Guidelines for Emergency Endodontic Diagnosis and Treatment
Efficient and accurate Endodontic emergency diagnosis depends upon three factors:
(1) The ability to obtain the right information from the patient (Listen to what the patient is telling you!)
(2) Using the patient’s dental history, your experience and intuition in those cases where the diagnosis is not clear-cut.
(3) The clinician’s ability to adhere to sound diagnostic principles that most often includes the ability to reproduce the patient’s current complaint in the chair. If you cannot reproduce symptoms with Endodontic tests, there is a good chance that the problem is not endodontically related. Attempting treatment on a tooth without a firm diagnosis can often result in error, embarrassment and significant adverse financial consequences for the patient and clinician.
Essential Endodontic Clinical Tests
- Thermal Tests
Thermal tests are helpful in determining the presence of pulp vitality
- Cold Tests – Useful for diagnosing Reversible or Irreversible Pulpitis
- Heat Tests – Essential for diagnosing Irreversible Pulpitis
- Electric Tests
The EPT is useful ONLY for determining the possibility of non-vital pulp. Electric tests cannot be used to determine stages of pulpitis. Number values given by these machines are meaningless. The EPT has become less popular as a pulp test because of its inconsistency. Metallic restorations, secondary dentin formation and immature apices can affect EPT readings.
- Percussion
Indicates the condition of the periodontal ligament and supporting structures.
- Palpation
Can indicate periapical involvement.
- Cavity Test
In any case of suspected necrosis, the cavity test remains the Gold Standard in order to obtain definitive proof of lack of vitality of the coronal pulp. Since pulp pathosis occurs coronally-apically, there is always a possibility of having vital tissue in the apical third of a tooth when the chamber is found to be non-vital. In multi-rooted teeth, caution must be exercised, as it is also possible to have necrosis in one root and vital tissue in the canal of an adjacent root.
- Transillumination and Occlusal Tests
With the ever increasing numbers of fractured teeth and teeth with CTS (Cracked Tooth Syndrome) it is important to examine cracks in marginal ridges and to use a Tooth Sleuth on individual cusps. While a fractured cusp or crack does not by itself indicate endodontic involvement, it can often explain symptoms in unrestored or minimally restored teeth.
Radiography and Diagnosis
Ideally, a cone beam tomograph should be available for ANY case that is being endodontically treated. If there is one rule regarding endodontic diagnosis it is: “Take another film”. (With thanks to Dr. Seymour Melnick of Boston University- LONG before cbCT’s were available !! )
Periapical radiography can often miss problems under restoration margins due to angulation of the film. Bitewing radiography can be useful in detecting these caries, faulty margins and relative depths of restorations. Where a cbCT is NOT present, at a minimum, a second periapical film, taken at a slightly different angle, must be taken. It can often can often show additional roots or evidence of additional canals. Draining areas, pockets, sinuses or fistulae should always be traced to source with a gutta-percha cone. Resist the temptation to use an anesthetic when inserting the tracer. Administration of local anesthetic prevents being able to use a cavity test as the final test of pulp vitality.
Recall radiographs should always include both periapical and bite wing views to examine for periapical pathology and marginal integrity of castings – and where previous radiolucent findings were present or with ANY retreatment, a follow up cbCT is indicated .
The Thermally sensitive tooth with no periapical symptoms
The problem is the coronal pulp. Treatment is complete pulpectomy (if there is sufficient time). This will relieve the thermal symptoms and allow the patient to be rescheduled for completion of endodontic treatment when time allows. Pulpotomy can sometimes be used in multiple canal teeth without periapical involvement.
The Periapically involved Tooth
Teeth with periapical involvement will have signs that may include percussive sensitivity, periapical palpation sensitivity and/or swelling and sometimes visible radiographic periapical pathology. Relief will be most predictably obtained by complete pulpectomy. Canals should be broached, irrigated and cleaned to approximately size #15 or #20 instrument (if possible) with electronic confirmation of working length. In this way, the minimal remaining pulp remnants have little possibility of increasing the periapical inflammation. Always use small files. Beware of forcing material out of the apex. The occlusion is relieved and the patient is placed on anti-inflammatory medication. Antibiotics are rarely required.
Post Treatment Exacerbation – (Blow Up)
In rare cases, you may need to place the patient on antibiotics if they develop post pulpectomy blow up. This usually occurs 48 hours after treatment and is due to pushing debris out of the apex. It is more often associated with necrotic or retreatment cases. Pathology is due to inoculation of the periapical area with pulp content and bacteria, inadvertently introduced into this area by a file. Working lengths must therefore be accurate. Use an apex locator to prevent being long with files. If the case blows up, there will be PDL inflammation. The tooth will extrude and periapical palpation sensitivity and swelling will occur. The first 48 hours post-treatment are the most critical. Good communication follow-ups by staff-members prevent cases from getting out of control. Antibiotics should be given in those cases where swelling is reported. It is important to start the medication early and to ensure that the patient does NOT apply heat to the area externally. THERE IS NO SCIENTIFIC BASIS FOR GIVING ANTIBIOTICS AS A “PROPHYLAXIS” IN THE CASE OF THE SINGLE APPOINTMENT TREATMENT OF AN ASYMPTOMATIC NECROTIC TOOTH.
Periapical Abscess
The tooth will exhibit no signs of vitality. Mobility can be very high due to the periapical inflammation. There may be intra and extra-oral swelling. Often the tooth will feel “high” due to PDL thickening. Percussive sensitivity is often acute and these teeth should never be intentionally percussed. Some have distinct periapical lesions associated with the tooth but many rapidly developing cases come on so quickly that radiographic changes may be minimal at time of presentation.
Treatment consists of establishing drainage through the canal (if possible). Incision and drainage should be performed in the case of obvious fluctuant swelling or if the abscess has pointed as the result of administration of antibiotics. Amoxicillin 500 mg 2 stat 1 q.i.d. (depending on the case) remains the drug of choice but the author has recently moved toward away from Clindamycin to Azithromycin 250 mg q24hr (5 days including loading doses) as recommended by the most recent AAE guidelines. Antibiotics are only given until such time as the canal can be accessed and cleaned. Then the medication is stopped.
Post Treatment Discomfort
The most common reasons for post-operative discomfort in endodontic treatment are:
1) Failure to adequately relieve the occlusion
2) Failure to maintain apical control of instruments resulting in tearing or abuse of the apical foramen areas.
3) Pushing necrotic debris or canal irritants out of the apex into the periapical tissues
In (1), ask the patient if NSAIDs relieve the discomfort. If so, check the occlusion in centric and lateral excursions. Ensure adequate clearance and take the tooth out of occlusion if necessary. Prescribe additional NSAIDs and check with the patient again in 48 hrs.
In (2), check for wet canals (if in mid treatment) and open the case for drainage if necessary. Ca(OH)2 medicaments can be helpful in these cases. If the case has been completed with large amounts of sealer excess, proceed as in (1). Surgery may be necessary in cases where there is gross tearing, transportation or perforation of the apex.
In (3), determine how severe the periapical symptoms are. Prescribe analgesics for discomfort and antibiotics if the area is beginning to exhibit more diffuse swelling.
If you are confident in the apical seal and quality of the Endo treatment, resist the urge to reopen the tooth for 48-72 hrs. Allow the antibiotic and NSAIDs to work. Most cases will resolve once the body has dealt with this extruded material. Immediately “re-opening ” the case by attempting to remove the gutta-percha filling and getting to the apex with instruments can induce additional periapical inflammation, further material extrusion and tear the apex. It will also necessitate complete re-instrumentation and refilling of the case, which can only delay healing and increase periapical inflammation.