ENDODONTIC EMERGENCIES

DEPT OF CONSERVATIVE DENTISTRY AND ENDODONTICS

SRM DENTAL COLLEGE
RAMAPURAM
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 Endodontic emergencies are usually associated
with pain or swelling and require immediate
diagnosis and treatment.

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Following questions can be asked to the patient to
determine the severity of the situation.
1. Does the problem disturb => sleeping, eating,
working, concentrating, or other daily activities?
(A true emergency is disruptive).
2. How long has the problem been bothering?
(A true emergency has rarely lasted more than a
few hours to 2 days.)
3. Have the patient taken any pain medication? Did
it help?
(A true emergency is unrelieved by analgesics.)
Affirmative answers to one or more of these questions
require an immediate office visit for management and
constitute a true emergency.
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 Identify source of pain
Odontogenic Non-Odontogenic
Pulpal origin TMJ
Periodontal Sinus
Pericoronitis Neurologic
Cardiac
Psycogenic

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 CLASSIFICATION OF ENDODONTIC
EMERGENCIES
PRETREATMENT EMERGENCIES
– Acute pulpitis
– Acute PULPITIS WITH ACUTE APICAL PERIODONTITIS
– PULPAL NECROSIS WITH ACUTE PERIRADICULAR ABSCESS

INTER APPOINTMENT EMERGENCIES

POST OBTURATION EMERGENCIES
REFFERED PAIN
TRAUMATIC EMERGENCIES & AESTHETIC EMERGENCIES
– Crown fracture –Intrusion
– Root fracture –Subluxation
– Crown & root fracture –Luxation
– Avulsion –Extrusion
–Concussion
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 PRE TREATMENT
EMERGENCIES

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 Dentin Hypersensitivity

Patient complains of excessive

sensitivity
Duration
Triggering factors
Post stimulus sensitivity

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 Acute irreversible pulpitis
Acute irreversible pulpitis is a clinical
term that implies that the inflamed,
vital pulp lacks the reparative ability to
return to health.

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 Pulp is enclosed with in a rigid mineralized
environment

very little ability to increase its volume during

episodes of inflammation.

an intense inflammatory response can lead to

adverse increase in tissue pressure, out pacing
the pulp’s compensatory mechanisms to
reduce it.

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 Clinical Features
#abnormally responsive to cold or hot
#pain may lasts for minutes to hours
#disturbs sleep
#pain increases while bending & in
lying posture

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 Management
Emergency treatment > pulpectomy
Prescribe an analgesic

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 IRREVERSIBLE PULPITIS WITH
ACUTE APICAL PERIODONTITIS

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 Dull, constant, throbbing pain

Tooth is extremely Always sensitive to

painful to touch percussion

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no radiographic changes at the root apex
or just widening of the periodontal
ligament or periapical radiolucency

Management

pulpectomy

Occlusal reduction

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 PULPAL NECROSIS WITH ACUTE
PERIRADICULAR ABSCESS
No response to cold or EPT
percussion/palpation pain

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In patients with pain and pulp necrosis
one of the following may be
encountered
#Necrosis without swelling
#Necrosis with localized swelling
#Necrosis with diffuse swelling

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 Necrosis without swelling
Removal of the necrotic pulp from the root
canal system
Cleaning & shaping
Irrigation with copious amount of Naocl
Canal dried with paper points
Placement of calcium hydroxide inside canal
A dry cotton is place inside the chamber
Sealed with ZOE cement

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 Pulp Necrosis with localized
swelling
Radigraphic findings => Ranges
from no apical change to a large
radiolencency

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 Treatment
Three ways to resolve swelling infection
1.Debridement of the canals.
2.Surgical intervention
3.Antibiotic treatment

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 In teeth that drain readily after
opening, instrumentation should be
confined within the root canal system.

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 In patients with a periradicular abscess
but not drainage through the canal
penetration of apical foramen with small
files (upto #25) may initiate drainage and
release of pressure.

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 Surgical Procedures

Incision for Drainage (I & D)

Needle aspiration
Surgical trephination

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Occasionally there may be more than one
abscess. One communicates with the
apex while another, separate abscess is
found in the vestibule.
Drainage in these conditions must be
done both through mucosal incision &
tooth drainage .

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 Incision & Drainage
Localized swelling should be incised
(whether fluctuant or non fluctuant )

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 Drainage accomplish two things

– Relief of pressure and pain

– Removal of a very potent irritant purulence

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 Principles of I & D
Incision should be made at the site of
greatest fluctuance.
Dissect gently & through the deeper tissues
A surgical hemostat can be used to facilitate
drainage.
To promote drainage the wound should be
kept clean with hot salt water mouth rinses

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 Pulp Necrosis with Diffuse
swelling
A diffuse
swelling can turn
into a medical
emergency of
potentially life
threatening
complication.

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 At the emergency visit
– The tooth is opened & the root canal is
thoroughly instrumented and irrigated.

– In the absence of drainage through the

tooth, soft-tissue drainage (INTRA ORAL
LOCALIZED SWELLING) must be established
and a rubber drain inserted.

This drain may remain until the treatment

completed
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 Occasionally the abscess localizes
subcutaneous requiring extra oral incision
for drainage. Should be referred to a
specialist.

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 Cortical trephination
Cortical trephination is defined as surgical
perforation of alveolar cortical plate to release
accumulated tissue exudates.
This procedure may be necessary for teeth with
an apical blockage; with no swelling. So no
drainage possible through the root canals
Trephination is not generally recommended
because of the additional trauma, invasiveness,
and questionably beneficial result.

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 Needle Aspiration
Use of suction to remove fluids from
a cavity or space.
Mainly performed for biopsy purpose

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 Antibiotic therapy

NOT THE FIRST TREATMENT OF

CHOICE!
DOES NOT REPLACE ROOT CANAL
TREATMENT!
Ideally the choice of antibiotic
depends on the definitive laboratory
results of culture and antibiotic
sensitivity test.
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Indications for antibiotic treatment

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 Pencillin V

Amoxycillin & Clavulanate

Metronidazole

Clindamycin.

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Erythromycin 36
 Analgesics
Narcotic analgesics are used to relieve acute, severe
pain
Non-narcotic or mild analgesics are used to relieve
slight-to-moderate pain.

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 Endodontic Flare-Ups and
Mid-treatment Urgent care

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 Interappointment Pain

INJURY

Mechanical Microbial Chemical

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 Contributing Factors
Inadequate Debridement
Debris Extrusion
Over instrumentation
Overfilling

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 Shaping the canal in the coronal aspect
before apical preparation may reduce
debris extrusion.
Forced irrigation of sodium
hypochlorite beyond the apex of the
tooth can cause violent tissue
reactions and unbearable pain.

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 HYPOCHLORITE ACCIDENT
Symptoms :
– 1.Severe pain
– 2. Swelling
– 3.Profuse bleeding, both intersititally and
through the tooth

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Causes
Ø Forceful injection of the irrigating solution
Ø Having an irrigating needle wedged into a root
canal
Ø Irrigating a tooth with a large apical foramen
Ø Apical resorption,
Ø An immature apex

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 Management
The immediate problem of pain and swelling should
be attended to first.
A regional block, with a long-acting anesthetic
solution, should be administered.
The clinician should assure and calm the patient
If drainage is persistent, leave the tooth open for the
net 24 hours.
antibiotic coverage, analgesic, a corticosteroid.
The patient should be given home care instructions.
For the first 6 hours the patient should use cold
compresses, warm compresses thereafter.
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 REFFERED PAIN

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 REFERRED PAIN
Although the most frequent cause of dental pain

is pulpoperiapical pathosis, the pain can

originate from many other sources.

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 According to Hurwitz, dental pain can have its
origin in
• -trigeminal neuralgia
• -atypical facial neuralgia
• -migraine
• -cardiac pain
• -temporomandibular arthrosis
• -Sinusitis
May cause pain referred to the maxillary
posterior teeth

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 Pain arising from periodontal problems,
such as
– periodontal abscess
– occlusal trauma,
– muscle spasm
– bruxism
– clenching
– pericoronitis
is often mistaken for pulpoperiapical pain
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 TRAUMATIC & AESTHETIC
EMERGENCIES

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 Complicated Crown Fracture
E/D fracture,with pulp exposure
In immature tooth:
Perform pulp capping or partial pulpotomy
with calcium hydroxide and bacteria tight
coronal seal.
In mature tooth:
treat as with immature tooth or
Pulpectomy

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 FRACTURED ROOT
A fractured root is an endodontic emergency if the
tooth is painful and, especially, if the incisal segment
is mobile.

The prognosis for a horizontally fractured root

depends on the location and direction of the fracture.

The closer the root fracture is to the root apex, the

more favorable the prognosis, sufficient root will
remain even if the fractured segment has to be
removed later.
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 Emergency treatment for a horizontally
fractured root consists of
Stabilization by ligation of the tooth and
adjacent teeth if mobility is present.

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 TOOTH AVULSION
The avulsed or luxated tooth is both a dental and
an emotional problem.

It is usually the result of trauma to an anterior tooth

of a child or young adult.

The shock and pain of the injury and the loss of a

tooth needed for eating, speaking and smiling often
lead to emotional impact in patient and parent.
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 The following instructions should be given to the
parent or patient as soon as the dentist has been
informed of the accident and in preparation for
an emergency visit
– 1. Wash the tooth in running water without brushing
or cleaning it and examine it to be certain that the
tooth is intact.
– 2. Have the patient rinse mouth. Replace tooth in its
socket using gentle, steady finger pressure. If the
patient is cooperative and able, have the patient gently
close the teeth together to force the tooth back into its
original position.
– 3.Take the patient to the dentist immediately

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 The longer the luxated tooth is out of its socket,
the less likely it will remain in a healthy,
functional state after replantation.
If the patient or parent cannot replace the tooth
in its socket, then care in transporting that tooth
to the dentist becomes essential.
The tooth must be carried in a moist vehicle to
maintain the viability of the torn periodontal
ligament.

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 Transport medium
Hank’s balanced salt solution
– very favorable transport medium
– Composition
Sodium chloride
Glucose
Potassium chloride
Sodium bi carbonate
Sodium phosphate
Calcium chloride
Magnesium chloride
Magnesium sulphate

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 Emergency tooth preservation
system (ETPS)
DEVELOPED BY KRASNER
– Contains HBSS
– A net for holding the tooth
atraumatically
– A container
Best chance for success is by
immediate reimplantation at the site
of trauma

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 Other transporting mediums are
– Patients own Saliva
– Milk
– Water(least preferable )

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 The tooth should not be wrapped in a dry
handkerchief or tissue because the
periodontal ligament will become
dehydrated.
Extraoral time for an avulsed tooth
optimally should not exceed 30 min.

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1. On the patient ’ s arrival at the dentist ’ s office the
following procedure obtains :

2. If the tooth is in its socket, ligate, stabilize, and

disocclude the replanted tooth.

3. If the tooth is out of its socket or is improperly

positioned, replant the tooth properly before ligation.

4. Take a radiograph to verify the position of the tooth in

its socket and to examine it for any root or alveolar
bone fracture.

5. Check the adjacent teeth for possible root fracture.

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 Endodontic Treatment
After 2 weeks endodontic treatment should be
initiated and calcium hydroxide placed (to
inhibit &reduce external resorption)

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 CONCLUSION
Endodontic emergencies are a challenge in both
diagnosis and management. Knowledge and skill in
several aspects are required; failure to apply these
will result in disastrous consequences.

Incorrect diagnosis or incorrect treatment will fail to

relieve pain and, in fact, may aggravate the
situation.

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