ENDODONTIC EMERGENCIES

Dr. Muneera Ghaithan

ENDODONTIC EMERGENCIES

Endodontic emergencies occurs with varying frequencies of pain and swelling in patients before, during and after root canal treatment.

The pain in endodontic emergencies is related to two factors .

The most common causes are:- pulpal and periapical pathosis.- traumatic injury.

Diagnosis and management of endodontic emergencies:

the basic steps for successful management are:

Follow a systematic approach.

Complete history

clinical examination

No treatment is indicated without clear diagnosis

Pretreatment endodontic

emergencies

Conditions requiring emergency treatment:

Acute reversible pulpits.

Acute irreversible pulpits.

Acute periapical abscess.

Acute apical periodontitis.

Mid-treatment flare-up in endodontic

Mid-treatment flare-up in endodontic

Flare up is described as the occurrence of pain,

swelling or the combination

of these during the course of

root canal therapy, which

result in unscheduled visits by

the patient.

Etiology: (multifactorial)Usually due to irritants left within root

canal system.

Iatrogenic factors.

Host factors.

Vital pulp less likely to demonstrate

symptoms.

Tooth with acute apical abscess + pain shows

sever emergency treatment in flare-ups.

Microbiology and immunology of :flare-ups1) Alteration of local adaptation

syndrome.2) Changes in periapical tissue

pressure.3) Microbial factors.4) Effect of chemical mediators.5) Changes in cyclic nucleotides.6) Immunological response.7) Psychological factors.

1-Alteration of local adaptation syndrome.

New irritant ch.inflammed tissue

Violent reaction may occur due to

disturbance in local tissue adaptation

to the applied irritants.

2-Changes in periapical tissue pressure.

Teeth with increased periapical pressure

Excessive exudates pressure on nerve ending pain

Teeth with less periapical pressure Microorganisms + other irritants get

aspirated into periapical area pain

3-Microbial factors.

Anaerobes in root canal produce enzymes, endotoxins and other irritants

persistence of

periapical lesions

4-Effect of chemical mediators.

• cell mediators

• Plasma mediators.

• Neotrophils products

5-Changes in cyclic nucleotides.

In flare up level of c GMP over

c AMP concentration.

Clinical conditions of flare-up:1. Apical periodontitis secondary to

teatment: Tooth become sensitive to

percussion. Throbbing or gnawing pain.

Causes: Over instrumentation. Over medication. Forcing debris into periapical

tissue.

Confirmatory test:Use paper pointMark W/L.Place the paper point in the canal.

Over-instrumentation the paper point tip will disclosed a reddish or brownish color

2. Incomplete removal of pulp tissue: Sensitivity to hot and cold or pain on

percussion is usually seen.

Confirmatory test:Sterile paper point short of W/L

display brownish discoloration.

Clinical conditions of flare-up:

3. Recrudescence of chronic apical periodontitis: (phoenix abscess).

alteration of internal environment of root canal space during instrumentation activates bacterial flora.

Signs and symptoms:- mobility, tenderness and swelling.

Clinical conditions of flare-up:

4. Recurrent periapical abscess:

Clinical conditions of flare-up:

Diagnosis and management: Establishing the cause is an important step

towards the management.

Inter-appointment emergencies is divided into:

- Previously vital pulp with complete debridement.

- Previously vital pulp with incomplete debridement.

- Previously necrotic pulp without swelling.- Previously necrotic pulp with swelling.

Previously vital pulp with complete debridement:

Here chance of flare-up is less.

Only patient reassurance and prescription of mild to moderate analgesic.

There is no need to re-opening the canal and place corticosteroid.

Previously vital pulp with incomplete debridement.

Here pulp remnants considered to be a major

irritant, causing sever pain.

W/L should be rechecked.

Canal cleaned with copious irrigation of NaHCl

Dry cotton pellet is placed + T.F

Mild analgesic is prescribed.

Relieve tooth from occlusion.

Previously necrotic pulp without swelling.

Establish accurate W/L.

Complete instrumentation.

Irrigation with copious amount of NaHCl.

If there is drainage from the canal, after drying

the canal place Ca(OH)2 dressing and access is

sealed.

Analgesic and antibiotic.

Previously necrotic pulp with swelling.

• These cases are best managed by

incision and drainage.

• Canal should be opened debrided and

gently irrigated with NaHCl.

• Ca(OH)2 should be placed and closed.

General management of flare ups1. Reassurance to the patient.2. Complete debridment of root canal

system.3. Establishment of drainage.4. Relief of occlussion.5. Ca(OH)2 therapy.6. Intracanal medicament.7. Medications.8. Placebo.

Good Luke