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199Pakistan Oral & Dental Journal Vol 31, No. 1 (June 2011)

Treatment of acute apical abscess by single visit endodontics

INTRODUCTION

Since its introduction, single visit endodontics has

been a form of focus of controversy. Some advocate that

all root canal treatments to be done in one visit while

others do not consider it even in cases of vital pulp

extripation.28Some studies have reported statistically

insignificant difference between single and multiple

visit endodontics in terms of survival, post-operative

pain or flare-ups.29-31So, it depends only on the prefer-

ence of the operator to adopt single or multiple visit

endodontics.

28

One of the acute emergencies in endodontics is

acute peri-apical abscess due to an infected or non-vital

tooth. Various treatment protocols and regimens using

different tools have been designed and implemented on

the basis of clinical results achieved by their users. The

cardinal rule for managing all these infections is to

achieve drainage and remove the source of the infec-

tion.3,4 Three avenues can address swelling and infec-

tion,1,2establish drainage through the root canal, estab-

lish drainage by incising a fluctuant swelling and

antibiotic treatment. But Systemic antibiotics provide

no additional benefit over drainage of the abscess in the

case of localized infections and should be administeredin the event of system complications ( fever, lymphad-

enopathy, cellulitis) or if the patient is immunocom-

promised.2 Cleaning and shaping are paramount to

success regardless of drainage, because bacteria re-

maining within the root canal system compromises the

resolution of the acute condition.5Copious irrigation

should be performed throughout the cleaning and

shaping of the canal.6,7

CASE REPORTS

1 A 38 year old male was seen in this hospital with

complaints of pain and swelling in the right upper

quadrant and had mild fever. The pain was con-

stant, throbbing, spontaneous, referred to the head

region and lasted for several minutes after initia-

tion. The pain was aggravated by hot foods and

upon mastication. On extra-oral examination the

patient had swelling of the right canine space

without any lymphadenopathy. On intraoral ex-

amination a moderate fluctuant swelling was vis-

ible 3mm beneath the gingival margin on the

buccal side between upper right canine and first

premolar. Clinically the upper right first premolar

TREATMENT OF ACUTE APICAL ABSCESS BY SINGLE VISIT

ENDODONTICS 2 CASE REPORTS

1MANSOOR KHAN, BDS1RANA MUHAMMAD AHMED KHAN, BDS

2MUHAMMED QASIM JAVED, BDS

3ALIA AHMED, BDS, FCPS2MUHAMMAD NABEEL, BDS

ABSTRACT

The purpose to publish these case reports is to show the effectiveness of single visit endodontics

in teeth with acute apical abscess. Infected non-vital teeth in two patients were treated with single visit

RCT along with incision and drainage of the abscess in the same appointment. Follow up of both the

patients showed relief of symptoms to remarkable extent in the evening of treatment day. Radiographs

showed significant periapical bone healing after 3 months in both patients.

1 House Officers

2 Post Graduate Resident, Department of Operative Dentistry, Islamic International Dental College and

Hospital, Islamabad

3 Head of Department of Operative Dentistry

Correspondence:Dr Rana Muhammad Khan, E mail: [email protected] 0333-8143910

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had discoloration of the crown due to caries with a

moderately large carious lesion. The tooth showed

a mild response to hot and cold test with moderate

pain on percussion and palpation of soft tissues

with grade 1 mobility. Radiographically the crown

had caries with pulp exposure. The lamina dura

was widened with apical radiolucency. The toothwas diagnosed to have acute irreversible pulpitis

and acute periapical abscess.

Once the tooth was diagnosed for endodontic treat-

ment, access cavity was made and pulp chamber

was opened and pus was allowed to drain. Incision

was made by using surgical blade #11, and drainage

by artery forceps and bone trephination. Maximum

drainage of pus was achieved by compressing the

swelling followed by copious irrigation with saline.

When pus stopped draining, canals were copiously

irrigated with saline. Then canal was prepared by

step back technique with 15-60K file. 5.25% sodium

hypochlorite was inserted into the canal for 30

seconds and copious irrigation was done before

changing to next file. Canals were obturated with

gutta purcha cones and eugenol based sealer by

lateral cold condensation technique, once they

were prepared. Crown was temporarily filled with

glass-ionomer cement. Quarter inch rubber dam

(latex) was cut to make a drain and was inserted

and sutured into the incision made for drainage.

Patient was medicated with coamoxi-clav, metron-

idazole and naproxen sodium. Patient was called in

the evening to know the extent of swelling, pain

and pyrexia which was considerably reduced. On

follow up after 3 days, swelling, pyrexia and pain

were not present. Considerable bone healing was

present at three months post operative visit. Pa-

tient was followed up every 3 months till one year

no signs of recurrence of apical infection were

noted. (Figs 1-3)

2 A 15 year old male patient was referred to the

Operative Department of Islamic International

Dental Hospital for the treatment of lower left and

right central and lateral incisor teeth. The patient

stated that he had a bicycle accident when he was

10 years old and had not seen a dentist since then.

The patients history did not reveal whether the

teeth were luxated, intruded or extruded. He some-

times had mild pain and swelling in the mandibular

anterior region. Clinical examination of soft tis-

sues showed no signs of scarring or fistulae. None

of these teeth were discoloured. Both the central

and lateral incisors were slightly sensitive to per-

cussion and palpation without any mobility. Man-

dibular right and left lateral and right central

incisor teeth failed to respond to electric pulp

testing, whereas the mandibular left lateral incisor

response was within normal limits.

Periapical radiographs showed a large radiolucent

lesion around the apices of the lower incisors with

a well-defined margin around the apex of the lower

left lateral central incisor. This tooth gave a nor-

mal response to electric pulp tests. Despite this

Fig 1: Preoperative radiograph showing radiolucency at the apical end of the first premolar.

Fig 2: 3 months post-operative radiograph.

Fig 3: 12 months post-operative radiograph showing adequate bone healing.

Fig 1 Fig 2 Fig 3

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positive sensitivity test, root canal treatment was

initiated on all mandibular incisors. Following

access cavity preparation, vital pulp tissue was

extirpated and the working length was estimated

as being 1 mm short of the radiographic apex. The

canal was prepared with size 1560 K-files using a

step-back technique. The other three incisors had

necrotic pulp tissue and were accessed and size 15

K-files were passed beyond the apical foramen.

Mucopurulent fluid was drained through incision

made in the fluctuent swelling by surgical blade #11

and bone trephination. When drainage ceased,

rubber dam drain was sutured and canals were

prepared 1 mm short of the radiographic apices

with size 1560 K-files using a step-back technique.

During preparation canals were copiously irrigated

with sodium hypochlorite (30 sec) and normal

saline. Cold lateral condensation was done and

post-obturation radiographs taken. (Figs 4-7)

DISCUSSION

Traditionally, endodontic treatment of teeth with

apical abscess aims at the complete elimination of

microbial invaders of the root canal system. Studies

have shown that instrumentation and irrigation of the

root canal system substantially reduce the number of

cultivable microorganisms but rarely lead to a total

eradication.8,9For this purpose intra-canal dressing

(calcium hydroxide) is recommended.10,11,12But it has

obvious disadvantages i.e. it does not repeatedly kill

the intra-canal flora,9,13,14,15,32it needs multiple visits to

be optimally potent.11Minute differences in peri-apical

healing were observed among individuals undergoing

single visit and multiple visit root canal treatment,28-31

and bacterial growth at the second appointment had a

significant negative impact on healing of the peri-apical

lesion.17 In addition to this, the clinical efficacy of

sodium hypochlorite irrigation in the control of root

canal infection is much more than the effectiveness of

inter-appointment calcium hydroxide dressing, in dis-

infecting the root canal system and treatment out-

come, indicating the need to develop more efficient

inter-appointment dressings.17 E. faecalis is the most

resistant bacterium against calcium hydroxide18while

sodium hypochlorite is effective against it in both

buffered and unbuffered states.19

However, quantity ofthe irrigant is more important than type of the irrigant,21

therefore copious irrigation is recommended.

Intra-canal medicaments can only work efficiently

if they are in direct contact with micro-organisms.

Most of the micro-organisms causing endodontic fail-

ure, resides deep in dentinal tubules or accessory

canals and multiple visits allow them to proliferate

resulting in poor apical healing and endodontic fail-

Fig 4 Fig 5 Fig 6 Fig 7

Fig 4: Pre-operative radiograph showing mandibular central and lateral incisors with large peri-apical lesion.

Fig 5: Post-operative radiograph taken immediately after completing the procedure in first visit.

Fig 6: Radiograph taken at follow-up examination 6 months after completion of endodontic treatment. Healingof periapical lesion is evident.

Fig 7: One year post-operative radiograph. Radiograph shows that the radiolucent area was absent and thattrabecular bone was forming. Clinical examination showed no sensitivity to percussion or palpation andthe soft tissues were healthy.

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ure.22,23Therefore these days it is considered a better

option to disinfect the canals with copious irrigation of

5.25% sodium hypochlorite and sealing the canals

resulting in elimination of the sources which will allow

the multiplication of micro-organisms and therefore

allow better peri-apical healing and better treatment

outcome.

The effectiveness of a clinical strategy must not be

evaluated only from a biological point of view but other

factors such as cost, patient comfort, and effort put into

the treatment by the dentist should be included in the

final assessment.16In single visit root canal treatment

net profit for the dentist is almost 50% which reduces

to 14% in second visit and 25% loss at third visit.20From

patients point of view one has to lose more hours of

work for multiple visits and needless travels are re-

quired. Without question, single appointments are

preferred by most of the patients.20

CONCLUSION

Treatment of acute apical abscess by incision and

drainage and single visit endodontics in the same visit

proves to be much better alternative than traditional

treatment protocols of treating acute apical abcess i.e.

incision and drainage in first visit and completing root

canal treatment in multiple visits with calcium hydrox-

ide as inter-appointment dressing. Because of the low

sample size further studies are warranted in this field

of endodontics.

REFERENCES

1 Pathways of pulp page 52, 9 ed, 2006, Elsevier

2 Emergency management of acute apical abscess in adults.Canadian collaboration on clinical practice guidelines in den-tistry 2003.

3 Harrington GW, Natkin E. Midtreatment-flare ups. Dent ClinNorth Am 1992; 36: 409.

4 Hutter JW. Fascial space infections of endodontic origin. JEndodon 1991;17:422.

5 Mattuso RJ, Goodall LB. Anaerobic isolates in primary pulpalalveolar cellulites cases: endodontic resolution and drug therapyconsiderations J Endodon 1983;9:535.

6 Harrison JW. Irrigation of the root canal system, Dent ClinNorth Am. 1984;28:797.

7 Turkun M, Cengiz T. The effects of the sodium hypoclorite andcalcium hydroxide in tissue dissolution and canal cleanliness.Int Endodon J 1997;30:335.

8 Bystrm A, Sundqvist G. Bacteriologic evaluation of theefficacy of mechanical root

canal instrumentation in endodontic therapy. Scand J DentRes 1981;89:32128.

9 Dalton BC, rstavik D, Phillips C, Pettiette M, Trope M.Bacterial reduction with nickel-titanium rotary instrumenta-tion. J Endod 1998;24:76367.

10 Bystrm A, Claesson R, Sundqvist G. The antibacterial effectof camphorated paramonocholorophenol, camphorated phe-nol and calciumhydroxide in the treatment of infected rootcanals. Endod Dent Traumatol 1985;1:170 75.

11 Sjgren U, Figdor D, Spngberg L, Sundqvist G. The antibac-terial effect of calcium hydroxide as a short-term intracanaldressing. Int Endod J 1991;24:119 25.

12 Shuping GB, rsatvik D, Sigurddsson A, Trope M. Reductionof intracanal bacteria using nickel-titanium rotary instru-mentation and various medications. J Endodon 2000;26:

75155.13 Akpata ES. Effect of endodontic procedures on the population

of viable microorganisms in the infected root canal. J Endod1976;2:369 73.

14. rstavik D, Kerekes K, Molven O. Effects of extensive apicalreaming and calcium hydroxide dressing on bacterial infectionduring treatment of apical periodontitis: a pilot study. IntEndod J 1991;24:17.

15 Peters LB, van Winkelhoff AJ, Buijs JF, Wesselink PR. Effectsof instrumentation, irrigation and dressing with calciumhydroxide on infection in pulpless teeth with periapical bonelesions. Int Endod J 2002;35:1321.

16 Sackett D. Evidence Based Medicine: How to Practice andTeach EBM, ed 2. Edinburgh: Churchill Livingstone; 2000.

17 Waltimo T, Trope M, Haapasalo M, rstavik D. Clinicalefficacy of treatment procedures in endodontic infection

control and one year follow-up of periapical healing. J Endod.2005;12: 863-66.

18 Bystro m A, Claesson R, Sundqvist G. The antibacterial effectof camphorated paramonochlorophenol, camphorated phe-nol and calcium hydroxide in the treatment of infected rootcanals. Endod Dent Traumatol 1985; 1: 17075.

19 Zehnder M, Kosicki D, Luder H, Sener B, Waltimo T. Tissue-dissolving capacity and antibacterial effect of buffered andunbuffered hypochlorite solutions. Oral Surg Oral Med OralPathol Oral Radiol Endod 2002;94: 75662.

20 Senia ES, Wildey WL. Single visit endodontics- A time forchange.Dental town 2004;9:42-48.

21 Siqueira JF Jr, Rjcas IN, Souto R, de Uzeda M, Colombo AP.Actinomyces species, streptococci, and Enterococcus faecalisin primary root canal infections. J Endod 2002;28: 16872.

22 Oguntebi B. Dentine tubule infection and endodontic therapyimplications. Int Endod J 1994;4:218-22.

23 Peters LB, Wesselink PR, Moorer WR. The fate and the roleof bacteria left in root canal dentinal tubules. Int Endod J1995;2: 95-99.

24 Gatewood RS, Himel VT, Dorn SO. Treatment of the endodon-tic emergency a decade later. J Endod. 1990; 28: 261-65.

25 Southard D, Rooney T. Effective one visit therapy for theacute apical abcess. J Endod. 1984;10: 580.

26 Jurcak JJ, Bellizzi R, Loushine RJ. Successful single visitendodontics during operaion desert shield. J Endod. 1993;19:412-13.

27 Eleazer PD, Eleazer KR. Flare up rate in pulpally necroticmolars in one visit versus two visit endodontic treatment. JEndod. 1994;9: 614-16.

28 Sathorn C, Parashos P, Messer H. Australian endodontistsperceptions of single and multiple visit root canal treatment.Int Endod J. 2009 ;9: 811-18.

29 Fleming CH, Litalcer LS, Alley LW, Eleazer PD. Comparisonof classic endodontic techniques versus contemporary tech-niques on endodontic treatment success. J Endod. 2010;3:414-18.

30 Figni F, Lodi G, Gorm F, Gagliani M. Single versus multiplevisits for endodontic treatment of permanent teeth. Evidencebased dentistry. 2008;1:24.

31 Single or multiple visit endodontics: which techniqueresults in fewer postoperative problems. Int Endod J. 2008;2:91-99.

32 Balto KA. Calcium hydroxide has limited effectiveness ineliminating bacteria from human root canal. Int Endod J2007;1: 2-10.

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