endo emergencies

what constitutes a dental emergency

potential life-threatening and require immediate tx to stop ongoing tissue bleeding, alleviate severe pain or infection, ex:

3 examples of dental emergencies

• uncontrolled bleeding

• cellulitis or a diffuse soft tissue bacterial infection w IO/EO swelling that potentially compromise the pts airway

• trauma involving facial bones, potentially compromising th epts airway

what constitutes a urgent dental care visit

conditions that require immediate attention to relieve severe pain and/or risk of infection and to alleviate the burden on hospital emergency departments

examples of dental urgency

• severe dental pain from pulpal inflammation

• pericornitis or 3rd molar pain

• surgical post-operative osteitis, dry socket dressing changes

• abscess, or localized bacterial infection resulting in localized pain and swelling

• tooth fracture resulting in pain or causing soft tissue trauma

• dental trauma w avulsion/luxation

• dental tx required prior to critical medical procedures

• final crown/bridge cementation if the temp restoration is loss/broken/causing gingival irritation

• biopsy or abnormal tissue

examples of non-emergency dental procedures

• initial or periodic exam

• routine cleaning

• ortho procedures other than those to address acute issues

• ext of asymp tooth

• aesthetic procedures

• restorative dental tx

overall, what was found w ER visits associated w dental problems

• lots of dental-related visits: 2.43 million

• ave charge of an ER visit is $992 → but all they are doing for the pt (usually) is a prescription

• want pts to see dental offices for their dental emergencies → but there is also a need/opportunity for interprofessional collaboration

what were the top 2 reasons for out-of-hours apts for pts

endo related:

1. periapical periodontitis

2. acute pulpitis

what was the #1 tx provided to pts who received out-of-hours apts

pulpal extirpation (removal of pulp)

endo emergencies are usually associated w what symptoms

pain and/or swelling

endo emergencies require an immediate…

unscheduled office visit for dx and tx

endo emergencies are usually caused by…

• pathoses of the pulp and/or periapical tissues

• traumatic injuries

endo emergencies may be pre-treatment, interappointment, or postobturation, but most of the time it is…

pretreatment

definition of flare-up

interappointment and postobturation emergencies that require an unscheduled office visit

pain from endo emergencies results from…

inflammatory mediators and pressure

inflammatory mediators sensitize and activate nociceptors causing…

hyperalgesia, allodynia, and spontaneous pain

inflammatory mediators _________ (inc/dec) vascular permeability producing ________

inc; edema- inc pressure mechanically stimulates nociceptors

goal when handling endo emergencies

reduce the concentration of inflammatory mediators and release pressure from root canal system and periradicular tissues

w endo emergencies, you must use a _________ approach

systematic

importance of the systematic approach w endo emergencies

do NOT want to rush into tx without proper/accurate dx → missed dx will NOT alleviate pain, and may exacerbate the problem

pts w preop percussion sensitivity are more likely to ecperience

postop pain

dx sequence of endo emergencies

1. medical hx

2. dental hx

3. CC

4. EOE

5. IOE

6. dx tests

7. radiographic exam

8. pulpal and periapical dx

9. tx plain (emergency and definitive)

2 types of pretreatment endo emergencies

• symptomatic irreversible pulpitis

• pulp necrosis w apical pathosis

symptomatic irreversible pulpitis can be with or without…

symptomatic apical periodontitis

pulp necrosis w apical pathosis can be with or without…

• without swelling

• with localized swelling

• with diffuse swelling

w symptomatic irreversible pulpitis, pain is a result of…

inflammation

inflammation associated w symptomatic irreversible pulpitis may or may not have spread to…

afect the periapical tissues

tx for symptomatic irreversible pulpitis generally

removal of inflamed tissue should reduce the pain

tx for symptomatic irreversible pulpitis without apical periodontitis if time permits

if time permits: complete cleaning and shaping of the root canal

tx for symptomatic irreversible pulpitis without apical periodontitis if limited time

limited time:

• extirpate pulp tissue w broach or files

• pulpotomy effective in molars- removes coronal pulp tissue

w sympotmatic irreversible pulpitis, most pain relief is provided by…

• removal of inflamed tissues

• analgesics for mild pain

antibiotics indicated for x for symptomatic irreversible pulpitis without apical periodontitis

NOT indicated

symptomatic irreversible pulpitis w symptomatic apical periodontitis has similar tx if it was without symp apical periodontis except a couple things…

• more likely to experience postop pain

• may require occlusal reduction → fine cause will probs require crown

what is this

borach file

pain associated w pulp necrosis w apical apthosis is related to…

periradicular inflammation; due to irritants in necrotic tissue in root canal system

foal in tx pulp necrosis w apical pathosis

• remove or reduce pulp irritants

• relieve apical fluid pressure

PA dx w pulp necrosis will be either…

• apical periodontitis

• acute apical abscess

tx for pulp necrosis without swelling

• remove irritants in the root canal system and relive apical fluid pressure

• if time permits: complete cleaning and shaping or the root canal system

• if limited time: partial debridement w light passive instrumentation to remove irritants in canal

• use NaOCl, Ca(OH)₂

• analgesics for moderate-severe pain

antibiotics indicated for pulp necrosis without swelling

NOT indicated

what is happening w pulp necrosis w localized swelling

abscess has spread to soft tissues, may be purulence in canals

tx for pulp necrosis w localized swelling

• incision and drainage: allow tooth to drain until it stops- drainage through tooth may not occur

• canal debridement: complete cleaning and shaping od the root canal system is preferred

• NaOCl, Ca(OH)₂

• analgesics for mild-moderate pain

can you leave the tooth open for a tooth w pulp necrosis and localized swelling

NO- very very rare to leave open

antibiotics indicated for pulp necrosis w localized swelling

NOT indicated, unless there is fever or other systemic signs

___________ is most important w tx for pulp necrosis w localized swelling

relief of pressure

pulpal necrosis w diffuse swelling is also termed..

cellulitis

what is cellulitis

rapidly progressive and spreading swelling, may be into fascial spaces

symptoms that may be seen w cellulitis

fever or systemic sings → more serious infection

tx for cellulitis

• canal debridement: complete cleaning and shaping of the root canal system is preferred

• incision and drainage- may or may not achieve drainage through the tooth

• NaOCl, Ca(OH)₂

• is spread into multiple spaces: hospitalization may be indicated

• antibiotics indicated

• analgesics for moderate-severe pain

• refer and followup

recovery of cellulitis depends on…

canal debridement and drainage

flare-ups are _______________ emergencies

interappointment- requires an unscheduled visit and tx

incidence of flare-ups

1.8-3.2% (percentages will vary between studies bc different definitions)

flare-ups usually happen in what teeth

teeth w necrotic pulps and apical pathosis, and in pts who presented w significant preop pain and/or swelling

risk factors associated w flare-ups

NO definitive tx risk factors (reassure pt)

what is common as a postobturation “emergency”

• mild pain is common- usually resolved spontaneously

• pain occurs in the first 24 hours and may last days- is important that pain starts getting better after 2 days

____________ is associated w the highest incidence of discomfort postobturation

overfills

postobturation pain correlated w level of _________

preobturation pain

what can you give for mild pain for postobturation emergencies

analgesics

rarely, additional tx is needed for postobturation emergencies, but may be:

• non-surgical tx: if prior tx is inadequate

• endo surgery: if prior tx is inadequate and unable to correct non-surgically

• I&D, if tx adequate