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December, 11th 2013

Now you are 4th year students, you are more clinically oriented and you have already started to work on patients, and you have to know how to treat emergencies.

What is an Emergency? Severe Pain and/or swelling associated with pulpal and/or periradicular pathosis that requires immediate treatment. So it is specific cases that we call them emergency cases. In which we cannot let the patient to wait or call him later. True emergency, when? Disrupts patients activities, the patient cannot sleep, cannot work Not relieved by mild analgesics. A true emergency has rarely been severe for more than a few hours to 2 days. So the patient will come to the clinic very dispirit, looking for help. A true emergency is a condition requiring an unscheduled office visit with diagnosis and treatment. The visit cannot be rescheduled because of the severity of the problem.

Why is it an Emergency? - Pain: Disrupts quality of life - Infection: because some patients are medically compromised, whose infection is severe and needs intervention. - Swelling: in facsial spaces that could affect breathing and needs intervention.

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In Endodontics, Pain is caused by: 1- Inflammatory mediators or irritants released by body defense cells. 2- Pressure caused by edema and fluid accumulation. Because as you know the pulp space is restricted, not like other parts of your body, in which if the tissues get inflamed it will swell, and induce pressure over the nerves which will cause pain. Reassure
Be confident and gain patients confidence Show sympathy and attention

Explain possible causes and expected outcomes

Classification of pain based on the time of onset Can happen: Before treatment (Pre-operative) During treatment (Inter-appointment) After treatment (Post-obturation) Clinically this classification is not really very important, because we are going to deal with the cause of the pain, not time of onset. :/

*Important* How to manage?

1- Reassure, when the patient comes to your clinic, and he couldnt sleep the
previous night, and he in pain and look distressful and angry. Firstly you have to reassure him. Explain to him that everything is fine. Explain what the problem is. And most importantly is to be confident in front of your patient and show your care. Otherwise your patient will be more anxious. And as long as he is anxious, he will feel a lot of pain.
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2- Diagnose, after you reassured your patient, you should decide what sort of
treatment you should give. Thats why you need to diagnose, it is similar to the examination you did in your clinic but it should be faster, A. pain history: so you have to ask the patient about his pain, where does he feel the pain? When does it start? For how long does it stay? What stimulate the pain? What reduces the pain? Does it disturb the sleep? How sever is it? B. Check the medical and dental histories C. Start your examination 1. Extra oral: Extent of swelling or tenderness 2. Intraoral: in a systematic way > Observation, look for any reason that may cause the pain in the area like deep cavity, fractured tooth, swelling, signs of draining tooth. > Palpation > Digital pressure or light percussion. Gently by your finger or by the blunt end of the mirror. > Pulp sensitivity test, it is not a must, because if your patient said that he has severe pain on cold, it will be for no reason to do the cold test, that may stimulate sever pain which you cannot control. > Radiographs, it is actually used to confirm your diagnosis or to give you further information leads to better diagnosis. It is also used during the Root canal treatment to estimate the working length. > Periodontal probing (exclude periodontal problems). Periodontal examination is always necessary. Probing helps in differentiating endodontic from periodontal disease.
For example, a periodontal abscess can stimulate an acute apical abscess. However with a localized periodontal abscess, the pulp is usually vital. In contrast, an acute apical abscess is related to an unresponsive (necrotic) pulp. Pulp testing is useful to differentiate between them.
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3- Treatment,
Put a plan and explain it to the patient. patient. For example you told the patient that his tooth needs extraction and he refused, and he asked you to do RCT, you have to discuss with him his case, if the tooth is restorable or not, and at the end of discussion, the patient himself will be the responsible about his choice choice. Remove the source of irritation (RCT or extraction) Reduce pressure: if there is edema or swelling you have to consider drainage. Drainage can be done through incision or through the root canal.

4- Postoperative instructions 5- Follow up

Recall; How to manage? 1- Reassure

2- Diagnose 3- Treatment 4- Postoperative instructions 5- Follow up

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Your treatment will be based mainly on four diagnoses abcdIrreversible pulpitis Necrotic pulp with apical pathosis (no swelling) Necrotic pulp with localised swelling Necrotic pulp with diffuse swelling

a. Irreversible pulpitis
Here you have vital, inflamed pulp, not necrotic. The patient will complain of severe pain Aim: To relief intrapulpal pressure and remove inflamed tissues. Management> 1. Profound anaesthesia: this is the first step to start relieving the pain. Supplementary injections (intraligamentary, intrapulpal,or intraosseous) may be needed. Profound means you give proper, correct anaesthesia. You might need 2-3 carpules. 2. Pulp extirpation: you go through the whole process > proper access and preparation, it does not have to be an ideal one, but it should have enough access to insert your files and extirpate the inflamed pulp. Also you need good irrigation with sodium hypochlorite; because it dissolves organic tissues which are the inflamed pulp and any mediators inside the canal will be flushed. > so proper irrigation with sodium hypochlorite, that is why we should consider placing rubber dam for the emergency Working length in this stage is important but not critical, because usually the tissues in the apical area are not involved. usually the inflamed tissues are close to the caries that why if you left some tissues in the apical area is not a serious problem, so you can take a radiograph and estimate the working length but it is not so critical.
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3. You might consider occlusal reduction, so after you did the extirpation and irrigation you put a temporary filling, and you might reduce the occlusion and make the tooth out of occlusion. Like in a scenario of pain on biting then you might consider relieving the occlusion (apical periodontitis). 4. Postoperative instruction. 5. Analgesics

b. Necrotic pulp with apical pathosis (no swelling):

Necrosis involving the apical tissues Aim: To relief apical fluid pressure and reduce pulp irritants 1. Profound anaestheisa 2. Encourage drainage: file # 10 beyond the apex. After you obtain your access you will start induce the fluids in the apical area you will insert a small file less than #20 and insert it beyond the apex. Either from the canal or through the vestibule. (Through the vestibule, you make an incision using scalpel and blade #11). Actually it is better to open both. But usually we use file #10 3. Complete or partial debridement (working length, copious irrigation). 4. Intracanal antimicrobial medicament ( Ca(OH)2 ) that will complement the effect of sodium hypochlorite. 5. Occlusal reduction (apical periodontitis) 6. Postoperative instructions 7. Analgesics What happens if you have swelling? If the swelling is localized mostly it is abscess, and if we have local abscess it is better to drain it. Because the pressure caused by the abscess is part of the pain. So to relief pain you need to drain the abscess. So again the aim is to relief apical fluid pressure and reduces pulp irritants.
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c. Necrotic pulp with localised swelling:

Aim: To relief apical pressure, reduce pulp irritants and drain the abscess. 1234567Profound anaestheisa Abscess Drainage: Incision, or file # 10 beyond the apex Complete or partial debridement (working length, copious irrigation). Intracanal antimicrobial medicament ( Ca(OH)2 ) occlusal reduction (apical periodontitis) Postoperative instructions Analgesics


Necrotic pulp with diffuse swelling:

It depends on the seriousness of the patient stage, he might have a severe swelling that endangers the airways, and sometimes you might consider referring the patient to hospital. So there are guidelines for referring patients to oral surgery, like in case of diffuse swelling that endanger the airways, but if the swelling is localized you may consider the same steps (pulp extirpation and drainage). But the swelling is not always abscess; it may be edema or cellulitis. So if you attempted to do incision, you might get no drainage, it is just fluids that are going out through the incision. But at least you tried. Most importantly you will remove the cause of the infection, or the swelling, you may need debridement or if the is severely carious, or is not essential you may consider extraction. Aim: To relief apical pressure, reduce pulpal irritants drain abscess. 12345Profound anaestheisa. drainage: Incision, or file # 10 beyond the apex Complete or partial debridement (working length, copious irrigation). Intracanal antimicrobial medicament ( Ca(OH)2 ) occlusal reduction (apical periodontitis)

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6- Postoperative instructions 7- Analgesicsal Antibiotics, refererral Among the previous cases you prescribe antibiotics only if you have diffuse swelling.

e. Flare ups
Same as intra appointment emergency, so you start through root canal treatment, then the patient came back to you telling you that he has the treatment yesterday. And he came with exuberant. Usually we have similar cases with necrotic pulps because you didnt do enough debridement, or you missed a canal. So the management is the same, but the whole difference for flare ups, is that the patient here is your patient, so you know what happened before and you know the prognosis, so the treatment here will be easier for you, You opened the tooth, you did debridement. So now you will say I might missed a canal, or I didnt made enough irrigation especially when you did not spend much time on that case. So the first thing you should think about is reassurance, because the patient now thinks that you are the cause of his current state. Because he came to you to do RCT and he was having neither pain nor swelling but after your treatment the patient had these complications, and now your patient will be ready to fight, so you have to explain to your patient why did this happen to him. Thats why it is really important to tell the patient before the treatment that there is a possibility that a swelling or infection could happen, so the patient should be informed what is expected after treatment. And in this case he wont be as angry as if he wasnt informed that this could happen.

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Flare ups is a true emergency and is so severe that an unscheduled patient visit and treatment are required. Despite judicious and careful treatment procedures, complications, such as pain, swelling, or both, may occur. Regional temporary paesthesia has even been reported. As with emergencies occurring before root canal therapy, these interappointment emergencies are undesirable and disruptive events and should be resolved quickly. Occasionally, flare-ups are unexpected, although they can often be better predicted according to certain patient presenting factors. 1- Reassurance: the most important aspect of treatment. - Explain why it happened - It is not unusual or unexpected to happen, 2- Profound anaesthesia. For extended anaesthesia and analgesia, administration of
bupivacaine hydrochloride is recommended

3- the treatment depends on the previous diagnosis

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Interappointment emergency Flare up

Previously vital pulp with complete debridement 1Reassurance 2- Mild to moderate analgesics Previously vital pulp with incomplete debridement
1-Reassurance 2- Open the canal and recheck working length 3- Careful cleaning and copious irrigation 4- Mild to moderate analgesics

Previously necrotic pulp with no swelling

1- Reassurance 2- Open the canal with gentle cleaning and copious irrigation 3- Establish drainage from apex (30 min) 4- Calcium hydroxide dressing 5- Analgesics

Previously naecrotic pulp with swelling

1- Reassurance 2- Open the canal with gentle cleaning and copious irrigation 3- Establish external drainage 4- Calcium hydroxide dressing 5- Analgesics +/- Antibiotics

> no need to reopen the canal > usully it is because of irritation of the periradicular tisses

sodium hypochlorite wont only flush th the tissues but it also dissolves the organic tissues, and remove all the inflammatory mediatores. so by that it cleans the canal and it reduces the pain. you might consider placing intracanal medicament. among them ledermix, it is a steroidbased medicament not like calcium hydroxide, the steroid has an antiinflammatory effect,but it is not usual even it is not needed . because there is no infection. so no need to apply it. but sometimes you consider placing calcium hydroxide because you did the RCT on muliple visits we dont leave the canal open, so we usually put calcium hydroxide.

you need to recheck the working length. you may need the apex locator for that.

if there are systematic symptoms like fever, swelling, medically compromised patients, you should consider antibiotics

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After you finish your treatment, you should give the instructions, Postoperative Instructions 1- Explain what the patient should expect; Recurrence of pain. Explain to the patient that we did the proper management but there is a possibility to have the same condition again. And if it happened, you should come back. 2- Adequate nutrition and hydration 3- Rest 4- Medicaments, mean analgesics, and if antibiotic is needed.

Analgesics: Ibuprofen, the most useful drug used, it is a non steroidal anti-inflammatory drug, it has analgesic effect, and it is mechanism of action is that it reduces the inflammatory mediators that cause pain. It is a better option than paracetamol or acetaminophen which is just analgesics, and has no anti inflammatory effect. Start with> Ibuprofen 200- 400 mg every 6 hours Ibuprofen 600-

If that wasnt enough, ask the patient to increase the dose> 800 mg every 6 hours

If the patient still in pain then prescribe > Ibuprofen 600 mg + Acetaminophen 1000 mg alternatively So tell him to take ibuprofen > after 4 hours ask him to take> acetaminophen >after 4 hours ask him to take ibuprofen and so on.

Thank you

Done by Sawsan Jwaied,

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