Anda di halaman 1dari 4

Treatment of acute apical abscess by single visit endodontics

TREATMENT OF ACUTE APICAL ABSCESS BY SINGLE VISIT ENDODONTICS 2 CASE REPORTS


1 1

MANSOOR KHAN, BDS

RANA MUHAMMAD AHMED KHAN, BDS 2 MUHAMMED QASIM JAVED, BDS


2

ALIA AHMED, BDS, FCPS MUHAMMAD NABEEL, BDS


3

ABSTRACT The purpose to publish these case reports is to show the effectiveness of single visit endodontics in teeth with acute apical abscess. Infected non-vital teeth in two patients were treated with single visit RCT along with incision and drainage of the abscess in the same appointment. Follow up of both the patients showed relief of symptoms to remarkable extent in the evening of treatment day. Radiographs showed significant periapical bone healing after 3 months in both patients. INTRODUCTION Since its introduction, single visit endodontics has been a form of focus of controversy. Some advocate that all root canal treatments to be done in one visit while others do not consider it even in cases of vital pulp extripation.28 Some studies have reported statistically insignificant difference between single and multiple visit endodontics in terms of survival, post-operative pain or flare-ups.29-31 So, it depends only on the preference of the operator to adopt single or multiple visit endodontics.28 One of the acute emergencies in endodontics is acute peri-apical abscess due to an infected or non-vital tooth. Various treatment protocols and regimens using different tools have been designed and implemented on the basis of clinical results achieved by their users. The cardinal rule for managing all these infections is to achieve drainage and remove the source of the infection.3,4 Three avenues can address swelling and infection,1,2 establish drainage through the root canal, establish drainage by incising a fluctuant swelling and antibiotic treatment. But Systemic antibiotics provide no additional benefit over drainage of the abscess in the
1 2

case of localized infections and should be administered in the event of system complications ( fever, lymphadenopathy, cellulitis) or if the patient is immunocompromised.2 Cleaning and shaping are paramount to success regardless of drainage, because bacteria remaining within the root canal system compromises the resolution of the acute condition.5 Copious irrigation should be performed throughout the cleaning and shaping of the canal.6,7 CASE REPORTS 1 A 38 year old male was seen in this hospital with complaints of pain and swelling in the right upper quadrant and had mild fever. The pain was constant, throbbing, spontaneous, referred to the head region and lasted for several minutes after initiation. The pain was aggravated by hot foods and upon mastication. On extra-oral examination the patient had swelling of the right canine space without any lymphadenopathy. On intraoral examination a moderate fluctuant swelling was visible 3mm beneath the gingival margin on the buccal side between upper right canine and first premolar. Clinically the upper right first premolar

House Officers Post Graduate Resident, Department of Operative Dentistry, Islamic International Dental College and Hospital, Islamabad Head of Department of Operative Dentistry

Correspondence: Dr Rana Muhammad Khan, E mail: rana-ahmad@hotmail.com 0333-8143910


Pakistan Oral & Dental Journal Vol 31, No. 1 (June 2011)

199

Treatment of acute apical abscess by single visit endodontics

had discoloration of the crown due to caries with a moderately large carious lesion. The tooth showed a mild response to hot and cold test with moderate pain on percussion and palpation of soft tissues with grade 1 mobility. Radiographically the crown had caries with pulp exposure. The lamina dura was widened with apical radiolucency. The tooth was diagnosed to have acute irreversible pulpitis and acute periapical abscess. Once the tooth was diagnosed for endodontic treatment, access cavity was made and pulp chamber was opened and pus was allowed to drain. Incision was made by using surgical blade #11, and drainage by artery forceps and bone trephination. Maximum drainage of pus was achieved by compressing the swelling followed by copious irrigation with saline. When pus stopped draining, canals were copiously irrigated with saline. Then canal was prepared by step back technique with 15-60K file. 5.25% sodium hypochlorite was inserted into the canal for 30 seconds and copious irrigation was done before changing to next file. Canals were obturated with gutta purcha cones and eugenol based sealer by lateral cold condensation technique, once they were prepared. Crown was temporarily filled with glass-ionomer cement. Quarter inch rubber dam (latex) was cut to make a drain and was inserted and sutured into the incision made for drainage. Patient was medicated with coamoxi-clav, metronidazole and naproxen sodium. Patient was called in the evening to know the extent of swelling, pain

and pyrexia which was considerably reduced. On follow up after 3 days, swelling, pyrexia and pain were not present. Considerable bone healing was present at three months post operative visit. Patient was followed up every 3 months till one year no signs of recurrence of apical infection were noted. (Figs 1-3) 2 A 15 year old male patient was referred to the Operative Department of Islamic International Dental Hospital for the treatment of lower left and right central and lateral incisor teeth. The patient stated that he had a bicycle accident when he was 10 years old and had not seen a dentist since then. The patients history did not reveal whether the teeth were luxated, intruded or extruded. He sometimes had mild pain and swelling in the mandibular anterior region. Clinical examination of soft tissues showed no signs of scarring or fistulae. None of these teeth were discoloured. Both the central and lateral incisors were slightly sensitive to percussion and palpation without any mobility. Mandibular right and left lateral and right central incisor teeth failed to respond to electric pulp testing, whereas the mandibular left lateral incisor response was within normal limits. Periapical radiographs showed a large radiolucent lesion around the apices of the lower incisors with a well-defined margin around the apex of the lower left lateral central incisor. This tooth gave a normal response to electric pulp tests. Despite this

Fig 1

Fig 2

Fig 3

Fig 1: Preoperative radiograph showing radiolucency at the apical end of the first premolar. Fig 2: 3 months post-operative radiograph. Fig 3: 12 months post-operative radiograph showing adequate bone healing.
Pakistan Oral & Dental Journal Vol 31, No. 1 (June 2011)

200

Treatment of acute apical abscess by single visit endodontics

Fig 4

Fig 5

Fig 6

Fig 7

Fig 4: Pre-operative radiograph showing mandibular central and lateral incisors with large peri-apical lesion. Fig 5: Post-operative radiograph taken immediately after completing the procedure in first visit. Fig 6: Radiograph taken at follow-up examination 6 months after completion of endodontic treatment. Healing of periapical lesion is evident. Fig 7: One year post-operative radiograph. Radiograph shows that the radiolucent area was absent and that trabecular bone was forming. Clinical examination showed no sensitivity to percussion or palpation and the soft tissues were healthy. positive sensitivity test, root canal treatment was initiated on all mandibular incisors. Following access cavity preparation, vital pulp tissue was extirpated and the working length was estimated as being 1 mm short of the radiographic apex. The canal was prepared with size 1560 K-files using a step-back technique. The other three incisors had necrotic pulp tissue and were accessed and size 15 K-files were passed beyond the apical foramen. Mucopurulent fluid was drained through incision made in the fluctuent swelling by surgical blade #11 and bone trephination. When drainage ceased, rubber dam drain was sutured and canals were prepared 1 mm short of the radiographic apices with size 1560 K-files using a step-back technique. During preparation canals were copiously irrigated with sodium hypochlorite (30 sec) and normal saline. Cold lateral condensation was done and post-obturation radiographs taken. (Figs 4-7) DISCUSSION Traditionally, endodontic treatment of teeth with apical abscess aims at the complete elimination of microbial invaders of the root canal system. Studies have shown that instrumentation and irrigation of the root canal system substantially reduce the number of cultivable microorganisms but rarely lead to a total
Pakistan Oral & Dental Journal Vol 31, No. 1 (June 2011)

eradication.8,9 For this purpose intra-canal dressing (calcium hydroxide) is recommended.10,11,12 But it has obvious disadvantages i.e. it does not repeatedly kill the intra-canal flora,9,13,14,15,32 it needs multiple visits to be optimally potent.11 Minute differences in peri-apical healing were observed among individuals undergoing single visit and multiple visit root canal treatment,28-31 and bacterial growth at the second appointment had a significant negative impact on healing of the peri-apical lesion.17 In addition to this, the clinical efficacy of sodium hypochlorite irrigation in the control of root canal infection is much more than the effectiveness of inter-appointment calcium hydroxide dressing, in disinfecting the root canal system and treatment outcome, indicating the need to develop more efficient inter-appointment dressings.17 E. faecalis is the most resistant bacterium against calcium hydroxide18 while sodium hypochlorite is effective against it in both buffered and unbuffered states.19 However, quantity of the irrigant is more important than type of the irrigant,21 therefore copious irrigation is recommended. Intra-canal medicaments can only work efficiently if they are in direct contact with micro-organisms. Most of the micro-organisms causing endodontic failure, resides deep in dentinal tubules or accessory canals and multiple visits allow them to proliferate resulting in poor apical healing and endodontic fail201

Treatment of acute apical abscess by single visit endodontics

ure.22,23 Therefore these days it is considered a better option to disinfect the canals with copious irrigation of 5.25% sodium hypochlorite and sealing the canals resulting in elimination of the sources which will allow the multiplication of micro-organisms and therefore allow better peri-apical healing and better treatment outcome. The effectiveness of a clinical strategy must not be evaluated only from a biological point of view but other factors such as cost, patient comfort, and effort put into the treatment by the dentist should be included in the final assessment.16 In single visit root canal treatment net profit for the dentist is almost 50% which reduces to 14% in second visit and 25% loss at third visit.20 From patients point of view one has to lose more hours of work for multiple visits and needless travels are required. Without question, single appointments are preferred by most of the patients.20 CONCLUSION Treatment of acute apical abscess by incision and drainage and single visit endodontics in the same visit proves to be much better alternative than traditional treatment protocols of treating acute apical abcess i.e. incision and drainage in first visit and completing root canal treatment in multiple visits with calcium hydroxide as inter-appointment dressing. Because of the low sample size further studies are warranted in this field of endodontics. REFERENCES
1 2 3 4 5 6 7 8 Pathways of pulp page 52, 9 ed, 2006, Elsevier Emergency management of acute apical abscess in adults. Canadian collaboration on clinical practice guidelines in dentistry 2003. Harrington GW, Natkin E. Midtreatment-flare ups. Dent Clin North Am 1992; 36: 409. Hutter JW. Fascial space infections of endodontic origin. J Endodon 1991;17:422. Mattuso RJ, Goodall LB. Anaerobic isolates in primary pulpal alveolar cellulites cases: endodontic resolution and drug therapy considerations J Endodon 1983;9:535. Harrison JW. Irrigation of the root canal system, Dent Clin North Am. 1984;28:797. Turkun M, Cengiz T. The effects of the sodium hypoclorite and calcium hydroxide in tissue dissolution and canal cleanliness. Int Endodon J 1997;30:335. Bystrm A, Sundqvist G. Bacteriologic evaluation of the efficacy of mechanical root canal instrumentation in endodontic therapy. Scand J Dent Res 1981;89:32128. Dalton BC, rstavik D, Phillips C, Pettiette M, Trope M. Bacterial reduction with nickel-titanium rotary instrumentation. J Endod 1998;24:76367.

10

Bystrm A, Claesson R, Sundqvist G. The antibacterial effect of camphorated paramonocholorophenol, camphorated phenol and calciumhydroxide in the treatment of infected root canals. Endod Dent Traumatol 1985;1:170 75. 11 Sjgren U, Figdor D, Spngberg L, Sundqvist G. The antibacterial effect of calcium hydroxide as a short-term intracanal dressing. Int Endod J 1991;24:119 25. 12 Shuping GB, rsatvik D, Sigurddsson A, Trope M. Reduction of intracanal bacteria using nickel-titanium rotary instrumentation and various medications. J Endodon 2000;26: 75155. 13 Akpata ES. Effect of endodontic procedures on the population of viable microorganisms in the infected root canal. J Endod 1976;2:369 73. 14. rstavik D, Kerekes K, Molven O. Effects of extensive apical reaming and calcium hydroxide dressing on bacterial infection during treatment of apical periodontitis: a pilot study. Int Endod J 1991;24:17. 15 Peters LB, van Winkelhoff AJ, Buijs JF, Wesselink PR. Effects of instrumentation, irrigation and dressing with calcium hydroxide on infection in pulpless teeth with periapical bone lesions. Int Endod J 2002;35:1321. 16 Sackett D. Evidence Based Medicine: How to Practice and Teach EBM, ed 2. Edinburgh: Churchill Livingstone; 2000. 17 Waltimo T, Trope M, Haapasalo M, rstavik D. Clinical efficacy of treatment procedures in endodontic infection control and one year follow-up of periapical healing. J Endod. 2005;12: 863-66. 18 Bystrom A, Claesson R, Sundqvist G. The antibacterial effect of camphorated paramonochlorophenol, camphorated phenol and calcium hydroxide in the treatment of infected root canals. Endod Dent Traumatol 1985; 1: 17075. 19 Zehnder M, Kosicki D, Luder H, Sener B, Waltimo T. Tissuedissolving capacity and antibacterial effect of buffered and unbuffered hypochlorite solutions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94: 75662. 20 Senia ES, Wildey WL. Single visit endodontics- A time for change.Dental town 2004;9:42-48. 21 Siqueira JF Jr, Rjcas IN, Souto R, de Uzeda M, Colombo AP. Actinomyces species, streptococci, and Enterococcus faecalis in primary root canal infections. J Endod 2002;28: 16872. 22 Oguntebi B. Dentine tubule infection and endodontic therapy implications. Int Endod J 1994;4:218-22. 23 Peters LB, Wesselink PR, Moorer WR. The fate and the role of bacteria left in root canal dentinal tubules. Int Endod J 1995;2: 95-99. 24 Gatewood RS, Himel VT, Dorn SO. Treatment of the endodontic emergency a decade later. J Endod. 1990; 28: 261-65. 25 Southard D, Rooney T. Effective one visit therapy for the acute apical abcess. J Endod. 1984;10: 580. 26 Jurcak JJ, Bellizzi R, Loushine RJ. Successful single visit endodontics during operaion desert shield. J Endod. 1993;19: 412-13. 27 Eleazer PD, Eleazer KR. Flare up rate in pulpally necrotic molars in one visit versus two visit endodontic treatment. J Endod. 1994;9: 614-16. 28 Sathorn C, Parashos P, Messer H. Australian endodontists perceptions of single and multiple visit root canal treatment. Int Endod J. 2009 ;9: 811-18. 29 Fleming CH, Litalcer LS, Alley LW, Eleazer PD. Comparison of classic endodontic techniques versus contemporary techniques on endodontic treatment success. J Endod. 2010;3: 414-18. 30 Figni F, Lodi G, Gorm F, Gagliani M. Single versus multiple visits for endodontic treatment of permanent teeth. Evidence based dentistry. 2008;1:24. 31 Single or multiple visit endodontics: which technique results in fewer postoperative problems. Int Endod J. 2008;2: 91-99. 32 Balto KA. Calcium hydroxide has limited effectiveness in eliminating bacteria from human root canal. Int Endod J 2007;1: 2-10.

Pakistan Oral & Dental Journal Vol 31, No. 1 (June 2011)

202