Restorative Dental Sciences

Endodontics
 Lecture 6

Endodontic Emergencies
 Objectives

To discuss the etiology of endodontic
emergencies

To classify endodontic emergencies

To discuss the management of the

unscheduled patient
 Definition

Endodontic emergencies are circumstances
associated primarily with pain and/or swelling
caused by various stages of inflammation and
infection of the pulpal and/or periradicular
tissues.

They require immediate diagnosis and

treatment

They are acute conditions

They should be differentiate from an urgency

which represents a less severe problem
whereby the patient can be scheduled for
convenience
 Etiologies

Microbial, mechanical and chemical irritation of
the pulp or periradicular tissues resulting in tissue
injury, inflammation and cell death

Microbial virulence or severity of the mechanical
or chemical irritant and host immune response
play an integral role in the degree of
inflammation

The inflammatory responses and their
consequences, such as increased tissue pressure
and release of chemical mediators in the pulp
and/or periapical tissues are the major causes of
painful dental conditions (emergencies)
 Management of Etiologic
factors of Pain
Primarily Pain Relief or Reduction
• By removal of the inflamed or infected
necrotic tissue from the root canal system.
• By reduction of painful pressure in the
periradicular or surrounding tissues.
• Pain reduction via the use of medication
(analgesics and/or antibiotics)
• (Associated swellings are usually also
addressed)
Treatment is performed only after a thorough
evaluation of the patient
Emergency Endodontic
Management

Pain is both a psychological and biological
entity.

Management of the emergency endodontic
patient must take into consideration both
physical symptoms as well as emotional state.

A definitive diagnosis must be determined.

A methodical approach based on evaluation of

the patients chief complaint, medical history
and objective and subjective assessments are
required to determine if endodontic treatment is
necessary.
 Clinician’s Predicament

An endodontic emergency usually results in an

unscheduled visit to the dental clinic that can
disrupt scheduled appointments and cause
inconvenience

Incorrect patient management and/or
misdiagnosis will likely result in improper treatment
and an exacerbation on the patient’s problem
that can sometimes be life threatening
 Diagnostic Procedure

Generally as discussed in the Diagnosis
& Treatment Planning Lecture

An orderly and step-by-step approach
is mandatory to arriving at a correct
diagnosis quickly under the stressful
conditions created by endodontic
emergencies

Emotional status of the patient, physical
limitations created as the result of
pulpal and/or periradicular diseases,
lack of time, and stress on the dentist
and staff should not affect such an
orderly approach
 Diagnostic Procedure

Can be divided into five stages:

1. The patient tells the dentist why the patient is

seeking help.
2. The dentist questions the patient about the
history and the symptoms that led to the visit.
3. The dentist performs the clinical tests.

4. The dentist correlates the clinical findings with

the history and creates a tentative differential
diagnosis.
5. The dentist formulates a definitive diagnosis.
 Diagnostic Procedures-
Review

Presenting Complaint

Medical History

Dental History

History of Presenting Complaint

- These are considered subjective findings

and enables the clinician to make a
tentative diagnosis
 History of Presenting
Complaint

Pertinent questions to ask:

1. Localization: Can you point to the offending

tooth?
2. Commencement: When did the symptoms first
occur?
3. Intensity: How severe is the pain?

4. Provocation and relief of pain?

5. Duration: Do they subside or do they linger after

the are provoked?
 Diagnostic Procedures-
Review

Extra-oral examinations

IO examinations

Diagnostic Tests
 Percussion and Palpation
 Mobility
 Periodontal examination
 Pulp sensitivity tests (Thermal, EPT)
 Special Tests- Bite tests, test cavity,
transillumination

Radiographs
POP 10th Edition
POP 10th Edition
POP 10th Edition
Diagnosis of Vertical Root Fracture

POP 10th Edition

Diagnostic Procedures-
Review

Only when the objectives tests have been
performed can a definitive diagnosis be
made.

The diagnosis should reveal the pulpal and

periapical state
 Classification of
Endodontic Emergencies

Before Treatment (Pretreatment)

During Treatment (Interappointment)

After Treatment (Postobturation / Posttreatment)

 Pretreatment

Pulpal pain
 Reversible pulpitis
 Irreversible pulpitis

Acute periradicular periodontitis

Acute periradicular or Phoenix abscess

Cracked tooth syndrome

 Interappointment

Acute Pulpitis or Periradicular Periodontitis or
Abscess or Accidents caused by
 Recent restorative treatment
 Periodontal treatment
 Exposure of the pulp
 Fracture of the crown or crown/root
 High temporary restoration
 Lost or leaky temporary restoration
 Pain as a result of instrumentation

Acute periradicular periodontitis

Acute periradicular or Phoenix abscess
 Missed canal or wrong tooth or incorrect initial
diagnosis (nonodontogenic pain)
 Postobturation (immediate or
delayed)

Acute Periradicular Periodontitist or Abscess or
Accidents (& rarely Pulpitis) caused by
 High restoration
 Overfilling (extruded material)
 Retained infection or reinfection of RC system
 Crown or Crown/Root fracture
 Missed canal or wrong tooth or incorrect initial
diagnosis (nonodontogenic pain)
 Treatment

Generally as discussed in the Diagnosis & Treatment Planning Lecture

Availability of TIME sometimes a factor

Treatment modalities
 Immediate

Reassurance

Occlusal adjustment

Analgesics with or without Antibiotics (if indicated)

Caries removal and sedative restoration (liner and IRM)

Pulpotomy/Pulpectomy with Ledermix

Incision and Drainage

Extraction
 Definitive

Definitive Restoration/Non-Surgical Root Canal
Treatment/Retreatment and/or Surgical Root Canal Treatment
or Extraction

Re-evaluation if diagnosis was incorrect or timely referral if
unable to diagnose or resolve condition
 Antibiotics

Only when signs and symptoms suggest systemic
involvement: fever, malaise, lymphadenopathy,
cellulitis and patients who are immunologically
compromised.

Should be adjunctive to appropriate clinical
treatment

For endodontic infections penicillin VK 500mg
every 4-6 hrs. has shown to be most effective.

Amoxicillin has a broader spectrum and is
recommended for the most serious infections.
Usually prescribed with a loading dose of
1000mg followed by 500mg every 4 to 6 hrs.
 Antibiotics

Metronidazole is not prescribed by itself
because it is only effective against
anaerobes. It may be prescribed in
combination with penicillin. It is prescribed
with a loading dose of 1000mg followed by
500mg every 4 to 6 hours.

For patients allergic to penicillin,

Clindamycin is prescribed with a loading
dose of 600mg followed by 300mg every 6
hours may be prescribed.
 Analgesics

NSAIDS are first choice because pulpal and
periapical pain involves inflammatory processes.

The good analgesic effect combined with the
additional anti-inflammatory benefit make NSAIDs
the drug of choice for acute dental pain in the
absence of any contraindications to their use.

Ibuprofen has been found to be superior to aspirin
(650mg) and acetaminophen (600mg) with or
without codeine (60mg)

Where GI problems are a concern, acetaminophen
is preferred.

Analgesics cannot replace the efficacy of proper
treatment.
 References

Harty’s Endodontics in Clinical Practice –
Chapter 13 – Edited by T R Pitt Ford

A Clinical Guide to Endodontics (Chapter 3) –
Peter Carrotte

Pathways of the Pulp – S Cohen & RC Burns –
Chapter 2 – 10th Edition

Baumgartner JC. Microbiological aspects of
endodontic infections. CDA Journal 2004; 32 (6):
469-473

Oxford League Tables of Analgesic Efficiency
(www.medicine.ox.ac.uk/bandolier/index.html)