Emergency Treatment in

Endodontics
(Endodontic diagnosis and management)

All of the important aspects will not be covered in the lectures, to

maximize learning the students are requested to refer the assigned
and other resources.
Lectures are not a replacement of the assigned readings but to
increase understanding and complement your assigned readings.
 Endodontic emergency is a Pulpal and / or
Periradicular pathologic condition; it manifests itself
through pain and / or swelling REQUIRE IMMEDIATE
DIAGNOSIS & TREATMENT .

 Before undertaking any definitive treatment, two

questions has to be answered:
(1) Does the pain emanate(originate) from a tooth?
(2) If it does, which tooth is responsible for the pain?

 The clinician is to be reminded that, even in a true

Endodontic emergency, it is most likely that only one
tooth is responsible for the acute situation.
 When obtaining diagnostic data, the dentist
must generate the following:

1. Subjective examination, including medical

history, dental history and chief complaint.

2. Objective clinical examination

3. Diagnostic tests, including pulpal sensitivity

testing and radiographic examination.
Radiographic examination
Provide information about the tooth and supporting
structure

1. Periapical films: thickening of the periodontal

ligament or periapical radiolucency
2. Bite-wing films
3. Supplemental films : panoramic film or
occlusal film
 Management of the dental emergency patient
 emotional state of the patient should be considered.
 Five key aspects will ensure a proper psychodynamic exchange between the clinician and the
patient

1. The patient must feel and see that the dentist is giving all complaints and symptoms serious
considerations.

2. A show of support for the patient’s complaint is reflected through listening actively.

3. A calm and professionally confident approach by the clinician should be displayed verbally and
nonverbally. Eye contact and supportive touching of the patient’s shoulder is reassuring to the
patient.

4. A positive attitude to the patient’s problem should be given even by referral to a specialist. The
patient should never feel abandoned.

5. Once diagnosis and treatment plan determined, the patient should be informed of what to
expect.
 Management of the dental emergency patient

 Attaining profound anesthesia can be difficult

even to the experienced practitioner:
1. As inflammatory process progress, local tissue
pH falls. The acidic environment prevents the
anesthetic molecule from dissociating into the
ion form and the cat ion is unable to penetrate
through the neural sheath
 To avoid this problem:

1. The nerve block injection is the standard

intraoral approach for achieving initial intraoral
anesthesia.
2. Consideration to the amount and the type of
local anesthetic used .
3. Intra-ligamentary injection
4. If the pulp chamber is exposed intra-pulpal
injection will anesthetize the remainder of pulp
tissue.
 Endodontic emergencies can be classified into:

 Pretreatment
emergencies  Inter appointment  Post appointment
1. Acute pulpitis emergencies emergencies
2. Acute pulpitis with apical 1.Apical periodontitis
periodontitis secondary to
3.Pulpal necrosis treatment
4.Pulpal necrosis with acute 2. Incomplete removal
periapical abscess of pulp tissue
5.Traumatic injuries: 3.Recrudescence of a
fractures chronic apical
periodontitis:
6.Traumatic injuries:
avulsed teeth
 Pretreatment emergencies
1. Acute irreversible pulpitis
Diagnosis:

1. location: patient can’t locate the pain

2. Pain may be precipitated by cold (early stage) or hot ( late stage =
hot tooth) or it may be spontaneous.

3. Pain may be continuous or intermittent

4. Pain continue after removal of the stimulus for minutes or hours.

5. Pain may be described as sharp shooting

6. Intensity: pain is severe
7. Pain increases by lying down or bending
Pain may be relieved by cold or analgesics
 2. Clinical examination:
1. Visual examination: (search for some cause of coronal pulp inflammation) as
Caries, large filling, crown preparation, fracture.
2. Diagnostic tests:
Mechanical tests:
Palpation: no pain , no swelling
Percussion: no pain
Sensitivity tests: + ve response, teeth respond to low grade than normal, i.e. the
teeth are more sensitive to thermal and electrical stimulation.
Radiographic examination:
Periodontal ligament is normal
Fracture of the root
deep proximal caries
Large filling
 Pretreatment emergencies
1. Acute irreversible pulpitis
 Line of treatment:
1. Aim of emergency ttt is to alleviate the pain by
delivering profound anesthesia and removal of the
inflamed pulp through pulpotomy (removal of
only the coronal pulp) or total pulpectomy.

2. Anesthesia: Standard Nerve block or infiltration ,

sometimes intraligamentary and intrapulpal
injections are necessary.
3. In multirooted teeth:
a) pulpotomy:
1-When minimal time is available and if the patient is highly
sensitive.
2-Correct access cavity is prepared and by means of a spoon
excavator or large round bur the coronal inflamed part of the
pulp is removed. The hopefully uninflamed pulp in the root
canal is left.
3-A cotton pellet dampened with formcresol is placed in the
chamber and the access cavity sealed with a temporary filling.

4-Occlusion is checked to avoid peridontitis.

 b) Total pulpectomy:
1-When considerable time is available, The removal
of the entire pulp will ensure that pain will be
relieved.
2-The access is closed with dry, sterile cotton pellet
and temporary filling.
3-Occlusion is checked.

4. In single rooted teeth:

1-Total pulpectomy and the access is closed with
dry, sterile cotton pellet and temporary filling.

2-Single visit endodontic treatment

 Pretreatment emergencies
2. Acute irreversible pulpitis with acute apical periodontitis

Diagnosis:

1.location: patient can locate the pain.

2. Spontaneous, sharp, throbbing pain that persists
after removal of stimulus
Mostly, heat causes the intense pain while cold
relieves.

Some patients come to the dental clinic with a glass

of ice water to keep pain to the minimal level.
Sensitivity to both heat and cold is also possible
2. clinical examination:
Percussion: Tender to percussion
Radiographic examination:
Periodontal ligament may be normal or exhibit
thickening. In multirooted teeth different roots
may exhibit different conditions.
Line of treatment:
1-This is the most difficult emergency condition, especially in
mandibular molars where a sufficient depth of anesthesia
can’t be easily achieved.

2. Aim of emergency ttt is to alleviate the pain by

delivering profound anesthesia and removal of all the
inflamed pulp till the apical part through total
pulpectomy.

3. Anesthesia: Standard Nerve block or infiltation (increase

the dose 2 carpules).

Once the roof of the pulp chanber is reached intrapulpal

injection can be used.
4. The correct access is prepared, the cooling
effect of the water spray may make approach to
the pulp endurable.
6.X-ray film is taken to determine root canal
length for proper debridment.
7.The access is sealed with dry, sterile cotton
pellet and temporary filling.
 Pretreatment emergencies
3. Pulpal necrosis
Diagnosis:
Pulp necrosis alone rarely causes an emergency. However the
patient should not be kept waiting, because the condition may
turn acute.

Usually the condition is first discovered during radiographic

examination or through development of a swelling for which
the patient requests an emergency treatment.

The tooth is not sensitive to thermal stimuli

The tooth is not sensitive to percussion

Radiographic examination ranges from no radiolucency at all

to small or large which is localized or diffuse.
 Line of treatment:

1.Aim of the treatment is canal debridement of the toxic materials and/or

reduce the population of microorganisms.

2.Anesthesia: not necessary, however, it is used in some cases where there

are still enough pain receptors to cause discomfort.

3. Proper coronal access and tooth length for canal debridement total
canal debridement in the first visit 1mm short of the apex and placing
Ca(OH)2 as intracanal medicament between the appointments to help
eliminate the remaining bacteria.

4. The canal is irrigated with NaOCl

5. The access is sealed with dry, sterile cotton pellet and temporary filling.
 Pretreatment emergencies
4. Pulpal necrosis with acute periapical abscess
Diagnosis:
1.The patient have swelling which may be localized within the oral cavity
or diffuse (cellulitis) spreading through adjacent soft tissues along fascial
planes.

2.The responsible tooth lacks vitality

3.The tooth is tender to percussion and is mobile

4. Generalized pain may be absent. Pain is present before the swelling

occurs as the toxic products build up pressure. Once the bone is
perforated, there is room for the exudate to expand through the soft
tissue and pain may be lessened.

5. Radiographs range from no periapical change (when inflammation is

rapid) to definite radiolucency (acute abscess developing from a chronic
lesion)
 Line of treatment
1.The aim is to achieve drainage, either through the root
canal, or by incising a fluctuant swelling or surgical
trephination
(perforation of the alveolar cortical bone over the root end of
the tooth) and antibiotics (aid elimination of pus from the
tissue spaces).
2. Anesthesia:
local infiltration should not be administered in the distended
area because:
a) pain caused by injection
b) chance of dissemination of virulent organisms
c) ineffectiveness of anesthesia
Block anesthesia is effective during the initial phases of
emergency treatment.
 Pretreatment emergencies
4. Pulpal necrosis with acute periapical abscess

Line of treatment (cont.)

3. Drainage through the root canal:
The correct access cavity is prepared using high speed
headpiece to minimize vibration.
A) Usually drainage occurs immediately upon removing the
pulp chamber roof. It starts with a pus of yellowish, whitish
or greenish color mixed with blood, gradually blood is
predominant. Finally the blood decreases and only a clear
serum exudation emerges this may take from15 to 60 min.

B) Other teeth may appear dry within the canal because the
apical constriction is preventing the exudate from draining
through the tooth. So the apical constriction is enlarged to a
size of 25 or 30 to allow exudate drainage.
C) When sufficient drainage has resulted, the access
cavity may be closed with a sterile cotton pellet and
temporary filling. When the tooth is kept close no new types
of microorganisms are introduced in the periapical tissues.

The patient appointed in 2 to 5 days for the second visit. [root

canal prep, irrigation NaOCl, dry, Ca(OH)2 intracanal
medicament, cotton and temp dressing].

D) For drainage the tooth Should not left open.

 Pretreatment emergencies
4. Pulpal necrosis with acute periapical abscess

E) Irrigants used in treating acute abscesses:

In the initial stages of inducing drainage, warm sterile
water or saline is the preferred irrigant. NaOCl is not used
because it has a tendency to clump the exudate and plug the
apical constriction and halt drainage.

When patency is maintained, NaOCl is used if further canal

preparation is to be performed.

NaOCl must be the final irrigant. This is done before

sealing of the access with dry cotton and temporary filling.
 Pretreatment emergencies
4. Pulpal necrosis with acute periapical abscess
Line of treatment (cont.)
F) Antibiotic therapy:
1- It is not needed in cases that had sufficient drainage and the patient is
afebrile, Localized swelling
2- Antibiotic coverage should be prescribed in cases of the patient is febrile,
Generalized swelling.

penicillins:e.g. amoxycillin (broad spectrum but not penicellinase resistant),

Ampiclox (broad spectrum and penicellinase resistant), 500 mg/6hr, for 7
days is effective against most aerobic and anaerobic oral bacteria

Metronidazole 250mg/6hr, for 7 days is effective against anaerobic bacteria

but not against facultative anaerobes. Combination of penicillin and
Metronidazole is recommended.

Clindamycin 150 mg/6 hr, for 7 days is effective against orofacial infection
and suitable in patients allergic to penicillin
 Pretreatment emergencies
4. Pulpal necrosis with acute periapical abscess

4. Incision and drainage:

Management of localized soft tissue swelling through incision
and drainage.
Fluctuation, the sensation (on palpation) that there is a
fluid movement under the tissue is indicative of presence of
pus
Anesthesia: Soft tissue infiltration around the periphery
may permit manipulation with the least discomfort.
Principles during incision and drainage:
*Vertical incision at the site of greatest fluctuation
*Surgical hemostat dissects and facilitate drainage
*rubber dam drain (optional)
*The wound is kept clean with hot saline mouthwash
5. Artificial fistulation (artifistulation) and trephination

When Intracanal drainage is not possible; in presence of post

and core, calcified canal.
Artificial fistulation (artifistulation):
If the swelling is diffuse, antibiotic coverage is prescribed with
hot mouth rinses. Once the area is fluctuant a stab incision at
the most dependent point with a No. 11 scalpel blade. The
apical bone is enlarged with spoon excavator or endodontic file
to ensure venting of the area. The incision is not closed and a
rubber dam drain is placed. Antibiotic is prescribed. The patient
return in 4 to 7 days.

Trephination: If artifistulation fails to provide drainage, the

flap is increased in size, bone is removed by fissure bur with
airotor and water spray until the bone root is uncovered, and
the necessary drainage obtained.
 Cellulitis
 Diffuse extraoral or intraoral
swelling
 Rapid spread into spaces
 Systemic signs of infection
 Lymphadenopathy, fever
 Difficulty swallowing, mouth
opening
 Sublingual and palatal aspects
 Referral to an oral surgeon or ER
 Pretreatment emergencies
Traumatic injuries

5.Fractures 6. Avulsed teeth

1)Crown fracture without pulp exposure
2) Crown fracture with vital pulp exposure
3) Crown fracture with necrotic pulp
exposure
4) Horizontal root fracture
 Inter appointment pain and/ or swelling (flare up)
The causes of flare ups are numerous and multifactorial :

1)Mis-diagnosis

2) Missed canals
3)Incomplete removal of the pulp tissue
In case of acute pulpitis if partial pulpectomy was done.

4) Inadequate debridement in case of teeth with necrotic pulps

5)Debris extrusion: especially from necrotic pulps. The crown

down concept of rotary instrumentation of the root canal, reduces
the amount of debris extrusion.
6)Overinstrumentation: instrumentation beyond the apical
foramen especially in cases with already inflamed apical
periodontal tissues. Treatment includes: strong anesthesia,
irrigation, dryness, calcium hydroxide paste and closure,
together with strong analgesic.

7)Method of irrigation: if NaOCl is forced beyond the apical

foramen it can cause severe pain and irritation (Hypochlorite
accident).

8)Open versus closed dressing: If the tooth is left open,

various microorganisms and irritants from the saliva can get
introduced into the already inflamed periapex.
The tooth is left open only in:
a) acute infection with diffuse cellulitis
b) teeth exhibiting excessive drainage
 Inter appointment pain and/ or swelling (flare up)
The causes of flare ups are numerous and multifactorial (cont.)

9) Intracanal medicament:
a) formcresol has been limited now in use because it can irritate the tissues and
initiate inflammation.
b) The use of antibiotics risks the induction of hypersensitivity and the development
of resistant strains.
c) Currently calcium hydroxide paste is recommended to be used as an intracanal
medicament especially in the following cases:
1- persistent exudation due to accidental overinstrumention
2-cases with necrotic pulps, particularly when complete debridement is not possible
in the first visit(to benefit its anti-microbial effect)
3-In flare up cases.

10) High occlusion: Periapical inflammation is found to aggravate as the patient

applied extra force on the supra-occluded tooth .

11)Retreatment: retreatment cases have higher incidence of flare ups.

Inter appointment pain and/ or swelling (flare up)
1. Apical periodontitis secondary to treatment

The tooth insensitive to percussion becomes sensitive to

percussion during the process of endodontic therapy .
Causes:
1.Most frequently overinstrumentation
2. May be from over medication
3.May be from forcing debris into the periapical tissues.
Test for diagnosing that the cause is overinstrumentation:

1.Place a rubber dam, a sterile paper point thin enough to reach the
apical portion of the preparation. If the apex is overinstrumented
the point will easily extend beyond the working length on
withdrawal the tip of the point will disclose reddish color.
2.Treatment:
1. A corticosteroid-antibiotic medication applied by a paper point to
reach the periapical tissue is used to give symptomatic relief
2. Routine endodontic therapy may be continued within 2-5 days
taking care to adjust the working length.
 Inter appointment pain and/ or swelling (flare up)
2. Incomplete removal of the pulp tissue

In chronic pulpitis and in some cases of acute pulpitis, the

inflammation may have extended into the radicular pulp. Although the
initial pulpotomy might relieve the pain, discomfort frequently returns.
Causes:
Incomplete removal of the inflamed pulp tissue

Test for diagnosing that the cause is Incomplete removal :

1.Anesthesia and place a rubber dam, a sterile paper point reach short
of the apical portion of the preparation. On withdrawal the tip of the
point will disclose reddish color.

2. Treatment:

1. Radiograph is taken to adjust the working length and the remaining

pulp tissue is removed.
 Inter appointment pain and/ or swelling (flare up)

3. Recrudescence of a chronic apical periodontitis

(Phoenix abscess)
Most teeth with necrotic pulps and chronic apical
lesions are asymptomatic. They are usually noticed when
routine full-mouth radiographs are taken, at which time
endodontic therapy is advised.

Unfortunately low cases of the chronic lesions become

acute after the first endodontic appointment.

The condition is referred to as recrudescence (breaking

out new) or phoenix (rebirth) abscess
 Inter appointment pain and/ or swelling (flare up)
3. Recrudescence of a chronic apical periodontitis
(Phoenix abscess)
The exact cause of the condition is :
1. The change in the environment within the root canal Virulent
strain may begin rapid multiplication
2. Acute reaction due to overinstrumentation or necrotic debris being
forced through the apex with an area of low resistance present.

1. The symptoms are identical to an acute periapical abscess:

Swelling, mobility, tenderness to percussion

2. The emergency treatment is the same as acute apical abscess

 Post appointment emergencies
 It was found that approximately one third of the endodontic patients experience some
pain following obturation
 Causes:
1.Overfilling
2. Poor coronal seal
3. High occlusion
4. Extrusion of sealer into the periapical tissues
Treatment:
1.At times the patient reports sever pain but there is no swelling while the root canal is well
done. Mild analgesics and reassurance of the patient; informing him of the possibility of
discomfort during the first few days
2. Patients with acceptable root canal treatment who develop swelling after obturation
should undergo incision and drainage.
3. Retreatment is indicated in persistently painful cases in which treatment has been
inadequate.
4.Apical surgery is required in patients with uncorrectable, inadequate root canal treatment.
Note -questions will be given from assigned
reference book