EMERGENCY

TREATMENT
IN ENDODONTICS
By: Mai hamdy
Ass. Prof. of Endodontics,
Faculty of Dentistry,
Suez Canal University
 outline

• Definition
• The Emergency Patient
• Diagnosis
• Classification
• Rationale for Treatment
• Management
Endodontic emergencies are usually
associated with pain or swelling and
require immediate diagnosis and
treatment in unscheduled appointment
Endodontic Emergency
Definition
• A disease that was associated with
pain and/or swelling that disrupt
the usual patient activities and
require immediate diagnosis and
treatment
Emergency vs. Urgency
• Disrupts daily activities
• Less than 2 days duration
• Unrelieved by analgesics
Is This a True
Endodontic
Emergency?
Three Key Questions:

1. Does the problem disturb your

sleeping, eating, working,
concentration or other daily
activities?

• A TRUE EMERGENCY IS DISRUPTIVE

Three Key Questions:
2. How long has the problem been
bothering you?

• A TRUE EMERGENCY RARELY LASTS

MORE THAN FEW HOURS TO TWO DAYS.
Three Key Questions:

3. Have you taken any pain

medications? Did it help?

• A TRUE EMERGENCY IS NOT RELIEVED BY

ANALGESICS.
It is most likely that only one tooth is
responsible for the acute situation
Sources of Acute oral pain
• 1. Acute noxious stimulation
- e.g. EPT, Ice test, etc
• 2. Dentinal Hypersensitivity
- exposed dentinal tubules
• 3. Referred pain
-e.g. from remote tooth or sinusitis
Sources of Acute oral Pain
• 4. Infection
e.g., periradicular abscess, exposed irreversible pulpitis, and
post-op infection.
(Inflammation and pain are 2ry to infection)
• 5. Inflammation
Mechanical (e.g., surgery, hyperocclusion)
Chemical (e.g., bacterial toxins)
Thermal (e.g. burns from steaming hot drinks)
Incidence of Types of Emergencies
• Most emergencies are for pain
relief
• Categories (incidence)
 Endodontic (75%)
. Pulpal (2/3)
. Periapical (1/3)
 Non-Endodontic (25%)
. Periodontal, Sinusitis
. Hyperocclusion, soft tissue
lesions
. Others
Sources of pain in Endodontic
Emergencies
Pulp irreversible pulpitis

Acute Apical
Periapical Periodontitis
Acute Apical
Abscess
 Diagnosis
• In order to adequately treat the pain, it is
necessary to establish the cause
• If you cannot establish etiology.. You should try
 Conservative treatment (palliative) + analgesics,
then reappoint the pt or refer to a specialist (if
you are in doubt send the pt out)
• Never ever start any treatment procedure before
confirmation of the correct diagnosis
 System of Diagnosis

Objective Examination
• Swelling, defective restoration, recurrent caries, fracture
• Palpation / percussion
• Vitality testing
. Thermal, electrical, mechanical
• Periodontal examination
. Differentiate periodontal vs. endodontic abscess
System of Diagnosis

• Radiographic
examination
- Periapical changes
- Periodontal changes
- Adjacent teeth
- Initial caries (bite wing
films)
Collection of Data
1. Medical and dental history
2. Extraoral examination of the face
3. Intraoral examination, use
palpation and percussion test to
determine periapical status.
4. Pulp testing
5. Appropriate radiographs
6. Other special tests as needed
 Differentiate between…

Odontogenic Vs Non-Odontogenic…..?!

Pulpal Vs Periapical ….?!

(i.e. Acute pulpitis Vs Acute Periapical condition..?!)

Acute Apical periodontitis Vs Acute Peiapical Abcess..?!

Acute Periapical Abcess Vs Phoenix Abcess….?!

 Classification of Endodontic
Emergencies

I. Pretreatment Emergency
II. Intra-appointment
Emergency
III. Inter-appointment
Emergency
IV. Post-treatment Emergency
Pretreatment Emergency

1- symptomatic irreversible pulpitis

3- Pulpitis with symptomatic Apical
Periodontitis
4- Acute Periapical Abscess
Rationale for emergency
treatment
• Remove the cause of pain
• Provide drainage
• Prescribe analgesics
• Adjust the occlusion if indicated
 Management of Emerg.
Cases.

Psycologic Management (Psycosedation)

• Establish and maintain Control of the situation
• Gain the Confidence to the patient
• Provide attention and sympathy
“Communication”
• Treat patient as important individual “Concern”

PROFOUND Local Anaethesia and other pain

control procedures

Specific Management for each condition

symptomatic irreversible
pulpitis
clinical management of
emergency treatment by:
• Remove the inflamed pulp
tissue either by pulpotomy or
complete instrumentation
• Analgesic & Anti-inflammatory
symptomatic irreversible pulpitis

• DO not ever partial

pulpectomize!!!!!!!

• If root canal therapy is completed at a

later date, medicating the canal with
calcium hydroxide reduce the chances of
bacterial growth between appointments
 Intracanal Medicaments

Calcium hydroxide advantages

• Tissue dissolving effect (Hasselgren et al, 1985)
Inhibits bacterial growth (Bystrom et al, 1985; safavi and Nichols,
1994)
• Temporary canal obturating material
• In canal for 7 days eliminates bacteria (Sjogren, 1991)
• Remove with 10 ml NaOCL and 10 ml EDTA before
obturation (Calt, 1999)
Pulpitis with symptomatic Apical
Periodontitis
• Remove the inflamed pulp tissue by
complete instrumentation & apply
ledermix* or calcium hydroxide
intracanal medication

• Reduce occlusion

• Analgesic & Anti-inflammatory

*Demeclocycline hydrochloride and Triamcinolone acetonide

 Acute Periapical Abscess

• Localized swellings are confined

within the oral cavity, whereas a
diffuse swelling, or cellulitis, is
more extensive, spreading through
adjacent soft tissues and along
fascial planes

• Antiobiotics!!!!!!!! When
to prescribe?
 Acute Periapical Abscess
• Swelling is controlled by establishing drainage
through the root canal or by incising the fluctuant
swelling

• Gentle finger pressure to the mucosa overlying the

swelling facilitate drainage through the canal. Once
the canals have been cleaned and allowed to dry,
the access should be closed
 I&D
The basic principles of incision for
drainage are as follows:
• Anesthetize the area.
• Make a vertically oriented incision at the site of
greatest fluctuant swelling.
• Dissect gently, through the deeper tissues
• To promote drainage, the wound should be kept clean
with warm saltwater mouth rinses
• A drain should be placed to prevent the incision from
closing too early. The preferable type of drain is 1-2-
inch iodoform gauze
• In many cases, the endodontic treatment can be
completed in one visit after the drain is placed
 I&D
Incision for drainage is
indicated whether the cellulitis is
indurated or fluctuant.
• To provide a pathway of drainage to prevent
further spread of the abscess or cellulitis
• allows decompression of the increased tissue
pressure associated with edema and provides
significant pain relief
• Provides a draining pathway not only for bacteria
and their products but also for the inflammatory
mediators associated with the spread of cellulitis
 Prettt Emergencies
Acute Apical Abscess

I&D

=
=
Acute Periapical Abscess

• Complete canal debridement and disinfection are

paramount for success, because the presence of
any bacteria remaining within the root canal
system will compromise the resolution of the
acute infection

• when not completing the treatment in a single

visit!!!!!!!!!!!! use calcium hydroxide as the
intracanal medicament
• Analgesic & Anti-inflammatory
Decision Making in Pain Management
Irreversible pulpitis Necrotic pulp

Without With With With

apical apical localized diffuse
periodon periodonti swelling swelling
titis tis

Pulpotomy Cleaning C & S and C & S,

or C & S and drainage drainage
shaping and
Antibiotics
Intraappointment flareup
 NaOCl Accident
• Severe and immediate pain, with marked edema
or bruising that may extend over the injured side
of the face, cheek, or lips
• Spontaneous and sometimes profuse hemorrhage
from the canal space
• Paresthesia, either transient or permanent

• In mandibular teeth, extension into the

submandibular, submental or sublingual regions
can compromise the airway
Etiology of NaOCl
Accident
• Inaccurate working length
• Iatrogenic widening of the
radicular foramen
• Lateral perforation of the root
• Wedging the irrigating needle.
 Mangement of NaOCl Accident
• Immediately irrigate the canal with normal saline
to encourage bleeding, diluting the irritant and
removing it from the site of the injury
• Negative pressure irrigation device with the
cannula placed at the radicular foramen.
• Analgesics along with cold compresses
immediately
• After one day, warm compresses & warm oral
rinses
• Antibiotics ?
• Reassurance
Prevention of NaOCl
Accident
◆ Carefully assess the canal integrity for
signs of perforation or other large portals of
fluid egress.
◆ Avoid wedging the needle tip in the canal
space or inserting it beyond the working
length.
◆ Confirm the identity of the solution prior
to injection or irrigation
 Prevention of NaOCl Accident
◆ Establish an accurate working length and avoid
over-instrumentation of the radicular foramen.
◆ Employ a small side vented needle placed not
closer than 2 mm from WL
◆ Express the fluid slowly and observe that it is
venting through the access cavity.
Inter-appointment emegency
 Definition
Development of pain and or swelling
which commences a few hours or
days after root canal procedures and
is of significant severity to require
an unscheduled visit for emergency
treatment.

Gerald W Harrington 1002, walton et al , 1993,Siqueira JF. 2003,Jayakodi et al

, 2012
Prevelance of flare-ups
More prevalent among
• females
• When there are large periapical lesions
• In the retreatment of previous root canals
There is no decrease in the endodontic
success for cases that had a treatment
flare-up
Causes of flare-ups
1. preparation beyond the apical terminus
2. overinstrumentation
3. pushing dentinal and pulpal debris into
the periapical area
4. Incomplete removal of pulp tissue
5. chemical irritants (such as irrigants,
intracanal medicaments)
6. Hyperocclusion
7. Microbiologic factors.
• local adaptation syndrome"
 Hypothesis

• Alteration of the local adaptation

syndrome
• Changes in periapical tissue pressure
• Microbial factors
• Various psychological factors
Alteration of local adaptation
syndrome
• If the irritant is not removed Chronic
inflammation persists and in turn there
is local adaptation.
• When a new irritant is introduced to
inflamed tissue, a violent reaction may
occur.
 Changes in periapical tissue
pressure
• +ve periapical pressure
excessive exudate not absorbed
by lymphatic system, presses on
nerve endings causing
pain.
 Microbial factors

1- Extrusion of microorganisms and their products result in flare-ups

2- Incomplete debridement of canal disrupts the balance between
various microbial communities in the root canal system and may favor
the overgrowth of virulent species
3-Coronal leakage leads to Secondary intraradicular infection
4- Introduction of oxygen during endodontic treatment may allow
facultative bacteria to shift to the much more energy efficient
State and result in a flare-up
 Psychological factors
•Anxiety
•Fear
•Psychosis
•Apprehension
•Previous traumatic dental
experience

These anxieties intensify painful episodes

 Clinical management
Proper diagnosis.
Establish profound local anaesthesia.
Magnification and illumination.
Reconfirm working length.
Thorough debridement and instrumentation
to the full working length.
 Clinical management
• Patency.
• Irrigation protocol.
• Establish drainage.
• Intra-canal Medication.
• Reseal the tooth .
• Relief occlusion.
 LEAVING TEETH OPEN
• The more current literature makes it clear that this
would impair uneventful resolution and create more
complicated treatment.
• For this reason, leaving teeth open between
appointments is not recommended.
• Foreign objects have been found in teeth left open for
drainage
• leaving a tooth open provides an opportunity for oral
• microorganisms to invade and colonize the root canal
system if the tooth is left open for an extended period.
Analgesics
NSAID Acetominophen taken
additive analgesia for controlling severe
dental pain
Patients who cannot tolerate NSAIDs
should consider 1000 mg acetominophen.
Pain that is not controlled by NSAIDs and
acetominophen, narcotic analgesics are
required and may be given in combination
with NSAIDs.
Simplified analgesic strategy to guide drug selection based on the
patient history and level of present or anticipated post-treatment pain.
(Courtesy Dr. A. Fouad.)
RECENT STUDIES FOUND THAT ANTIBIOTIC
ADMINISTRATION BEFORE TREATMENT OF
NECROTIC TEETH EITHER LESS EFFECTIVE THAN
ANALGESICS OR TO HAVE NO EFFECT IN
REDUCING INTERAPPOINTMENT EMERGENCIES
OR POSTTREATMENT SYMPTOMS.
 Preventive measures
1. Maintain aseptic condition and isolation
during root canal treatment.
2. Dental unit waterlines harbor bacteria
at alarming levels, so Avoid.
3. Determine accurate working length.
4. Instrumentation technique: crown-down
technique reduces apical extrusion of
debris
 Preventive measures
5. Avoid end-vented needle.
6. Complete chemomechanical
preparation
7. One visit otherwise use intracanal
medication between multiple visits.
8. NSAID pre-operative then around the
clock post-operative.
Postobturation
Emergency

• Pain: Tenderness to finger pressure

or percussion or an inability to
comfortably bite on the tooth.
• Swelling.
 Predisposing factors

1. There is a correlation between the

level of obturation and pain
incidence
Overextension is associated with the
highest incidence of discomfort.
Overfilling Vs Overextension
Predisposing factors

2. Postobturation pain also relates to

preobturation pain. Levels of pain
reported after obturation correlate to
levels of pain before the appointment.
Management
• Whether the primary cause of the
patient’s symptoms is inflammatory in
nature due to the procedure itself, or
active infection?
 Treatment

• Discomfort in the first few days : occlusal adjustment,

reassurance about the availability of emergency services, and
administration of analgesics for mild pain significantly control
the patient’s anxiety and prevent overreaction.

• At times, the patient reports severe pain, although there is no

evidence of acute apical abscess and the root canal treatment
has been well done: reassurance and appropriate analgesics,
the symptoms usually subside spontaneously. If not retreat!!
Treatment

Swelling:
• If there is localized swelling & root canal
treatment was acceptable, incision and
drainage of swelling should be
performed. Swelling usually resolves
without further treatment.
Treatment

When to remove the root canal filling ?

• Retreatment is indicated when prior
treatment has been obviously
inadequate.
• When an acute apical abscess develops
and there is uncorrectable procedural
errors, Apical surgery is often scheduled
later on.
 Prevention
• Gauging the apical terminus
• Accurate selection of the master cone
• The MC should be marked to indicate the working
length
• If displacement of the master cone during compaction
is suspected, a radiograph is made before excess gutta-
percha is removed
• Avoid Forcing gutta-percha apically by applying excessive
pressure over the spreader (can induce VRF)
Hamdy.mai21@yahoo.co
m