Endodontics Emergencies

Conservative lec No. 10

3.12.2008
Today we are going to talk about endodontic emergencies, its
something that the patient complain of, has to be either pain or swelling that
would required an unscheduled visit (extra visit) for management, so it may
be pain or swelling or both, but you need to see the patient immediately in a
visit and manage him, usually its caused by a pathosis either in the pulp or
in the pulp and periapical tissue and the diagnosis will be irreversible pulpitis
or apical periodontitis in addition to that.

Endodontic emergencies can be classified into:

1) Pretreatment : it means before you see the pt, he come to you as an
emergency. So he is a new patient and that is the first time you see him.
2) Interappointment : you treat the patient and the next day he will come
back complaining of swelling and pain that wasnt before your
treatment and he will blame you.
3) Postobturation : everything is good and when you finish the obturation
he will get a flare-up, he will get sever pain and swelling.

System of diagnosis :
1) Medical and dental history : if a new patient came to you and you see
him for the first time, then you should take medical and dental history,
you ask about previous treatment if present. The second thing you must
take into consideration is the history of pain, if its spontaneous or
stimulated by something, disturbing the sleep or not, if its relieved by
analgesic or not, localized to a tooth or not.
2) Examination (subjective and objective) : palpation, percussion,
radiographs, vitality test.
3) Periodontal examination: you should do periodontal examination to the
teeth and check the PD, sometimes there is a tooth with a PD equals 1-2
mm and suddenly become 7 mm in a certain area on the tooth (buccaly
or lingualy), this tooth either cracked or has vertical root fracture that
need extraction.

4) Radiographic examination : you should see if there is any caries

because some of them cant be seen clinically like class II
caries(interproximal).

Cold Test :
The most reliable one is the CO2 test because it have the lowest degree
(-78) , but we dont have it in our clinics. The one that we use in the clinics
is the DichloroDifluoroMethan (DDM) that has -50 boiling point, we apply it
on a cotton and put it on the tooth surface, the normal response will be sharp
and short pain that relieved by removing the stimulus and will appear within
a 15 sec, delayed response is very rare but happened in elderly due to pulp
shrinkage after secondary dentine formation, if the pain remained for 30 sec
then that is a clue for RCT to this tooth. If the tooth is crowned you will test it
palataly or lingual if there is exposed structure of the tooth, if not then you
retract the gingiva and test on cementum.

Mechanism of the cold test:

Cold test will do disturbance in dentinal fluids and cause an outflow for it,
which will stimulate the mechanoreceptors in A fibers, this is what called
the HYDRODYNAMIC THEORY.
So, the cold doesnt reach the nerves directly, it only cause a fluid
movement.
**The hot has an action similar to the cold .
In each response (+ve or ve) we may have false results, sometimes we
may reach false ve like in atrophic pulp (due to aging) which will give a
delayed response, or false +ve like when you fail to dry the tooth
completely before applying the cotton, that will make the saliva transfer the
response through the gingiva to the adjacent tooth or in multi roots teeth.

CASE I :
Page 2 slide 8 .

20 years female complains of severe pain in upper left premolars for 3

days, the pain was continuously there and she complained from sensitivity on
hot.

Here we can do hot test (we rarely do it), we isolate the tooth with rubber
dam and apply hot water on the tooth, the tooth which is sensitive to hot
mostly will be sensitive to the cold, but not necessarily. If hot test isnt the
test you want to do, so you must do radiographs. In this case, we took a
periapical radiograph for the tooth, it had a class I cavity, then recurrent
caries happened and became a class II that make exposure to the pulp. Its
an easy case for diagnosis, you can never miss that this tooth need an
endodontic treatment although this tooth is periapicaly sound.

CASE II :
Page 2 slide 9
53 years old male complains of a very severe pain on lower left
premolars, he hasnt slept for two days with disturbing daily activities, that
indicate and irreversibly inflamed pulp. When radiographs was taken, the
lower premolar are already treated, root canal looks fine, there is a periapical
radiolucent area but this wont be a cause of a pain from irreversible pulpitis,
in this tooth there is no pulp, so the pt wont feel pain, the pain may happen
when the patient bite.

In these pictures in, 34 and 35 are obturated and have no problems, 25

also obturated and 24 has DO cavity with cracked line on the mesial marginal
ridge and extremely sensitive in cold, so the patient reported pain in the
lower jaw, but the test show problem in the upper teeth, and that what we
call REFERRED PAIN .
** So pain in the upper teeth sometimes referred in the lower teeth and vice
versa.
**Note: if you are suspecting a problem in a tooth that has a pain and you
gave anesthesia and the pain disappeared, so your suspicion is true.
In this case we do:
1. Rubber dam.
2. Access.
3. Extirpation.
If the tooth was vital we do extirpation to the estimated working length
and irrigation with sodium hypochlorite (do as much as you can
instrumentation, barbed broaches files to the estimated working length).You
put dressing and close it and relieve the occlusion by reducing the cusps or
at least functional cusps (In the upper the palatal cusp including with the
buccal of the lower). Reduce the palatal cusp by 1mm.If the lower need post
crown you can reduce it by 2mm, this is(relieve from the occlusion) effective
in reducing interappointment pain .

Referred pain:
1. The inflammation remains confined within the pulp.
2. Histology: liquifaction necrosis with an increase in intrapulpal pressure
and primarily involves C-fibers.
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3.
4.
5.
6.
7.

Anterior teeth dont refer to posterior teeth.

Posterior teeth dont refer to anterior teeth.
Usually doesnt cross the midline.
Upper premolar often refer to lower premolar
Upper molar often refer to lower molar.

There is some teeth dont refer pain, the tooth must be inflamed virgin to
refer pain. But tooth with previous endodontic treatment, tooth with sinus
tracts, tooth with periodontitis or tooth undergoing endodontic treatment will
not refer pain, the pain will be in the same area of the tooth.
Other sources of referral of pain:
1. TMJ diseases: patient came to you complaining of pain in the tooth
and he has Phantom tooth syndrome or atypical facial pain which
is psychological, he has muscle pain and say to you this tooth is
harming me, you do class I , class II, endodontic treatment ,
extraction and the pain remains, this is Phantom tooth syndrome,
any muscle pain (temporalis , lateral pterygoid , medial pterygoid)
can cause pain in the upper teeth.
2. Heart- myocardial infarction, thrombosis, angina pectoris.
3. Lower molar refers to ear.
4. Upper molar refers to sinus.

If patient complain of a pain and you took this radiograph, the cause is
the first premolar has a big restoration and periapical changes.

In the pictures below, you can see a patient which has swelling in the
palate, you can see the crown, remember that you should do periodontal
examination before the diagnosis, notice the probe has entered 7mm, this is
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an isolated pocket ,so we expect that this tooth has crack or root fracture. By
the way, this tooth was treated by a good endodontic treatment and there
was crack then become a sinus tract. The solution for this tooth is extraction,
it is a hopeless tooth.

Student question:

can we drill a cavity through the

crown?
If the crown has good margins with good adaptation then you can drill the
access cavity through the crown as a normal tooth and do endodontic
treatment, it is more difficult and the vision isnt clear, but if the crown is old
and a bad one you remove the crown, do endodontic treatment and
temporary cement until you replace it with a new crown. Not every crowned
tooth should have an endodontic treatment.
**Sometimes it is class I cavity, from the heat of preparation and because
there is no sufficient cooling, there is no enough water with the high speed
you will cook the pulp, it will become irreversibly inflamed then dies, when
you come to do cementation the patient will complain from pain so you
should drill the crown that you prepared.

Detecting cracks
The patient complain of pain on release of a pressure (when he bites and
opens), this pain is a diagnostic for a cracked tooth. How we can decide that?
We have to reproduce the patient pain by tooth slot, not found in the clinic,
so you can use the handle of the mirror, put it on the tooth that the patient
complain from, then the patient should bite and open, during biting there is
no pain but after he opens the pain starts, this is a diagnostic for cracked
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tooth. May be you cant see the crack, but there is certain managements that
we will study it later on.

That treatment for a cracked tooth is orthodontic band, which we put

around the cracked tooth and do cementation (splinting the crack) so the
pain will disappear, after that we do a crown or an overlay .The crack usually
found mesiodistally .

When can we doubt in a cracked tooth?

When the tooth looks sound and its vital on the cold test and on the
radiograph you cant detect anything, there is no other diagnostic features
for pulpal involvement and the pain found on release of pressure(when open
mouth from bite).
You can notice in the picture below that there is a crack started at the
buccal pit and then continued downward, and here there is sinus, this tooth
has been crack because it was treated by endodontic, the temporary
restoration wasnt removed and no crown has been done for this tooth, teeth
with temporary restoration will get crack within 5 years. The tooth which
treated by endodontic if not crowned finally it will break.

In intraoral examination in this picture below, you can see sinus tract, it
looks like an ulcer, sometimes it can be sever to be present as an ulcer, this
patient was infected with hepatitis C, so he had low immunity and had
external swelling and internal ulcer, this isnt the first visit, it is the third visit
after its improved( it was bigger than what we can see here in the picture).

After we took
diagnosis is:

the history, the possible

1. Irreversible pulpitis.
2. Acute apical periodontitis.
3. Acute apical abscess(swelling with pus).
After examination and diagnosis, our goal now is to reduce the irritant
and reduce the pressure by removing the inflamed tissue and you can
achieve a profound anesthesia.

A-Pretreatment emergencies
1.Irreversible pulpitis:
As we said in irreversible pulpitis we do complete pulp extirpation by a
barbed broach, files to estimated working length, sometimes the patient in
severe pain so we do pulpatomy, it might be enough and this is called in
physiology Axotomy.
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Pain perception starts in the receptors and periapical nerve, after that to
the nuclei and CNS, if you cut the periapical nerve you will cut the receptors
of pain, so we expect to reduce the pain, but what remains is the
prostaglandin pain mediator in the brain, so the patient may be still feels
pain.
But at least if the patient complains of a severe pain and you gave him
intrapulpal anasthesia and he still in pain, then you can do pulpotomy.
Pulpotomy: it means removing the pulp chamber alone, not necessarily
to reach the canals, we must remove as much as possible from the pulp
chamber with a big round bur, then you apply chemical medicament in the
chamber like formocresol or a dry cotton pellet alone (its as effective as
relieving the pain with a pellet that is moistened with formocresol).
This treatment is temporary not definitive, you have to complete pulp
extirpation after a few days because the ideal is to proceed all the way to
estimated working length, and reduce the tooth from occlusion if there is any
apical periodontits.
**dont give the patient any antibiotics (this is a misuse), give him
analgesics.

2. Pulp necrosis :
In case of pulp necrosis it will be either acute periapical periodontitis
without swellings (only tenderness to percussion), or it will be acute apical
abscess. If there are no swellings so there is no pulp, you should take the
corrected working length and enlarge the canals if you can from the 1 st visit,
but if you cant so you do to the estimated.
We have localized swelling or diffuse swelling, if its localized you have to
open the tooth and try to do drainage through the tooth to drain the pus, in
this case the pus may go out or maybe not.
This is a rubber dam and this is an access, notice the bloody discharge
(blood with pus), and if you tried to dry the canal with a paper point you will
notice that it will be wet completely.

Sometimes it might be oozing, in this case we can do intracanal drainage

(not found in our clinic), we put this tip on the ordinary suction and like the
non-setting CaOH, and we insert it inside the canal and suction the pus.

If the patient
came with a pain and sinus
that found close to 5 or 6, we cant say that this sinus is for the 5 or the 6,
you should always trace the sinus, its may be from the adjacent tooth.

So,

how can we do tracing??

We insert a gutta percha (35 or 40) inside the sinus tract and take a
radiograph to see where is the cone pointing, sometimes you have to
penetrate the sinus with a probe or a local anesthesia needle to insert the
cone.
Sometimes the radiograph is misleading, in case where the sinus is
between the 5 and 6, we do cold test, if the 6 test +ve then its definitely the
5, but if it had abnormal response then its the 6.
Another shape of the sinus tract can be found palataly. This is orthodontic
band around the 4 which is broken down, here we cant apply a rubber dam,
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so its usually recommended to build it up with a temporary material then we

put the orthodontic band and then apply the rubber dam.

Pulp necrosis either localized or diffused swelling, in the a-localized

swelling you have to palpate and see if its fluctuant or hard, if its fluctuant
you can do incision and drainage.
Never leave the canal open, although the pain disappear (because the
pressure has been relieved) but the bacteria from the saliva will enter inside
the canal and cause an infection further than the edno, also in the localized
swelling, if it is just inside the sulcus then there is no need for antibiotics.
(Antibiotics just for the systemic manifestation).
b-Diffuse swelling means swelling in the cheek, neck, face, near the
eye, or outside according to the position of the tooth, ex. Infection in the
canine can reach the eye and cause a swelling, and the pt will have a
systemic signs like fever,malasie, or joint pain, these patient have to take
analgesic and antibiotics (penicillin or mitronidazole) and the swelling will
subside in 2-3 days or may reach 5 days according to the patient response.
These patients will have flare-up risk, it means that you may finish the
treatment and suddenly they may get another swelling.

This is a localized swelling, you check for fluctuation either by your finger,
mirror head, or the suction. You must find the most dependant point which is
the point that has the largest amount of pus (most accumulation of pus) and
has a head.

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You make an incision with a scalpel blade no. 15 or 11 (there is a way to

make an incision with the least amount of harm and damage to the patient),
the length of this incision is about 1 cm, as we increase this length it will be
better for draining more pus and it will heal quickly, we leave it open, not
suture it or we can use the hemostat (artery forceps) and widen the opening
and then we do irrigation with saline or CHX but not with sodium hypochlorite
because it will cause necrosis to the tissue.
You should give anesthesia before, either ID block but away from the
swelling because this environment is acidic that will cause failure for the
anesthesia, or we give posterior alveolar nerve block, or anterior and
posterior to the swelling.

This is a case of cellulitis, in this case you should not think to do incision
and drainage, you should refer it to a specialist (oral surgery) immediately, if
the patient could open his mouth then they will do extraction, here there is a
risk for an infection to occur in the spaces mostly in the upper which can
reach the cavernous sinus then thrombosis will occur which may cause
blindness.

In the lower spaces there is what we call Ludwigs angina (swelling

in the submandibular , submental and sublingual spaces) which starts
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suddenly and accompanied with systemic symptoms (elevated temp. ,

difficulty in breathing or swallowing, trismus which complicate the
extraction), the specialist will give the patient IV antibiotics and wait 2-3 days
then extract the tooth or sometimes they do extraoral drainage.

Indications for antibiotics:

Fever, malaise, cellulitis, palpable lymph nodes, or un-explained trismus.
All what we talked about before was the pretreatment emergencies, now we
will talk about the interappointment emergencies (during treatment).

B-Interappointment(flare up):
1.You treat the pt and he came back with swelling and severe pain, the
incidence for this to happen is 1-3% (not common).
2.Doesnt has any relation to the age, sex, intracanal medications ,single or
multiple visit , medical history.
3.Preoperative pain and pulp necrosis are predicators of a flare-ups. usually
there is no flare-up in vital teeth.
4.Ledermix as an intracanal medicament (antibiotic corticosteroid mix). This
is effective in cases which need vital extirpation, you put it as an intracanal
medicament instead of CaOH or you mix them together with a spatula, it will
reduce the pain (anti inflammatory).
5.The most important is reassurance, if you cleaned the canal very well then
you have to reassure the patient that it happens.
6.Previously vital pulps with complete debridement, you give the patient
analgesic. (Dont give antibiotic unless there is a diffuse swelling).
7.If you arent sure that you cleaned the canal very well, then you have to
reopen the tooth and debride it.
8.If the pulp is necrotic with no swelling then you have to reopen the tooth,
then take the exact working length, do enlargement and widen the canal,
complete your instrumentation, then do dressing and let the patient go
home.

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9.If there was swelling, then you should make an incision and drainage or
give antibiotics.

C-Postobturation emergency:
You treated the patient and after that he will come with swelling, this
swelling because of trauma from treatment. (that is if your work was good,
but if it wasnt adequate so there may be other reasons like bacterial
infection and it has to be retreated)
There is correlation with the level of obturation,if there is a gross
overfilling, the patient will get flare-up(too much gutta percha or sealer
outside the apex), here you need retreatment, but if there is a little overfilling
the patient will complain of slight pain which relieved by analgesic. So
sometimes you need retreatment and sometimes you need incision and
drainage.

Analgesics:
Options:
Paracetamol (acetaminophen) or there is Revacot which is
combination of paracetamol with codeine (which is not found in the market
now because people get addiction), now what present is Pnadinfort which
contain caffeine and codeine (low %)not like the revacort .

What are the option of analgesics that we can

give to a patient that is complaining of pain ??
According to studies, Ibuprofen 800 mg(two tablets)loading dose was
relieved pain in 50% of patients who have severe pain by 100%. So its
preferred to start with Ibuprofen (400 mg), two tablets every 3-4 hours for
the first two days only, no need for more.
Paracetamol alone isnt enough, you can do a combination of Ibuprofen and
paracetamol at the same time, and its very effective.
Codeine with acetaminophen (revanin) isnt efficient (57%).

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In Ibuprofen 400 mg (one tablet), you can notice the % here was decrease
from 100% to 56%. You have to give instructions to the patient to take the
drugs with full stomach, not empty.
Codeine (60 mg) isnt effective (15%).
Placebo is not effective (18%).
So Ibuprofen is enough. Sometimes you can give voltaren injection, its
more rapid, and within 15 min the patient will give response.

Done by:
Shahd Qeadan.

The End
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