Emergency endodontic therapy: report of case

bridement of the pulp chamber is most efficient

J a m e s R. L a n c e , DDS
F. J a m e s M a rs h a ll, DMD, MS, C olum bus
In em ergency s itu a tio n s re lie f of a p a tie n t’s dis­
c o m fo rt, caused by a diseased pulp, may be o b ­
tained w ith use o f a deep p u lp o to m y procedure.
A 23-year-old w om an was seen late at n ig h t be­
cause of pain in the region o f the rig h t m a n d ib u­
lar firs t m olar. A d ia g n o sis of irreversible p u lp itis
was made. A fte r anesthesia had been obtained,
th e ro o f o f the p ulp al ch a m b e r was rem oved co m ­
pletely. The ch a m b e r was d ebrided and the canals
w ere in strum ente d to a d e p th o f 16 mm. A m ed­
icated pe llet was placed in th e cham ber and the
access o pe ning was closed w ith a te m p o ra ry ce­
m ent re sto ra tio n . The p a tie n t was in stru cte d to
see her d e n tist fo r co m p le te e n d o d o n tic therapy.
when accompanied by copious water irrigation
and high-speed evacuation. Reamers or files, or
both, are introduced into each canal to the length
of the spiral channel (16 mm for standardized
instruments) and the pulp tissue is removed (Fig
2). This will remove the bulk o f the radicular
pulp and yet not penetrate the apical tissue. N o
attempt should be made to enlarge or to shape
the canals and care should be taken to prevent
ledging.
When the pulp tissue has been removed com­
pletely the hemorrhage will stop. A no. 4 cotton
pellet, medicated with metacresylacetate (Cres-
atin) and squeezed dry twice to prevent over­
medication, is placed in the pulp chamber. Ad­
ditional sterile nonmedicated cotton pellets may
be placed in the chamber for bulk. The access
opening then is sealed with quick-setting zinc
oxide-eugenol or Cavit (Premier Dental Prod-

A simple and expedient method for the relief of

acute pain in tooth pulps is required when a limit­
ed amount o f time is available.
The traditional endodontic procedure for
treating a diseased pulp is extirpation. This in­
volves the use of radiographs and calculated
tooth measurements. These are necessary to
prevent instrumentation beyond the apex and to
prevent the possibility of additional periapical
inflammation. The procedure is unnecessarily
time-consuming in emergency situations, and is
not required to obtain the’ prime objective—re­
lief of the patient’s discomfort.

Procedure

Once a diagnosis of irreversible pulpitis is made,

the region of the tooth is anesthetized. Supple­
mentary anesthesia, as obtained by intraos-
seous injections, may be necessary for the com­
plete relief of pain. The tooth then is isolated
with a rubber dam and an access opening is
made into the pulp chamber. The opening pro­
cedure must remove the pulp chamber roof com­ Fig 1 ■ Pulpotomy technique for mandibular molar with no. 8 reg­
pletely. The contents of the chamber are re­ ular length round bur. Pulp chamber floor is not penetrated even
moved with use of large round burs (Fig 1). De- though bur is at its full extension.

JADA, Vol. 85, November 1972 ■ 1119


Fig 2 ■ Deep pulpotomy technique (or partial pulpotomy) with use
of no. 40 reamer in mesial canal and no. 55 reamer in distal canal.
Only the spiral channel of reamer Is inserted, and tips do not extend
to apexes.
ucts Co.) cement (Fig 3). The rubber dam is re­
moved and the occlusion is relieved.
Before the patient is dismissed, he should be
assured that the discomfort will subside. Anal­
gesics or sedatives should be prescribed if re­
quired. Acetylsalicylic acid, 325 mg every two
hours, should be prescribed for the anti-inflam-
matory effect even if stronger analgesics are not
required. The patient should be instructed to
return for further treatment when an adequate
amount o f time can be scheduled.
Report of case
A 23-year-old woman was referred to the grad­
uate endodontic clinic at Ohio State University
for treatment. The patient had experienced se­
vere pain in the right mandibular molar region
for several days; the pain only could be relieved
with intramuscular injections of meperidine hy­
drochloride. When she was seen at 11:30 p m ,
she was distraught. The right mandibular pos­
terior teeth were not sensitive to palpation or
percussion and responded normally to heat.
1120 • JADA, Vol. 85, November 1972
Fig 3 ■ Medication technique for deep pulpotomy (as shown) or
regular pulpotomy. Note remaining apical tissue (1) and empty
space above. Single no. 4 pellet of medication (2) and occlusal
seal (3) can be seen.
However, the mandibular right first molar was
extremely sensitive to cold and an inferior al­
veolar nerve block with a 2% solution o f lido-
caine hydrochloride, 1:100,000 epinephrine, was
required to alleviate the acute symptoms. A
diagnosis of irreversible pulpitis was made.
Although the acute symptoms ceased within
minutes o f the inferior alveolar block, a long
buccal injection and an intraosseous injection
distal to the tooth were given to ensure com ­
plete anesthesia.
The tooth was isolated with a rubber dam
(Fig 4, top) and the previously described pro­
cedure was followed. Three canals were located
(Fig 4, bottom) after debridement of the pulp
chamber; each canal was instrumented to 16
mm. In the mesial canals a no. 20 reamer was
used and in the larger distal canal, a no. 30 ream­
er.
A cotton pellet medicated with metacresyl-
acetate was placed in the pulp chamber and a
temporary cement (Cavit) restoration was
placed.
The patient was reassured and dismissed with
instructions to return to her dentist for comple­
tion of the endodontic treatment. In a later com­
munication with us, she related that the imme­
diate relief of the pain had continued and that
analgesics were not needed after the anesthesia
had worn off.

Fig 4 ■ Top: Deep pulpotomy in mandibular molar. Note position
of instruments. Instruments’ cutting edges are seen at lip of o c­
clusal cavity. Bottom: Radiograph of technique showing instru­
ments in canals. Note distance remaining between tips of Instru­
ments and apexes of canals.
Discussion
This technique has been used by the students in
the Ohio State University undergraduate and
graduate endodontic clinic for several years as
an emergency treatment. It has proved to be an
expedient and extremely successful procedure.
Although the reason for the success of this
treatment can only be conjectured, several con­
ditions created by the procedure might explain
its effectiveness. First, the apical portion of the
pulp is free of inflammation. In a histologic study
of 26 teeth with inflamed pulps, Mitchell and
Tarplee1 reported that no inflammation in the
pulp tissue was found in the apical third of all
the canals. Second, with removal o f the bulk of
tissue, a space is created for the inflammatory
exudate, a cause for pain in itself. This also
would decrease the pressure of the exudate on
the pulp and, therefore, reduce the pain. Third,
with the removal of a large amount of the in­
flamed pulp, the normal repair mechanisms of
the body have a better chance to control the dis­
ease process and to reduce the symptoms.
The medication also may have a small role
and give some relief because of its anodyne ef­
fect. Cresatin is the intracanal medication of
choice because it combines antibacterial and
anodyne effects. Cresatin, rather than eugenol,
is used since it causes less tissue damage and is
a more effective germicide.2
Regardless of the treatments performed or the
reasons for success, the pain relief depends on
the locating and treating o f all canals. Molars
particularly should be examined carefully for
extra or fourth canals.
Ideally, of course, and when time permits,
the treatment of choice is pulp extirpation and
canal preparation at the first visit. Unfortunate­
ly, pulp extirpation takes longer than an extrac­
tion and, in a busy office, this may preclude sav­
ing the teeth. A deep pulpotomy, however, stops
the pain, reduces treatment time approximately
to that of an extraction, and it saves teeth.
Sum m ary
An expedient technique for the relief of the
symptoms of acute pain caused by a diseased
pulp has been presented. It involves the per­
formance of a deep pulpotomy, followed by
minimal medication with metacresylacetate.
This has proved to be an effective and effi­
cient procedure that requires a minimal amount
of time and instrumentation.
Dr. Lance was a graduate student in the department of en-
dodontics, the Ohio State University, College of Dentistry, and
is now in specialty endodontic practice, 5311 Patterson Ave,
Richmond, Va 23226. Dr. Marshall was professor and head of
the department of endodontics at the Ohio State University,
College of Dentistry. He is now professor and head of the de­
partment of endodontics, the University of Oregon Dental
School, 611 SW Campus Dr, Portland, 97201.
1. Mitchell, D.F., and Tarplee, R.E. Painful pulpitis. Oral Surg
13:1360 Nov 1960.
2. Penick, E.C., and Osetek, E.M. Intracanal drugs and chem­
icals In endodontic therapy. Dent Cl In North Am 14:743 Oct
1970.
Lance— Marshall: EMERGENCY ENDODONTIC THERAPY • 1121