Management Of Endodontic Emergencies

MANAGEMENT OF PAINFUL IRREVERSIBLE PULPITIS

Because the pain is the result of inflammation, primarily in the coronal pulp, removal of the inflamed tissue will usually reduce the pain.

Without Acute Apical Periodontitis

Complete cleaning and shaping of the root canals is the preferred treatment if time permits.

With limited time, most pulpal tissue is extirpated with a broach (partial pulpectomy) in single-rooted teeth.In molars, a partial pulpectomy is performed on the largest canals (palatal or distal root). Pulpotomy is usually effective in molars when minimal time is available.

An old but still popular idea is that chemical medicaments sealed in chambers help control or prevent additional pain; this is not true. A dry cotton pellet alone is as effective in relieving pain as a pellet moistened with camphorated mono-chlorophenol (CMCP), formocresol, Cresatin,eugenol, or saline. Therefore, after irrigation of the chamber or canals with sodium hypochlorite a dry cotton pellet is placed  and the access is sealed temporarily. A mild analgesic may be prescribed for patients with irreversible pulpitis. Antibiotics, however, are definitely not indicated.

With Acute Apical Periodontitis

In patients with extreme tenderness on percussion, a partial or total pulpectomy (as described above) is appropriate. Reducing the occlusion to eliminate contact has been shown to aid in relief of symptoms.  Trephination (artificial fistulation) by creating an opening through mucosa and bone is not useful and is contraindicated

MANAGEMENT OF PULP NECROSIS WITH APICAL PATHOSIS

The pain is related to periradicular inflammation,which results from potent irritants in the necrotic tissue in the pulp space.

Treatment now is biphasic: (1) remove or reduce the pulp irritants and (2)relieve the apical fluid pressure.

The diagnosis may be acute apical periodontitis (no significant periradicular resorption) or acute apical abscess with or without swelling.

Therefore, with pain and pulp necrosis there may be (1) no swelling, (2) localized swelling, or (3) diffuse, more extensive swelling. Each is managed differently. Of these three conditions, diffuse swelling is the least common.

Pulp Necrosis Without Swelling

These teeth may contain vital inflamed tissues in the apical canal and have inflamed painful peri-radicular tissues (acute apical periodontitis).

Profound local anesthesia may be a problem, requiring a supplemental injection.

Alternatively, the lesion may have expanded and formed an abscess that is confined to bone.These are often painful, primarily because of fluid pressure in a noncompliant environment.

The aim is to reduce the canal irritants and to try to encourage some drainage through the tooth.

Complete canal debridement, after determining the corrected working length, is the treatment of choice. If time is limited, partial debridement at the estimated working length is performed with light instrumentation with a passive step-back or crown-down technique to remove irritating debris.

Canals are not enlarged without knowledge of the working length. During cleaning, canals are flooded and flushed with copious amounts of sodium hypochlorite. Finally, canals are irrigated with the same solution, dried with paper points, filled with calcium hydroxide paste (if the preparation is large enough), and sealed with a dry cotton pellet and a temporary filling.

Some clinicians empirically place a cotton pellet lightly dampened with intracanal chemical medication in the pulp chamber before placing a temporary filling. There is no value to these medicaments.

Administering a long-acting anesthetic, reassuring the patient, removing (or reducing) the irritant, and prescribing an analgesic will usually reduce postoperative pain significantly. Antibiotics are not indicated.

The patient is told that there will still be some pain (the inflamed, sensitive tissues are still present), but should subside during the next 2 or 3 days, as the inflammation decreases.

Pulp Necrosis with Localized Swelling

The abscess has now invaded regional soft tissues and at times, there is purulence in the canal. Radiographic findings range from no periapical change (rarely) to a large radiolucency.

Again, treatment is biphasic. First and most important is debridement (complete cleaning and shaping if  time permits) of the canal or canals,and second in urgency is drainage

Localized swelling (whether fluctuant or nonfluctuant) should be incised.Drainage accomplishes two things: (1) relief of pressure and pain and (2) removal of a very potent irritant-purulence.

In teeth that drain readily after opening, instrumentation should be confined to the root canal system.

In patients with a periradicular abscess but no drainage through the canal,penetration of the apical foramen with small files (up to 25) may initiate drainage and release of pressure. This release often does not occur because the abscess cavity does not communicate directly with the apical foramen.

Occasionally there may be more than one abscess.One communicates with the apex while another, separate abscess is found in the vestibule. Because they do not communicate, drainage must occur through both the tooth and a mucosal incision.

Often, a drain is placed to permit continued drainage for 1 or 2 days or until debridement is complete. Several designs of drain are used.Copious irrigation with sodium hypochlorite is performed throughout. The canals are then dried with paper points and filled with calcium hydroxide paste. After placement of a dry cotton pellet, the access is sealed temporarily.

These teeth should not be left open to drain, although leaving teeth open has been a common procedure. A canal exposed to the oral cavity is a potential home for introduced bacteria, food debris, and even viruses.

Occasionally, purulence will continue to fill the canal during the preparation (the so-called "weeping" canal). If this occurs, the patient should sit for a time. Usually, the flow will cease and the access may be closed.

These patients seldom have elevated temperatures or other systemic signs. Therefore, in acute apical abscess with localized swelling, the use of systemic antibiotics is not necessary, having been shown to be of no benefit.

Pulp Necrosis with Diffuse Swelling

These rapidly progressive and spreading swellings are not localized and may have dissected into the fascial spaces. These patients usually should be referred to a specialist.

Most important is removal of the irritant by canal debridement (cleaning and shaping is completed, if possible) or by extraction. 

The apical foramen may then be gently penetrated with a file to hopefully permit a flow of exudate, although drainage often does not occur.

Also at this time, swelling may be incised and a rubber drain inserted for 1 or 2 days. Occasionally the abscess localizes extraorally and subcutaneously, requiring extraoral incision for drainage.

Speed of recovery (whether the swelling is localized or diffuse) depends primarily on canal debridement and drainage. Because edema (fluid) has spread through the tissues, diffuse swelling decreases slowly, over a period of perhaps 3 to 4 days.

As with patients undergoing removal of impacted third molars, pretreatment with nonsteroidal antiinflammatory drugs may reduce the frequency and amount of postoperative discomfort.

After placing calcium hydroxide paste and a dry pellet, the access is closed with a temporary filling.

Systemic antibiotics are indicated for the diffuse, rapidly spreading swelling. The preferred and first (albeit empirical) choice is penicillin; the causative microorganisms are likely to be streptococci. An alternative for penicillin-allergic patients is clindamycin.

Systemic steroids, advocated by some, are probably of no benefit.

Analgesics for moderate to severe pain should be prescribed.