Category Archives: Emergency

New Antibiotic Guidelines

While the most important step in managing endodontic infections is prompt treatment by general dentists or endodontists, use of antibiotics when indicated may be necessary in managing certain endodontic emergencies.  The American Association of Endodontists (AAE) has recently updated the guidelines for the use of systemic antibiotics for the urgent management of dental infections.  The full article can be viewed here.

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In summary:

  • antibiotics are NOT indicated in immunocompetent patients who have no evidence of lymphadenopathy, fever, malaise, fascial space involvement
  • first line of effective antibiotics in endodontic infections: amoxicillin 500mg
  • in resistant infections: amoxicillin combined with metronidazole 500mg
  • in patients with true allergy to penicillin (i.e., history of anaphylaxis, angioedema or hives): azithromycin 500mg
  • in patients with reported allergy to penicillin (i.e. not true allergy): oral cephalexin 500mg
  • if patient cannot take azithromycin: clindamycin 300mg
  • clindamycin now has U.S. FDA black box warning for C. difficile infection, which can be fatal.
  • antibiotic treatment is discontinued as soon as definitive treatment and improvement of the condition occurs (as short as three days).

CSI: canine space infection.

The maxillary canine space can become directly involved as the result of infections from the maxillary canines. The infection from these long teeth can involve the canine space, the area superior to the muscles of facial expression. The resultant swelling obliterates the nasolabial fold on the affected side [obliteration of the nasolabial fold on the right side of patient’s face in the image below].

canine space infection

Superior spread of CSI, if not treated, may cause orbital/periorbital cellulitis or cavernous sinus thrombosis, both very serious infections requiring aggressive surgical interventions.  Emergency treatment for such infections include establishing drainage [detail described in previous post “Don’t Let the Sun Set on Pus!“], removing the source of infection through access, instrumentation, irrigation and placing intracanal medicament and prescribing antibiotics if indicated.  Antibiotics alone is not sufficient.


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Not Every Hole is a Canal!

Sometimes when we try locating canals during access preparation stage, we may accidentally exit the pulp chamber in the wrong spot and create perforations.  Perforations or accidental communications need to be repaired as soon as possible in order to achieve the best possible prognosis.  The choice of repair material depends on the location and the size of perforation. MTA is still one of the best materials that can be used to seal the pulp floor perforations as long as it is not communicating with the sulcus.

To Prevent Perforations:
1. The pulp chamber floor is always at or slightly below the level of CEJ and the canals are located at the periphery of the pulp chamber floor.  Any attempt to locate canals farther apically may result in perforation.
2. The chamber floor colour is always greyish. If the colour during locating canals is turning dentin-colour, that would be the best time to stop and reorient ourselves.
3. Always probe around the CEJ to gain a better appreciation the outline of the root trunk, as the chamber floor is at the center and concentric to the CEJ outline.
4. When in doubt, stop and take an X-ray to confirm that treatment is progressing in the right direction.

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To Treat Perforations:
1. If facing significant difficulty with locating canals, the procedure should be stopped, the tooth should be medicated with CaOH, and patient should be referred out for proper care.  More digging may result in multiple perforation sites, further weakening of the tooth structure and enlargement of the existing perforation site, which ultimately results in an unfavorable outcome.
2. If canals are already located, ignore the perforation site, complete the root canal treatment and repair the perforation site with MTA.  Attempting to repair the site before obturating the canals may result in the repair material occluding the shaped and cleaned canals.
3. When dealing with established infection in the canal system which benefits from the utilization of short term CaOH medicament, the perforation site can be repaired and sealed before final obturation. In this case, the other canals need to be protected by paper points while the site is being repaired (the above case).


I’m having a flare-up!

When our patients experience a “flare-up”, we wish they were experiencing a transcendental jazz trumpet experience, and not the other kind, the endodontic kind!

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Fortunately, the reported incidence of flare-ups is relatively low, generally somewhere between 1-8%.  But when it happens, no one is happy, which is a negative experience for the patient, of course, but is hard on the clinician too, especially when we secretly congratulated ourselves only 12 hours earlier for getting through that tough and calcified access or for creating one of the most beautiful obturation radiographs known to man. It can happen to any of us, and we cannot predict who, exactly, will experience a flare-up.

Definition:  moderate to severe pain hours or days after initiation or completion of endodontic treatment, with or without swelling.

Etiology & Diagnosis:  the main culprit is usually microbes, but can be due to mechanical or chemical reasons too.  Over-instrumentation, incomplete instrumentation, apical extrusion of infected debris, and the irrigants or sealers used can all contribute to the occurrence of a flare-up.  The diagnosis of a flare-up is often simple, but is important to rule out pain from adjacent teeth and pain of non-endodontic origin.  The local considerations for the tooth itself might include a crown or root fracture or an untreated canal (particularly if there is temperature sensitivity).  We also need to identify any signs of spreading infection, osteomyelitis, fever, swelling, etc., and treat that appropriately, with the appropriate antibiotics and very careful follow-up, or referral to an oral surgeon if there is potential for danger, which can develop extremely quickly.

Management:

1. Reassure your patient: patient does appreciate when we explain what is happening and why, and the steps we are going to take, including following up.

2. Definitive treatment:

  • opening the tooth up under a rubber dam again, to provide re-instrumentation to a proper working length with copious irrigation.  This also gives us a chance to search for any untreated canals, and allow for any suppurative drainage.  If there is drainage, allow the tooth to drain, which can take several minutes.  Avoid leaving the tooth “open” – that is, without a temporary filling in the access- and always place an intra-canal medicament, such as calcium hydroxide.  Occlusion can be reduced.
  • incise and drain (I&D) if there is vestibular swelling.  If the abscess is localized, generally antibiotics are not needed unless there are other signs of systemic infection, cellulitis, poor drainage, or immune compromise.
  • cortical trephination – the jury is out on this one.  While this is not indicated routinely, it should be considered in areas with dense and thick cortical plates (i.e. lower molars).

Drugs: NSAIDS such as ibuprofen address inflammation very well, but some patients may require stronger analgesics, or combinations of analgesics for adequate pain relief.  My “go-to” is generally ibuprofen, and I rarely find that I need to prescribe narcotic analgesics.  However, I will consider acetaminophen only (plus or minus an opioid), other NSAIDS, or combinations of analgesics, depending on the patient’s risk of GI bleeding.  Antibiotics will not reduce post-treatment pain or decrease the risk of developing a flare-up when used prophylactically, but are indicated when there is sign of systemic involvement, presenting as fever, malaise, cellulitis, lymph node involvement, trismus, rapid onset of severe infection, or a compromised immune system.

Prevention: it is important to inform your patients that they may experience a flare-up!  Tell them what to expect, how to identify the symptoms, and how they may reach you if this should happen.  I discuss this possibility with every patient.  If your patient comes to you with significant pain before you even start treatment, now is the time to consider pre-operative dosing of analgesics, and possibly a single oral dose (some prefer supra-periosteal infiltration) of an appropriate steroid (a common dose is 4 mg of dexamethasone) if there is no know contraindications.  Finally, shaping techniques such as a “crown-down” method may help prevent us from pushing infected debris into the periapical area.


Antibiotics: Knowing When Not To Use Them!

Inappropriately prescribing antibiotics is one of the main contributing factors in the development of antibiotic resistant microorganisms.

The most effective treatment of endodontic infections are: removal of the source of infection through endodontic treatment, incision for drainage, or extraction.  Antibiotics are used in addition to appropriate treatment to aid the host defenses in the elimination of remaining bacteria.

Antibiotics are INDICATED when there is systemic involvement or evidence of spread of infection.  Signs and symptoms include: fever >100F, malaise, cellulitis, unexplained trismus, lymphadenopathy, rapid onset swelling.  Antibiotic prophylaxis should also be considered for medically at-risk patients, for prevention of infective endocarditis and delayed prosthetic joint infection.

Antibiotics are NOT INDICATED in: teeth with signs of irreversible pulpitis (hot teeth, cracked teeth, teeth with large decays, etc.), teeth with necrotic pulps and a radiolucency, teeth with a sinus tract, and teeth with localized fluctuant swellings.

What to use?  Pen-V-K is the antibiotic of choice for endodontic infections.  Metronidazol should be used in combination with Pen-V-K or clindamycin if patient’s symptoms worsen 48-72 hours after the initiation of treatment.  Amoxicillin is often used for antibiotic prophylaxis cases.  Clindamycin is the antibiotic of choice for patients allergic to penicillins or when a change in antibiotic is indicated.  Amoxicillin-Clavulanate should be reserved for unresolved infections and patients who are immunocompromised.

[AAE Colleagues for Excellence – Summer 2006]


Don’t Let the Sun Set on Pus!

One of my favorite instructors at UBC, Dr. Matthew, used to say this all the time and I think it is a very good advice. Here is a case that walked into my office a few weeks ago. A young female patient developed a very large and extremely painful swelling over night on the roof of her mouth. She had been in pain for a few days prior to the the development of swelling for which she had been placed on appropriate type and dosage of antibiotics. Tooth#25: previously treated ~5 years ago, crown came off due to long-standing leakage one month ago, cemented back on permanently, pain started 2 weeks ago, referred out by her dentist for re-treatment.

At emergency appointment, I&D was performed. For achieving appropriate and safe drainage, the tip of the blade should make contact with the bone and the incision line must be parallel to the path of nerve and blood vessels in the area. Rinse the area with saline and apply digital pressure with moist gauze. I personally do not place a drain in.

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When the patient returned a week ago, she was comfortable and ready to continue with the initiation of re-treatment. Antibiotics alone would have not helped in this case and there is usually no real need for initiation of re-treatment at the emergency appointment.


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