[Kuilliyyah of Dentistry International Islamic University Malaysia]

Emergencies
DR.SHAWFEKAR BTE HJ ABDUL HAMID

[2009]

Emergencies
Acute Pulpitis Acute Apical Periodontitis
Acute pulpitis

Acute pulpitis is usually caused by rapidly progressing caries or by leaking fillings associated with secondary caries. In emergency treatment the main emphasis must be on 1) effective pain control and 2) ensuring a good long term prognosis. Adequate local anesthesia is a prerequisite for most of the treatment choices above.

ZOE filling

When excavation of caries does not lead to pulp exposure, placement of zinc oxide eugenol may prove to be effective. Leakage of eugenol in a pulpward direction probably accounts for the fact that over 95 % of teeth without exposure become symptom free with ZOE.

Eugenol pellet + ZOE in lesion

When excavation of caries leads to pulp exposure, effective pain control (over 90 %) can be obtained by covering the exposure site with a eugenol pellet and filling the cavity with a zinc oxide eugenol dressing. The eugenol pellet should not be used in shallow cavities. In addition to eugenol, corticosteroid-containing solutions and pastes (e.g. "Ledermix") are widely used in many countries with good clinical effect.

Pulpotomy; Eugenol + ZOE

To further increase the effectiveness of pain control (over 95 %) in pulpitis cases in carious teeth with pulpal involvement, the coronal pulp tissue should be removed (pulpotomy). A cotton wool pledget soaked in eugenol (or corticoid preparation) and a zink oxide dressing are then applied to the pulpal wound as shown in the figure.

Partial pulpectomy; Eugenol + ZOE

Sometimes a partial pulpectomy is performed as the first stage of treatment for acute pulpitis. However, a complete cleaning and shaping procedure followed by placement of a non-setting calcium hydroxide paste is preferable. If cleaning and shaping cannot be completed, eugenol (or
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a corticoid preparation) may be applied into the canal system and the cavity restored with (a eugenol pellet and) a ZOE top filling. The effectiveness of pain control of this treatment mode is still high (over 90 %), but slightly lower than that for a pulpotomy. It is therefore better not to commence the initial preparation of the canals unless they can be instrumented completely.

Pulpectomy; Ca(OH)2 + topfilling

Often time is the limiting factor in the treatment of patients with acute pulpitits. However, when this is not the case, the canals should be completely preparaed. Calcium hydroxide in the root canal and a temporary restoration with good marginal seal results in excellent pain control in almost all cases (over 95 %). In cases in which all of the pulp tissue can be removed, the canal(s) may be obturated.

Acute apical periodontitis

In emergency treatment of acute apical periodontitis the main emphasis is on 1) effective pain control, 2) inhibition of the spread of infection, and 3) ensuring good long term prognosis. The preferred treatment of acute apical periodontitis is as follows: 1) Anesthesia: Often, anesthesia is not needed because the pulp is necrotic. However, occasionally part of the pulp tissue may be vital, the tooth is periostitic or placement of the rubber dam necessitates administration of a local anesthetic agent. 2) The optimal treatment comprises complete preparation of the whole canal system. Apical patency may be checked with #10 or 15 file (avoiding overinstrumentation) to allow drainage of pus. Following the cleaning and shaping procedure, the canals are filled with a non-setting calcium hydroxide paste and the access cavity is sealed with a temporary restoration. Control of occlusion is essential. 3) If an abscess present, drainage of pus should be established by surgical incision following local anesthesia to the surface mucosa. A piece of rubber dam may be sutured to hold the incision open for a few days. Good knowledge about anatomy is required to ensure thet nerves and blood vessels in the region are not damaged. 4) Antibiotics are prescribed only when there are general indications for such treatment (e.g. fever, malaise, dangerous location or spreading of the infection, certain risk patients). 5) Drainage of pus from the canal seldom lasts for more than five minutes. In such rare cases, the patient is examined again later the same day.

Endodontic Emergencies Self Assessment

Acute pulpitis
True In symptomatic pulpitis without caries perforation (into pulp), ZnO eugenol filling almost always removes the symptoms rapidly In emergency treatment of acute irreversible pulpitis, pulpotomy with eugenol pellet in the chamber and top filling removes symptoms effectively In emergency treatment of acute irreversible pulpitis, even partial removal of pulp tissue from the root canals further increases the probability to make the tooth 6 False

totally symptomfree Whenever time allows, instrumentation should be completed during the first appointment in emergency treatment of acute irreversible pulpitis

AAP
True Antibiotics should be always prescribed in the treatment of AAP (acute apical periodontitis) False

Anesthesia is never required in the treatment of AAP because the pulp is necrotic

Control of occlusion is a crucial step in the treatment of AAP

Fluctuating abscesses should be incised in the treatment of AAP

Drainage of pus, if present, from the canal, seldom lasts over five minutes

Canals should not be instrumented during the emergency treatment of AAP even if the time would allow this Whenever time and symptoms allow, instrumentation should be completed during the first appointment in emergency treatment of AAP