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
treatment

immediate

diagnosis

and

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
play an integral
inflammation

The

and host
role in

immune response
the degree of

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.

Clinicians 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 patients 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 ProceduresReview

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 ProceduresReview

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 ProceduresReview

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

Hartys 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)