Hot tooth

This is a short presentation elaborating on Hot tooth and its management. It is a type of pre-treatment endodontic emergency. Most common failure for anaesthesia. Supplementary anaesthetic techniques are also briefed .

1. HOT TOOTH PRESENTED BY ABIRAMI VETRISELVAN

2. The term "hot" tooth generally refers to a pulp that has been diagnosed with irreversible pulpitis, with spontaneous, moderate-to-severe pain. Clinically, Hot tooth is a term given to a tooth that is difficult to anaesthetize. What is iT?

3. Common sites Sites of recent or defective restorations. Sites of recent trauma. Mandibular molars are more challenging to anesthetize. Patients with anxiety about dental treatment or patients who have been in pain for several days usually require a more sophisticated approach. Where ??

4. Hypotheses for failure of LA !

5. Tetrodoxin resistant channels ( TTXr ), a class of sodium channels resist the action of local anesthesia. They are sensitized by prostaglandins and are increased in inflammed dental pulp thereby stimulating C- fibres for pain conduction. They are 4 to 5 times resistant to blockade by lidocaine . 1.Tetrodoxin resistant channels

6. Nerves from inflamed tissue shows decreased excitability threshold and altered resting potential. Studies show that lowered excitability thresholds are responsible for transmission of impulses even with action of local anesthetic. 2.Altered Membrane excitability

7. 3 . Ion trapping According to this hyphothesis , low tissue pH is responsible for local anesthetic to being trapped in the charged acid form of the molecule and thus decreasing its membrane permeability. DRAWBACK : I on trapping is for infiltration injections only, block injections are likely to involve acidotic tissues.

8. Patient anxiety is one of the factor for local anesthetic failure. It is understood that apprehensive patients have a reduced pain threshold and more likely to complain pain during the time of endodontic treatment. 4. Psychological factors

9. Earlier presentation: often intense, lingering pain in response to cold. Later presentation: intense pain in response to heat; relieved by cold water . Pain may be spontaneous or on biting often radiating from ear to temple for maxillary teeth. Increased sensitivity to temperature extremes. Symptoms

10. Deep restorations or caries Tenderness on percussion Coronal fracture lines Thickening of the periodontal ligament Failure of LA Signs

11. Management

12. Most of traditional injections might not work every time, so the clinician should go for alternative supplemental injection for managing pain. Intraligamentary (Periodontal ligament) Injection Intraosseous Injection Intraseptal anesthesia Intrapulpal Anesthesia I . Supplemental injections

13. Periodontal ligament (PDL) injection has been reported showing 50-96 % of cases with successful anesthesia for endodontic procedures . But , most of the times, a re-injection is advisable for good result . The duration of pulpal anesthesia to be around 15 min for single rooted teeth and rather less for lower molar Intraligamentary Injection

14. In about 5-10% of mandibular posterior teeth with irreversible pulpitis, supplement injections even when repeated do not produce profound anesthesia. When Pain persists when pulp is entered. This is an indication for an intrapulpal injection. Intrapulpal Anaesthesia

15. Intra-osseous Intra-osseous Injections The onset of intra-osseous anesthesia is rapid. The onset of anesthesia ranged from 10 s to 120 sand lasts an hour. The LA is injected deep into the cancellous bone adjacent to the tooth.

16. Other common injections

17. Anesthetic efficiency of 4% articaine with 1:100,000 epinephrine shows higher anesthetic efficiency than using 2% lidocaine with 1:100,000 epinephrine when used as buccal infiltration. Bupivacaine is a better alternative in case of TTX-r conditions. II. Change in anesthetic solution

18. Use of NSAID as an adjunct 1 hour before the procedure inhibits the action of prostaglandins that are the key factor for pain transmission. III. NSAID

19. Anti-anxiety agents like diazepam or lorazepam can be given to the patient the previous day of procedure or 2 hrs before to calm the patient . IV.Anxiolytics