Treatment of Inflammation

Pulpal inflammation
Periapical inflammation
Incision on abscess

Treatment of pulpal inflammation with symptoms

Objective: To eliminate the symptoms When the offending tooth is found, it is anesthetized, caries and old fillings are removed.

If the pulp is not exposed, but surrounded by sound dentin, the pulpal floor is covered with calcium hydroxide (or e.g. Dycal) and a temporary filling (e.g., zinc oxide - eugenol cement) is placed in the cavity.
Wait for at least one week.
(a) If the symptoms have disappeared, sensitivity tests are carried out. If tests are positive the permanent filling can be made.
(b) If the symptoms have not disappeared within a week, the coronal portion of the pulp is removed (see B).

When the pulp is exposed, the following emergency treatment is carried out:

Access, remove the coronal portion of the pulp, expose the canal orifice(s). This procedure is referred to as a pulpotomy.
Place a sterile cotton pellet (or part of a cotton pellet depending on available space) in the cavity.
Seal the tooth with a temporary cement.
Pulpectomy and endodontic treatment should be performed in the near future.

Note: If there is sufficient time during the first emergency appointment the optimal treatment is to carry out the pulpectomy immediately. However, this procedure has to be carried out with working length film and removal of pulp tissue. A "quick pulpectomy " with thin instruments will give less pain relieving effect than a pulpotomy.

Treatment of periapical inflammation with symptoms

Objective: To eliminate symptoms by creating drainage, and to remove the source of infection, and also to prevent another flare-up. When the offending tooth is found, caries and/or fillings are removed. It is usually not necessary to anesthetize the tooth.

Access preparation and exposure of the canal orifices. This is done after the application of rubber dam.
A thin instrument is placed in each root canal.
Radiograph (working length film).
Cleaning of the root canal(s); copious irrigation.
When the canal is cleaned a thin endodontic instrument is put through the apical foramen to create drainage.
If there is a drainage, do not close the canal until it has stopped. On the other hand, do not leave a canal open unless the abscess is draining for a long time (40-60 minutes).
When the drainage has ceased, irrigate the canal and dry it thoroughly. Place calcium hydroxide in the root canal and then seal it with a temporary cement.

It is essential to debride the root canal thoroughly during the emergency visit in order to get rid of the infected necrotic tissue. It is not necessary to shape the canal to such an extent that the canal is ready to be filled at this point.

In most instances it is possible to close a draining tooth at the end of the first emergency visit. In a few instances the drainage may be long lasting and the tooth has to be left open for some hours or at most overnight. Do not leave teeth open for longer periods of time. This results in new infections that are hard to get rid of.

If the patient has a fever caused by the infected root canal or cellulitis without drainage, antibiotic therapy should be considered.

Incision of abscess

If the abscess has broken through the bone, and it is not possible to obtain complete drainage through the tooth, an incision should be made. 1. Check that the swelling of the mucous membrane over the abscess is fluctuant. 2. If necessary - anesthetize by means of topical anesthesia or a block. Do not inject into the abscess. 3. Place the incision in such a way that drainage is facilitated, i.e. at dependent part of swelling. 4. Have the suction ready to remove pus and exudate. 5. Sometimes it is necessary to place a "H-drain" in the incision to keep it open for drainage. 6. Recall the patient in 2-3 days. Note: An incision is a treatment of symptoms. The abscess will come back if the cause is not eliminated, i.e. endodontic treatment is not carried out.