5-13
d. If a glass ionomer cement was not used, cover the calcium hydroxide or zinc-eugenol base and
adjacent enamel with several coats of cavity varnish (Copalite). Cavity varnish has low solubility
in oral fluids.
- This can provide protection for up to 6 weeks. Have the patient see a dentist as soon as possible.
Extensive fractures involving the dentin and exposed pulp:
- Anesthetize the tooth. (See Procedures section.)
- Wash gently with warm saline.
- Isolate and dry the tooth with cotton gauze or rolls.
- Cover the pulp and dentin with a mix of (Dycal) calcium hydroxide (DO NOT USE ZINC OXIDE AND
EUGENOL-IT CAUSES NECROSIS OF THE PULP), and allow to harden. Apply several coats of cavity
varnish to the calcium hydroxide base. - If a glass ionomer cement is available, it can be substituted for the (Dycal) calcium hydroxide. A
condensable type of glass ionomer is preferable. Do not coat a glass ionomer cement with cavity varnish. - The efficiency of this treatment regimen depends on the size of the pulp exposure. If the exposure is
larger than 1.5 mm. consider extraction. If all you have available is zinc oxide and eugenol you must
also consider extraction. - Evacuate for consultant care.
c. ACUTE PERIAPICAL (ROOT END) ABSCESS
Subjective: Symptoms
Repeated episodes of pain that have gradually become more continuous and intense. The accumulating pus
causes increased pressure and the tooth will feel “high” to the patient. It will seem to be the first tooth to
strike when the teeth are brought together. Malaise and anorexia are sometimes noted.
Objective: Signs
Severe tooth pain on percussion (very significant); swollen, tender gingival tissues around the tooth; fever;
bright red elevation of the soft tissues in the area (parulis) due to untreated periapical abscess burrowing
through alveolar bone.
NOTE: Always begin percussion testing on a tooth that appears normal, then progress to the suspected
tooth.
Assessment:
Pain on percussion of posterior maxillary teeth may indicate sinusitis.
Plan:
Drainage usually provides immediate relief from pain. (See Procedures for abscess drainage.) If abscess is
severe, consider antibiotics only if fever, malaise and anorexia are present. (See Dental Antibiotics section.)
Extracting the offending tooth should be a last resort. Evacuate for consultant care.
d. UNTREATED ACUTE PERIAPICAL ABSCESS
The typical course: Accumulation of pus and destruction of bone at the root end of the tooth, invasion of
the marrow spaces and destruction of bone trabeculae, destruction of the cortex and displacement of the
periosteum by suppurative material (subperiosteal abscess), rupture of the periosteum with resulting gingival
swelling (gum boil or parulis) and finally spontaneous drainage by rupture of the parulis.
Subjective: Symptoms
Various presentations, depending on direction of spread of the abscess, which is usually toward the lateral
aspect of the jaw, but may drain into the palate, mouth (rare), tongue or facial skin. Tongue infection
can spread through the facial spaces of the neck, and grave, possibly fatal complications (e.g., Ludwig’s
angina) may result.