Emergencies in conservative dentistry
Part 1
I/ introduction
Emergencies in conservative dentistry
Emergencies
no risk to life
long-term consequences
II/definition or lack of definition ;
What is an emergency?
Latin “urgers” “to press”
Urgens literally means “in all haste” (dubois 2005)
According to the dictionary, urgent is “that which does not suffer from delay” (Larousse médicale 2003)
In the case of a medical emergency, this term refers to “all medical and surgical interventions that must be performed without delay” or cases requiring rapid intervention and care (Robert 2007)
Due to the lack of a precise definition or the variability of existing definitions, it is therefore up to the dental surgeon to assess the urgency of the situation; according to which criteria.
2 types of situations
The one where the patient requests care because of pain or trauma.
The one where the patient has an accident during a treatment session; faintness, loss of consciousness, allergic shock, hemorrhage, etc.
Medical emergency
Perception of urgency differs from subject to subject
III/ Objective of emergency treatment
The main objective being to relieve the patient; 3 key words will direct the emergency
Time
Diagnosis
Effective treatment
2nd part
Emergency and ethics
Can you refuse an emergency?
Emergency is a difficult concept to define, subjective, which makes its assessment delicate by the practitioner; a certain number of situations presented as emergencies by the patient are in reality not true emergencies and their management could be delayed in time;
However, an emergency is the only case where the practitioner is not authorized to refuse treatment.
Providing on-call service is an ethical obligation that applies to all practitioners;
Emergency actions should be automatic since they will be carried out in stressful situations where hesitations can have dramatic consequences.
Emergencies in conservative dentistry
Part 3
Endodontic emergencies
I/ emergency in endodontics
II/ specificity of pain in endodontics
III/ establish the diagnosis
1- dental history
2- the clinical examination
IV/ Pathology that may lead to an emergency consultation
A- Pathology of pulp origin
1- reversible pulp inflammation
a- pulp hyperemia treatment
2- irreversible pulp inflammation
a- pulp pathology (pulpitis)
use of anesthetic
treatment on single root
treatment on multi-rooted
clinical cases
B-Periapical pathology
acute apical periodontitis
1- apical periodontitis associated with acute pulpitis treatment
2- acute apical periodontitis associated with a necrotic or pulpless tooth treatment
3- acute apical abscess treatment clinical case
V/ drug prescription and endodontic emergency
III/ Establish the diagnosis
Collect Relevant Information
Locate the causative tooth to define the nature of the pulp or periapical pathology
Choosing the appropriate treatment which may involve several phases, surgical and medicinal
The clinical examination; As with any pathology or trauma, it must be methodical and systematized. After having comfortably installed and reassured the victim, this examination begins with an interview which is a crucial time in the diagnostic process. Inspection and palpation are followed by X-rays, often multiple.
It is at this point that the initial medical certificate is drawn up.
On a patient who has previously been reassured and calmed, especially if it is a child, and in whom the pain has been alleviated by taking medication, we begin with a global inspection of the oral cavity and its annexes (cutaneous then mucous membrane of the lips).
All lesions must be carefully analyzed and then recorded on the initial medical certificate, such as those of the soft tissues (lips, gums, tongue) which are too often forgotten.
It is first of all a brief and rapid examination. The X-rays deemed necessary, the diagnosis and the definitive or provisional treatment which usually aims to relieve the patient are also an integral part of this examination.
Anamnesis:
Ask the patient about the onset, development and type of pain. Their answers often make some diagnostic tests unnecessary, for example, when they reflect sensitivity to temperature changes or pressure, etc.
do not neglect the human factor when treating a patient.
The patient who is suffering tolerates treatment better and is receptive if the dentist shows interest in him.
“examination of the causal tooth”
For this we have inspection; palpation;
The inspection:
It is necessary to note the color of the tooth, any lesions (volume, location, etc.), the supporting tissues, the bottom of the vestibule, the lingual surface
Palpation:
Intraorally, the gum opposite the apices of the teeth should be palpated. A painful area suggests the presence of a lesion or an extracortical apex.
X-ray examination
Radiographic examination provides further information on the stage of root development, the presence or absence of root fractures and the involvement of periodontal structures.
Generally a retro alveolar is sufficient and in certain cases a panoramic
Emergencies in conservative dentistry
1-Dental history; Reason for emergency consultation
If the patient has recently received dental treatment that could have an impact on the pulp condition
When did the pain start and how?
The location, nature of the acute, dull, spontaneous or provoked pain
Triggering factors: hot, cold, stress, chewing
If pain persists after stopping the causative agent
If the pain is reproducible, continuous or intermittent
If other factors intervene in the triggering of pain; body posture, night pain, etc.
The clinical examination
a- extra-oral examination; the slightest swelling
facial asymmetry
redness
presence of extraoral fistula
lockjaw
B- intra-oral examination; observe carefully
soft tissues
the bottom of the vestibule opposite a decayed tooth;
feel the bottom of the vestibule
palpate the antero-inferior surface of the maxillary sinus opposite the upper premolar-molar group (the symptoms of sinusitis are very similar to pulpitis on the upper molar)
Emergencies in conservative dentistry
IV/ Pathologies that may lead to an emergency consultation
pulp pathologies
periapical pathologies
with inflammatory process (redness, pain, etc.) with infectious syndrome
A/ Pathologies of pulp origin
ACUTE REVESSIBLE PULPITIS ; Reversible pulpitis is a pre-inflammatory state due to vasodilation of blood capillaries and an increase in the volume of the painful pulp in the acute phase
It is said to be reversible because the pulp has not undergone severe degenerative phenomena and blood circulation and apical drainage are preserved.
The pain will be caused by the same stimuli as in acute dentinitis, slightly prolonged after the irritation has stopped
Reversible pulp inflammation (pulpal hyperemia)
Physicochemical aggression (milling, etc.)
root denudation (not due to bacteria but rather by the movement of fluid inside the canaliculi which has an impact on the odontoblasts)
by bacteria (bacterial toxins)
the patient complains of acute, transient pain caused by cold which disappears when the stimulus is stopped; (no spontaneous pain);
Localized pain stimulation of A&B fibers
The X-ray shows carious lesions, for example.
Moderate pulp injuries result in reversible changes initiated by the release of vasoactive neuropeptides by nerve fibers in direct contact with odontoblasts.
Conservative treatment (no pulp removal)
Etiological reassure the patient
Emergencies in conservative dentistry
2- Irreversible pulp inflammation
a- Pulp pathology (pulpitis, Depending on the extent of the phenomenon, a situation of “no return” can be reached, the entire cameral pulp being affected, the algogenic substances and the increase in intrapulpal blood pressure then cause very intense pain
It results from a significant pulpal inflammation with increased intrapulpal pressure which leads to foraminal strangulation of the neurovascular bundle of the tooth. The intensity of the pain depends on the intensity of the intrapulpal pressure and evolves into a severe, throbbing, continuous, spontaneous pain increased in decubitus, diffuse and the radiographic desmodontal space is regular; the tooth is vital and sensitive to thermal tests.
Irreversible pulp inflammation; spontaneous, acute, pulsating, stabbing pain, sometimes radiating to the eye, ears, neck, etc., difficult to localize and very unpleasant, depressive, even when chewing
C fiber activity
It is exacerbated by heat and often alleviated by cold.
Does not give in with medications even non-steroidal anti-inflammatory drugs are not localizable.
Emergencies in conservative dentistry
THE THERAPY
Use of an anesthetic
An operation is always necessary to relieve the patient, the prescription must complement the emergency procedure;
Fear and apprehension can complicate therapy;
Local anesthesia can be particularly difficult to achieve
Treatment of irreversible pulpitis
Treatment
Anesthesia before the surgical field, the objective is to reduce intrapulpal pressure
If no ligament pain is associated, and if the practitioner’s organization lends itself to it, endodontic treatment can be carried out during the session
Otherwise, all of the carious tissue is removed before it enters the pulp chamber.
if it is a monoroot, the entire pulp parenchyma must be eliminated and the canal irrigated;
If it is a multi-rooted disease, pulpotomy is sufficient;
Compression is performed with a cotton ball soaked in sodium hypochlorite for 2 min; if the hemorrhage is controlled, a sterile cotton ball is placed in the pulp chamber and covered with a non-compressive dressing
If bleeding persists from the canal after removing the cotton, pulpectomy of the canal is necessary.
Calcium hydroxide medication may be placed in the pulped canal
The temporary filling is carried out with glass ionomer cement.
If ligamentous inflammation is associated with pulpitis, the tooth should be placed under occlusion
B- periapical pathology
Acute apical periodontitis; is an inflammation of the periapical connective tissue following a pulp infection or root canal treatment (septic discharge during treatment, non-watertight treatment)
Simple PAA is manifested by spontaneous and continuous pain of mild to intense intensity and sensitivity to percussion; vitality tests are negative, there is no palpable swelling but a slight radiographic desmodontal enlargement is visible
occlusal trauma (overbite filling)
Acute irreversible pulpitis (especially for multi-rooted ones where periodontitis can set in on one of the roots but not the others)
Acute apical periodontitis ; The transition from a chronic lesion to an acute phase (persistence of bacteria and toxins, etc.); in some cases, sensitivity to heat may persist, the dilation of fluids could be the cause of this pain (the tooth is extremely painful when chewing, when occluded and when struck)
Protrusion of instruments beyond the apex during endodontic treatment
Propulsion of necrotic debris
Propulsion of disinfectant products or endodontic obturation
X-ray shows slight thickening
Treatment of apical periodontitis;
1- transient apical periodontitis ; following occlusal trauma causes mild, non-moderate pain
Taking painkillers may be enough
2- acute apical periodontitis associated with a still vital pulp
The situation can become complicated in cases of multiple radicles (pulpotomy in a canal with sub-occlusion of the tooth)
A prescription for painkillers adapted to the pain
3- acute apical periodontitis associated with a necrotic or pulpless tooth
The balance between the ductal bacteria and the body’s defenses is disrupted
Onset of significant, spontaneous pain exacerbated by occlusion and chewing
Remove all organic debris (trimming, disinfection)
if the tooth is not treated endodontically , create the access cavity, the canals shaped and disinfected, calcium hydroxide (its high pH promotes the return to normal after the acidification induced by bacteria and the inflammatory process)
The tooth is placed under occlusion
Prescription of antibiotics and painkillers
Emergencies in conservative dentistry
3- Acute apical abscess ; Corresponds to a severe inflammatory response of the infected deep periradicular periodontium, the passage of bacteria and their toxins leads to its infection and the formation of pus in the bone crypt
The pain is intense
Tooth excessively sensitive to percussion and chewing
Palpation of the bottom of the vestibule opposite the apex is painful.
The radiograph shows apical bone lysis, indicating the presence of a periapical lesion.
Presence of fever, or even malaise
The lesion can in certain cases damage the bony cortex and cause pus to pass into the subperiosteal space, which leads to the formation of an abscess.
This reduction in intraosseous pressure is accompanied by relief
There is a chronic form of the qpical abscess where the drainage of pus occurs through a fistula.
Emergencies in conservative dentistry
Treatment of acute apical abscess; relieve pain
The objective is twofold.
Prevent the spread of infection
If the endodontium is accessible and permeable, after instrumentation and disinfection of the canals, a small diameter file is used 1 mm beyond the foramen; the tooth can be left open for 48 h in order to continue drainage
If the endodontium is not accessible, some practitioners suggest trephining the alveolar bone opposite the inflamed lesion to obtain drainage of the inflammatory excreta and thus reduce intraosseous pressure.
The gum is incised opposite the apex of the affected tooth and the bony cortex is perforated with a small round burr.
If a gingival abscess is associated with the acute apical abscess, the pain is less significant because the abscess has crossed the periosteum either by canal route
either a clean incision up to bone contact
V/ Drug prescription ; Pulpotomy and pulpectomy are not always sufficient to relieve the patient
the prescription of analgesics is an essential complement to the therapy (non-steroidal anti-inflammatory drugs; but in case of allergy paracetamol)
the prescription of antibiotics is useless in endodontic emergencies, only in the case of acute alveolar abscess (if general signs accompany it; fever, malaise, etc.)
1- non-steroidal anti-inflammatory drugs; it is currently clearly demonstrated that the administration of 800 mg of Ibuprofen one hour before the therapeutic act has a double effect
on anesthesia
reduction of post-operative pain
2- reasoned prescription and management of pain; 3 levels of pain can be considered; (weak, moderate and strong)
It is much easier to prevent pain from setting in than to fight it once it has set in.
Treatments for severe pain are only needed for 24 to 48 hours.
Emergencies in conservative dentistry
4th part
Alveolo-dental trauma
I/ clinical examination
II/ dental trauma without dental fractures “pathophysiology of dental trauma”
1-concussion and subluxation
2- extrusion
3- lateral dislocation
4- intrusion
5- expulsion
III/ trauma with dental fracture
1- coronal fracture
a- coronal fracture without pulp exposure
1- the cracks
2- enamel fracture
b- coronal fracture with pulp exposure
2- coronal-radicular fracture
3- root fracture
a- fracture line at the coronal 1/3 or at the middle 1/3
b- fracture line at 1/3 apical without alveolar fracture
c- fracture line at 1/3 apical with alveolar fracture
d- suprabony coronal fracture line with contact with the oral environment
IV/ fracture of periodontal tissues
a- alveolar bone b- soft tissues
Clinical examination; determine the cause
– the exact circumstances and location of the accident
Real reason for emergency – determine the patient’s medical condition,
background
– when the accident happened
– note the tooth conservation environment
the consequences
affect the pulp (pulp necrosis, canal obliteration, certain root resorptions)
affect the periodontium (inflammatory resorption, ankylosis, etc.)
See trauma course
Conclusion; Knowing how to make the right diagnosis; knowing how to manage time to possibly provide good emergency management.