Emergencies in conservative dentistry/endodontics
Definitions:
– The emergency: According to Ackermann:
“Emergency is the occurrence of a diagnostic and therapeutic problem whose examination cannot be postponed and which requires immediate intervention.”
– The pain:
According to the WHO: “Pain is the unpleasant sensation and emotion associated with actual or potential tissue damage or presented in terms describing such damage.”
Objectives of emergency treatment:
- Preserve pulp vitality whenever possible, particularly in the case of immature teeth.
- Maintaining the pulpless dental organ on the arch.
- medical balance of the patient.
4. combat the patient’s stress and pain
5. Stop the progression of a pathological process.
6. prevent potential complications in the ongoing process.
IN THE EVENT OF AN EMERGENCY:
Clinical examination: The clinical examination by questioning provides information on the intensity, time, nature of the pain, pulp vitality tests, should always be essential.
1- The interview: It is important and allows us to collect the triggering factor and the time of appearance for adequate management.
2- The exorbital examination:
a- Inspection:
-Symmetry or asymmetry of the face
-Skin covering: it will be necessary to note:
*Color change: diffuse or localized redness, rashes.
*Swelling: note: Its location, Describe its limits with anatomical landmarks.
b- Palpation: Looking for pain or heat by feeling the skin coverings.
For swellings we note:
*Consistency: soft, fluctuating, hard.
*Sensitivity: Is palpation of this swelling painful or not?
*Temperature: Is this swelling hot or not?
*For skin sensitivity: look for anesthesia, hypoesthesia or hyperesthesia.
*Palpate the lymph node areas: looking for adenopathies.
3- The intraoral examination:
a- Inspection: we note:
Patient hygiene, Dental formula, Malpositions, Condition of crowns (cavities, cracks, fractures), Occlusion, Periodontal condition.
Palpation: of the alveolar arches in their apical, vestibular and lingual regions.
It allows:
– to detect the existence of desmodontal inflammation (painful pressure).
– to specify the nature of a swelling
4- Diagnostic tests:
a- Pulp vitality tests: The patient’s state of fatigue and fear must be taken into account. Test the neighboring teeth and leave the incriminated tooth in last position.
1- The cold test:
Performed with a cotton ball soaked in a few drops of ethyl chloride, the painful manifestation can be immediate or delayed:
-Pain upon application of the stimulus, disappears upon removal of the stimulus (Healthy tooth.)
-Absence of painful manifestation (pulp mortification)
2- The warm test.
Percussion: The suspected tooth is never tested first.
c- Periodontal exploration: Is carried out using a graduated periodontal probe.
-Purpose: Localization of periodontal lesions, measurement of pocket depth.
e- The anesthesia test:
In the case of dento-dental synalgia, and in the presence of multiple and deep caries, perform intraligamentary anesthesia to eliminate the pain.
When the pain goes away, we can blame the last anesthetized tooth.
f- The bite test: For the diagnosis of a crack.
5- Additional examinations:
Radiography: It is an essential complement to diagnosis and treatment.
6- emergency treatment.
Inflammatory emergency:
A- Dentin hyperesthesia:
The pain is sharp, brief, throbbing and stops with the cessation of the stimulus which can be mechanical, chemical or thermal.
Treatment: It is essentially etiological, that is to say suppression of painful stimuli and modification of the patient’s habits.
– at the first emergency consultation, the same active ingredients can be used in the chair in the form of varnish or adhesives or both.
– Outpatient prescription:
*Either a chemical desensitization agent based on potassium nitrate (Colgate sensitive®, etc.)
*Or a canaliculus sealing agent: fluorinated derivatives, potassium oxalate, strontium chloride.
*In addition, a desensitizing solution or gel may be prescribed.
B- Acute reversible pulpitis (pulp hyperemia):
It is a pre-inflammatory pulp condition.
Pain is induced, slightly prolonged after the stimulus stops.
Emergency treatment:
-Removal of irritating factors: occlusal trauma, overbite, caries, etc.
It consists of carious removal, direct or indirect pulp capping and then definitive restoration.
C- Septum syndrome:
The pain is pulsatile, provoked (hot, cold, food compression) or spontaneous, of low to intense intensity. The tooth is more or less sensitive to percussion. The papilla is normal or slightly edematous. The pathognomonic sign is pain on bidigital palpation of the interdental papilla.
Emergency treatment:
The treatment is etiological with possible application of a local anesthetic. It consists of removing debris located at the interdental space in order to achieve decompression, cleaning the painful area with antiseptic irrigation and reconstituting the contact point or opening the interdental space while waiting for a reduction in inflammation allowing reconstitution in good conditions. No prescription is necessary.
Emergencies in conservative dentistry/endodontics
D- Irreversible acute pulpitis:
-It is the worsening of the stage of pulp hyperemia. Irreversible syndrome characterized by significant congestion of the pulp.
Symptoms:
Acute, spontaneous, stabbing, paroxysmal, unbearable pain, exploding in crises, exhausting leading to insomnia, intermittent, radiating, triggered by heat _cold _contact _sugars _acids.
– Thermal tests cause very sharp immediate pain, which lasts for several minutes.
Emergency treatment:
-Local or locoregional anesthesia depending on the tooth concerned.
-Watertight operating field.
-Complete dentin curettage.
-Disinfection of the cavity.
-Opening of the pulp chamber.
-Pulpectomy or pulpotomy
Between two sessions, the operator can place a cotton ball impregnated with a volatile analgesic in the pulp chamber.
-Application of a temporary waterproof dressing.
Infectious emergencies:
A-Acute apical periodontitis:
Acute apical periodontitis corresponds to inflammation established in the periapex, following the extension of the endodontic infection towards the apical region.
Emergency treatment: the treatment consists of creating an access cavity, root canal trimming and disinfecting the canals as much as possible:
Canal trimming under dam with abundant irrigation.
Calcium hydroxide between sessions
Temporary waterproof sealing
Placed under occlusion of the tooth.
B-Acute apical abscess and Phoenix abscess:
Emergency treatment:
Intracanal route: a file is placed in the canal and used beyond the foramen. The pus can then gradually drain back up into the canal; abundant irrigation is continued as long as a flow is perceptible; the tooth is left open for 48 hours.
Emergencies in conservative dentistry/endodontics
By incision: if intracanal drainage cannot be obtained and a gingival abscess is present and collected, drainage is obtained by incision of the abscess.
If no abscess is present (or not collected) and intraductal drainage cannot be obtained:
The tooth is left open for 24 to 48 hours.
An antibiotic prescription is recommended.
Traumatic emergencies:
Simple coronal fractures : Symptoms: dentin hyperesthesia, pain when chewing
Immediate emergency treatment:
Composite restoration.
Penetrating coronal fracture : emergency treatment depends on several factors:
- Degrees of exposure
- The time elapsed between the accident and the consultation
- Maturation of the apex.
Mature tooth:
Minimum exposure 1-2mm:
Direct Pulp Styling.
Extended or old exhibition:
Endodontic treatment.
Immature tooth:
Emergencies in conservative dentistry/endodontics
Root fracture:
1/3 apical:
Followed
1/3 medium:
Reduction of the fracture line and contention for 3 months
Endodontic treatment if complication
1/3coronary:
Extraction of the mobile fragment
Crown elongation and prosthetic restoration
Emergencies in conservative dentistry/endodontics
Intrusion:
Emergency treatment:
Mature tooth:
Minimal intrusion: physiological re-eruption
If the movement is significant:
Surgical traction: the tooth is dislocated using forceps and then repositioned correctly + a retainer is left in place for 4 to 8 weeks.
Immature tooth:
Physiological re-eruption
Clinical and radiographic control
A spontaneous re-eruption is usually observed which can take several weeks.
If re-eruption does not occur after 4 weeks, extrusion is performed with light orthodontic forces.
Emergencies in conservative dentistry/endodontics
Extrusion:
Emergency treatment:
Gently push the tooth into its socket
Contention 2-3 weeks
Clinical and radiographic control.
Emergencies in conservative dentistry/endodontics
The expulsion:
The clinical expression corresponds to the complete displacement of the tooth out of the socket.
-If the tooth is found, the entire root must be checked (possibility of a root fracture of the apical third, the fragment remaining in the alveolus).
-If the tooth has not been found, an X-ray examination is necessary to make the differential diagnosis with a total intrusion.
Emergency treatment:
Mature tooth with irreversible damage to the ligament and pulp tissue (extra-oral time less than 90 min):
-Rinse the tooth with physiological serum.
-Examine the alveolus. In case of alveolar fracture; it is necessary to reposition the alveolar bone wall.
– Rinse the alveolus gently with physiological serum to remove the clot.
-Local anesthesia is often unnecessary except in cases of suturing of gingival lacerations and in young patients shocked by the trauma.
– Gently replace the tooth in the socket with light digital pressure. The correct repositioning is checked by an X-ray.
-Soft support for 1 to 2 weeks.
-Prescribe:
*Good oral hygiene (chlorhexidine mouthwash).
*Antibiotic coverage.
*A firm diet to stimulate the function of the periodontal ligament.
Mature tooth with irreversible damage to the ligament and pulp tissue (extra-oral time greater than 90 min):
-Soak the tooth in a 2.4% sodium fluoride solution for 20 minutes, in order to incorporate F ions into the cementum and dentin surfaces to delay the resorption process.
-Remove all necrotic periodontal ligament from the root surface with sterile gauze.
-Perform endodontic treatment extra-orally.
-Reimplant the tooth.
-Semi-rigid support for 6 weeks.
-Regular monitoring and checks.
Cosmetic emergency:
1-Blackening of the tooth: Treatment:
Bleaching or lightening
Aesthetic reconstruction.
2-Loss of an aesthetic reconstruction:
it is necessary to ensure pulp vitality.
Resume preparation.
Redo the restoration.
3-Loss of an aesthetic prosthesis or Loosening of a jacket crown or a tenon crown:
Ensure good apical health (Rx), before permanently re-sealing the prosthesis.
Conclusion:
Emergency OC occupies an important place in daily practice. The essential objective of our emergency treatment is to properly control the ongoing pathological process, immediately relieve the patient and initiate a healing process which promotes the subsequent implementation of usual therapies.
Sensitive teeth react to hot, cold or sweet.
Sensitive teeth react to hot, cold or sweet.
Ceramic crowns perfectly imitate the appearance of natural teeth.
Regular dental care reduces the risk of serious problems.
Impacted teeth can cause pain and require intervention.
Antiseptic mouthwashes help reduce plaque.
Fractured teeth can be repaired with modern techniques.
A balanced diet promotes healthy teeth and gums.