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Endodontic emergencies

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Endodontic emergencies

  1. 1. -V.NIVEDHA
  2. 2.  It is defined as a condition associated with pain/swelling which requires immediate diagnosis and treatment 3 types:  Pre-treatment  Intra appointment  Post-obturation
  3. 3.  Dentin hypersensitivity  Reversible/irreversible pulpitis  Acute apical periodontitis  Acute periapical abscess  Traumatic injury  Cracked tooth syndrome
  4. 4.  Mid treatment flare ups  Exposure of pulp  Fracture of tooth  Recently placed restoration  Periodontal treatment
  5. 5.  Over-instrumentation  Over extended filling  Underfilling  Fracture of root  High restoration
  6. 6. ANAESTHESIA • The pain management is the most critical factor which affects the prognosis of the treatment. • To obtain an adequate anaesthesia of inflamed tissues is the challenge. Maxillary anaesthesia is easier to obtain by giving infiltration or block injections in the buccal or palatal region. • For adequate pulpal anaesthesia in the mandible, inferior alveolar, lingual and long buccal injections are preferred. • If anaesthesia is required in the lower premolars, canine and incisor, then other alternative techniques such as mental nerve block, periodontal ligament injection, intraosseous anaesthesia and intrapulpal injection are given
  7. 7. DENTIN HYPERSENSITIVITY  It is defined as sharp, short pain arising from exposed dentin in response to stimuli typically thermal, chemical, tactile or osmotic and which can’t be ascribed to any other form of dental defect or pathology. Treatment  Two main treatment options are plug the dentinal tubules preventing the fluid flow and desensitize the nerve.  Etiology The primary underlying cause for dentin hypersensitivity is exposed dentinal tubules which can occur by two processes- by loss of enamel or by loss of covering periodontal structures.
  8. 8. ACUTE REVERSIBLE PULPITIS:-[Hyperemia] • DEFINITION: It is a mild to moderate inflammatory condition of the pulp caused by noxious stimuli in which the pulp is capable of returning to the uninflamed state following removal of the stimulus • It is characterized by sharp pain lasting for a moment, more often brought on by cold than hot food or beverages. The patient can identify the tooth. Momentary pain that subsides on removal of stimulus. • Symptoms: A.R.P. is characterized by: •Sharp pain lasting for a moment. •Shooting pain lasting for short-duration. •Pain brought on by cold beverages and sweets. •Clinically – the patient can identify the tooth by pointing to it. • ETIOLOGY:- 1.Caries  Lesions which are close to pulp can cause mild to moderate sensitivity to patients. Treatment  Caries excavation and placing a sedative cement like dycal and zinc oxide eugenol (IPC). 2.Recent restoration  which has a premature contact point. Treatment  Recontouring or removal of high points.
  9. 9. • Recurrent caries -> under an old restorations. Treatment  Remove all caries and replace with a sedative cement. • Thermal shock from preparing a cavity with a dull bur or keeping the bur in contact with the tooth for a long time can cause acute reversible pulpitis which exaggerates on placing a metallic restoration over the tooth. 3.Persistent pain and severe sensitivity after cavity preparation  Suggesting chemical leakage. Treatment  Removal of restoration and placing sedative cement like ZOE. • TREATMENT:- The best Rx is prevention.  In a recently restored tooth, occlusion is adjusted.  In cases of marginal leakage or secondary caries ,the old restorations are removed and replaced with sedative cement.  Pain usually disappears with in several days ,if it persists then pulp has to be extirpated • Prognosis: The prognosis is favourable if early removal of irritant is achieved ,otherwise the condition may develop into irreversible pulpitis
  10. 10. ACUTE IRREVERSIBLE PULPITIS DEFINITION: It is a persistent inflammatory condition of the pulp, symptomatic or asymptomatic, caused by a noxious stimulus. Acute Irreversible Pulpitis exhibits pain usually caused by hot or cold stimulus Symptoms: Pain lasts for minutes to hours. •It is spontaneous. •It often continues even when the cause is removed. •Pain is present even on bending over. •Patient complains of disturbed sleep. •Pain is experienced on sudden temperature change. •On taking sweets or acidic foodstuff. •From packing of food into cavity/food impaction. Causes: •The most common cause of irreversible pulpitis is bacterial involvement of pulp through caries. •Reversible pulpitis may also deteriorate into irreversible pulpitis. In irreversible pulpitis the pulp may be Vital Non-vital
  11. 11. MANAGEMENT: • Profound anaesthesia of the affected teeth • Preparation of access cavity • Extirpation of the pulp from the chamber • Thorough irrigation and debriment • Placement of intra canal medicaments • Appropriate analgesics therapy and antibiotics
  12. 12. ACUTE APICAL PERIODONTITIS:- DEFINITION:- It is a painful inflammation of periodontium as a result of trauma, irritation or infection through root canal whether the pulp is vital or non vital. CAUSES:- caries,Occlusal trauma Wedging of foreign objects Blow to tooth Over instrumentation or over filling Symptoms: Pain & tenderness of the tooth,sometimes the tooth may be extruded. TREATMENT:- Vital tooth--------symptomatic Rct Management of Non vital tooth Profound anaesthesia of the involved tooth Preparation of the access cavity Total extirpation of pulp in pulp chamber Determination of working length Total extirpation of the pulp Bio-mechanical preparation Thorough irrigation Placement of sedative dressing folllowed by closed dressing Relieve occlusion if indicated Prescribe analgesics to reduce pain
  13. 13. ACUTE ALVEOLAR ABSCESS: Also called as: Acute periapical abscess. Phoenix abscess. DEFINITION: It is a localized collection of pus in the alveolar bone at the root apex following pulp death with extension of infection through apical foramen into periapical tissues. Causes (Non-vital pulp) •Bacterial involvement. •H/O trauma. •Mechanical or chemical irritation. The acute episode may result from: a)PULPITIS that progressively developed into pulp necrosis affecting the periapical tissues. b)ACUTE EXACERBATION of a chronic periapical lesion c)ENDO-PERIO lesion when the periodontal abscess secondarily affects the pulp through the lateral canals or deep infrabony pockets. 38 SYMPTOMS There are local reactions like: •Tenderness of tooth. •Severe throbbing pain. •Swelling. •Sinus tract. Systemic reactions are: •Elevated temperature. •Malaise. •Nausea. •Dizziness. •Lack of sleep
  14. 14. TREATMENT • The main treatment is biphasic in nature i.e. I – Debridement of canals. II – Drainage of abscess. The emergency treatment of acute alveolar abscess differs from acute irreversible pulpitis, as the pulp is necrotic, local anaesthesia is not required and frequently contraindicated. Forcing anaesthetic solution into an acutely infected and swollen area may increase pain and may spread infection. • “BLOCK MAY BE USED IN SUCH CASES” Most of the pain that occurs during access cavity preparation is caused by tooth movement resulting from vibration of the bur, therefore, one should stabilize tooth with finger pressure so that the pain is reduced. Treatment procedure follows as: •Access cavity preparation. •Profuse irrigation avoiding forcing of any solution or debris into the periapical tissue. •In most cases PURULENT EXUDATE escapes into the chamber and indicates that root canal is patent and draining. •If drainage does not occur, the apical constriction is purposefully violated and enlarged to a minimum of 20/25 no. instrument to allow for exudate to drain because in most cases the apical constriction may prevent the drainage
  15. 15. EMERGENCIES DURING TREATMENT Endodontic emergencies can occur during the course of treatment. Most emergencies are reactive phenomenon to pressure and chemical mediators created as a result of inflammatory response in periradicular tissues. According to Grossman The emergencies can be due to: •Instrumentation beyond the root apex causing trauma to periradicular tissue. •When debris and microorganisms are pushed beyond the apical foramen which can cause an infectious reaction. •Chemical irritants like - Irrigating solution. - Intracanal medicament •Incomplete debridement of all root canals. •Lost or depressed access cavity seals leading to recontamination. •Overfilled root canals with subsequent periapical inflammation. The inflammation in the peri-radicular tissue is induced as a result of release of substances such as vasoactive amines, kinins and arachadonic acid metabolites.
  16. 16. FLARE UPS: • Irritants within the pulp system. • Operator controlled or iatrogenic factors. • Host factors. • General systemic factors which are related to Flare-up. Patients can accept that pain may continue to a lesser extent when they come to the dental office for emergency treatment. What is difficult for patients to comprehend is when they enter the office having little or no pain before therapy but then encounter an explosive flare-up after the treatment is done. Therefore PREVENTION OF FLARE-UPS can be done by: • The most important preventive measure is preparing the patient to accept some discomfort which should subside in a day or two i.e. psychological preparation of patients. • Using long acting anaesthetic solution. • Complete cleaning and shaping of root canals. • Administration of appropriate analgesics, prophylactic analgesics before next appointment reduces the incidence of discomfort and flare-ups.
  17. 17. FRACTURE OF TEETH If it occurs during treatment,then one should go for extraction of the tooth RECENTLY PLACED RESTORATIONS CAN CAUSE DISCOMFORT DUE TO HGH FILLINGS,MARGINAL LEAKAGE,INADEQUATE PULP PROTECTION,GALVANISM,CHEMICAL IRRITANTS HYPOCHLORITE ACCIDENT Another very important but rare emergency is due to expelling of an irrigant such as NaOCl beyond the apex. This happens only by locking the needle of the irrigating syringe in the canal and forcefully injecting the irrigant. • Within minutes the patient feels SUDDEN EXTREME PAIN. • SWELLING within minutes. •eccymosis, Profuse, prolonged BLEEDING through the root canal. This bleeding is the body’s reaction to the irrigant. Remove the toxic fluid with high volume evacuation to encourage further drainage from periradicular tissue.
  18. 18. Treatment: ice packs •Allow the bleeding to continue. If the body rids itself of toxic fluid healing may be faster. •If the treated tooth is pulpless consider prescribing an antibiotic and an analgesic for 5 and 3 days respectively. •Since this may be hypersensitive reaction consider prescribing an antihistaminic TISSUE EMPHYSEMA Collection of gas or air in tisssue spaces When, blast of air is directed towards open root canals Treatment-antibiotics,heat application to reduce inflammation,medical attention is required if it is serious
  19. 19. VERTICAL ROOT FRACTURE May occur during bio-mechanical preparation,obturation, or during post Preparation. It results from wedging forces within the canal. It leads to Fatigue and fracture. CLINICAL FEATURES: • Commonly occurs in facio-lingual plane. • Sudden crunching sound accompanied by pain • Susceptibility increases by excessive dentin removal during canal preparation PREVENTION: • Avoid wedging forces and weakening the canal wall. TREATMENT: • Mostly extraction • In multirooted tooth,root resection or hemisection can be tried.
  20. 20. INADEQUATE CANAL PREPARATION: OVERINSTRUMENTATION: • Excessive instrumentation beyond the apical constriction violates the Periodontal ligament and the alveolar bone. • Leads to overfilling which causes pain and discomfort to the patient. • It is recognised when haemorrhage is evident in the apical portion of the canal TREATMENT: • Re-establish the working length • Filling an apical barrier which includes materials like Dentinal chips,calcium hydroxide powder, Hydroxy apatite and MTA. PREVENTION: • Use a good radiograph • Use sound reference points • Using stable instrument stops
  21. 21. OVERFILLING OF ROOT CANALS Overfilling of the root canals is filling more than 2mm beyond the apex of the root. ETIOLOGY: • Over instrumentation of the root canal • Inadequate determination of working length • Incompletely formed root apex • Inflammatory apical root resorption • Improper use of reference points SIGNIFIANCE: • Over filling may cause foreign giant cell reaction and may act as foreign body which may Support the formation of biofilms. • Over instrumentation often precedes overfilling which poses risk of forcing infected root Canal contents into the peri radicular tissues thereby impairing the healing process
  22. 22. VARIOUS ANALGESICS USED: • Aspirin • Ibuprofen • Paracetamol • Nsaids
  23. 23. THANK YOU

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