BE BUS INSIDE THE

CANALS WHEN OPEN THE PULPCHAMBER.

-THESE PATIENTS MAY HAVE

ELEVATED TEMPRATURES ORLYMPHADENOPATHY


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-RADIOGRAPHIC FINDINGS

RANGE FROM NO PERIAPICAL

RADIOLUCENCY TO LARGERADIOLUCENCY.


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DRAINAGE IS VERY

IMPORTANT


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-TREATMENT IS BIPHASICFIRST: DEBRIDMENT OF THE

CANALS

SECOND:DRAINAGE OF BUS


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LOCALIZED SWELLING

SHOULD BE INCISED

&DRAINED TO :

1-RELEASE OF PRESSURE

2-REMOVAL OF THE VERY

POTENET IRRITANT ( THE BUS)


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-IN PATIENTS WITH A PERIRADICULAR

ABCESS & NO DRAINAGE FROM THECANALS,PENETRATION OF THE APICAL

FORAMEN WITH SMALL FILE(UP TO 25)

MAY INITIATE DRAINAGE & RELEASE

PRESSURE.-DRAINAGE THROUGH THE TOOTH MAY

BE ENOUGH IN SOME CASES.


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-MOST OF THE CASES NEED

DRAINAGE THROUGH THE

TOOTH & THE MUCOSAL

INCISION-DRAIN MAY BE NEEDED

TO PERMIT CONTINUED

DRAINAGE


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TREATMENT- DEBREDMENT & DRAINAGE .

-HEAVY IRRIGATION WITH DISTILLED WATER

-IT IS ADVISED NOT TO USE SODIUM HYPOCHLORIDEWITH THE PRESENCE OF BUS BECAUSE THIS MAY

LEAD TO THE FORMATION OF PLUG.-DRY THE CANALS WITH PAPER POINTS &

CLOSE.

-MEDICAMENTS :CAMPHOR SEALED IN THE

CANALS

-CLOSE WITH GOOD TEMPORARY FILLING

-MILD ANALGESIC &ANTIBIOTIC IS NEEDED

Make sure that there is no bus in


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-Make sure that there is no bus in

the canals before you close

-Dont leave these teeth open fordrainage

ButIf the drainage through the canal

is not stopped, the access may be

left opened for further drainageBUT NOT MORE THAN 24 HRs


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Leaving the tooth on open drainageshould

be avoided if possible,but if absolutelynecessary for less than 24 hrs,as after this

time further contamination of root canal by

anaerobic bacteria makes subsequent RCTvery difficult

OXFORD HANDBOOK OFCLINICAL DENTISTRY 2003

ANTIBIOTIC OF CHOICE:


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ANTIBIOTIC OF CHOICE:

A COMBINATION OF-WIDE SPECTRUM

ANTIBIOTIC FOR AEROBICBACTERIA(Penecillins)

-METRONEDAZOLE(Flagyl)

FOR ANEROBIC BACTERIA


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5-PULP NECROSIS WITH

DEFFUSE SWELLING


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THESE LESIONS ARE RAPIDELY

PROGRESSIVE &SPREADINGSWELLING THAT HAVE DISSECTED

INTO TISSUE SPACES.

-THESE PATIENTS OCCASIONALLY

HAVE AN ELEVATED TEMPRATURE

& SYSTEMIC SIGNS


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-SPREADING OF INFECTIONS INTO

FACIAL SPACES

-VERY DANGEROUS SITUATION

-SYSTEMIC MANIFESTATION ARE

PRESENT

-EYE CLOSURE IF ASSOCIED WITH

UPPER TEETH &

TRISMUS IF ASSOCIATED WITH

LOWER TEETH


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TREATMENT

-DRAINAGE IS VERY IMPORTANT IF THEREIS FLUCTUATION & BUS.

-EXTRAORAL INCISION WITH DRAIN MAY

BE NEEDED (ORAL SYRGEON)

-REMOVAL OF IRRETANTS BY

DEBRIDMENT OF CANALS OR EXTRACTION

OF INFECTED TOOTH

-STRONG ANTIBIOTIC (I.V.)&ANALGESIC .

-MAY NEED HOSPITALIZATION.


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INTERAPPOINTMENTEMERGENCIES

(FLARE UPS)

CAUSITIVE FACTORS


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CAUSITIVE FACTORS

-PREOPERATIVE COMPLICATION

-OVERINSTRUMENTATION( BLOOD IN

TH CANALS)

-REMAINING INFLAMMMED PULP

TISSUE

-IMPROPER PREPARATION OF

PATIENT


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-PROPER DIAGNOSIS IS

ALSO NEEDED.

-MOST IMPORTANT:IS TOREGAIN THE CONFIDENCE

OF THE PATIENT.


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TREATMENT OF FLARE-

UPS:

-REASSURANCE OF THE

PATIENT

-BREAK THE CYCLE OF PAIN

WITH ANESTHESIA


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TYPES OF FLARE-UPS

1-PREVIOIUSLY VITAL


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CASES WITHOUT

SWELLING

TREARTMENT-ASSURANCE OF PATIENT

-GOOD ANALGESIC

-REOPEN THE TOOTH( MAKE GOOD

DEBRIDMENT & IRRIGATE)

-INTRACANAL MEDICAMENTS


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2-PREVIOUSLY NECROTIC

CASES WITH NO SWELLING


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TREATMENT

-OPEN THE TOOTH

-RECLEAN & IRRIGATE THE

CANALS WITH SODIUM

HYPOCHLORITE

-DRY & CLOSE.

IF ACUTE APICAL ABCESS IS


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IF ACUTE APICAL ABCESS IS

DEVELOPED:

-DRAINAGE IS NECESSARY( THROUGH

THE TOOTH OR THE SOFT TISSUE)

-CLEANING & IRRIGATION OF THE

CANALS

-DRY & CLOSE.

-ANTIBIOTIC & NSAID IS NEEDED


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THE TOOTH SHOULD NOT

BE LEFT OPEN

3-CASE WITH SWELLING


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3 CASE WITH SWELLING

-INCISION & DRAINAGE.-OPEN THE CANALS &

CLEAN-DRY & CLOSE.

-STRONG ANTIBIOTIC &

ANALGESIC IS NEEDED.


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POSTOPERATIVE

EMERGENCIES


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ONE THIRD OF ALL ENDO

CASES EXPERIENCE SOME

PAIN FOLLOWING

OBTURATION.


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CAUSES:

-OVERFILLING IS THE MAIN

CAUSE-HIGH OCCLUSION

-IRRITATION FROM THE SEALER

OR GUTTAPERCHA

TREATMENT


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TREATMENT

-DISCOMFORT: REASSURANCE&MILD ANALGESICS.

-REMOVAL OF THE HIGH POINTS

-RETREATMENT IS INDICATED IF

PAIN PERSIST &ENDO TREATMENT

HAS BEEN OBVIOUSLYINADEQUATE.

APICAL SURGERY (


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-APICAL SURGERY (

APECICTOMY) IN PATIENTS

WITH PERSISTENT PAIN WITH

OVER FILLING

-PATIENTS WITH GOOD ROOTCANAL TREATMENT BUT WITH

PERSISTENT SWELLING AFTER

OBTURATION,INCISION &DRAINAGE MAY BE ENOUGH.


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REFERENCES

PRINCIPLES & PRACTICE OF

ENDODONTICS ( WALTON & TORABINJAD)

OXFORD HANDBOOK OF CLINICALDENTISTRY ( 2003)

PATHWAYS OF THE PULP ( COHEN &

BURNS)


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THE END

tic Emergency- Dr Firas Elayyan

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