Endodontics

Emergencies
Conservative lec No. 10
3.12.2008
Today we are going to talk about endodontic
emergencies, it’s something that the patient complain of, has
to be either pain or swelling that would required an
unscheduled visit (extra visit) for management, so it may be
pain or swelling or both, but you need to see the patient
immediately in a visit and manage him, usually it’s caused by a
pathosis either in the pulp or in the pulp and periapical tissue
and the diagnosis will be irreversible pulpitis or apical
periodontitis in addition to that.

Endodontic emergencies can be classified into:

1) Pretreatment : it means before you see the pt, he come to
you as an emergency. So he is a new patient and that is
the first time you see him.
2) Interappointment : you treat the patient and the next day
he will come back complaining of swelling and pain that
wasn’t before your treatment and he will blame you.
3) Postobturation : everything is good and when you finish
the obturation he will get a flare-up, he will get sever pain
and swelling.

System of diagnosis :
1) Medical and dental history : if a new patient came to you
and you see him for the first time, then you should take

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 medical and dental history, you ask about previous
treatment if present. The second thing you must take into
consideration is the history of pain, if it’s spontaneous or
stimulated by something, disturbing the sleep or not, if
it’s relieved by analgesic or not, localized to a tooth or
not.
2) Examination (subjective and objective) : palpation,
percussion, radiographs, vitality test.
3) Periodontal examination: you should do periodontal
examination to the teeth and check the PD, sometimes
there is a tooth with a PD equals 1-2 mm and suddenly
become 7 mm in a certain area on the tooth (buccaly or
lingualy), this tooth either cracked or has vertical root
fracture that need extraction.
4) Radiographic examination : you should see if there is any
caries because some of them can’t be seen clinically like
class II caries(interproximal).

Cold Test :
The most reliable one is the CO2 test because it have the
lowest degree (-78°) , but we don’t have it in our clinics.
The one that we use in the clinics is the
DichloroDifluoroMethan (DDM) that has -50° boiling point, we
apply it on a cotton and put it on the tooth surface, the normal
response will be sharp and short pain that relieved by
removing the stimulus and will appear within a 15 sec, delayed
response is very rare but happened in elderly due to pulp
shrinkage after secondary dentine formation, if the pain
remained for 30 sec then that is a clue for RCT to this tooth. If
the tooth is crowned you will test it palataly or lingual if there is
exposed structure of the tooth, if not then you retract the
gingiva and test on cementum.

Mechanism of the cold test:

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 Cold test will do disturbance in dentinal fluids and cause an
outflow for it, which will stimulate the mechanoreceptors in Aδ
fibers, this is what called the HYDRODYNAMIC THEORY.

So, the cold doesn’t reach the nerves directly, it only cause
a fluid movement.

**The hot has an action similar to the cold .

In each response (+ve or –ve) we may have false results,

sometimes we may reach false –ve like in atrophic pulp (due
to aging) which will give a delayed response, or false +ve like
when you fail to dry the tooth completely before applying the
cotton, that will make the saliva transfer the response through
the gingiva to the adjacent tooth or in multi roots teeth.

CASE I :
Page 2 slide 8 .

20 years female complains of severe pain in upper left

premolars for 3 days, the pain was continuously there and she
complained from sensitivity on hot.

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 Here we can do hot test (we rarely do it), we isolate the
tooth with rubber dam and apply hot water on the tooth, the
tooth which is sensitive to hot mostly will be sensitive to the
cold, but not necessarily. If hot test isn’t the test you want to
do, so you must do radiographs. In this case, we took a
periapical radiograph for the tooth, it had a class I cavity, then
recurrent caries happened and became a class II that make
exposure to the pulp. It’s an easy case for diagnosis, you can
never miss that this tooth need an endodontic treatment
although this tooth is periapicaly sound.

CASE II :
Page 2 slide 9

53 years old male complains of a very severe pain on lower

left premolars, he hasn’t slept for two days with disturbing
daily activities, that indicate and irreversibly inflamed pulp.
When radiographs was taken, the lower premolar are already
treated, root canal looks fine, there is a periapical radiolucent
area but this won’t be a cause of a pain from irreversible
pulpitis, in this tooth there is no pulp, so the pt won’t feel pain,
the pain may happen when the patient bite.

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 In these pictures in, 34 and 35 are obturated and have no
problems, 25 also obturated and 24 has DO cavity with cracked
line on the mesial marginal ridge and extremely sensitive in
cold, so the patient reported pain in the lower jaw, but the test
show problem in the upper teeth, and that what we call
REFERRED PAIN .

** So pain in the upper teeth sometimes referred in the lower

teeth and vice versa.

**Note: if you are suspecting a problem in a tooth that has a

pain and you gave anesthesia and the pain disappeared, so
your suspicion is true.

In this case we do:

1. Rubber dam.
2. Access.
3. Extirpation.

If the tooth was vital we do extirpation to the estimated

working length and irrigation with sodium hypochlorite (do as
much as you can instrumentation, barbed broaches files to the
estimated working length).You put dressing and close it and
relieve the occlusion by reducing the cusps or at least
functional cusps (In the upper the palatal cusp including with
the buccal of the lower). Reduce the palatal cusp by 1mm.If the
lower need post crown you can reduce it by 2mm, this
is(relieve from the occlusion) effective in reducing
interappointment pain .

Referred pain:

1. The inflammation remains confined within the pulp.

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 2. Histology: liquifaction necrosis with an increase in
intrapulpal pressure and primarily involves C-fibers.
3. Anterior teeth don’t refer to posterior teeth.
4. Posterior teeth don’t refer to anterior teeth.
5. Usually doesn’t cross the midline.
6. Upper premolar often refer to lower premolar
7. Upper molar often refer to lower molar.

There is some teeth don’t refer pain, the tooth must be

inflamed virgin to refer pain. But tooth with previous
endodontic treatment, tooth with sinus tracts, tooth with
periodontitis or tooth undergoing endodontic treatment will not
refer pain, the pain will be in the same area of the tooth.

Other sources of referral of pain:

1. TMJ diseases: patient came to you complaining of pain

in the tooth and he has Phantom tooth syndrome or
atypical facial pain which is psychological, he has
muscle pain and say to you this tooth is harming me,
you do class I , class II, endodontic treatment ,
extraction and the pain remains, this is Phantom
tooth syndrome, any muscle pain (temporalis , lateral
pterygoid , medial pterygoid) can cause pain in the
upper teeth.
2. Heart- myocardial infarction, thrombosis, angina
pectoris.
3. Lower molar refers to ear.
4. Upper molar refers to sinus.

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 If patient complain of a pain and you took this radiograph,
the cause is the first premolar has a big restoration and
periapical changes.

In the pictures below, you can see a patient which has

swelling in the palate, you can see the crown, remember that
you should do periodontal examination before the diagnosis,
notice the probe has entered 7mm, this is an isolated pocket
,so we expect that this tooth has crack or root fracture. By the
way, this tooth was treated by a good endodontic treatment
and there was crack then become a sinus tract. The solution for
this tooth is extraction, it is a hopeless tooth.

Student question: can we drill a cavity through

the crown?

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 If the crown has good margins with good adaptation then
you can drill the access cavity through the crown as a normal
tooth and do endodontic treatment, it is more difficult and the
vision isn’t clear, but if the crown is old and a bad one you
remove the crown, do endodontic treatment and temporary
cement until you replace it with a new crown. Not every
crowned tooth should have an endodontic treatment.

**Sometimes it is class I cavity, from the heat of preparation

and because there is no sufficient cooling, there is no enough
water with the high speed you will cook the pulp, it will become
irreversibly inflamed then dies, when you come to do
cementation the patient will complain from pain so you should
drill the crown that you prepared.

Detecting cracks
The patient complain of pain on release of a pressure (when
he bites and opens), this pain is a diagnostic for a cracked
tooth. How we can decide that? We have to reproduce the
patient pain by tooth slot, not found in the clinic, so you can
use the handle of the mirror, put it on the tooth that the
patient complain from, then the patient should bite and open,
during biting there is no pain but after he opens the pain starts,
this is a diagnostic for cracked tooth. May be you can’t see the
crack, but there is certain managements that we will study it
later on.

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 That treatment for a cracked tooth is orthodontic band,
which we put around the cracked tooth and do cementation
(splinting the crack) so the pain will disappear, after that we do
a crown or an overlay .The crack usually found mesiodistally .

When can we doubt in a cracked tooth?

When the tooth looks sound and it’s vital on the cold test
and on the radiograph you can’t detect anything, there is no
other diagnostic features for pulpal involvement and the pain
found on release of pressure(when open mouth from bite).

You can notice in the picture below that there is a crack

started at the buccal pit and then continued downward, and
here there is sinus, this tooth has been crack because it was
treated by endodontic, the temporary restoration wasn’t
removed and no crown has been done for this tooth, teeth with
temporary restoration will get crack within 5 years. The tooth
which treated by endodontic if not crowned finally it will break.

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 In intraoral examination in this picture below, you can see
sinus tract, it looks like an ulcer, sometimes it can be sever to
be present as an ulcer, this patient was infected with hepatitis
C, so he had low immunity and had external swelling and
internal ulcer, this isn’t the first visit, it is the third visit after
it’s improved( it was bigger
than what we can see here
in the picture).

After we took the history, the possible diagnosis is:

1. Irreversible pulpitis.
2. Acute apical periodontitis.
3. Acute apical abscess(swelling with pus).

After examination and diagnosis, our goal now is to reduce

the irritant and reduce the pressure by removing the inflamed
tissue and you can achieve a profound anesthesia.

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A-Pretreatment emergencies
1.Irreversible pulpitis:

As we said in irreversible pulpitis we do complete pulp

extirpation by a barbed broach, files to estimated working
length, sometimes the patient in severe pain so we do
pulpatomy, it might be enough and this is called in physiology
“Axotomy”.

Pain perception starts in the receptors and periapical

nerve, after that to the nuclei and CNS, if you cut the periapical
nerve you will cut the receptors of pain, so we expect to reduce
the pain, but what remains is the prostaglandin pain mediator
in the brain, so the patient may be still feels pain.

But at least if the patient complains of a severe pain and

you gave him intrapulpal anasthesia and he still in pain, then
you can do pulpotomy.

Pulpotomy: it means removing the pulp chamber alone,

not necessarily to reach the canals, we must remove as much
as possible from the pulp chamber with a big round bur, then
you apply chemical medicament in the chamber like
formocresol or a dry cotton pellet alone (it’s as effective as
relieving the pain with a pellet that is moistened with
formocresol).

This treatment is temporary not definitive, you have to

complete pulp extirpation after a few days because the ideal is
to proceed all the way to estimated working length, and reduce
the tooth from occlusion if there is any apical periodontits.

**don’t give the patient any antibiotics (this is a misuse), give

him analgesics.

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2. Pulp necrosis :

In case of pulp necrosis it will be either acute periapical

periodontitis without swellings (only tenderness to percussion),
or it will be acute apical abscess. If there are no swellings so
there is no pulp, you should take the corrected working length
and enlarge the canals if you can from the 1st visit, but if you
can’t so you do to the estimated.

We have localized swelling or diffuse swelling, if it’s

localized you have to open the tooth and try to do drainage
through the tooth to drain the pus, in this case the pus may go
out or maybe not.

This is a rubber dam and this is an access, notice the bloody

discharge (blood with pus), and if you tried to dry the canal
with a paper point you will notice that it will be wet completely.

Sometimes it might be oozing, in this case we can do

intracanal drainage (not found in our clinic), we put this tip on
the ordinary suction and like the non-setting CaOH, and we
insert it inside the canal and
suction the pus.

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 If the patient came with a pain and sinus that found close
to 5 or 6, we can’t say that this sinus is for the 5 or the 6, you
should always trace the sinus, it’s may be from the adjacent
tooth.

So, how can we do tracing??

We insert a gutta percha (35 or 40) inside the sinus tract
and take a radiograph to see where is the cone pointing,
sometimes you have to penetrate the sinus with a probe or a
local anesthesia needle to insert the cone.

Sometimes the radiograph is misleading, in case where the

sinus is between the 5 and 6, we do cold test, if the 6 test +ve
then it’s definitely the 5, but if it had abnormal response then
it’s the 6.

Another shape of the sinus tract can be found palataly. This

is orthodontic band around the 4 which is broken down, here
we can’t apply a rubber dam, so it’s usually recommended to
build it up with a temporary material then we put the
orthodontic band and then apply the rubber dam.

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 Pulp necrosis either localized or diffused swelling, in the a-
localized swelling you have to palpate and see if it’s
fluctuant or hard, if it’s fluctuant you can do incision and
drainage.

→ Never leave the canal open, although the pain disappear

(because the pressure has been relieved) but the bacteria from
the saliva will enter inside the canal and cause an infection
further than the edno, also in the localized swelling, if it is just
inside the sulcus then there is no need for antibiotics.
(Antibiotics just for the systemic manifestation).

b-Diffuse swelling means swelling in the cheek, neck,

face, near the eye, or outside according to the position of the
tooth, ex. Infection in the canine can reach the eye and cause a
swelling, and the pt will have a systemic signs like
fever,malasie, or joint pain, these patient have to take
analgesic and antibiotics (penicillin or mitronidazole) and the
swelling will subside in 2-3 days or may reach 5 days according
to the patient response. These patients will have flare-up risk,
it means that you may finish the treatment and suddenly they
may get another swelling.

This is a localized swelling, you check for fluctuation either

by your finger, mirror head, or the suction. You must find the

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most dependant point which is the point that has the largest
amount of pus (most accumulation of pus) and has a head.

You make an incision with a scalpel blade no. 15 or 11

(there is a way to make an incision with the least amount of
harm and damage to the patient), the length of this incision is
about 1 cm, as we increase this length it will be better for
draining more pus and it will heal quickly, we leave it open, not
suture it or we can use the hemostat (artery forceps) and
widen the opening and then we do irrigation with saline or CHX
but not with sodium hypochlorite because it will cause necrosis
to the tissue.

You should give anesthesia before, either ID block but away

from the swelling because this environment is acidic that will
cause failure for the anesthesia, or we give posterior alveolar
nerve block, or anterior and posterior to the swelling.

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 This is a case of cellulitis, in this case you should not think
to do incision and drainage, you should refer it to a specialist
(oral surgery) immediately, if the patient could open his mouth
then they will do extraction, here there is a risk for an infection
to occur in the spaces mostly in the upper which can reach the
cavernous sinus then thrombosis will occur which may cause
blindness.

In the lower spaces there is what we call “Ludwig’s

angina” (swelling in the submandibular , submental and
sublingual spaces) which starts suddenly and accompanied
with systemic symptoms (elevated temp. , difficulty in
breathing or swallowing, trismus which complicate the
extraction), the specialist will give the patient IV antibiotics and
wait 2-3 days then extract the tooth or sometimes they do
extraoral drainage.

Indications for antibiotics:

Fever, malaise, cellulitis, palpable lymph nodes, or un-
explained trismus.

All what we talked about before was the pretreatment

emergencies, now we will talk about the interappointment
emergencies (during treatment).

B-Interappointment(flare up):

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1.You treat the pt and he came back with swelling and severe
pain, the incidence for this to happen is 1-3% (not common).

2.Doesn’t has any relation to the age, sex, intracanal

medications ,single or multiple visit , medical history.

3.Preoperative pain and pulp necrosis are predicators of a

flare-ups. usually there is no flare-up in vital teeth.

4.Ledermix as an intracanal medicament (antibiotic

corticosteroid mix). This is effective in cases which need vital
extirpation, you put it as an intracanal medicament instead of
CaOH or you mix them together with a spatula, it will reduce
the pain (anti inflammatory).

5.The most important is reassurance, if you cleaned the canal

very well then you have to reassure the patient that it
happens.

6.Previously vital pulps with complete debridement, you give

the patient analgesic. (Don’t give antibiotic unless there is a
diffuse swelling).

7.If you aren’t sure that you cleaned the canal very well, then
you have to reopen the tooth and debride it.

8.If the pulp is necrotic with no swelling then you have to

reopen the tooth, then take the exact working length, do
enlargement and widen the canal, complete your
instrumentation, then do dressing and let the patient go home.

9.If there was swelling, then you should make an incision and
drainage or give antibiotics.

C-Postobturation emergency:
You treated the patient and after that he will come with
swelling, this swelling because of trauma from treatment. (that

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is if your work was good, but if it wasn’t adequate so there may
be other reasons like bacterial infection and it has to be
retreated)

There is correlation with the level of obturation,if there is a

gross overfilling, the patient will get flare-up(too much gutta
percha or sealer outside the apex), here you need retreatment,
but if there is a little overfilling the patient will complain of
slight pain which relieved by analgesic. So sometimes you
need retreatment and sometimes you need incision and
drainage.

Analgesics:
Options:

Paracetamol (acetaminophen) or there is Revacot

which is combination of paracetamol with codeine (which is not
found in the market now because people get addiction), now
what present is Pnadinfort which contain caffeine and
codeine (low %)not like the revacort .

What are the option of analgesics that

we can give to a patient that is
complaining of pain ??
According to studies, Ibuprofen 800 mg(two
tablets)loading dose was relieved pain in 50% of patients
who have severe pain by 100%. So it’s preferred to start with
Ibuprofen (400 mg), two tablets every 3-4 hours for the first
two days only, no need for more.

Paracetamol alone isn’t enough, you can do a combination of

Ibuprofen and paracetamol at the same time, and it’s very
effective.

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‫‪Codeine with acetaminophen (revanin) isn’t efficient (57%).‬‬

‫‪In Ibuprofen 400 mg (one tablet), you can notice the % here‬‬
‫‪was decrease from 100% to 56%. You have to give instructions‬‬
‫‪to the patient to take the drugs with full stomach, not empty.‬‬

‫‪Codeine (60 mg) isn’t effective (15%).‬‬

‫‪Placebo is not effective (18%).‬‬

‫‪So Ibuprofen is enough. Sometimes you can give voltaren‬‬

‫‪injection, it’s more rapid, and within 15 min the patient will‬‬
‫‪give response.‬‬

‫‪Done by:‬‬
‫‪Shahd Qeadan….‬‬

‫‪The End‬‬
‫تحية للصديقات والصدقاء‪:‬‬

‫أماني عفانه )بغدرش أستطيع(‪ ,‬فرح‪ ,‬ربى ابو ريمه‪ ,‬نور حمدان‪ ,‬دينا)شكرا ً لنك‬
‫حاولت تسكتي(‪ ,‬ميس‪ ,‬مديحه‪ ,‬فاطمه أسعد‪ ,‬سكينه‪ ,‬لينا كتانه‪,‬مرام‪ ,‬نور‬
‫الرحمون‪ ,‬جمانه عبد الصاحب‪,‬جمانه تيسير‪ ,‬زينب‪ ,‬سناء‪,‬هدى‪ ,‬نور النجار‪,‬‬
‫فاطمه‪ ,‬لمياء‪ ,‬فكريه‪ ,‬أمل العمري‪ ,‬أروى مخلوف‪ ,‬روان عطاالله)كرابه(‪,‬‬
‫أسماء‪,‬نور جيوسي‪ ,‬نور نادية‪ ,‬نور عيني‪ ,‬نور فائزه‪ ,‬نور هدايو‪ ,‬نور ايمن‪ ,‬عين‬
‫زبيده‪)...‬طربيزه(‬

‫عبدالله عوضي) غلبتك معي كثيييييييير(‪,‬محسن‪ ,‬ابوالوليد‪ ,‬اياس‪ ,‬حلحولي‪ ,‬معاذ‪,‬‬

‫علي الثاني)روح جز(‪ ,‬رشيدان‪ ,‬حسين‪,‬صالح اليافعي‪,‬محمد الشمري‪ ,‬انس‬

‫‪19‬‬
 ‫السيد‪ ,‬انس ربحي‪ ,‬صالح القاضي‪ ,‬منتصر )ال‪ ....‬وفقرة قصيرة(‪ ,‬زين‬
‫العابدين)الله يسامحك على هالعمله(‪,‬امين مدلج‪,‬باسل‪,‬ادهم‪,‬علي معله)سرك‬
‫ببير( ذو القرنين‪ ,‬انجكو‪ ,‬نور حليم‪ ,‬محمد نازيرول‪ ,‬نعيم‪ ,‬صوالحة النيرد‪ ,‬عبد‬
‫الرحمن ‪.‬‬

‫‪20‬‬