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List 6 types of Endodontic Emergencies

1) Pulpitis

2) Periapical Infection

3) Cracked Tooth

4) Mid & Post Treatment Flare Ups

5) Trauma Involving the Pulp

6) Iatrogenic Damage involving the Pulp

What is Pulpitis

Inflammation of the Pulp

We need to differentiate between Reversible and Irreversible Pulpitis. This is a Clinical Diagnosis and cannot be differentiated histologically.

What are the Signs & Symptoms of Reversible Pulpitis (5)

1) Pain by Hot, Cold & Sweet

2) Short Duration

3) Difficult to Localise

4) Exaggerate Response to Sensibility Testing

5) Radiographs are generally Normal i.e. no PA radiolucency

What is the Treatment for Reversible Pulpitis

1) Removal of the Causative Factor i.e. Caries, Failed Restoration

2) Place a Temporary Restoration i.e Zinc Oxide Eugenol

3) Monitor Response to Treatment

Why is Zinc Oxide Eugenol used as a Temporary Restoration for Reversible Pulpitis

It is a Sedative Dressing and has Obtundent Properties

You have provisionally diagnosed a patient with Reversible Pulpitis. You place a ZnO Eugenol Temporary Restoration

Before Placing a Definitive Restoration, It is important to monitor response of a patient after you've placed a temporary restoration. Explain Why

Monitor over few days/weeks. If your diagnosis was correct, then on review, symptoms will have reduced or stopped indicating that you have treated the Reversible Pulpitis.

If Symptoms continue then this may indicate your provisional diagnosis was incorrect and you need to re-assess.

What instructions do you give to a patient with Reversible Pulpitis once you have placed the temporary ZnO Eugenol Restoration

- Pain should hopefully gradually decrease

- Take Analgesics

- Emphasise the need to complete treatment if required

- Return if symptoms become more severe

What dose of Paracetamol can be taken for Reversible Pulpitis

2 x 500mg up to QDS

Max 8 x 500mg in 24 hours

What dose of Ibuprofen can be taken for Reversible Pulpitis

2 x 400mg up to TDS

We need to differentiate between Reversible and Irreversible Pulpitis. This is a Clinical Diagnosis and cannot be differentiated histologically.

What are the Signs & Symptoms of Irreversible Pulpitis (6)

1) Spontaneous Pain

2) Long Lasting Pain

3) Triggered by Heat and Relieved by Cold

4) Keeps Patient awake at night

5) Tooth can be TTP

6) Pain can Radiate

What is the treatment of Irreversible Pulpitis if Time & Pain Permits

- LA, Access Cavity and Removal of Pulp Tissue

- Coronal 2/3 Opening

- Determine Working Length and Complete Chemo Mechanical Debridement

- Copious Irrigation

- Dry the Canal and Place CaOH into the Canal

- Place a Bacteria Tight Seal

However it is ideal if possible to complete the RCT at the same appointment therefore after drying the canal

- complete obturation

- place a bacteria tight seal

What approach is used to remove pulp tissue

Barbed Broach

The Barbed Broach is used to remove parts of the pulp in one go and in large chunks

What is the treatment of Irreversible Pulpitis if Time & Pain Do not Permit

1) LA

2) Access Cavity

3) Removal of Pulp Tissue

4) Copious Irrigation

5) Dry Pulp Chamber

6) Place a Sedative Dressing

7) Place Bacteria Tight Seal

8) Complete Root Canal Instrumentation in the Next Few Days

What are Hot Pulps

A Tooth with Pulpitis which can be incredibly painful and difficult to anaesthetise

How do you manage Hot Pulps

- Regional Anaesthesia

- Consider all additional sources of innervation

- Multiple Anaesthetics

- Intra-ligamentary Anaesthesia (infiltration into the PDL)

- Intra-Pulpal Anaesthesia (expose small area of pulpal tissue and then inject directly into there) however can the patient tolerate you drilling into their tooth without LA

- Intra-osseous anaesthesia

- Inhalational Sedation

What is Intra-Ligamentary Anaesthesia

Infiltration into the PDL via a short fine needle using a specific syringe. Generates high pressure, therefore require special syringes which reduce the risk of cartridge of anaesthetic fracturing. This can be useful for delivering LA closer to the root and nerve. High pressure within PDL so can cause Cell necrosis so avoid placing large volumes

What is Intra-Pulpal Anaesthesia

If you have a tooth difficult to anaesthetise. If you expose small area of pulpal tissue, then inject directly into the pulpal tissue. The main problem is exposing the small area of pulp tissue whilst the patient not fully numb, if patient can tolerate you drilling into the tooth until you get pulp exposure.

What is Intra-Osseous Anaesthesia

Intends delivering anaesthetic around medullary bone around root apices of the tooth in question. Drill through gingivae and bony cortex then place a lumen/catheter through hole and inject directly through and into this. Very easy to drill through and damage root structure, place in between adjacent roots. deliver distal to the tooth in question.

What instructions are given to patients with Irreversible Pulpitis

1) Pain will gradually decrease

2) Take Analgesics

3) Emphasise the need to complete treatment

4) Return if the symptoms become more severe

List Signs & Symptoms of Symptomatic (acute) Apical Periodontitis (7)

1) Tender to Percussion

2) Tender to Palpation especially over the Apices

3) Swelling and Redenning of the Mucosa

4) No Responses to Vitality Testing

5) Pain in Function or Pressure

6) Pain which is Constant and Worsening

7) Pain which is present for several hours

How is Symptomatic Apical Periodontitis treated if Time Permits

RCT Full Procedure if Time Permits

How is Symptomatic Apical Periodontitis treated if Time does not permit

Prepare the Canal, Dry it and place an antibacterial dressing i.e. CaOH and then place a bacteria tight seal.

Complete RCT in next few days

What are the Signs & Symptoms of Acute Apical Abscess

1) Swelling

2) Severe Pain especially on Pressure

3) Feeling of the tooth being elevated in the socket

4) Mobility

5) Systemic Involvement i.e. Fever, Malaise, Lymphadenopathy

What is the Treatment for Acute Apical Abscess

1) Attempt Drainage through the Tooth

- LA (Regional)

- Access Cavity

- Drain the Pus

If no pus occurs immediately, then explore the canal with a small file to encourage pus drainage.

Copious Irrigation

Dry the Canal and Place CaOH into Canal. Followed by Bacteria Tight Seal.

What is Open Drainage

Where you open the tooth, allow it drain and then don't put a restoration in the access cavity.

It is important to Reduce Vibration when draining an Acute Apical Abscess. Explain Why

Use A Diamond Bur to Reduce Vibration as the tooth will be Acutely Painful and Difficult to Anaesthetise

How do treat Acute Apical Abscesses when there is no/inadequate drainage through the tooth and a Fluctuant Swelling is still present

1) Spray the Swelling with Ethyl Chloride or Place Topical LA for 3 minutes

2) Incise the Swelling Vertically with a Scalpel & Aspirate the Pus. Followed by Copious Irrigation

Leave to continue to drain and heal. Complete RCT when patient is able to

When are Antibiotics Required for Acute Apical Abscesses

Only required when there is

- Signs of Spreading Infection i.e. Diffuse Swelling & Trismus

- Signs of Systemic Involvement i.e. Fever, Malaise

- Patients who are Medically Compromised

What are the instructions to the patient with an Acute Apical Abscess

Return to the Dentist or Attend A&E if

- The swelling progresses

- Difficulty opening mouth

- They start to feel unwell

- Any difficulty swallowing/breathing

Return to Dentist for completion of treatment as soon as possible following resolution of symptoms

What are the causes of Cracked Tooth Syndrome

- Masticatory Incidents

- Bruxism

- Thermal Cycling

Which teeth are commonly affected by Cracked Tooth Syndrome

Second Premolars

First Molars

What are the Symptoms of Cracked Tooth Syndrome (3)

1) Pain on Chewing

2) Sensitivity to Cold & Hot Fluids

3) Pain which is difficult to locate

Describe the pattern of the Fracture Line in Cracked Tooth Syndrome

From Mesial to Distal

How do you diagnose Cracked Tooth Syndrome

- Ask the Patient to bite on a cotton wool roll

- Pain on release of pressure is the most reliable aid and most expressive clinical finding

- Visual Detection of Crack can be done by Fibreoptic or Staining

- Radiographs are of little value.

What is the Treatment for Cracked Tooth Syndrome when there is no signs of Pulpitis

Stabilisation of the Tooth with an Adhesive Restoration or Partial/Full Coverage Crown

Consider using a copper or orthodontic band to stabilise the tooth to aid prognosis and provide immediate relief/protection

What is the treatment of Cracked Tooth Syndrome when there are signs of Irreversible Pulpitis

Endodontic Treatment followed by Full Crown

What is the treatment of Cracked Tooth Syndrome when the fracture lines extend below the alveolar crest

Extraction

What are the signs of Vertical Root Fracture

Deep but Narrow Periodontal Pockets which follow the path of root fracture.

The fracture may be clinically visible but often hidden under a restoration and the gingivae

Radiographically how may Vertical Root Fractures present

J Shape Lesion at the Apex. Difficult to Diagnose definitively on a radiograph unless the two segments separate.

To treat Mid & Post Treatment Flare-Ups it is important to Define the Source of Pain.

List Possible Sources

1) Recent Restorative Treatment

2) Recent Endodontic Treatment

- Mid Treatment

- Post Treatment

Describe How Recent Restorative Treatment can cause Flare Ups

Risk of Symptoms is dependent on the depth and amount of tooth structure removed and the condition of the pulp.

Assess the Restoration for Leakage, Occlusion and Exposed Dentine. Consider Monitoring and recommending analgesics, adjusting the occlusion and placing a sedative dressing.

Endodontic Flare-Ups can occur Mid-Treatment or Post-Treatment.

List potential causes

Usually due to Bacterial Contamination/Change in the Bacterial Flora.

- Poor Rubber Dam Technique

- Unsatisfactory Temporary Restoration, Poor Coronal Seal

- Inappropriate intra-canal medication

- Incomplete Chemo-Mechanical Preparation, Bacteria left inside the canal

- Missed Canals

- Forcing Debris through Apex

- Overfill of Root Filling Material

What are the Signs & Symptoms of Mid & Post Endodontic Treatment Flare Ups

Similar to Acute Apical Periodontitis

- Tender to Percussion

- Tender to Palpation

- Swelling and Redenning of the Mucosa

- Pain in Function or Pressure

- Can be Constant & Worsening Pain

- Pain present for Several Hours

What is a Phoenix Abscess

When a Non-Vital Tooth Flares Up when it has previously been asymptomatic

What is the cause of Phoenix Abscess

Alteration in the Internal Environment of the Root Canal Space during Instrumentation

Bacterial Flora is Altered and Causes Symptoms

How do you manage Mid-Treatment Flare-Ups

Assess the Need to Re-open the Root Canal

- Will the patient be able to tolerate treatment

- Is there clinical time available

If The Canal is Not Re-opening, provide advice regarding analgesics

If the Canal is Re-opened, follow conventional procedure. Try to ascertain the reason for the flare-up and leave the tooth with a well condensed CaOH in situ

What advice do you give patients who have Mid-Treatment Flare Ups

Return if Symptoms Worsen

Symptoms are unlikely to affect the outcome of the Endodontic Treatment

Take Analgesics. Antibiotics are not indicated.

What is the cause of Post-Endodontic Treatment Flare Ups

Often due to Bacterial Contamination at the Apex or Overfill of the Material.

Post-Endodontic Treatment Flare Ups become difficult to manage. Explain Why

The Root Filling is in Situ and often the Definitive Restoration.

How do you manage Post-Treatment Flare Ups

Usually best to monitor symptoms and reassure the patient that they will resolve with time.

Take Analgesics. No Need for Antibiotics unless Systemic Invovlement.

What is a Complicated Crown Fracture

A crown fracture involving the Pulp

How do you diagnose a Complicated Crown Fracture

Clinical Presentation, Pulp is Exposed

How do you treat Trauma involving the Pulp in young patients with Open apices

Preserve Pulp Vitality by Pulp Capping or Partial Pulpotomy in order to secure further Root Development

How do you treat Trauma involving the Pulp in patients with closed apices

Preserve Pulp Vitality by Pulp Capping or Partial Pulpotomy

When should Pulp Capping be indicated after Trauma to the Pulp

Pulp Capping should be attempted if the injury is recent due to the risk of contamination.

Calcium Hydroxide Compounds or MTA are suitable

What is the Treatment of Trauma involving the pulp in Older Patients with Closed Apices and an Associated Luxation Injury

Endodontic Treatment

What is the Treatment of Trauma Involving the Pulp when the Injury presents to you old and there are signs of Pulpal Necrosis

Endodontic Treatment

List the Procedure for Pulp Capping (7)

1) LA

2) Rubber Dam

3) Clean with Water, Saline or Chlorhexidine

4) Disinfect with NaOCl and Dry

5) Apply Pulp Capping Material over exposed Pulp

- MTA, Biodentine, CaOH

6) Seal Exposed Dentine with GIC or Composite

7) Restore Remaining Tooth with Composite

List the Procedure for Partial Pulpotomy

1) Local anaesthetic

2) Isolate with rubber dam

3) Clean with water, saline or chlorhexidine

4) Perform pulpotomy to a depth of 2mm with a clean, round

diamond bur under water spray

5) Place a saline moistened cotton pellet over the pulp until

bleeding has stopped

6) Apply pulp capping material (either MTA, biodentine or

calcium hydroxide) over exposed pulp tissue

7) Seal exposed dentine with GIC or composite

8) Restore remaining tooth with composite

Why is a Partial Pulpotomy preferred over a Pulp Cap

Slightly better Long Term Outcomes

Partial pulpotomy removes superficial part of the pulp tissue and removes contamination. Cap material underneath then better chance of healing

After how long should Trauma Involving the Pulp be Followed Up

- Clinical and Radiographic Follow-up at 6-8 weeks and then 1 year

Describe the Prognosis of Trauma involving the Pulp

Depends on Extent of Injury, Time of Intervention and Stage of Root Development

Iatrogenic Damage involving the Pulp can be divided into 2 Categories. (2)

1) Non Carious Exposure

2) Carious Exposure

The Difference between the two will affect the Pulp Vitality.

Describe How Non-Carious Iatrogenic Damage involving the Pulp occurs

Over-Enthusiastic Cavity/Tooth Preparation

Non Carious Iatrogenic Damage has the better prognosis but still should be avoided.

How do you manage Non-Carious Iatrogenic Damage involving the Pulp

Pulp Capping.

How do you manage Carious Iatrogenic Damage involving the Pulp

If the exposure still has soft caries over it or the patient has symptoms of pulpitis then you should undertake Endodontic Treatment.

If possible leave affected dentine over the pulp and place a bacteria right restoration to prevent pulp exposure.

If pulp exposure occurs but all infected dentine has been removed, the patient has no symptoms, attempt a pulp cap or partial pulpotomy.

Why is Partial Pulpotomy preferred over Pulp Capping

Partial pulpotomy is preferred in this situation as it

removes the superficially and potentially infected layer

of the pulp

Surrounding dentine is also removed to create a well

defined space for the pulp capping material to be placed

It is essential to stop the bleeding from the pulp before placing the pulp capping material.

What do you do if bleeding cannot be stopped

Proceed to Endodontic Treatment

Describe differences in using MTA and CaOH for Pulp Capping (3)

1) MTA has a higher success rate

2) MTA results in less pulpal inflammatory response

3) MTA results are more predictable in terms of hard dentine bridge formation

How can Infection in the PDL affect the Pulp

Pathogenic Bacteria and Inflammatory Products of Periodontal Disease can enter Accessory Canals/Lateral Canals and the Apical Foramen.

This may cause Pulpal Infection/Necrosis

How can Pulpal Infection affect the PDL

Pulpal Disease, Perforations, Errors in RCT or Vertical Root Fractures can stimulate bacteria from the Pulp to spread via the apex or lateral canals to the PDL causing Clinical Attachment Loss and Bone Loss +/- Pus Discharge

How can Endo-Perio Lesions be Classified according to the Simon Classification

1) Primary Endodontic Lesion, Secondary Periodontal Lesion

2) Primary Periodontal Lesion, Secondary Endodontic Lesion

3) True, Combined Perio-Endo Lesion

What is a True Perio-Endo Lesion

A true combined lesion is where you have a separate periodontal lesion and a separate endodontic lesion which can coalesce

What is a Primary Endo Secondary Perio Lesion

Originally an Endo Lesion, the infection spreads from the Apex and along the root to the gingiva.

Pulpal infection can also spread from accessory canals to the gingiva or furcation

What is a Primary Perio Secondary Endo Lesion

A periodontal pocket which can deepen to the apex and secondarily involve the pulp.

Alternatively a Periodontal Pocket can infect the pulp through a Lateral Canal

In Reality it can be difficult to determine which the original source of the infection was i.e. Was it from Periodontal Tissues or Was it from Periapical Tissues or Both.

Therefore Other Classifications other than Simon's have been Suggested.

Give an Example

Abbot & Castro Salgado 2009

- Concurrent Endodontic & Periodontal Disease without Communication

- Concurrent Endodontic & Periodontic Disease with Communication

Radiographically, how can you determine if the Periodontal and Endodontic Lesions communicate

If the Radiograph shows Periapical Pathology and a Deep Pocket, with no bone in between the lesion then assume there is communication between the two lesions

What do Non-Communicating Lesions suggest

True Combined Lesions with Independent Aetiologies

Describe when Communicating Lesions can be True Combined Lesions

Communicating Lesions may be true lesions which have merged or lesions which have started primarily as Endo or Perio then spread.

Knowing the original source of the infection can have an implication for the management and prognosis of the case.

How can we Diagnose Perio-Endo Lesions

1) Take a Thorough History

2) Endodontic Examination

3) Periodontal Examination

4) Special Tests

- Sensibility

- Radiographs

- Others

List Common Symptoms of Perio-Endo Lesions

1) Swelling of Gingiva

2) Pus Discharge

3) Pocket Formation

4) Fistula Tract

5) Tender to Percussion

6) Mobility

Perio Endo Lesions can result in the Loss of Periapical Bone or Periodontal Bone, therefore the tooth becomes Mobile.

What factors need to be assessed before beginning treating the Perio Endo Lesion

Need to assess if the tooth is going to be Restorable if the tooth is Mobile

What is Assessed in an Endodontic Examination (4)

1) Restorative Status

2) TTP

3) Tenderness in Sulcus

4) Swelling/Sinus

What is assessed in a Periodontal Examination (4)

1) 6PPC including Bleeding Index

2) Pus Discharge from Pocket

3) Mobility

4) Furcation

How do we commonly test if the Tooth is Vital (2)

Cold Testing (Ethyl Chloride)

EPT

Teeth with Perio-Endo Lesions tend to be negative to both tests.

What is the most appropriate modality to assess Perio-Endo Lesions

Periapical Radiographs

What 3 Signs on Radiographs indicate Perio-Endo Lesions

1) A Vertical Periodontal Defect

2) A Radiolucency around the Apex

3) A J-Shaped Lesion

A J-Shape Lesion on a Radiograph can indicate

1) Perio-Endo Lesion

OR

2) Vertical Root Fracture

When would an OPT be requested in Diagnosing Perio-Endo Lesions

Only indicated if Multiple Sites needed to be radiographed, likely for a Periodontal Assessment..

However Further Intra-oral Radiographs would likely be needed in addition

When is a CBCT Scan indicated to Diagnose Perio Endo Lesions

When conventional radiography does provide sufficient detail

Complex 3-D Anatomy or Suspicion of other causes such as resorption or perforation

How do you Rule out the Possibility of Vertical Root Fracture

Tooth Slooth, Transillumination

Management of Perio Endo Lesions depends on the Initial Diagnosis.

How do you manage Primary Endo Secondary Perio Lesions

RCT

Management of Perio Endo Lesions depends on the Initial Diagnosis.

How do you manage Primary Perio Secondary Endo Lesions

RCT & Periodontal Therapy

Management of Perio Endo Lesions depends on the Initial Diagnosis.

How do you manage True Combined Lesions

RCT and Periodontal Therapy

Explain the Rationale for Management of Primary Endo Secondary Perio Lesions

These have an Endodontic Aetiology.

Endodontic Infection is draining via the PDL in this instance causing the Periodontal Lesion to present as a Narrow Defect.

The Endodontic Treatment Alone will eradicate the source of infection

When do you Review Primary Endo Secondary Perio Lesions

Review after 3 months and instigate Non Surgical Periodontal Therapy if pocketing is still present.

Review after another 3 months, if there is no resolution of Perio Lesion then consider Surgical Intervention

Explain the Rationale for Management of Primary Perio Secondary Endo Lesions

These Lesions have a Periodontal Aetiology, but the tooth has become Non-Vital so also Requires RCT.

This means Endodontic and Periodontal Therapy are both required. It is best to undertake these Simultaneously.

Why is it best to Undertake Periodontal & Endodontic Therapy simultaneously

There are Separate sources of bacteria in the Perio Pocket and in the Endo Lesion, therefore you do not want to treat one and leave the other as this is a potential for the other bacteria to contaminate the treated lesion

When do you review Primary Perio Secondary Endo Lesions

Review after 3 Months and instigate further Non Surgical Periodontal Therapy if Pocketing is Still Present.

Review after another 3 months, if pocketing is still present then consider Surgical Intervention.

Explain the Rationale for Management of True Combined Lesions

These Lesions have Endodontic and Periodontal Aetiologies

They May or May Not Communicate, yet require both Endodontic & Periodontal Therapy.

It is best to undertake these simultaneously