Management of hot tooth

"hot tooth" management by various techniques of anesthesia

1. Management of “Hot Tooth” Dept.Of Conservative Dentistry& Endodontics

2. The term ‘‘hot’’ tooth generally refers to a pulp that has been diagnosed with irreversible pulpitis , with spontaneous, moderate-to-severe pain. A classic example of one type of hot tooth is a patient who is sitting in the waiting room, sipping on a large glass of ice water to help control the pain. “HOT TOOTH” LA strategies for hot tooth mgmt: Nusstein et al, DCNA 2010

3. When the clinician is confronted with the case of a severe irreversible pulpitis in which the conventional IANB using 2% lidocaine with 1:100,000 epinephrine achieves lip numbness but not pulpal anesthesia, several supplemental techniques have been followed. LA strategies for hot tooth mgmt: Nusstein et al, DCNA 2010

4. In patients with irreversible pulpitis, Cohen and colleagues reported that the supplemental PDL injections were successful 74% of the time, whereas reinjection boosted success to 96%. The key to giving a successful PDL injection remains the attainment of back-pressure during the injection. PDL injections are usually given using either a standard dental anesthetic syringe or a high-pressure syringe . The development of computer-controlled anesthetic delivery systems ( the Wand or the Single Tooth Anesthesia ) have been found to be able to deliver a PDL injection. 1. INTRA-LIGAMENTARY (PDL) INJECTION LA strategies for hot tooth mgmt: Nusstein et al, DCNA 2010

5. The Wand system was able to deliver 1.4 ml of the anesthetic over the course of the injection. When this system was used, the duration of anesthesia for the first molar averaged from 31 to 34 minutes. In patients diagnosed with irreversible pulpitis and experiencing moderate-to severe pain , when a supplemental PDL injection was delivered using the Wand, the rate of success of the injection was 56 % . [ Nusstein et al,J Endod 2005;31(5):354–8 ] LA strategies for hot tooth mgmt: Nusstein et al, DCNA 2010

6. D eliver local anesthetic solutions directly into the cancellous bone surrounding the affected tooth. S everal IO systems available in the market: The Stabident system (Fairfax Dental Inc, Wimbledon, UK), X-Tip system (Dentsply, York, PA, USA), and IntraFlow handpiece (Pro-Dex Inc, Santa Ana, CA, USA). 2 . INTRA-OSSEOUS INJECTION LA strategies for hot tooth mgmt: Nusstein et al, DCNA 2010

7. STABIDENT SYSTEM: Consists of a 27-gauge beveled wire that is driven by a slow-speed handpiece, which perforates the cortical bone. Anesthetic solution is then delivered into the cancellous bone with a 27-gauge ultrashort needle through the perforation using a standard anesthetic syringe. INTRAFLOW HANDPIECE: The IntraFlow handpiece holds and drives a perforating needle and an anesthetic cartridge, which is engaged via an internal clutch to deliver the local anesthetic through the perforation. LA strategies for hot tooth mgmt: Nusstein et al, DCNA 2010

8. X-TIP SYSTEM: The X-Tip system consists of a 2-part perforator/guide sleeve component, which is also driven by a slow-speed handpiece. The perforator leads the guide sleeve through the cortical bone and then is separated from it and removed. This leaves the guide sleeve in place and allows for a 27-gauge needle to be inserted for injecting the anesthetic solution. The guide sleeve is then removed with a hemostat at the end of the appointment. LA strategies for hot tooth mgmt: Nusstein et al, DCNA 2010

9. One of the benefits of the IO injection is the reported immediate onset of anesthesia . The injection is recommended to be given distal to the tooth to be anesthetized . The exception to this rule would be the maxillary and mandibular second molars, for which a mesial site injection would be needed . The perforation site for the IO injection should be equidistant between the teeth and in the attached gingiva , to allow for the perforation to be made through a minimal thickness of tissue and cortical bone and to prevent damage to the roots of the teeth. LA strategies for hot tooth mgmt: Nusstein et al, DCNA 2010

10. 4% articaine with 1:100,000 epinephrine as a supplemental injection to increase the success of the IANB injection. In asymptomatic patients, the use of the articaine solution was found to be superior to the lidocaine solution. 3. Mandibular Buccal Infiltration injection with Articaine Articaine buccal infiltration enhances the effectiveness of lidocaine inferior alveolar nerve block. Kanaa M, Whitworth J, Corbett I, et al ( Int Endod J 2009;42(3)(238–46) 91% LA strategies for hot tooth mgmt: Nusstein et al, DCNA 2010

11. The intrapulpal injection works well when it is given under back-pressure. Simply placing local anesthetic solution in the pulp chamber will not achieve adequate pulpal anesthesia. A disadvantage of the intrapulpal injection is its short duration of action (approximately 15–20 minutes). The intrapulpal injection also requires that the pulp tissue be exposed to permit the injection to be given. The patient should be warned to expect moderate to severe pain during the initial phase of the injection. 4 . INTRA-PULPAL INJECTION LA strategies for hot tooth mgmt: Nusstein et al, DCNA 2010

12. TAKE HOME MESSAGE!!! “To treat a hot tooth ” Mandibular Posterior teeth Mandibular Anterior teeth Maxillary Anterior teeth Maxillary Posterior teeth IANB + LB + IO/PDL/IP IANB/( IANB+IO/IP) Double dose (3.6ml) of buccal infiltration + 0.5ml at apex palatally+ IO/PDL Labial + Palatal infiltration Cohen’s Pathways For the pulp 10 th edition