management of endodotics emergencies.pptx

this presentation describes the management of endodontics emergencies

this presentation describes the management of endodontics emergencies

this presentation describes the management of endodontics emergencies

this presentation describes the management of endodontics emergencies

this presentation describes the management of endodontics emergencies

1. Management of endodontic emergencies 1 Dr. Morouj Adil Badawi BDS, AEGD.

2. Outline 2 Introduction Definition Endodontics emergences Emergency Endodontic classification Emergency Endodontic management Facial space infections Management of Abscesses and Cellulitis Incision for Drainage Symptomatic Teeth with Previous Endodontic Treatment Systemic Antibiotics for Endodontic Infections Analgesics Flare-Ups Cracked and Fractured Teeth

3. Introduction The proper diagnosis and effective management of acute dental pain are possibly the most rewarding and satisfying aspects of providing dental care. 3

4. Definition An endodontic emergency is characterized by pain or swelling resulting from inflammation or infection in the pulpal or periradicular tissues . The common causes include caries , deep restorations , trauma , and cracks . 4 🔹 Clinical Relevance: 85% of dental emergencies are pulp or periapical in origin .

5. 5 Endodontics emergences 🔹 Current Emergency Classifications (5 Legitimate Conditions): Symptomatic irreversible pulpitis with normal apical tissues Symptomatic irreversible pulpitis with symptomatic apical periodontitis Necrotic pulp with symptomatic apical periodontitis Necrotic pulp with fluctuant intraoral swelling Necrotic pulp with diffuse facial swelling

6. 6 Endodontics emergences 🔹 Other Endodontic-Related Emergencies Traumatic dental injuries Previously treated teeth with acute apical issues Endodontic flare-ups between visits Non-odontogenic facial pain

7. 7 Emergency Endodontic Management 1. Holistic Approach to Emergency Pain Dental pain has both physical and emotional components. Building trust and rapport with the patient is critical. Diagnosis must be methodical , including chief complaint, history, and objective tests.

8. 8 Emergency Endodontic Management 2. Patient Communication & Consent Clinicians must explain: Diagnosis & treatment options (RCT vs extraction) Risks, benefits, and prognosis Treatment should never be forced ; informed decisions are shared with the patient.

9. 9 Emergency Endodontic Management ◾ Reversible Pulpitis Triggered by caries, exposed dentin, or defective restorations. Managed with conservative treatment , caries removal, and desensitizing agents.

10. 10 Emergency Endodontic Management ◾ Irreversible Pulpitis Subdivided into: Asymptomatic: No pain, but deep caries present. Symptomatic: Spontaneous, lingering pain , especially with cold stimuli. Management Options: Pulpotomy or full instrumentation depending on the case. If multi-visit: Use calcium hydroxide to control bacteria between appointments. Occlusal reduction is only advised if there is percussion sensitivity . Antibiotics are not recommended for irreversible pulpitis.

11. 11 Emergency Endodontic Management ◾ Necrotic Pulp with Symptomatic Apical Periodontitis Complete instrumentation , even if swelling is present. Avoid pushing necrotic debris beyond apex to reduce post-op pain. Crown-down technique and negative pressure irrigation (e.g., EndoVac ) are preferred. Cryotherapy (cold saline irrigation at 2.5°C) has shown to reduce post-op pain.* CBCT and apex locators improve accuracy in working length determination. * Vera J, Ochoa J, Romero M, et al: Intracanal cryotherapy reduces postoperative pain in teeth with symptomatic apical periodontitis: A randomized multicenter clinical trial, J Endod 2018;44: 4 Trephination Surgical perforation of cortical bone to relieve pressure (only used in rare, resistant cases). Controversial and requires caution due to proximity to anatomical structures.

12. 12 Emergency Endodontic Management 6. Necrosis and Single-Visit Endodontics Some studies support single-visit RCT for necrotic teeth. Others caution about long-term success , especially with apical periodontitis. Clinical judgment and case complexity should guide treatment planning.

13. 13 Emergency Endodontic Management ◾ Necrotic Pulp with intra oral swelling Types of Swelling Localized: confined to oral cavity Diffuse (cellulitis): spreads across soft tissue planes Main Goals: Establish drainage (through canal or incision if fluctuant). Remove infection source via complete debridement . Place calcium hydroxide as an intracanal medicament. Antibiotics only if systemic symptoms (fever, malaise) are present.

14. 14 Emergency Endodontic Management Case Difficulty Assessment Use the AAE Case Difficulty Assessment Form to determine if referral is needed. Higher case difficulty increases chances of mishaps and multiple visits.

15. Fascial space infections Infected root canals can lead to acute apical abscesses. If uncontrolled , infection can spread to fascial spaces , causing cellulitis and systemic symptoms: Swelling Fever, chills, lymphadenopathy Headache, nausea Tenderness to percussion and palpation is usually present. 15

16. Fascial space infections Treatment Principles Drainage through root canal, incision , or extraction . Antibiotics only if: Systemic signs (fever, malaise) Fascial space involvement Immunocompromised patient 16

17. Fascial space infections Mechanism of Spread Spread depends on: Root apex position relative to cortical plate Relationship to muscles (e.g., buccinator, mylohyoid) Example: If infection from a mandibular molar apex is above the mylohyoid → sublingual space . If below → submandibular space . 17

18. Fascial space infections 18

19. Fascial space infections As described by Hohl and colleagues, the fascial spaces of the head and neck can be categorized into four anatomic groups ➡️ Mandible and Below ➡️ Cheek and Lateral Face ➡️ Pharyngeal and Cervical Areas ➡️ Midface 19 Hohl TH, Whitacre RJ, Hooley JR, et al: A self instructional guide: diagnosis and treatment of odontogenic infections 1983; Stoma Press Seattle.

20. Fascial space infections Anatomic Groupings of Fascial Spaces ➡️ Mandible and Below Buccal vestibule Body of mandible Mental space Submental space Sublingual space Submandibular space Example: Infection spreading into submandibular space can lead to Ludwig’s angina , a life-threatening cellulitis that threatens airway patency. 20

21. Fascial space infections Anatomic Groupings of Fascial Spaces ➡️ Mandible and Below Buccal vestibule Body of mandible Mental space Submental space Sublingual space Submandibular space Example: Infection spreading into submandibular space can lead to Ludwig’s angina , a life-threatening cellulitis that threatens airway patency. 21

22. Fascial space infections Anatomic Groupings of Fascial Spaces ➡️ Mandible and Below Buccal vestibule Body of mandible Mental space Submental space Sublingual space Submandibular space Example: Infection spreading into submandibular space can lead to Ludwig’s angina , a life-threatening cellulitis that threatens airway patency. 22

23. Fascial space infections Anatomic Groupings of Fascial Spaces ➡️ Mandible and Below Buccal vestibule Body of mandible Mental space Submental space Sublingual space Submandibular space Example: Infection spreading into submandibular space can lead to Ludwig’s angina , a life-threatening cellulitis that threatens airway patency. 23

24. Fascial space infections Anatomic Groupings of Fascial Spaces ➡️ Mandible and Below Buccal vestibule Body of mandible Mental space Submental space Sublingual space Submandibular space Example: Infection spreading into submandibular space can lead to Ludwig’s angina , a life-threatening cellulitis that threatens airway patency. 24

25. Fascial space infections Anatomic Groupings of Fascial Spaces ➡️ Mandible and Below Buccal vestibule Body of mandible Mental space Submental space Sublingual space Submandibular space Example: Infection spreading into submandibular space can lead to Ludwig’s angina , a life-threatening cellulitis that threatens airway patency. 25

26. Fascial space infections 26 Anatomic Groupings of Fascial Spaces ➡️ Cheek and Lateral Face The buccal vestibule of the maxilla The buccal space The submasseteric space The temporal space Example: Infected third molar → submasseteric space infection.

27. Fascial space infections 27 Anatomic Groupings of Fascial Spaces ➡️ Cheek and Lateral Face The buccal vestibule of the maxilla The buccal space The submasseteric space The temporal space Example: Infected third molar → submasseteric space infection.

28. Fascial space infections 28 Anatomic Groupings of Fascial Spaces ➡️ Cheek and Lateral Face The buccal vestibule of the maxilla The buccal space The submasseteric space The temporal space Example: Infected third molar → submasseteric space infection.

29. Fascial space infections 29 Anatomic Groupings of Fascial Spaces ➡️ Cheek and Lateral Face The buccal vestibule of the maxilla The buccal space The submasseteric space The temporal space Example: Infected third molar → submasseteric space infection.

30. Fascial space infections 30 Anatomic Groupings of Fascial Spaces ➡️ Cheek and Lateral Face The buccal vestibule of the maxilla The buccal space The submasseteric space The temporal space Example: Infected third molar → submasseteric space infection.

31. Fascial space infections 31 Anatomic Groupings of Fascial Spaces ➡️ Pharyngeal and Cervical Areas Pterygomandibular space Parapharyngeal space (lateral and retropharyngeal) Cervical spaces ( pretracheal , retrovisceral , danger space) Example: Infection in the retropharyngeal space can descend into the mediastinum , becoming fatal if untreated.

32. Fascial space infections 32 Anatomic Groupings of Fascial Spaces ➡️ Pharyngeal and Cervical Areas Pterygomandibular space Parapharyngeal space (lateral and retropharyngeal) Cervical spaces ( pretracheal , retrovisceral , danger space) Example: Infection in the retropharyngeal space can descend into the mediastinum , becoming fatal if untreated.

33. Fascial space infections 33 Anatomic Groupings of Fascial Spaces ➡️ Pharyngeal and Cervical Areas Pterygomandibular space Parapharyngeal space (lateral and retropharyngeal) Cervical spaces ( pretracheal , retrovisceral , danger space) Example: Infection in the retropharyngeal space can descend into the mediastinum , becoming fatal if untreated.

34. Fascial space infections 34 Anatomic Groupings of Fascial Spaces ➡️ Midface Palate Base of upper lip Canine (infraorbital) space Periorbital space Example: Infection spreading to the canine space can progress to cavernous sinus thrombosis , a life-threatening condition.

35. Fascial space infections 35 Anatomic Groupings of Fascial Spaces ➡️ Midface Palate Base of upper lip Canine (infraorbital) space Periorbital space Example: Infection spreading to the canine space can progress to cavernous sinus thrombosis , a life-threatening condition.

36. Fascial space infections 36 Anatomic Groupings of Fascial Spaces ➡️ Midface Palate Base of upper lip Canine (infraorbital) space Periorbital space Example: Infection spreading to the canine space can progress to cavernous sinus thrombosis , a life-threatening condition.

37. Fascial space infections 37 Anatomic Groupings of Fascial Spaces ➡️ Midface Palate Base of upper lip Canine (infraorbital) space Periorbital space Example: Infection spreading to the canine space can progress to cavernous sinus thrombosis , a life-threatening condition.

38. Fascial space infections Key Dangers Ludwig’s angina: Submandibular, sublingual, and submental space infection; risk of airway obstruction. Cavernous sinus thrombosis: Midface infections spreading through venous pathways, causing brain complications. 38

39. Fascial space infections Important Points Early diagnosis and prompt drainage are critical. Antibiotic therapy is adjunctive, not primary, unless systemic signs exist. Understanding anatomical pathways helps predict the spread. Serious infections can threaten life (airway obstruction, mediastinal spread, brain infections). 39

40. 40 MANAGEMENT OF ABSCESSES AND CELLULITIS The two most important elements of effective patient management for the resolution of an odontogenic infection are  correct diagnosis and removal of the cause. The majority of cases of endodontic infections can be treated effectively  without the use of systemic antibiotics . The appropriate treatment is removal of the cause of the inflammatory condition. Antibiotics are not recommended for irreversible pulpitis, symptomatic apical periodontitis, draining sinus tracts, after endodontic surgery, to prevent flare-ups, or after incision for drainage of a localized swelling (without cellulitis, fever, or lymphadenopathy)

41. 41 MANAGEMENT OF ABSCESSES AND CELLULITIS When Are Antibiotics Indicated ? Only recommended when there are systemic signs and symptoms such as: Fever (>37°C) Malaise Cellulitis Progressive or persistent swelling Trismus

42. 42 Basic Steps : 1. Anesthetize  the area. 2. Make a  vertical incision  at the point of greatest fluctuation. 3. Gently dissect  through deeper tissues and explore the abscess cavity to ensure all pockets of infection are opened and drained. 4. Promote drainage  by keeping the area clean (warm saltwater rinses, intraoral heat for vasodilation). 5. Place a drain  (preferably iodoform gauze) to prevent premature closure—remove it the next day. 6. Endodontic treatment  can often be completed after drainage to eliminate the source of infection and facilitate healing. INCISION FOR DRAINAGE Indicated for both indurated and fluctuant cellulitis Establish drainage from localized soft tissue swelling to prevent spread of infection and relieve pressure/pain.

43. 43 SYMPTOMATIC TEETH WITH PREVIOUS ENDODONTIC TREATMENT Emergency management  can be technically challenging and time consuming, especially with extensive restorations (posts, cores, crowns, bridges). Main goal: Remove contaminants from the root canal system Establish canal patency to achieve drainage Access to periapical tissues may require: Removal of posts and obturation materials Negotiation of blocked or ledged canals If root canal debridement and periapical drainage cannot be completed: Persistent symptoms may require trephination or apicoectomy

44. 44 LEAVING TEETH OPEN Not recommended  to leave teeth open for drainage between appointments. Although historically some clinicians did this, current evidence shows it can impair healing and complicate treatment. Risks include: Entry of foreign objects into the canal or periapical tissues Increased chance of microbial invasion and colonization of the root canal system Preferred approach: Allow drainage during the visit, then close the tooth before the patient leaves

45. 45 SYSTEMIC ANTIBIOTICS FOR ENDODONTIC INFECTIONS Antibiotic resistance  is a growing global problem, accelerated by overuse and misuse of antibiotics Oral bacteria  have shown increasing resistance to commonly used antibiotics, including penicillins , cephalosporins, macrolides, and metronidazole. Beta-lactamase production by oral anaerobes (mainly  Prevotella ) is a key mechanism of resistance, making some antibiotics less effective. Overuse and misuse (e.g., using antibiotics when not indicated, wrong agent/dose/duration, excessive prophylaxis) are major causes of resistance. Antibiotics are needed in only about 20% of infectious disease cases, they are prescribed in up to 80%, often with errors in choice or duration.

46. 46 SYSTEMIC ANTIBIOTICS FOR ENDODONTIC INFECTIONS Proper indications for systemic antibiotics in endodontics include: Systemic involvement (fever, malaise, cellulitis, trismus, spreading or persistent swelling) Medically compromised patients (prophylaxis) Persistent exudation not resolved after intracanal revision Following avulsed tooth replantation Empirical antibiotic selection is standard due to the delay in culture results for anaerobic bacteria First-line:   Amoxicillin (broad spectrum, well absorbed) For severe cases: Combine amoxicillin with clavulanic acid or metronidazole If allergic to penicillin: Azithromycn 500 mg 3 dayes

47. 47 LABORATORY DIAGNOSTIC ADJUNCTS Culturing for anaerobic bacteria takes 1–2 weeks, so it is  not routinely used in acute endodontic emergencies. In emergencies, if antibiotics are indicated ,  treatment should start immediately  because oral infections can progress rapidly.

48. 48 ANALGESICS NSAIDs   are considered the first choice of analgesics. However, no pain medication can replace the efficacy of thoroughly cleaning the root canal system to eliminate the source of pain Aspirin  has been used as an analgesic for over 100 years. Its analgesic and antipyretic effects are equal to those of acetaminophen, and its anti-inflammatory effect is more potent. Aspirin’s side effects include gastric distress, nausea, and gastrointestinal ulceration. Its analgesic effect is inferior to that of ibuprofen Acetaminophen  (paracetamol) is recommended when NSAIDs or aspirin are contraindicated, but the maximum daily dose should not exceed 4 grams to avoid liver toxicity.

49. 49 ANALGESICS Ibuprofen (NSAID) provides superior pain relief compared to aspirin (650 mg) and acetaminophen (600 mg), with or without codeine (60 mg). Ibuprofen has fewer side effects than opioid combinations. Maximum daily dose: 3.2 grams in 24 hours. NSAIDs can also suppress swelling after surgical procedures. The combination of analgesic and anti-inflammatory effects makes NSAIDs, especially ibuprofen, the drug of choice for acute dental pain (unless contraindicated) NSAID (Ibuprofen )

50. 50 ANALGESICS If NSAIDs alone are not sufficient for pain control, the addition of an opioid may provide extra analgesia. Opioid side effects: nausea, constipation, lethargy, dizziness, disorientation Opoids

51. 51 FLARE-UPS An endodontic flare-up is an acute exacerbation of periradicular pathosis after the start or continuation of nonsurgical root canal treatment. Incidence: Occurs in about 2%–20% of cases; strict meta-analysis estimates the rate at 8.4%. Risk Factors: More common in females under 20 years More likely in maxillary lateral incisors and mandibular first molars with large periapical lesions More likely during retreatment cases Presence of pretreatment pain increases risk

52. 52 FLARE-UPS Causes: Over-instrumentation or extending preparation beyond apex Pushing debris into periapical area Incomplete pulp removal Overextension of filling material Chemical irritants ( irrigants , medicaments, sealers) Hyperocclusion , root fractures, and microbiological factors Management: Most cases can be pharmacologically managed Recalcitrant cases may require surgical intervention, reentry, drainage, or occlusal adjustment Antibiotic Prophylaxis: Controversial; recent studies show antibiotics are not effective in preventing flare-ups and may be less effective than analgesics Prognosis: Flare-ups do  not decrease endodontic success rates

53. 53 CRACKED AND FRACTURED TEETH Cracks and incomplete fractures  are often hard to locate and diagnose, but their detection is important in emergency management. Early Detection methods include: removal of restorations dye application selective cusp loading transillumination magnification.