Endodontic emergency

treatment

Drg. Hesti Witasari JE, Sp.KG

• 90% of patients
requesting treatment for
the relief of pain

• Have pulp and/or

periapical disease

• Endodontic therapy
• The most important aspect of treating the
endodontic emergency patient is the
accurate diagnosis and treatment.
• Dentist should
interfere the
case
• NEVER depend
on medications
alone
DEFINITION OF EMERGENCY

• Cases associated with pain &/ or swelling

& require immediate diagnosis & treatment
 The causes
• Caries
• Deep or defective restorations
• Trauma

Are irritants that induce severe inflamation in

pulp & periradicular tissues
Pathogenesis
Keys questions to determine the case:

• Distruption of sleeping,working & eating

• Duration
• Pain medication
 Most of emergency cases
• Flare up
• Acute pulpitis
• Acute pulpitis with apical
periodontitis
• Pulp necrosis with acute
periapical abscess
• Tooth fracture (trauma)
 “W
ha
Flare up td
id
Id
o
• Exacerbations of w
ro
ng
chronic cases may ?”
occur during
treatment
• While there may be
an iatrogenic factor
involved in an
exacerbation
 Flare up
Preoperative complication
Over instrumentation
Remaining inflammmed pulp
tissue
Improper preparation
etc.
 Painful pulpitis (Hot Tooth)

• A “hot tooth” tooth with irreversible

pulpitis that does not respond normally to
local anesthesia.
cardinal feature of “hot tooth”
• severe sensitivity numb lip following
the administration of local anesthesia.
• Pain may persist
• Most often it occurs in the mandibular
molar area, although there are exceptions.
 Pulp Necrosis with acute
apical periodontitis
• The most difficult emergency
condition to treat

• Because the inflamed tissue

that must be removed is in the
apical portion of the root Canal
• Diagnosis aware to
percussion
 Pulp Necrosis with acute
periapical abscess
Signs:
•Large diffuse swelling
•Tenderness response
to percussion
•Mobile
•Lacks vitality
 Treatment goal
the immediate goal of the treatment
should be the reduction of
pressure or removal of the
inflamed pulp or periradicular
tissue.
 Treatment of flare up
vital cases without swelling
Assurance of patient
Good analgesic
Reopen the tooth ( make good
debridment & irrigate)
Intracanal medicaments
 Treatment of flare up
Necrotic cases with no swelling
Open the tooth
Reclean & irrigate the canals with sodium
hypochlorite
Dry & close.
 Treatment of flare up
If acute apical abcess is developed:
Drainage is necessary ( through the tooth or
the soft tissue)
Cleaning & irrigation of the canals
Dry & close
Antibiotic & NSAID is needed
 Treatment of acute pulpitis

• Adequate anesthesia
- block or infiltration injection
- periodontal, intrapulpal, or intraosseous
injection
• Remove the inflamed tissue (minimal
treatment)
• Complete cleaning and shaping of the
root canal(if time permits)
 Treatment of acute pulpitis
with apical periodontitis
• Heavy dosage of local anesthetic
• Correct access cavity is prepared
• If still pain apply intrapulpal injection
• Complete pulpectomy is the therapy
• Seal the cavity with ZOE
 Treatment of pulp necrosis
with acute periapical abscess
• Should be incised
and drained through
the root canal space
• Don’t do infiltration
injection
• Apply stick
impression
compound to the
labial surfacemin.
The vibration
Drainage from root canal
Longitudinal fracture

• Cracked teeth and

their related entities
as wel as vertical root
fracture
Longitudinal fracture
• These contrast with horizontal fractures
predominate in anterior teeth and result from
impact trauma.
• Occur in all tooth groups
• Are caused by occlusal force and dental
procedures
Longitudinal fracture
• Treating is usually challenging
• Sometime not difficult to diagnose or
manage, whereas at other times they
are so devastating that involved tooth
extracted
• Many situations present with significant
problems
considered for referral
INCIDENCE
• Increasing age of patients
• Present for longer periods of timed
• Procedures restorative & endodontic treatments that remove
dentin
internal strength, absorb external forces alter tooth
structure
destructive force is beyond the elastic limit of dentin or
enamel
FRACTURE OCCURS
5 CATEGORIES
CRAZE LINE
• Common
• Usually permanent teeth in
adults
• Usually extend over
marginal ridges and
along buccal and lingual
surfaces
• Confined to enamel
FRACTURED CUSP
• Usually have a good
prognosis.
• This occurs often in
teeth with extensive
caries or large
restorations that do
not protect
undermined cusp
Pathogenesis of Fractured cusp
• Lack of cusp support
loss of tooth structure
because of extensive
caries
• Traumatic injury
occurs immediately
loss of one or more
cusps
• Particularly maxillary
premolars
 Subjective Findings
• Sharp pain on mastication
• Sensitivity to temperature changes(cold)
• Occurs only on stimulus
• Symptoms are often relieved when the
cusp finally breaks off
Objective Tests

• The most indicative test is biting

• Patients ordinarily respond to pulp
testing
• Not visible radiographically
Treatment
• The cusp is removed
• Tooth is restored as appropriate(crown)
• Occasionally, restoration is unnecessary
• Root canal treatment is often not required
because the pulp is usually not exposed
CRACKED TOOTH
• Incomplete fracture
initiated from the
crown and extending
subgingivally, usually
directed
mesiodistally
 Pathogenesis
• Forces in excess of dentin strength are
responsible
• These forces are greater in the posterior
region
• “Nutcracker” effect
Subjective Findings
• Cracked tooth syndrome
• Acute pain on mastication (pressure or
release)
• Brief pain with cold
• Once the fracture has extended to and
exposed the pulp, severe pulp and/or
periapical pathosis will be present
Objective Tests
• The pulp is usually responsive(vital) but
may be non responsive(necrosis)
• Percussion that separates the crack may
cause pain
• Not visible radiographically
 Treatment
• If there are no symptoms of
irreversible pulpitis crown
• If partial fracture of the chamber
floor is detected crown may be
bond with a stainless steel or an
orthodontic band or temporary
crown to protect the cusps until
final restoration is performed
• Treatments are complex
referral to an endodontist
 SPLIT TOOTH
• The evolution of a cracked tooth
• The fracture is now complete and
extends to a surface in all areas
• The root surface involved is in the middle
or apical third
• There are no dentin connections, tooth
segments are entirely separate
 Subjective Findings
• Pain on mastication
• A periodontal abscess may be present,
often resulting in mistaken diagnosis
 Treatment
• If fracture not too far apical, the smaller
segment very mobile  good possibility
Split teeth treatment
VERTICAL TOOTH FRACTURE

Differs from the entities

Occur in teeth that have

complex procedures such
as root canal treatment,
and intraradicular post
retention
 Treatment
• Root amputation or
hemisection
• For high anxiety
patients:
– Sedation
– Hypnotherapy