Emergency Case I:
Interprofessional Collaboration between Medical and Dental
Andrew Xu
Chief Complaint
“My daughter has a draining fistula on her face and her face has been swollen. What can we do about this?”
Medical History
The patient (Pt) was a 9-year-old Caucasian female. The Pt was healthy with no medical history of note. According to her parents, she was taking Clindamycin. Vital signs were: Blood pressure (BP) 115/68 mmHg, pulse 78 beats per minute (BPM) and regular, respiratory rate (RR) 18 breaths per minute. A temperature of 98.7° F was taken sublingually. A complete review of systems was conducted. No significant findings were noted, and there were no contraindications to dental treatment.
The Pt was classified as American Society of Anesthesiologist Physical Status Scale (ASA) Class I.
Dental History
The Pt’s mother stated that the Pt had a filling completed on tooth #19 a year ago. The Pt developed a toothache in the area three months ago and went to the general dentist to seek treatment (Tx). The general dentist stated that the tooth #19 did not require any Tx and that the pain was coming from tooth #18 due to eruption. No Tx was performed at the time. A few weeks later, the Pt developed left facial swelling and an extra-oral sinus tract (Figures 4.1 and 4.2). The Pt went to seek treatment at an otolaryngologist (ENT) office. The ENT drained the sinus tract (Figure 4.3), prescribed antibiotics and referred the Pt to the endodontic clinic. The Pt had spontaneous moderate pain while at the endodontic clinic.
Figure 4.1 Preoperative photograph, before drainage procedure by an otolaryngologist.
Figure 4.2 Preoperative photograph during the emergency appointment.
Figure 4.3 Postoperative photograph, after drainage procedure on the sinus tract by an otolaryngologist.
Clinical Evaluation (Diagnostic Procedures)
Examinations
Extra-oral Examination (EOE)
Examination showed facial swelling associated with the left mandible, extending to the inferior border of the mandible. Slight facial asymmetry was noted, with erythematous appearance over the cheek in the affected area. The left submandibular gland region and lymph nodes were palpable, moveable and tender. The temporomandibular joint (TMJ) demonstrated no discomfort to opening or closing, and no popping or clicking or deviation to either side upon opening. An extra-oral sinus tract was noted, and scar tissue had formed around the facial sinus track.
Intra-oral Examination (IOE)
Examination showed a fluctuant swelling in the area of the apices of the roots of tooth #19 with distension of the vestibular tissues.
Diagnostic Tests
| Tooth | #18 | #19 | #20 |
| Percussion | – | + | N/A |
| Palpation | – | + | – |
| Cold | + | – | N/A |
| EPT | + | – | N/A |
EPT: Electric pulp test; + : Severe response to percussion and palpation, normal response to cold and EPT; – : No response to percussion, palpation, cold, or EPT, N/A: Not applicable
Radiographic Findings
An initial periapical radiograph of tooth #19 was taken (Figure 4.4) which yielded a partial view of tooth #18. Tooth #19 had a deep occlusal restoration close to the mesial (M) pulp horn. The pretreatment radiograph demonstrated a small, well-defined periapical radiolucency (PARL) involving the distal (D) root apex. There was a widened periodontal ligament (PDL) around M root. Pt also had a radix entomolaris root on the distal (D) side of the tooth.
Figure 4.4 Preoperative radiograph.
Pretreatment Diagnosis
Pulpal
Pulp Necrosis, tooth #19
Apical
Acute Apical Abscess, tooth #19
Treatment Plan
Recommended
Emergency:Pulp Debridement and placement of calcium hydroxide (Ca(OH)2)
Definitive:Non-surgical Root Canal Therapy (NSRCT)
Alternative
Extraction or no treatment
Restorative
Core build-up and stainless steel crown until permanent crown can be placed
Prognosis
| Favorable | Questionable | Unfavorable |
| X |
Clinical Procedures: Treatment Record
First visit (Day 1): Pt’s medical history was reviewed (RMHX) and informed consent was obtained. The endodontic evaluation and treatment plan were discussed with the Pt’s parents; alternative Txs were discussed. Local anesthesia was obtained by inferior alveolar nerve block (IANB) and long buccal infiltration using 72 mg of 2% Xylocaine with 1:100,000 (0.036 mg) epinephrine (epi). The tooth was isolated with rubber dam (RD) placement and then access was made using a #330 carbide bur using a high-speed hand-piece under copious water. A non-vital pulp was noted. An Endo-Z® bur (Dentsply Sirona, Ballaigues, Switzerland) was used to de-roof the pulp chamber. Copious irrigation was conducted using sodium hypochlorite (NaOCl). M buccal (B), M lingual (L), DB, DL were found with the use of a dental operating microscope (Global Surgical Corporation, St. Louis, MO, USA). No evidence was observed of any fractures inside the tooth. The canals were negotiated with a size #10 hand stainless steel Lexicon® K-file (Dentsply Sirona, Johnson City, TN, USA) and a chelating agent (RC-Prep®; Premier Dental Products, Morristown, PA, USA). Working length (WL) was obtained using an electronic apex locator (Root ZX®II, J. Morita, Kyoto, Japan) and recorded. MB canal length of 19 mm was obtained using MB cusp, ML canal length of 18.5 mm was obtained using ML cusp, DB canal length of 20 mm was obtained using DB cusp, and DL canal length of 18 mm was obtained using DL cusp. The canals were cleaned and shaped with NiTi rotary instrument (EndoSequence®; Brasseler USA, Savannah, GA, USA) to size #35, .04 taper on the MB and ML canals. DB and DL were prepared to size #40, .04 taper. Canals were dried with paper points. Ca(OH)2 (Ultracal® XS; Ultradent, South Jordan, UT, USA) was applied as an inter-appointment medicament. CavitTM (3M, Two Harbors, MN, USA) was used for a temporary seal to the coronal access. The occlusion was examined and adjusted (Figure 4.5). Postoperative instruction (POI) was given. Pt was scheduled for next appointment.
Figure 4.5 Postoperative radiograph after the initial emergency treatment (pulp debridement and placement of calcium hydroxide).
Second visit (Day 13): RMHX. BP 109/67 mmHg, pulse 70 BPM and regular. The Pt presented as asymptomatic, with no signs of extra-oral swelling. A preoperative radiograph was taken (Figure 4.6). Local anesthesia was achieved with 72 mg. of 2% Xylocaine with 1:100,000 (0.036mg) epinephrine by IANB and B infiltration to tooth #19. A single tooth isolation was exercised with RD, temporary restorations were removed, and canals and chamber were irrigated with copious 2.5% NaOCl. The canals were dried with paper points. WL was re-established with an electronic apex locator. All canals were re-instrumented with NiTi rotary instruments, and master cones were fitted and verified with radiograph. The canals were obturated by vertical warm method by using gutta-percha (GP) and Roth’s 801 (Grossman type) sealer (Figures 4.7 and 4.8). Amalgam was used as a final restoration. Occlusion was examined and the final radiograph was taken. POI was given and Pt was advised to take children’s ibuprofen as needed for pain. The Pt was referred back to her dentist for any further Tx. Sealer extruded beyond the apex of the radix entomolaris root on radiograph needed to be monitored during follow-up.
Figure 4.6 Preoperative radiograph for the second visit after 13 days of calcium hydroxide treatment. Patient was asymptomatic at this appointment.
Figure 4.7 Master cone radiograph with gutta percha.
Figure 4.8 Final radiograph with gutta percha and amalgam core build-up.
Working length, apical size, and obturation technique
| Canal | Working Length | Apical Size | Obturation Materials and Techniques |
| MB | 19.0 mm | 35 | GP, Roth’s 801 sealer, Vertical warm compaction |
| ML | 18.5 mm | 35 | GP, Roth’s 801 sealer, Vertical warm compaction |
| DB | 20.0 mm | 40 | GP, Roth’s 801 sealer, Vertical warm compaction |
| DL | 18.0 mm | 40 | GP, Roth’s 801 sealer, Vertical warm compaction |
Post-Treatment Evaluation
Third visit (6-month follow-up): Pt came in for a six-month recall examination. She remained asymptomatic, EOE and IOE revealed no swelling, and tissue appeared healthy. Pt’s scar tissue development on her left side of neck area was still present (Figure 4.9). A periapical (PA) radiograph was taken (Figure 4.10). PDL and bone pattern were within normal limit (WNL). Pt’s parent had taken the Pt to see a dermatologist for the evaluation for the scar tissue in the previously facial sinus track region. Dermatologist’s report stated that Pt’s parent declined any Tx for the scar tissue.
Figure 4.9 Six-month recall photograph.
Figure 4.10 Six-month recall radiograph.
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