Endodontics Emergency Treatment Sound and Simplified by Gunnar Hasselgren, D.D.S., Ph.D.; Dory Calev, D.D.S. Emergency treatments tend to disrupt the office schedule. Therefore, itis important to carry out the diagnosis and treatment rationally, so that the patient's problem is taken care of in a reasonable time. If possible, the emergency treatment should be carried out in such a way that it becomes part of the permanent treatment. round one-third of all emer- A sis Sstecuatont This does not mean that all these cases require endodontic treatment. Many times extraction may be the treatment of choice if, for example, the tooth has no value for the whole dentition. Ninety percent of emergency cases with pain are caused by endodontic problems. When treat- ing these patients, a diagnosis is absolutely necessary before any kind of definitive treatment can be considered. If it is not possible to obtain a diagnosis, that is, if we do not know the reason for the pain, treatment should not be started. Give the patient analgesics, a new appointment or refer him/her, but do not start any treatment. Too many teeth have been root-filled unnecessarily by well-meaning col- leagues who wanted to help the patienteven if the origin of the pain Was unknown, Even though endodontic cas- es dominate among oral pain patients, pain in the oral cavity does not equal endodontics. Sinusitis, eruption problems, periodontal abscesses, neurologic disorders, are among other painful conditions that should be considered. When dealing with patients with pain, the most important step is to obtain a good history. It has been said thatiifa clinician does not want to take the time to listen to the patient, the patient should be re- ferred to a veterinarian, who is trained to deal with patients who cannot give a history. In other words: Listen to the patient. Often, the cause of the pain can be found in what the patient tells you. Endodontics has certain tools for examining patients: percussion and palpation tests, thermal tests, electric pulp tests and mechanical tests. Most of the time a single test will not give us the full answer. We Dr. Hasselgren and Dr. Caleo are afte with Columbia University Schoo! of Dental and Oral Surgery. Dr. Hasselgren is professor and chairman, Departmen! of Endodontics. Dr. Calo is assistant roissorand director ofundergraduateendodontcs, NYSDUJUNEWULY 1994 9have to rely upon multiple tests, and radiographs to make the cor- rect diagnosis. While discussing these differ- enttests it must be emphasized that the most important tool is the den- tist himself/herself. Whatever test results we obtain, itis the clinician who has to weigh these results, compare them with the patient his- tory and radiograph, then use his/ her own knowledge and experi ence. Out of all this will come the diagnosis. All patients are different Therefore it is necessary to deter- mine how the patient reacts to testing before the suspected tooth is tested. An easy way to do this is to test an innocent tooth first. Percussion Tost A positive response means that somewhere in the periodontal tis- sues there is a sensitive area, most likely inflammation. Further tests are needed to determine whether this is periapical inflammation, pe- riodontal inflammation, sinusitis, or some other condition. Palpation The presence of aperiapical inflam- mation can usually be confirmed by palpation of the periapical area, buccally as well as lingually. In cas- es with recession it can sometimes bedifficult todiscriminatebetween apical and marginal tenderness. The palpation can then be performed ‘by means of an instrument smaller than a fingertip, for example, the end of a mirror handle. ‘Thermal Tests Cold: Cold tests can be carried out bymeansofairspray, ice, ethyl chlo- tide or carbon dioxideice. A positive response means that there isa vital pulp in the tooth. This is the most reliable clinical, non-invasive vital- ity test. Heat: Most commonly, heated base plate gutta-perchais used. Heattests are useful only if the patient com- plains of pain/sensitivity to hot. 2 NYDU JUNEWULY 1994 ili it is explained that an excavation will be started without anes- thesia, the patient will accept it : Electric Pulp Tests Itmust be emphasized that this is a strict yes or no test. If one tooth responds at a higher number than another tooth, itdoesnot mean that the second tooth has an inflamed pulp. The numerical values found in the more advanced electric pulp testcan be used to follow teeth after trauma, but are basically not useful in the everyday clinic. Electric tests should be supplemented with an- other form of vitality test, for example, the cold test. Mechanical Test Atestcavity preparationis the most reliable vitality check ina tooth that cannot be tested otherwise. How- ever,asthisisan invasive procedure there must be a valid reason for doing it. If there is a carious cavity or an old filling that needs to be replaced, excavation without anes- thesia will tell whether the tooth is, vital or not. Also, if there is a deep cavity, probing can many times re- veal a vital response. If itis explained clearly to the patient that an excavation will be started without anesthesia, the pa- tient will accept it. The patient is then told to tell the operator as soon as he/she feels something. (Make sure the patient understands that it is a matter of feeling, not a matter of feeling pain.) A patient will sel- dom insist on anesthesia if the procedure is explained. Moreover, anesthetizing too early often makes a correct diagnosis impossible. Vital Teeth Sensitive dentin: As a result of ener- getic toothbrushing, scaling and root planing, exposed dentin may be sensitive. There are many meth- ods for treating sensitive dentin— which shows that no method is re- ally good. Of all the methods we have used, we have found that ox- alate applications are the most successful. Oxalate solutions are now available commercially. Pulpal pain / Hypersensitive teeth ‘These teeth have often been called hyperemic, but as we do not know muchabouttheactualblood flow in them the term isa misnomer. There can be several reasons for the in- creased. sensitivity, among them, exposed dentin, leakage under a crown or filling, or preparation without sufficient water coolant. It is sometimes hard to find the rea- son, but in most instances endo- dontic treatment is not necessary. Pulpal pain / Pulpal inflammation: Many studies have shown that itis not possible to make a correct (histopathological) pulpal diagno- sis based on clinical symptoms. Therefore, unless a pulp is actually exposed, thisisa gray area in which you have to decide whether or not endodontic treatment should be done. The decision is made on clin- ical and radiographic findings and the clinician’s knowledge of and past experience with similar cases, ‘The rule of thumb is to use the duration of the pain as a guide for whether the pulp chamber should be accessed. When questioning the patient about the pain it is not pro- ductive to use subjective express- ions like “long,” “short” or “a while.” Give the patient examples: “When the pain starts, does it last for seconds, minutes, hours?” If the pain lasts beyond seconds and lin- gers when the hot, cold, sweet or whatever thestimulusthat triggered the pain has been removed, it is usually an indication that endo- dontic treatment is needed. Sensitivity to changes in tem-perature are signs of a vital pulp. Lingering pain to hot and/or cold is a sign of a troubled pulp. No other pulp testhas tobe performed, and the treatment can be initiated after the tooth has been anesthe- tized. The optimal treatment is a proper pulpectomy. However, most of the time when youare deal ing with an emergency patient, time is at a premium, and the second best treatmentisa pulpotomy.Car- ies or leaky fillings, which are the sources of infection, should be re- moved together with the most inflamed partof the pulp. The quick pulpectomy, which is sometimes recommended, has a markedly poorer result in rendering a symp- tom-free tooth than the pulpectomy and pulpotomy (Bjerken, et. al 1980). So, if there is not enough time to carry out a careful pul- pectomy, the root canals should be left alone for the next appointment, and only the coronal portion of the pulp tissue removed Ithas been shown that use of various medicaments does not in- fluence the pain relief (Hasselgren & Reit, 1989). A sterile cotton pellet is as effective as any medicament. Sometimes it is practical to let the ‘temporary filling, forexample, zinc oxide-eugenol cement, fill the whole access cavity without a cot- ton pellet if itis difficult to obtain good retention otherwise. Non-vital Teeth A necrotic pulp is free from clinical symptoms. The periapical inflam- mation is caused by infection in the root canal. Breakdown products seep out through the apical fora- men, and the body protects itself from these endotoxins, by resorb- ing periapical bone to make space for inflammatory cells. The more bacterial byproducts there are, the more inflammatory cells are neces- sary for the defense. So, the more bacteria there are in the root canal, the larger the radiolucency. Most periapical lesions are ance between attack and defense. These teeth, of course, need treat- ‘ment, but not on an emergenc basis. Dark areas in the radiogra donot hurt. However, occasionally this balance is tipped the wrong way and we get a flare-up. The tooth becomes tender to percussion, and the periapical area is tender to palpation. To treat this condition it isnecessary to thoroughly clean the root canals. It is a time-consuming, procedure, but there is no way around it; the infection must be re- moved in order to obtain a symptom-free tooth. Occasionally, a periapical in- flammation flares up early, before any radiographic signs can be de- tected. However, these teeth are utterly painful and extremely ten- der to percussion, so it is usually no problem to identify them. When the periapical inflam- mation flare-up has reached a later stage of development, there will be an abscess formation. A mature abscess must, of course, be drained. ‘This can be done either through an incision or through the tooth. It is beneficial if a tooth is not left open for drainage for long time periods. ‘Most of the time it is possible toclose the root canal after the tooth has been open during the cleaning and irrigation. An irrigation syringe can be used to extract exudate from the root canal. Ifit is not possible to obtain a dry canal, the tooth may be left open overnight. Itis not nec- essary and absolutely not beneficial free from symptoms—there is a bal- to leave a tooth open for longer than 24 hours. Longer open peri- ods will give new bacteria a chance to establish themselves in the root canal system. The average periapical flare- up patient does not require antibiotics. If the patient has mal- aise, fever, or if an abscess is situated in a submandibular area, antibiotics are required. The instru- mentation and irrigation of the root canal are the most important aids in removing the infection. An intracanal medicament is second- ary, but still necessary. Liquid medicaments disappear into the body and aiso react with periapical tissues. This leaves the root canal without any antibacterial agent af- ter some time. A slurry of calcium hydroxide and sterile water stays in the canal and provides a long- term, anti-bacterial effect. This gives freedom when it comes to schedul- ing the next appointment. Summary Emergency treatment of a patient with pain is a rewarding experi- ence. Ifyou take the time to listen to the patient, the diagnosis will many times reveal itself quickly. A ratio- nale for diagnosis and treatment is giveninthisarticle Successfulemer- gency treatment is an excellent practice builder. References 1 Hasselgren G,Relt C Emergency pulpotomy: Pain olleving effect with ard without the use ‘ofsedative dressings J Endod 1988/15251-256, 2. Tronstad , Bjrken , BorglinE Hasselgren, Petersson K, Segerscin M, “Wennberg. A. Behandling av exacerberande apikal perio- dont Jimfrelsemellan nlagasmedikament ‘Tandlikartidningen 1980, 72234255 Creat- ment of flare-ups of periapical inflammations; arionbbetwreen intacanal medicament). ‘A, Tronstad L. Endo- i. Tandlkartdeingen 3, Bjrken E, Wennber dontisk Akutbehs 1980; 72:314-318, NYSDS JUNEUULY 1904 $8Where Shall the Root Filling End? by Gunnar Hasselgren, D.D.S., Ph.D. The answer could depend upon the practitioner's age and clinical training. But to achieve the best here is an old story about a dentist who, when he had sotten an overfill, wrote in the patient's chart: “Filled accord- ing to Calahan-Johnson.” When the root filling was short, he wrote “Filled according to Davis.” The story reflects how differ- ent generations of dentists have been taughtto carry out endodontic treatment. In the early days, an overfill “proved” that the whole canal was filled; so an overfill was desirable. Later, the wisdom of shoving a foreign material into the peri- radicular tissues was questioned, and the general recommendation became: “fill to the apex.” Howev- et, studies have shown that the radiographic apex and the apical foramen in most instances are two different things (Kuitler, 1955). Therefore, endodontists like Davis (1921) and Nygard-Ostby (1939), who based their clinical recommenda- tions on anatomic studies, said that the root fillings should ideally end {4 NYSDU JUNELIULY 1994 possible result, stay inside the canal. inside the apical foramen, at the narrowest portion of the canal. Inrecent years, dental schools have started to teach that the root filling should end shy of the radio- graphic apex. So, to a great degree, root fillings end at different levels depending on which year the den- tist graduated. The logical question emerg- es: Does it matter where the root filling ends? There are quite a few gray areas in dentistry, and many of our procedures are based on opinions, not on facts. Therefore, we must thoroughly evaluate the procedures we have adopted. There is only one way to do this, and that is to follow up on patients who have had root canal treatments. These “prognosis studies” are the clinician's way of achieving quality control. Prognosis studies must be based on a sufficient number of patients. The material must not be selected, which means that all treat- ed teeth must be included in the study. Far too often one will read enthusiastic reports on some new treatment method or a new mate al, yet only a few cases are pre- sented. This is not acceptable as a Dr. Hasselgren is profesor and chairman, Depart- ‘ment of Endodontics, Columbia University School of Dental end Oral Surgerytrue evaluation of the outcome of a particular treatment. ‘A good prognosis study must be carefully designed using strict criteria; and all pertinent data must be presented so that the reader can make his/her evaluation. There is certainly a lot of planning and work involved in carrying out such a study. However, this is the only way to determine the facts, to free us from beliefs, and to eliminate the wishful thinking and biased opinions on which our treatment methods are, unfortunately, too of- ten based. Prognosis studies are based on hundreds of cases in order to pick up factors that influence the outcome. Informed by these stud- ies, we have increased the odds for a successful outcome in individual cases, There are quite a few impor- tant prognosis studies done within endodontics. The classic study by Strindberg (1956) is still quite rele- vant, and his work has inspired other investigations. The results might vary somewhat from study tostudy depending on, among oth- er things, the methods used and differences in interpretation. How- ever, there is one finding that is common toall these prognosis stud- ies: an overfill will markedly de- crease the success rate (Strindberg 1956; Grahnén & Hansson 1961; Seltzer, Bender & Turkenkopf 1963; Grossman, Shepard & Pearson 1964; Harty, Parkins & Wengraf 1970; Motven 1974; Adenubi & Rule 1976; Barbakow, Cleaton-Jones & Friedman 1980; Swartz, Skidmore & Grif- {fin 1983; Sjogren, Hlgglund, Sundquist & Wing 1990). The optimal result is to end the root filling one to two mm in- side the radiographicapex—exactly the same recommendation that emerged from the anatomic stud- ies. Ifthe root filling is shorter than that, the success rate will drop; but overfill will yield an even poorer result. Endodontic treatment is of- ten technically difficult. Canals may be curved, apices may be difficult to visualize radiographically, elec- triccanal length measuring devices may render obscure readings, to name a few problems. In other words, it is sometimes very diffi- cult to know where the root canal ends and the rest of the body be- gins. Therefore, upon studying a radiograph, we are sometimes sur- prised to find that we have created an overfill, though the goal was to stay inside the apical construction. Nothing is 100 percent cer- tain when one is dealing with biology; and this is certainly the case regarding the location of the apical foramen and the apical con- striction. It is often impossible to know where the apical foramen is, located until after the root has been filled. ‘Does this mean that if we see a puff of root filling material periapically that apical surgery should be carried out imumediaté- ly? Of course not. But if we continuously show root fillings with “puffs,” the number of suc- cessful cases will be lower than if we let our fillings stop within the canal, ‘The outcome in an individual case is based on correct diagnosis, proper cleaning and shaping of the canal, and a well-condensed filling providing an optimal seal. The pres- ence of an overfill is definitely not desirable, but proper cleaning to remove infection and /or pulpal tis- sue, proper shaping to make a good filling possible, and a proper well- condensed root filling to seal the canal are even more important fac- tors. However, as we should aim for the best possible result, the rec- ‘ommendation is to stay inside the root canal. References 1. Adenubi JO, Rule DC. Success rate fr root flings in young patients: A retrospective analysis of treated cases. Brit Dent J. Ivrea 27, 2, Burbakow FH, Cleaton Janes, Friedman D. Anevaluation ofootcanal therapy in gener: al. dental practice. Il, Postoperative bservations J Endodon 19803548, 3. Davis WC Structuralchanges withinthepulp canals ofteeth following partial pp tenor Sl Dent Cosmos 1921611198 4, Davis WC.Pulpotomy and parti pulp canal filing. Dent Suramary 1921,41:311 5, Grahtin H, Hansson L. The prognosis of pulp and root canal therapy. A clinical and Eadiographic. follow-up” examination, Odontol Revy 196:12146"165, 6. Grossman] ShepardLl Pearson,LA Roent- genologic and’ clinical obturation of fdodontcally treated teeth, Oral Surg Oral ‘Med Oral Path 196417368376 7. Harty E], Parkin 8, Wengraf AM, Success zate in oot canal therapy A retropective Study’ of conventional cases, Brit Dent J. iw7070. 8, HelingB,Tamse A, Evaluation ofthesuccese fof endodontcally treated teeth. Oral Surg (ral Med Ora Path 1970;30585, 9, Kutler¥, Microscope investigation of root apices. | Am Dent Assoc 1955 50.54. 10, Molven©. The frequency, technicalstandar and results of endodontic therapy. Diserta- tion, University of Bergen, 1974 11, Nygard Ostby B, Ober die Gewebsvern- dlerungen im apikalen Paradentium des Menschen nach verschied enartigen Eingrtfen in der Wurzslkanlen. Norwessan Academy of Sciences, Oslo 1939, 12, Selter 8, Bender IB, Turkenkopf 8. Factors atfecting successful repair after rot canal therapy] Am Dent Assoc 1963; 67651 13, Sjogren V, Haglund B, Sundquist G, Wing K. Factors affecting the long term results oF ‘endodontic treatment. J Endodon 1990; 1698-504 114 Storms JL Factor that influence the success of endodontic treatment. J. Can Dent Assoc 196933553, 1B, Strindberg LZ. The dependence ofthe ests ofpulptherapy on certain factors. Ananalyt- te study based on radiographic and clinical follow-upexaminations Ada Odontol Scand 1956; 14Sappl 21 16, Swartz DB Skidmore AE, Griffin], Twenty years of endodontic success and failure. Endedon 19838198 NYSDU JUNELIULY 1994 95