Emergency Case II:
Pulpal Debridement, Incision and Drainage (Intra-oral)
Victoria E. Tountas
Chief Complaint
“My tooth started hurting really bad yesterday. Today I woke up swollen. I can’t even touch the tooth with my tongue; the pain is excruciating.”
Medical History
The patient (Pt) was a 42-year-old male who had hypertension and was at the time on Hydrochlorothiazide/Valsartan 160 mg/12 mg per os per day. No known drug allergies (NKDA) were reported. Previous physical examination had been within the preceding six months.
The Pt was American Society of Anesthesiologists Physical Status Scale (ASA) Class II.
Dental History
The Pt reported that tooth #19 had received a porcelain-fused-to-metal (PFM) crown approximately two years previously. Pt started experiencing pain the previous day, and the pain rapidly intensified overnight. Pt noted extra-oral swelling on his lower left (LL) quadrant on the morning of his visit to this office (Figure 5.1). The pain was severe, constant and throbbing in nature; spontaneous and aggravated by mastication and pressure; and was intensified with supination. The pain localized to tooth #19 (The Pt pointed to offending tooth). The Pt had also been experiencing referred pain to his left ear. The Pt had not been able to get relief after four tablets of Ibuprofen 200 mg.
Figure 5.1 Pt presents with extra-oral swelling on LL quadrant and facial asymmetry.
Clinical Evaluation
Examinations
Extra-oral Examination (EOE)
There was facial swelling in the LL quadrant (Figure 5.2); The temporomandibular joint (TMJ) showed no popping, clicking or deviation on opening; lymph nodes were not swollen.
Figure 5.2 Extra-oral swelling on LL with asymmetry.
Intra-oral Examination (IOE)
Soft tissue was erythematous (Figure 5.3); with swelling. There was no sinus tract and oral hygiene was fair. The Pt had a PFM crown on tooth #19.
Figure 5.3 Intra-oral swelling on buccal area of tooth #19. Gingival tissues are erythematous.
Diagnostic Tests
| Tooth | #19 | #18 |
| Percussion | +++ | – |
| Palpation | +++ | + |
| Cold | – | + |
| Heat | Not performed | Not performed |
| Mobility | Grade 1 | 0 |
| Bite Stick | +++ | + |
| Discoloration | None | None |
| Periodontal Examination | ||
| Probing Depth | 4 mm | 3 mm |
| Recession | 0 | 0 |
| Furcation | 0 | 0 |
| Bleed Probing | +++ | ++ |
+++: Significant response to percussion, palpation and bite stick and significant probe bleeding.
Radiographic Findings
Tooth #19 presented with PFM crown (Figure 5.4). Teeth #18 (partially visible), #20 and #21 (partially visible) were also present. Large periapical radiolucency (PAR) noted on mesial (M) root. Radiolucency extended to mid-root level. M root appeared severely calcified. Distal (D) root presented with PAR. The pulpal chamber appeared calcified. Crestal bone appeared intact. Tooth #18 also presented with PFM crown. Mesial root of tooth #18 presented with periodontal ligament space (PDL) widening.
Figure 5.4 Preoperative radiograph of tooth #19. Tooth #19 presents with PFM crown, large PAR on M root and smaller PAR on D root. MB and ML canals appear calcified.
Pretreatment Diagnosis
Pulpal
Pulp Necrosis, tooth #19
Apical
Acute Apical Abscess, tooth #19
Treatment Plan
Recommended
Emergency:Emergency palliative debridement (open and medicate), and Incision and Drainage (I&D)
Definitive:Non-surgical root canal treatment (NSRCT)
Alternative
Extraction, no treatment
Restorative
Build-up
Prognosis
| Favorable | Questionable | Unfavorable |
| X |
Clinical Procedures: Treatment Record
First visit (Day 1): Reviewed medical history (RMHX). Blood pressure (BP) was 131/98 mmHg, pulse 101 beats per minute (BPM) and regular. Treatment (Tx) plan was reviewed and informed consent was obtained. Operations: Emergency palliative debridement (open and medicate). Anesthesia and rubber dam isolation (RDI): topical anesthesia was obtained with benzocaine (20%) placed on buccal gingiva of tooth #19; lidocaine (lido) 2% with 1:100,000 epinephrine (epi) was given via inferior alveolar nerve block (IANB) (one carpule); articaine 4% with 1:100,000 epi was given via local infiltration on B gingiva, at the height of tooth #19 apices (one carpule). 10 minutes was allowed for anesthetic to take effect.
Pt reported numbness on left side of tongue and lower lip. Anesthesia was verified with application of explorer to B and L gingiva of tooth #19. Pt reported no sensation.
A medium-sized bite block was placed on Pt’s right side. A latex RDI was placed. OraSeal® (Ultradent Products, Inc., South Jordan, UT, USA) used on buccal (B) and lingual (L) surfaces to enhance isolation. A #14 RD clamp was used (Hu-Friedy, Chicago, IL, USA). Access was created through PFM crown with extra coarse diamond and Transmetal burs (Dentsply Sirona, Ballaigues, Switzerland) and refined with Endo-Z® bur (Dentsply Sirona, Ballaigues, Switzerland). A counterbalance was used to minimize discomfort to the Pt’s TMJ. Magnification and enhanced lighting were used throughout the procedure.
Heavy purulence was noted upon accessing pulpal chamber (Figure 5.5). Copious amounts of sodium hypochlorite (NaOCl) were used as an irrigant to facilitate drainage.
Figure 5.5 Purulent discharge noted upon accessing pulpal chamber. RDI in place with tooth #14. RD clamp and OraSeal® on B and L surfaces.
In cleaning and shaping, three separate canals were identified using endodontic explorer: mesiobuccal (MB), mesiolingual (ML) and D.
Initial scouting of canals was performed with stainless steel (SS) size #8 K-files. An electronic apex locator was used to determine canal lengths. All canals were patent. Canals were cleaned and shaped (C&S) using a combination of rotary and hand files. The cleaning and shaping procedure was initiated by enlarging the canal orifices with nickel–titanium (NiTi) orifice shaper rotary files. Copious amounts of NaOCl were used as irrigant throughout the procedure.
All canals exhibited slight curvature, and mesial canals were calcified. Instrumentation was performed using a hybrid technique. Electropolished NiTi rotary files were used, in conjunction with SS hand files (size #10), to verify patency. Following initial shaping up to size #20, .04 taper, purulence stopped and hemorrhage was noted through all canals (Figure 5.6).
Figure 5.6 Hemorrhage noted after initial C&S, under RDI.
MB and ML canals C&S to size #30, .04 taper at 21.0 mm. D canal was C & S to size #40, .04 taper at 20.5 mm.
Calcium hydroxide (Ca(OH)2) placement, temporary restoration and I&D: All canals were dried with paper points. Dry conditions were achieved with minimal hemorrhage still present in D canal. Ca(OH)2 was placed using an engine-driven Lentulo® Spiral Filler (Dentsply Sirona, Ballaigues, Switzerland). Proper distribution of Ca(OH)2 was verified by radiograph (Figure 5.7). Extrusion of Ca(OH)2 was noted radiographically on M root.
Figure 5.7 Ca(OH)2 placement verification. Extrusion noted on M root. D canal appears filled to mid-root level.
The tooth was temporized with cotton and CavitTM (3M, Two Harbors, MN, USA). The intra-oral swelling was incised with 15C scalpel at the most fluctuant point. Purulent and hemorrhagic discharge were noted (Figure 5.8). Digital pressure was applied to surrounding structures to facilitate drainage.
Figure 5.8 I&D performed on buccal gingiva. Hemorrhage and purulent discharge noted.
Pt was prescribed Ibuprofen 800mg / 6 hours, Amoxicillin 500 mg q8h (t.i.d.) and Chlorhexidine 0.12% (rinse). Pt was instructed to return in one week for completion of treatment, but to contact us if symptoms persisted or worsened.
Second visit (Day 7): Operations: NS-RCT: Pt presented asymptomatic, without intra-oral or extra-oral swelling.
Anesthesia and RDI: RMHX. BP was 123/87 mmHg, pulse 86 BPM and regular. Tx plan was reviewed and informed consent was obtained.
Topical anesthesia was applied (Benzocaine 20%) and placed on buccal gingiva of tooth #19. Lido 2% with 1:100K epi was given via IANB (1 carpule). Articaine 4% with 1:100K epi was given via local infiltration on B gingiva, at the height of tooth #19 apices (1 carpule). 10 minutes was allowed for anesthetic to take effect.
Pt reported numbness on left side of tongue and lower lip. Anesthesia was verified with application of explorer to B and L gingiva of tooth #19; Pt reported no sensation.
A medium size bite block was placed on Pt’s right side and a latex RDI placed. OraSeal® was used on B and L surfaces; to enhance isolation, a #14 RD clamp was used (Hu-Friedy, Chicago, IL, USA). CavitTM was removed with diamond bur and the cotton pellet was retrieved with an explorer. A counterbalance was used to minimize discomfort to the Pt’s TMJ. Magnification and enhanced lighting were used throughout the procedure.
No purulence was noted. Copious amounts of NaOCl were used as irrigant to remove remaining Ca(OH)2. MB and ML canals were further C&S to size #35, .04 taper at 21.0 mm. EDTA was used as final irrigating solution, to allow for smear layer removal.
Obturation and Temporary Restoration: All canals were dried with paper points. Dry conditions were achieved, without drainage noted. Gutta-percha (GP) points were selected based on the size of the final apical preparation and a master cone radiograph was obtained (Figure 5.9).
Figure 5.9 Master cone fit radiograph of tooth #19.
Canals were filled with warm vertical compaction (WVC), using AH26® Root Canal Sealer (Dentsply Sirona, Konstanz, Germany). Canal orifices were sealed with flowable composite to prevent contamination, and the tooth was temporized with cotton and CavitTM (Figure 5.10). Small sealer extrusion (puff) was noted on the M root. Tooth #19 treatment was completed uneventfully.
Figure 5.10 Postoperative radiograph of tooth #19, with sealer puff on M root.
Working length, apical size, and obturation technique
| Canal | Working Length | Apical Size, Taper | Obturation Materials and Techniques |
| MB | 21.0 mm | 35, .04 | GP and AH26® sealer, WVC |
| ML | 21.0 mm | 35, .04 | GP and AH26® sealer, WVC |
| DB | 20.5 mm | 40, .04 | GP and AH26® sealer, WVC |
The Pt was given the option to take a break during the procedure. He was told to return to general dentist for permanent restoration of tooth #19. The patient was informed that tooth might need extraction if not permanently restored upon completion of endodontic Tx.
Post-Treatment Evaluations
None available. Pt was a sailor and left the country the day after Tx was completed.
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