endodontic emergencies / orthodontic courses by indian dental academy
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ENDODONTIC EMERGENCIES
INTRODUCTION
EMERGENCY according to Dorland’s Medical dictionary is
defined as a sudden, urgent, usually unforeseen occurrence requiring
immediate action. Life threatening emergencies can and do occur in the
practice of dentistry.
Although, all forms of medical emergency may develop in dental
practice, some are seen with greater frequency. These are situations
produced entirely by stress or those that are acutely exacerbated when
the patient is under stress.
These situations include:
- Vasodepressor syncope.
- Respiratory difficulty.
- Airway obstructions.
- Hyperventilation syndrome.
- Asthma.
- Acute cardiovascular emergencies.
Effective management of STRESS in the dental office will
minimize the occurrence of these situations.
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Other life threatening situations that occur with greater
frequency in dental practice are those reactions associated with the
administration of DRUGS.
The most frequently observed reactions are those associated with
administration of local anesthetics.
Others are:
- Drug overdose.
- Drug allergy.
Most dental emergencies are unscheduled intrusions into the
routine of daily practice. Nevertheless the dentist must provide speedy
and effective relief because such care is essential part of daily practice.
The reason for endodontic emergency treatment is PAIN and at times
SWELLING ensuing from pulpoperiapical pathosis. Because dental
pain has many causes, the adept clinician must diagnose the origin of
pain as quickly as possible to render rapid and effective relief.
“Knowing what to do and when to do it are as important as knowing
how to do it”.
DIAGNOSIS
In an ACUTE pain emergency, the PHYSICAL as well as the
EMOTIONAL state of the patient should be considered. The doctors
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reactions to the patient is important for both pain and patient
management. The patients needs, their fears about the immediate
problem and their defenses for coping with the situation must be
understood.
The chief tool in establishing a correct diagnosis remains in
careful history taking followed by a thorough but quick clinical
examination.
According to Grossman – The diagnostic methods available to
clinicians are:
I. SUBJECTIVE SYMPTOMS : Which is the chief complaint of
patient eliciting either:
(A) 1) Pain
2) Swelling
3) Lack of function
4) Esthetics
II. DENTAL HISTORY
III. MEDICAL HISTORY
IV. OBJECTIVE SYMPTOMS
Which are determined by tests and observations performed
by clinicians.
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The tests are as follows:
1. Visual and Tactile Inspection.
2. Percussion.
3. Palpation.
4. Mobility and Depressibility.
5. Radiographs.
6. Electric pulp test
7. Thermal tests - Hot
- Cold
8. Anesthetic test
9. Test cavity
CLASSIFICATION OF ENDODONTIC EMERGENCIES
(A) According to WALTON
a) Pretreatment emergencies.
b) Interappointment emergencies.
c) Post-obturation emergencies
(B) According to GROSSMAN
1) Acute Conditions
1. Reversible pulpitis
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2. Irreversible pulpitis.
3. Alveolar abscess.
4. Periodontal abscess
2) Emergencies During Treatment
3) Fractures
Crown
Root
4) Avulsed tooth
5) Referred pain
(C) According to GUTTMAN
I] TREATMENT OF VITAL PULP
- Acute reversible pulpitis
- Hypersensitive dentin.
- Recurrent decay.
- Recent restoration.
- Cracked tooth syndrome.
II] TREATMENT OF NON-VITAL PULP
- Acute apical periodontitis.
- Necrotic pulp.
- Acute alveolar abscess.
- Phoenix abscess.
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- Acute irreversible pulpitis - Localized.
- Non-localized
III] AESTHETIC EMERGENCY
- Fracture of crown.
- Fracture of root.
- Avulsed tooth.
Coming to the PRE-TREATMENT EMERGENCIES
ACUTE PULPITIS
ACUTE REVERSIBLE PULPITIS [HYPEREMIA]
Definition:
Reversible pulpitis is a mild-to-moderate inflammatory
condition of the pulp caused by noxious stimuli in which the pulp is
capable of returning to the uninflamed state following removal of the
stimuli.
Symptoms:
A.R.P. is characterized by:
1. Sharp pain lasting for a moment.
2. Shooting pain lasting for short-duration.
3. Pain brought on by cold beverages and sweets.
4. Clinically – the patient can identify the tooth by pointing to it.
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Causes and Treatment
1) Caries Lesion which are close to pulp can cause mild
to moderate sensitivity to patients.
Treatment Caries excavation and placing a sedative cement like
dycal and zinc oxide eugenol (IPC).
2) Recent restoration which has a premature contact
point.
Treatment Recontouring or removal of high points.
3) Persistent pain and severe sensitivity after cavity
preparation Suggesting chemical leakage.
Treatment Removal of restoration and placing sedative cement
like ZOE.
4) Recurrent caries -> under an old restorations.
Treatment Remove all caries and replace with a sedative cement.
5) Thermal shock from preparing a cavity with a dull bur or
keeping the bur in contact with the tooth for a long time can cause
acute reversible pulpitis which exaggerates on placing a metallic
restoration over the tooth.
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Treatment Removal of metallic restoration and palliative
treatment by placing the cement.
Because the best treatment of reversible pulpitis is removal of
irritants of any sorts.
Prognosis: The prognosis is favourable if early removal of irritant is
achieved otherwise the condition may develop into irreversible
pulpitis.
ACUTE IRREVERSIBLE PULPITIS
Definition:
Irreversible pulpitis is a persistent inflammatory condition of the
pulp, caused by a noxious stimuli.
As opposed to that of reversible pulpitis, irreversible pulpitis is
caused by both hot / or cold stimuli.
Therefore, the difference between reversible and irreversible
pulpitis is distinguished by the duration of pain experienced by the
patient.
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Symptoms:
- Pain lasts for minutes to hours.
- It is spontaneous.
- It often continuous even when the cause is removed.
- Pain is present even on bending over.
- Patient complains of disturbed sleep.
- Pain is experienced on sudden temperature change.
- On taking sweets or acidic foodstuff.
- From packing of food into cavity/food impaction.
Causes:
1. The most common cause of irreversible pulpitis is bacterial
involvement of pulp through caries.
2. Reversible pulpitis may also deteriorate into irreversible
pulpitis.
In irreversible pulpitis the pulp may be Vital
Non-vital
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A) Vital pulp
According to Grossman, the preferable emergency treatment is
‘PULPECTOMY’ i.e. complete removal of the pulp and placement of
an intracanal medicament to act as a disinfectant or obtundent.
According to many authors like Weine, Walton and Grossman,
in posterior teeth, where time is a factor, PULPOTOMY or removal of
coronal pulp and placement of formocresol or similar dressing on the
radicular pulp should be performed as an emergency treatment whereas
in single rooted teeth pulpectomy can be performed directly.
Procedure:
- After administration of local anaesthesia.
- Access cavity is prepared.
- With a spoon excavator and round bur the coronal pulp is
removed.
- A cotton pellet moistened with formocresol is placed in the
cavity and it is sealed with ZnOE cement.
After removal of the tissue the site of inflammation precipitating
a painful response is gone.
The formocresol fixes the non-inflammed tissues in the canal
until the subsequent treatment of endodontics is followed.
The tooth involved is then relieved out of occlusion.
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B) Non-Vital Pulp
Necrotic pulp rarely causes an emergency procedure.
Most of the time these teeth do not respond to stimuli such as
hot, cold or electric stimulation, they may still contain vital inflamed
tissue in the apical portion of root canal and also inflamed periapical
tissue which causes pain.
Radiographically:
A) If a lesion is seen – ACUTE APICAL ABSCESS.
B) If no lesion is seen – ACUTE APICAL PERIODONTITIS
ACUTE ALVEOLAR ABSCESS
Also called as:
- Acute periapical abscess.
- Acute apical pericementitis
- Phoenix abscess.
Definition:
Is defined as a localized collection of pus in the alveolar bone at
the root apex of the tooth following death of pulp with extension of
infection through the apical foramen into the periapical tissue.
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Causes (Non-vital pulp)
a) Bacterial involvement.
b) H/O trauma.
c) Mechanical or chemical irritation.
The acute episode may result from:
1) PULPITIS that progressively developed into pulp necrosis
affecting the periapical tissues.
2) ACUTE EXACERBATION of a chronic periapical lesion
3) ENDO-PERIO lesion when the periodontal abscess
secondarily affects the pulp through the lateral canals or deep
infrabony pockets.
SYMPTOMS
There are local reactions like:
- Tenderness of tooth.
- Severe throbbing pain.
- Swelling.
- Sinus tract.
Systemic reactions are:
- Elevated temperature.
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- Gastro-intestinal disturbances.
- Malaise.
- Nausea.
- Dizziness.
- Lack of sleep.
TREATMENT
The main treatment is biphasic in nature i.e.
I – Debridement of canals.
II – Drainage of abscess.
The emergency treatment of acute alveolar abscess differs from
acute irreversible pulpitis, as the pulp is necrotic, local anaesthesia is
not required and frequently CONTRAINDICATED.
Forcing anaesthetic solution into an acutely infected and
swollen area may increase pain and may spread infection.
“BLOCK MAY BE USED IN SUCH CASES”
Most of the pain that occurs during access cavity preparation is
caused by tooth movement resulting from vibration of the bur therefore
one should stabilize tooth with finger pressure so that the pain is
reduced.
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Treatment procedure follows as:
1) Access cavity preparation.
2) Profuse irrigation avoiding forcing of any solution or debris into
the periapical tissue.
3) In most cases PURULENT EXUDATE escapes into the chamber
and indicates that root canal is patent and draining.
4) If drainage does not occur, the apical constriction is purposefully
violated and enlarged to a minimum of 20/25 No. instrument to
allow for exudate to drain because in most cases the apical
constriction may prevent the drainage.
According to GROSSMAN & COHEN leaving the tooth OPEN
for drainage reduces the possibility of continued pain and swelling.
Open root canals permit drainage and frequently eliminate the need for
surgical incision as well as routine administration of oral antibiotics
and analgesics.
According to WALTON, after copious irrigation, the canals are
dried with paper points and a medicated temporary cotton pellet is kept
– in other words – open dressing is given.
Some clinicians suggested that acutely abscessed teeth be sealed
with an intracanal medicament after the initial emergency treatment is
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done. According to them this stops the infiltration of new
microorganisms.
As opposed to them AUGUST found that only 3% out of 311
abscessed teeth which had been left open reacted adversely.
Therefore, the decision to keep the canal patent or closed must
be made depending on the amount of drainage and size of swelling.
SWELLINGS ASSOCIATED
1) If it is slight and localized it will disappear 24 to 48 hours after
drainage.
2) If it is extensive, soft and fluctuant an incision through soft
tissue is a must.
3) If swelling is hard – it can be converted to soft fluctuant state by
rinsing with hot saline solution 3-5 minutes at a time repeated
every hour.
ACUTE PERIODONTAL ABSCESS
It is often mistaken for an acute alveolar abscess.
Cause
It can occur with either Vital pulp
Necrotic pulp
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1) Its origin usually is an ACUTE EXACERBATION of infection
with pus formation in an existing deep infrabony pocket.
If the pulp is VITAL
Treatment Consists of curettage, debridement and establishment of
drainage of the infrabony pocket through sulcus.
If the pulp is NECROTIC
Treatment – extirpation and pulpectomy, similar to acute alveolar
abscess.
If the pulp is ABNORMAL and VITAL.
Treatment is same as acute alveolar abscess.
In any case, emergency periodontal treatment must be done
simultaneously otherwise the patient will not be relieved of pain and
swelling.
EMERGENCIES DURING TREATMENT
Endodontic emergencies can occur during the course of
treatment.
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Most emergency are reactive phenomenon to pressure and
chemical mediators created as a result of inflammatory response in
periradicular tissues.
According to Grossman
The emergencies can be due to:
1) Instrumentation beyond the root apex causing trauma to
periradicular tissue.
2) When debris and microorganisms are pushed beyond the apical
foramen which can cause an infectious reaction.
3) Chemical irritants like - Irrigating solution.
- Intracanal medicament
4) Incomplete debridement of all root canals.
5) Lost or depressed access cavity seals leading to recontamination.
6) Overfilled root canals with subsequent periapical inflammation.
The inflammation in the peri-radicular tissue is induced as a
result of release of substances such as vasoactive amines, kinins and
arachadonic acid metabolites. This interappointment emergency as
classified by WALTON is referred to as “FLARE-UP”.
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WALTON has suggested the possible factors related as
discussed before as:
1) Irritants within the pulp system.
2) Operator controlled or iatrogenic factors.
3) Host factors.
4) General systemic factors which are related to Flare-up.
Patients can accept that pain may continue to a lesser extent
when they come to the dental office for emergency treatment. What is
difficult for patients to comprehend is when they enter the office
having little or no pain before therapy but then encounter an explosive
flare-up after the treatment is done.
Therefore PREVENTION OF FLARE-UPS Can be done by:
1) The most important preventive measure is preparing the patient
to accept some discomfort which should subside in a day or two
i.e. psychological preparation of patients.
2) Using long acting anaesthetic solution.
3) Complete cleaning and shaping of root canals.
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4) Administration of appropriate analgesics, prophylactic
analgesics before next appointment reduces the incidence of
discomfort and flare-ups.
HYPOCHLORITE ACCIDENT
Another very important but rare emergency is due to expelling
of an irrigant such as NaOCl beyond the apex.
This happens only by locking the needle of the irrigating syringe
in the canal and forcefully injecting the irrigant.
Within minutes the patient feels SUDDEN EXTREME PAIN.
SWELLING within minutes.
Profuse, prolonged BLEEDING through the root canal.
This bleeding is the body’s reaction to the irrigant.
Remove the toxic fluid with high volume evacuation to
encourage further drainage from periradicular tissue.
Treatment:
1) Allow the bleeding to continue. If the body rids itself of toxic
fluid healing may be faster.
2) If the treated tooth is pulpless consider prescribing an antibiotic
and an analgesic for 5 and 3 days respectively.
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3) Since this may be hypersensitive reaction consider prescribing
an antihistaminic.
TRAUMATIC & ESTHETIC EMERGENCY
It can be broadly classified as:
1) Crown fracture.
2) Root fracture.
3) Tooth avulsion.
A traumatic injury to a tooth can cause a: - Cracked crown
- Fracture crown.
- Fracture root
And all this results in pain.
Coming to ‘CRACKED TOOTH SYNDROME’
Causes:
1) Intact tooth that has an opposing plunger cusp occluding
centrically against a marginal ridge.
2) Biting unexpectedly on a hard object like stone.
3) Trauma / blow.
Symptoms:
1. Sharp, piercing pain during mastication.
2. Fleeting pain on thermal changes.
3. Hypersensitivity.
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DETECTION is made by:
1) Dental history.
2) Transillumination.
3) Placing a disc and making the patient bite, the disc acts like a
wedge on the cracked tooth and causes pain.
4) Dye.
5) When a visible crack is found, lateral pressure, either digital or
from the handle of an instrument is applied to see if the segment
shears off or not.
TREATMENT
1) Immediate treatment is covering the exposed dentin with a
sedative cement like ZnOE and cementing a stainless steel band.
2) If a green stick fracture of the crown is present and the crown
segment does not shear off under pressure, one should cement
stainless steel band.
3) If the pulp is exposed, a band should be placed and cemented
and a pulpectomy should be performed.
4) This should be immediately followed by relieving of occlusion
by grinding the cusps of the tooth.
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Because any traumatic accident can temporarily affect the usual
responses to the electric pulp test, cold test and test cavity, negative
test responses for pulp vitality are non diagnostic and should not be the
basis for selecting endo emergency treatment. It is wiser to assume that
pulp is vital as vital pulp in the root canal of fractured tooth can
enhance the prognosis of healing.
CROWN FRACTURES
Crown fractures can be divided into 4 major groups:
1) Only enamel.
2) Enamel and dentine without pulp exposure.
3) Enamel and dentin with pulp exposure.
4) Untreatable.
ONLY ENAMEL
Can be treated by composite restoration.
ENAMEL AND DENTINE WITHOUT PULP EXPOSURE
Can be treated by early placement of restoration with pulpal
protection like sandwich technique.
ENAMEL AND DENTINE WITH PULP EXPOSURE
These fall into two categories Developing apex
Open apex
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It apex is developed pulpectomy.
If apex is open pulpotomy – patient is checked for apical
closure after every 3 months and then routine endodontic treatment.
UNTREATABLE
These imply to crown fracture in which an aesthetic and
periodontally healthy condition is impossible.
ROOT FRACTURE
Can be divided as : - Vertical
- Horizontal
Coronal third.
Middle third
Apical third.
Vertical fractures have hopeless prognosis because it is not
possible to either stabilize the fragments or remove one part surgically
and leave the other in situ.
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Horizontal fractures
Above alveolar crest excellent prognosis.
The closer the root fractures to the apex the more favourable the
prognosis as sufficient root length is seen if fracture fragment is to be
removed.
Treatment stabilize by ligation to adjacent teeth.
Check pulp vitality after 6 weeks as the pulp will be in a
“stunned” state.
If the fracture is at mid root or below the alveolar crest poor
prognosis.
If remaining root portion is left post and core can be given.
TOOTH AVULSION
The avulsed or luxated tooth is both a dental and an emotional
problem.
Cause:
Result of trauma to an anterior tooth of a young adult or child.
The longer the luxated tooth is out of its socket, the less likely it
will remain in a healthy, functional state after replantation.
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The instruction to the patients are:
1) To carry the avulsed tooth in a moist vehicle preferably in the
patients mouth i.e. saliva to maintain the viability of periodontal
ligament. Others are milk, saline etc.
The tooth should not be dried.
The extra-oral time for a tooth should not exceed 30 minutes.
Procedure
The tooth is placed in the socket
Ligated.
Stabilised and disoccluded.
Radiograph to verify the position should be taken.
This procedure was first given by ANDREASON
REFERRED PAIN
Although the most frequent cause of pain is pulpoperiapical
pathosis, the clinician knows that the pain can originate from many
other sources.
According to Hurwitz dental pain can have its origin in:
- Trigeminal neuralgia.
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- Atypical facial neuralgia.
- Migrane.
- Cardiac pain.
- Temporomandibular arthrosis.
Sinusitis or cold may refer to maxillary posterior teeth.
Pain arising from periodontal problems:
- Periodontal abscess.
- Occlusal trauma.
- Muscle spasm.
- Bruxism and clenching.
- Pericoronitis may be confused as pulpoperiapical pain.
Spicer reported pain referred to a lower molar from a basilar
artery aneurysm that produces pressure in the trigeminal nerve.
Verbin and colleagues described odontalgia in a maxillary lateral
incisor due to herpes zoster of trigeminal nerve.
Sanubai and Richardson described vascular neck pain referred to
mandibular posterior teeth.
Otitis Media may refer to mandibular molars.
Myocardial infarction or angina pectoris may cause tooth ache
on left side especially if it occurs while patient is exercising.
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Other causes of referred or unusual pain are:
- Intensive radiation.
- Malaria, typhoid, influenza.
- Menstrual pain.
- Some malignant diseases and tumors.
Thus, the role of diagnosing a true endo emergency cannot be
over emphasized.
ANALGESICS AND ANTIBIOTICS
The use of analgesics and antibiotics is important in endodontic
emergency treatment. Every clinician should be familiar with their:
- Mode of action.
- Dosage.
- Indications.
- Interactions with other drugs.
- Route of administration.
- Toxicity
- Contraindications.
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ANALGESICS
Analgesics are pain relievers
NARCOTIC analgesics are used to relieve acute, severe pain.
NON-NECROTIC or mild analgesics are used to relieve slight to
moderate pain.
The most frequently used non-narcotic analgesics are:
- Aspirin.
- Acetaminophen.
- Naproxen.
- Ibuprofen.
ASPIRIN alone or in compound is used most often in the dosage
of 600mg. Aspirin should be taken with caution as it can cause an
anaphylactoid reaction in an allergic person or an adverse reaction in
persons with gastric ulcers.
Aspirin is contra-indicated in patients receiving anticoagulant
therapy, diabetes and arthritis.
ACETAMINOPHEN, the second most commonly used
analgesics is effective for mild-to-moderate. It has lower incidence of
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side effects than aspirin. It lacks anti-inflammatory effect of aspirin. It
is recommended for children and is available in liquid form.
IBUPROFEN a proprionic acid derivative prescribed in doses of
300-400mg 4 times daily is more effective for severe pain relief than
aspirin. But it should not be used in patients with h/o peptic ulcer or
aspirin intolerance.
NARCOTIC ANALGESICS like morphine, codine 30mg
neperidine, hydrocone 5mg with acetaminophen 500mg etc are
generally not used or are used with caution as it may depress the
C.N.S. They interact adversely sometimes fatally with alcohol, local
anaesthetic, antihistaminics etc.
ANTIBIOTICS
Antibiotics are life saving therapeutic agents which are used for
prophylactic coverage of medically compromised patients and as an
adjunctive treatment for acute periapical and periodontal infections.
Ideally, the selection of antibiotics should be based on the
susceptibility tests that indicate effectiveness against the infecting
microorganisms. Therefore, the more lethal the antibiotic the less likely
resistant the microorganisms will develop to it.
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The most effective antibiotics for use in endodontic emergencies
is PENICILLIN.
Penicillin acts by inhibiting the cell wall synthesis during
multiplication of microorganisms and are effective against gm+ve
cocci, viridans strains, many anaerobes which are involved in
endodontic infections.
The standard regime for dental procedures is penicillin V, 2.0gm
1 hr before treatment and 1.0gm 6 hourly later.
This is quite feasible according to the European standards owing
to their larger physique and body wt and higher BMR, but according to
Indian Standards this regime works out to be on a larger scale owing to
its less body wt. Therefore, the dosage reduces in accordance to the
body wt which is 250mg to 500mg tid.
In case of PENICILLIN ALLERGY, ERYTHROMYCIN may be
prescribed which acts by inhibiting proteins synthesis. The dosage in
250mg-500mg 6 hourly.
Other antibiotics useful for treating endo-emergencies are:
- Cephalexin – 250-500mg 6 hourly.
- Clindamycin phosphate – 150-30mg 6 hourly.
- Tetracycline Hcl – 250-300mg 6 hourly.
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Tetracycline is the least effective of all antibiotics for endo
emergencies.
CONCLUSIONS
A satisfying and rewarding experience is to successfully manage
a distraught patient who initially presented with severe pain for an
emergency appointment.
Proper operators attitude, patient control, accurate diagnosis, and
profound anaesthesia as well as prompt and effective treatment are all
integral components of management of endo-emergencies.
REFERENCES:
- Grossman.
- Weine.
- Walton.
- Cohen.
- Ingle.
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