Clinical Continued »
between the clinical and radiographic findings at the initial appointment and subsequent review. Various literature proposes the
strategy of waiting for a period of three months during which pulp sensibility tests give negative responses prior to initiating root canal treatment on injured teeth. The obvious exception to this is in the case of an avulsed tooth with a closed apex. Root canal treatment is advised immediately in this situation although practically, clinicians may often delay this by one week. This allows the focus of the initial appointment to be on patient reassurance and emergency management. Additionally, healing of soft tissue injuries will have progressed well during that initial period. Caution must be exercised in
interpreting the results of pulp sensibility tests following a traumatic injury. The injured pulp may be in a state of ‘shock’ and may not respond positively to the stimulus applied. Equally, it is well documented that immature teeth may give erroneous results due to the lack of development of the pulpal neural network. Equally, a prolonged delay leading to necrosis of the pulp may affect the outcome of root canal treatment and put the tooth at risk of catastrophic resorption. Where possible, endodontic treatment
should be commenced with the splint in place as this confers extra stability on the injured teeth during the procedure. This is usually limited to teeth which have suffered an avulsion injury due to the recommended splinting times (Table 2) and the timing of definitive treatment. It may also lead to difficulties in rubber dam placement, with the split dam technique in the isolation of multiple teeth being necessary. Timely management of complicated enamel dentine fractures is essential to optimise the outcome. Depending on the duration of pulpal exposure, the goal must be maintenance of pulpal vitality in these cases. Any direct exposures should be capped using a slurry of non-setting calcium hydroxide and restored with a glass ionomer cement base followed by a composite restoration. While mineral trioxide aggregate (MTA) remains the gold standard material for pulp capping of posterior teeth, caution must be exercised in the use of both grey and white MTA in these cases as subsequent discolouration of the tooth may provide
an aesthetic challenge in the future. Biodentine may provide a suitable alternative in non-load bearing areas. Endodontic access to injured teeth
is often straightforward due to their anterior location and lack of complex anatomy. Care must be taken to design and position the access cavity correctly, ensuring that the pulp horns are included to allow for removal of necrotic debris and access for irrigant. This prevents subsequent discolouration of these teeth post-treatment. Access may prove much more difficult in the case of traumatised incisors which have undergone pulp canal obliteration (PCO). Several groups have reported that 4-24 per cent of teeth undergo these changes in response to traumatic injuries, while McCabe & Dummer (20ı2) highlighted a useful series of steps to follow clinically in the management of this clinical scenario. Instrumentation and irrigation of the
root canal system should be carried out adhering to the biological principles of
endodontic treatment. Difficulty may be encountered in determination of working length (WL) in teeth with open apices or in those with crowns and should be confirmed radiographically where doubt exists over the accuracy of the electronic apex locator (EAL) reading. Teeth suffering from horizontal root fractures should only be instrumented to the level of the fracture line and not beyond (Fig 6). The apical fragment of these teeth is almost always vital and unnecessarily instrumenting and obturating it poses difficulties for the clinician. Care must also be taken in the placement of the irrigation needle in close proximity to an open apex or root fractured tooth to avoid extrusion of sodium hypochlorite, the gold standard irrigant in such cases where dissolution of pulpal tissue is essential. Various inter-appointment medicaments have been proposed
Continued » Ireland’s Dental magazine 29
Fig 6a
Fig 6b
Series of radiographs showing definitive endodontic treatment of tooth 11 in patient following traumatic injury. Tooth 11 obturated using MTA plug apically and subsequent Obtura backfill. Fig 6d shows tooth with horizontal root fracture filled through fracture line
Fig 6c Fig 6d
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