Table of Contents

ACKNOWLEDGEMENT.......................................................................................2
CHAPTER 1............................................................................................................3
INTRODUCTION...................................................................................................4
CHAPTER 2............................................................................................................6
LITERATURE REVIEW.........................................................................................6
2.0 Endodontic Emergency..................................................................................6
2.1 Management of Pain from A Disease of the Pulp And Periodontal Tissues...7
2.2 Irreversible Pulpitis......................................................................................16
2.3 Acute Apical Periodontitis............................................................................17
2.4 Acute Apical Abscess..................................................................................20
2.5 Iatrogenic Emergencies................................................................................26
2.5.1 Perforations during access preparation.................................................26
2.5.2 Accidents During Cleaning and Shaping..............................................33
2.5.3 Accidents during obturation..................................................................44
2.5.4 Accidents during post space preparation...............................................47
CHAPTER 5..........................................................................................................49
CONCLUSION......................................................................................................49
REFERENCES.......................................................................................................50

ACKNOWLEDGEMENT
We from group 7 KPBI would like to express our gratitude towards those who
have participate in this tutorial. Not to forget out tutor whom guided us so that we
didn't run out out of topic that we discussed. We hope after this tutorial, we
understand about the endodontic emergency in dentistry, how do we manage a
pain when a disease of the pulp and periodontal tissues has occurred on a patient.
Besides that, we would also learn about what is a acute apical periodontitis and
abscess although both sounded the same , they are totally different though. Last
but not the least, iatrogenic emergencies always occur in dental during the access
of preparation, accident during cleaning and shaping, accident during obturation
and accidents during post space preparation.

CHAPTER 1
INTRODUCTION

The proper diagnosis and effective management of acute dental pain is

possibly one of the most rewarding and satisfying aspects of providing dental
care. Endodontic emergencies are a challenge for both diagnosis and management.
Incorrect diagnosis or incorrect treatment will fail to relieve pain and, in fact, may
aggravate the situation. The clinician must have knowledge of pain mechanisms,
patient management, diagnosis, anesthesia, therapeutics, and appropriate treatment
measures for both hard and soft tissues.
Pain results from two factors related to inflammation: (1) chemical mediators
and (2) pressure. Most orofacial pain is of pulpal or periradicular origin, and pain
to thermal stimulus is often an indication of an endodontic problem. Chemical
mediators cause pain either directly by lowering the response threshold of the
sensory nerve fibers or indirectly by increasing vascular permeability and
producing edema. Edema results in increased fluid pressure, which directly
stimulates pain receptors. Of the two causes of pain, pressure is the more
important.
Irreversible pulpitis is often a sequel to and a progression from reversible
pulpitis. Severe pulpal damage from extensive dentin removal during operative
procedures or impairment of pulpal blood flow caused by trauma or orthodontic
movement of teeth may also cause irreversible pulpitis. Irreversible pulpitis is a

severe inflammation that will not resolve even if the cause is removed. The pulp
slowly or rapidly progresses to necrosis.
Acute apical periodontitis would be better described as symptomatic apical
periodontitis. The first extension of pulpal inflammation into the periradicular
tissues is called acute apical periodontitis (AAP). Eliciting irritants include
inflammatory mediators from an irreversibly inflamed pulp or egress of bacteria
toxins from necrotic pulps, chemicals (such as irrigants or disinfecting agents),
restorations in hyperocclusion, overinstrumentation, and extrusion of obturating
materials. The pulp may be irreversibly inflamed or necrotic. Acute (symptomatic)
apical abscess (AAA) is a localized or diffuse liquefaction lesion that destroys
periradicular tissues. It is a severe inflammatory response to microbial and
nonbacterial irritants from necrotic pulp.
Like other complex disciplines of dentistry, an operator may encounter
unwanted or unforeseen circumstances during root canal therapy that can affect
the prognosis. These mishaps are collectively termed procedural accidents.
However, fear of procedural accident should not deter a practitioner from
performing endodontic therapy if proper case selection and competency issues are
observed. Knowledge of the etiologic factors involved in procedural accidents is
essential for their prevention. In addition, methods of recognition and treatment as
well as the effects of such accidents on prognosis must be learned. Most problems
can be avoided by adhering to the basic principles of diagnosis, case selection,
treatment planning, access preparation, cleaning and shaping, obturation, and
postpreparation.

CHAPTER 2
LITERATURE REVIEW

2.0 Endodontic Emergency

An endodontic emergency is defined as pain and/or swelling, caused by
various stages of inflammation or infection of the pulpal and/or periapical tissues,
which require immediate diagnosis and treatment.
The main causative factors responsible for occurrence od endodontic
emergencies are:
1. Pathosis in pulp and periradicular tissues, generally from caries, deep or
defective restorations
2. Ttraumatic injuries that result in luxation, avulsion, or fractures of the hard
tissues.
Endodontic emergencies are categorized into 3 main types, which include
pretreatment, intra-appointment and postobturation.

2.0.1 Pretreatment Emergency

These are situations in which the patient is seen initially with severe pain
and/or swelling. Problems occur with both diagnosis and treatment.

2.0.2 Inter-appointment and Postobturation Emergency

This is also referred to as the "flare-up," this problem occurs after an
endodontic appointment. Although an upsetting event, this is easier to manage
because the offending tooth has already been identified and a diagnosis has been
previously established. Also, the clinician has knowledge of the prior procedure
and will be better able to correct the problem.

2.0.3 Emergency versus Urgency

A true emergency is a condition requiring an unscheduled office visit with
diagnosis and treatment now. The visit cannot be rescheduled because of the
severity of the problem. Urgency indicates a less severe problem; a visit may be
scheduled for mutual convenience of the patient and the dentist.

2.1 Management of Pain from A Disease of the Pulp And Periodontal Tissues
2.1.1 Pain Reaction
The pain reaction threshold is significantly altered by past experiences and by
present anxiety levels and emotional status. To reduce anxiety and consequently
obtain reliable information about the chief complaint and to receive cooperation
during treatment, the clinician should:
1. Establish and maintain control of the situation
2. Gain the confidence of the patient
3. Provide attention and sympathy

4. Treat the patient as an important individual

Psychologic management of the patient is the most important factor in
emergency treatment. Pain or swelling may limit mouth opening, thereby
hampering diagnostic procedures as well as treatment. In addition,
hypersensitivity to thermal stimuli or pressure influences diagnosis and treatment.
The three important factors constituting the quality and quantity of pain are its
spontaneity, intensity, and duration.

2.1.2 Diagnosis
The diagnosis sequence for endodontic emergency is:
1. Obtain pertinent information about the patients medical and dental histories.
2. Ask pointed subjective questions about the patients pain : History, location,
3.
4.
5.
6.
7.

severity, duration, character, ad eliciting stimuli.

Perform an extraoal examination.
Perform an intraoral examination.
Perform pulp testing as appropriate.
Use palpation and percussion sensitivity tests to determine periapical status.
Interpret appropriate radiographs.

2.1.2.1 Medical and Dental Histories

Medical and dental histories should be reviewed first.

2.1.2.2 Subjective Examination

1. Review the past dental history
2. Review the patients chief complaint which include location, severity,
duration, character, and eliciting stimuli of pain.
3. Review aspects of pain
i.
Nature of pain. Identifying the nature of the pain can help to
differentiate pain of dental origin from pain stemming from other
tissues. Pain which is very indicative of endodontic pathosis is
ii.

irreversible in nature, intense, spontaneous, and continuous.

Referred pain. Referred pain is most commonly manifested in other
teeth in the same or opposing quadrant. It almost never crosses the
midline of the head. However, referred pain is not necessarily limited
to other teeth. It may be unilaterally referred to the preauricular area,
down the neck, or up to the temporal region. In these cases the source

iii.

of the referred pain is almost always a posterior tooth.

Pain of nonodontogenic origin. Pain of nonodontogenic origin
includes pain from a broad range of sources such as organic (e.g., sinus
disease and tumor), functional (e.g., myofacial pain dysfunction and
TMJ dysfunction), vascular (e.g., migraine headache), neurological
(e.g., trigeminal neuralgia),psychological.

Pain that is elicited by thermal stimuli and/or is referred is likely to originate

from the pulp. Pain that occurs on mastication or tooth contact and is well
localized is probably periradicular.

2.1.2.3 Objective Examination

The best test is to repeat the stimulus that reportedly causes the pain. In
addition, objective tests include extraoral and intraoral examination.
Periradicular tests include (1) palpation over the apex, (2) digital pressure
on or wiggling of teeth (preferred if the patient reports severe pain on
mastication), (3) light percussion with the end of the mirror handle, and (4)
selective biting on an object such as a cotton swab or Tooth Slooth.
Pulp vitality tests are most useful to reproduce reported pain. Cold, heat,
electricity, and direct dentin stimulation, however, usually indicate the pulp
status (vital or necrotic).

2.1.2.4 Periodontal Examination

When the periodontium is involved it must be determined whether the
condition is of endodontic origin, periodontal origin or a combination of both. In
endodontic diagnosis the vitality of the tooth in question should be determined
first.
There are several guides to determine the origin of the condition :
1. If the pulp is vital, then it may be ruled out as the source of the problem
2. If the pulp is necrotic or partially vital, then it is either the cause of the
problem or a contributing source

3. Radiographically, when only a portion of the root is involved or if the

furcation is involved when the mesial and distal crestal bone is intact, an
endodontic lesion is suspected.
4. If the defect can be probed, it is usually a narrow tubular defect as compared
to a wider periodontal defect, an endodontic origin is suspected.
5. If the gingiva is inflamed and bone loss is widespread and present on adjacent
teeth, periodontal disease is suspected.
6. If upon probing, plaque or calculus is encountered and the defect is diffuse
and crater-like, periodontal treatment may be indicated. If the defect is of
periodontal origin, the tooth will probably test within normal limit.

2.1.2.5 Radiographic Examination

Multiple diagnostic radiographs, taken from various angles, should be
interpreted carefully.
Periapical and bitewing radiography may detect the presence of
interproximal and recurrent caries, possible pulpal exposure, internal or external
resorption, and periradicular pathosis, among other entities. After carefully
working through the sequence just described, the clinician should have identified
the offending tooth and the tissue (pulpal or periradicular) that is the source of
pain and should have recorded a pulpal or periradicular diagnosis.

Figure 2.1 : Root canal x-ray, xray of endodontics, periapical x-rays radiographs
(Source : http://www.nycdentist.com/dental-photo-detail/1192/166/165/root-canalx-ray-xray-of-endodontics-periapical-x-rays-radiographs)
Description : Emergency tooth pain symptoms in the mandibular right posterior
quadrant.
1. This bitewing radiograph shows big teeth cavities - dental caries - in the
second premolar and first molar and smaller dental cavities in both the second
and third molars. This bitewing dental x-ray was also used to rule out referred
pain from maxillary teeth.
2. In addition to the significant tooth decay noted above this periapical xray
shows a large periapical pathology radiolucency around the tooth root apex of
the second premolar.
3. Photo of the second premolar and first molar.
4. Radiographic post-op following root canal treatment of both teeth. The patient
felt better immediately following this.
Note: these teeth were treated following a careful differential diagnosis using
dental radiographs xrays and clinical pulp vitality testing performed by an

Endodontist. It would not be surprising, if in another patient, the pain came from a
tooth with a less obvious cause.

2.1.3 Treatment Planning

As previously discussed, inflammation and its consequences, that is, increased
tissue pressure and release of chemical mediators in the pulp or periradicular
tissues, are the major causes of painful dental emergencies. Therefore, reducing
the irritant, or reduction of pressure or removal of the inflamed pulp or
periradicular tissue should be the immediate goal; this usually results in pain
relief. Of the two, pressure release is the most effective.
2.1.3.1 Pretreatment Emergencies
These emergencies require a diagnosis and treatment sequencing. Each step is
important:
(1) categorizing the problem,
(2) taking a medical history,
(3) identifying the source,
(4) making the diagnosis,
(5) planning the treatment, and
(6) treating the patient.

2.1.3.2 Postoperative Instructions

Patients must be informed of their responsibilities and of what to expect.
The pain and swelling will take time to resolve, proper nutrition and adequate
intake of fluids are important, and medications must be taken as prescribed. The
problem may recur or worsen (flare-up), requiring another emergency visit.
2.1.3.3 Interappointment Emergencies
The interappointment flare-up is a true emergency and is so severe that an
unscheduled patient visit and treatment are required. Most postoperative
discomfort is in the mild range. These factors generally can be categorized as
related to the patient, to pulpal or periapical diagnosis, or to treatment procedures.
Prevention: Use of long-acting anesthetic solutions, complete cleaning and
shaping of the root canal system (possibly), analgesics, and psychologic
preparation of patients (particularly those with preoperative pain) will decrease
interappointment symptoms in the mild to moderate levels.
2.1.3.4 Postobturation Emergencies
True emergencies postobturations are infrequent although pain at the mild
level is common. Therefore, active intervention is seldom necessary; usually
symptoms will resolve spontaneously.
Approximately one-third of endodontic patients experience some pain
after obturation. There is a correlation between the level of obturation and pain
incidence, with overextension associated with the highest incidence of discomfort.

Postobturation pain also relates to preobturation pain; levels of pain reported after
obturation tend to correlate to levels of pain before the appointment.
Retreatment is indicated when prior treatment obviously has been
inadequate. Apical surgery is often required when an acute apical abscess
develops, and there is uncorrectable, inadequate root canal treatment. If root canal
treatment was acceptable, excision and drainage of swelling after obturation (an
occasional occurrence) should be performed, usually the swelling resolves without
further treatment. Patients with postobturation emergencies that do not respond to
therapy should be referred to an endodontist for other treatment modalities, such
as surgery.

2.2 Irreversible Pulpitis

Figure 2.2 : Irreverible pulpitis

(source: American Family Physician 2003)

2.2.1 Signs and Symptoms

A rapid onset of pain when any stimulus like cold foods, or sweet food,
pressure from packing of food into cavity, or pressure exerted by tongue, that
results in congestion of the blood vessels of the pulp. The pain persists, even after
the removal of the stimuli, and sometimes may come and go spontaneously
without any particular known cause. The pain may be sharp, shooting or piercing
in nature. Exacerbation of pain when the patient bends over or lies down. The pain
may be referred to adjacent teeth sometimes, and also to ear if lower teeth are
involved, and to temple region if the upper teeth are involved. In the later stages,
the pain is described as throbbing, boring or gnawing type where the tooth is
subjected to constant pressure as described by the patient. Relief of the pain is

seen through cold water, or any cold substance. Pain would return back if the food
packs into the cavity, or beneath a leaky filling.

2.2.2 Management Of Painful Irreversible Pulpitis

The only way to definitively treat the discomfort is root canal treatment (removal
of the pulp and filling of the empty pulp chamber and canal) or extraction of the
tooth. The urgency of referral to a dentist should be determined by the patient's
level of discomfort, but examination should not be delayed for more than a few
days. The pain should be managed with appropriate analgesia such as a
nonsteroidal anti-inflammatory drug (NSAID) or a weak opioid combined with an
NSAID or acetaminophen in an appropriate quantity to last until the dental
appointment. Patients should be warned of the risks of further complications if
they do not have prompt definitive treatment and advised to return to their
physician if symptoms change or worsen before they see the dentist.
Because the pain is the result of inflammation, primarily in the coronal pulp,
removal of the inflamed tissue will usually reduce the pain.
2.3 Acute Apical Periodontitis
Acute apical periodontitis would be better described as symptomatic apical
periodontitis. The first extension of pulpal inflammation into the periradicular
tissues is called acute apical periodontitis (AAP).It can be defined as
inflammation of all the supporting structures of the teeth in the area surrounding
the apex of the tooth. Periapical inflammation is usually due to tooth infection
which characteristically causes pain of tooth in its socket. It is often accompanied

by destruction of bone and occasionally, the root apex of tooth. However the
periapical tissue has the ability to heal if the cause of inflammation is removed.

Figure 2.3 : Apical Periodontitis

(source: American Family Physician 2003)

2.3.1 Causes of apical periodontitis

1. Infection by far the most common cause, bacteria causes decay of tooth
which leads to pulp inflammation (pulpitis) and death of the pulp (the soft
inner part of the tooth). If pulpitis is not treated; bacteria, bacterial toxins
or products of inflammation can extent down the root canal and cause
periodontitis.
2. Trauma any direct blow to the tooth can sometimes cause the pulp of the
tooth to die and it may become infected by bacteria from the gum margins,
leading to apical periodontitis. A sudden bite on a hard object, undue

pressure during orthodontic treatment or a filling that is high can

sometimes cause acute periodontitis though usually short-lived.
3. Root canal treatment mechanical instrumentation through the tooth root
during treatment or chemical irritation from root-filling materials may
result in inflammation of the periapical region.
2.3.2 Signs and Symptoms
1. The affected tooth is often having a large decay area, a filling or may be
discolored due to a dead pulp in the tooth.
2. The gum over the root of the affected tooth is red and sore.
3. May be associated with swelling of the face for infection can penetrate the
overlying bone or soft tissues.
4. Sometimes connected with fever or body discomfort.
5. Radiologically there is usually widening of the periodontal ligament space.
6. Pain associated with the disease:

1)

Is spontaneous in onset with a moderate to severe intensity in pain and

usually persists for long periods of time (hours).

2)

Is more intense and throbbing if inflammation becomes more severe

and pus starts to form.

3)

Can be pinpointed to the affected tooth.

4)

Is aggravated by biting of teeth. In some cases, the tooth feels high

or like it is coming out and is very sensitive to touch.

5)

Has often been followed by pain in the pulp and usually associated
with a dead tooth.

6)

Hot or cold substances do not cause pain unless in multirooted teeth

whereby some pulp tissue remains healthy.

2.3.3 Treatment
1. Root canal treatment is required. The root canals must be completely cleaned,
shaped and dressed. The tooth may need to be stabilized whilst cutting the
access cavity, as the vibration when cutting can be uncomfortable.
2. Sodium hypochlorite is used as an irrigant, and calcium hydroxide as the
medicament after complete cleaning.
3. The occlusion is adjusted to relieve any discomfort on biting.
4. Antibiotics are ineffective for the treatment of acute apical periodontitis if root
canal treatment is not carried out.
5. Therefore the practice of prescribing antibiotics instead of undertaking root
canal treatment is not recommended, as pain will be prolonged.
6. Analgesics may be required, and a combination of paracetamol (500 mg six
times daily) and ibuprofen (200 mg six times daily) should be sufficient.

2.4 Acute Apical Abscess

Acute (symptomatic) apical abscess (AAA) is a localized or diffuse liquefaction
lesion that destroys periradicular tissues. It is a severe inflammatory response to
microbial and nonbacterial irritants from necrotic pulp.
A tooth which has experienced bone loss around it may afford bacteria access
along the root somewhere, resulting in a periradicular abscess. Teeth which have
been injured, displaced (luxated), frequently experience periapical injuries due to
mechanical leverage forces applied on the tooth. There are many other possible
mechanisms for allowing bacteria access to the tooth and its surrounding
structures.

Figure 2.4: A lower molar tooth with deep caries (tooth decay), which provided a
pathway for bacteria into the pulp of the tooth and led to an abscess at the root
apex.
2.4.1 Sign and Symptoms
1. The abscess may develop from apical periodontitis or an exacerbation of a
chronic periapical abscess.

2. Tooth is non-vital
3. Pain
i.

Rapid onset

ii.

From slight tenderness to intense, throbbing pain

iii.

Marked pain to biting or percussion

4. Swelling
i.

Palpable, fluctuant

ii.

May be a localised sense of fullness

5. Radiographic changes
i.

No changes to large periapical radiolucency

2.4.2 Treatment
1. To relieve the pain, drainage must be established, ideally through the root
canal (Fig. 2).
2. Following this full root canal treatment is carried out and the tooth is
dressed with calcium hydroxide.
3. Fluctuant buccal swellings may be incised to drain pus (Figs. 3-5).

4. Teeth are generally not left open to drain unless there is an uncontrollable
exudate, and then only for no more than 24 hours.
5. Antibiotics may be required for a patient with systemic effects and a raised
temperature.
6. Amoxycillin (250 mg three times daily) or metronidazole (200 mg three
times daily) for three days should be sufficient.
7. Some authorities recommend a single dose of 3 g amoxycillin.
8. Analgesics may also be required. It is advisable to review all patients
within 24 hours.
Recommendations

1.

In the case of localised and diffuse abscesses, drainage should be started as

soon as possible. This may include non-surgical endodontic treatment (root
canal therapy), incision and drainage, or extraction, depending upon the
clinician's judgement and taking into account the patient's preferences.

2.

If immediate drainage is not possible, appropriate analgesia (NSAID)

should be recommended until the infection can be drained adequately.

3.

Systemic antibiotics provide no additional benefit over drainage of the

abscess in the case of localised infections.

4.

In the presence of systemic complications (fever, lymphadenopathy,

cellulitis), diffuse swelling or a patient with medical indications,
antibiotics may be a helpful addition. There is no evidence to recommend
one antibiotic over another in the management of AAA with systemic
complications.

5.

Antibiotic therapy may be indicated when drainage cannot be achieved.

6.

Patients should be given the appropriate dose of analgesics (NSAID if not

contra-indicated) pre-operatively, and/or immediately post-operatively.
This should be continued as needed to control pain.

7.

Antibiotic therapy is not indicated in otherwise healthy patients nor when

the abscess is localised.

Figure 2.5 :Drainage through the root canal of a tooth with an acute apical
abscess.

Figure 2.6 : A fluctuant buccal swelling. The root canal system of the
maxillary first premolar has been thoroughly cleaned and dressed with
calcium hydroxide. The swelling is to be incised.

Figure 2.7 :The swelling has been incised; a

microsurgical aspiration tip is being used to
remove pus.

Figure 2.8 :Pus has stopped discharging.

Antibiotics would not be required in this case.

2.5 Iatrogenic Emergencies

Iatrogenic is due to the action of a physician or a therapy the doctor
prescribed. An iatrogenic disease may be inadvertently caused by a physician
or surgeon or by a medical or surgical treatment or a diagnostic procedure.
Puerperal fever (childbirth fever) was an iatrogenic infection; it was carried from
one woman to another by the doctor before the days of antisepsis. If in the course
of a procedure, an artery is nicked and bleeds, that is an iatrogenic accident. The
word "iatrogenic" comes from the Greek roots "iatros" meaning "the healer or
physician" + "gennan" meaning "as a product of" = due to the doctor.
2.5.1 Perforations during access preparation
The prime objective of an access cavity is to provide an unobstructed or
straight-line pathway to the apical foramen. Accidents such as excess removal of
tooth structure or perforation may occur during attempts to locate canals. Failure
to achieve straight-line access is often the main etiologic factor for other types of
intracanal accidents.

Figure 2.9 : Perforation caused by misdirection of bur

(Source: Textbook of Endodontics, Nisha Garg, Amit Garg.)

Figure 2.10 : The excavation of deep decay with a metal carbide bur carries the
risk of not only removing infected dentin, but also unintentionally cutting away
affected dentin. This may cause an inadvertent iatrogenic pulp exposure.
(Source: Oral Health Journal, George Freedman)

The early signs of perforation (1) sudden pain during the working length
determination when local anesthesia was adequate during access preparations, (2)
sudden appearance of haemorrhage, burning pain or a bad taste during irrigation
with sodium hypochlorite, and (3) a radiographically malpositioned file or a
periodontal ligament reading from an apex locator that is far short of the working
length on an initial file entry.
The later signs of perforation are (1) the unusually severe postoperative pain
may result from cleaning and shaping procedures performed through an
undetected perforation, and (2) at a subsequent appointment, the perforation site
will be hemorrhagic due to the inflammation of the surrounding tissues.

Figure 2.11 : Failure to recognize when the bur passes through the roof of the pulp
chamber if the chamber is calcified may result in gouging or perforation of the
furcation. The use of apex locators and angled radiographs is necessary for early
perforation detection.
(Source: Endodontics Principles and Practice, Torabinejad, Walton)

Perforations during access cavity preparation present a variety of problems.

When a perforation occurs or is strongly suspected, the patient should be
considered for referral to an endodontist. In general, a specialist is better equipped
to manage these patients. Also, after long-term evaluation, other procedures such
as surgery may be necessary if future failure occurs.
Lateral Root Perforation
The location and size of the perforation during access are important factors in
a lateral perforation. If the defect is located at or above the height of crestal bone,
the prognosis for perforation repair is favorable. These defects can be easily
"exteriorized" and repaired with standard restorative material such as amalgam,
glass ionomer, or composite. Periodontal curettage or a flap procedure is
occasionally required to place, remove, or smooth excess repair material. In some
cases, the best repair is placement of a full crown with the margin extended
apically to cover the defect.
Teeth with perforations below the crestal bone in the coronal third of the
root generally have the poorest prognosis. Attachment often recedes and a
periodontal pocket forms, with attachment loss extending apically to at least the
depth of the defect. The treatment goal is to position the apical portion of the
defect above crestal bone. Orthodontic root extrusion is generally the procedure of
choice for teeth in the aesthetic zone. Crown lengthening may be considered when
the aesthetic result will not be compromised or when approximal teeth require
surgical periodontal therapy. Internal repair of these perforations by mineral

trioxide aggregate (MTA) has been shown to provide an excellent seal as

compared to other materials.

Figure 2.12 : The arrow indicates that there is a root perforation.

(Source: theendoblog.com)

Furcation Perforation
Looking for a canal orifice on the chamber floor of molars can lead to
perforations into the furcation area. This type of perforation should be
immediately (if possible) repaired with MTA, or, if proper conditions exist
(dryness), glass ionomer or composite, in an attempt to seal the defect. Prognosis
is usually good if the defect is sealed immediately.

Figure 2.13 : The clinical applications of MTA

(Source: endodovgan.com)

Figure 2.14 : Initial periapical image of left first mandibular molar showing furcal
perforation and apical lesions.
(Source: Journal of Conservative Dentistry, jcd.org.in)

Figure 2.15 : Pericapical image after treatment

(Source: Journal of Conservative Dentistry, jcd.org.in)

Figure 2.16: At 2-year follow-up, there is complete osseous healing at the apex
and the bifurcation
(Source: Journal of Conservative Dentistry, jcd.org.in)

2.5.2 Accidents During Cleaning and Shaping

The most common procedural accidents during cleaning and shaping of the
root canal system are ledge formation, artificial canal creation, root perforation,
instrument separation, and extrusion of irrigating solution periapically. Correction
of these accidents is usually difficult and the patient should be referred to an
endodontist.

2.5.2.1 Ledge Formation

By definition, a ledge has been created when the working length can no longer
be negotiated and the original patency of the canal is lost. The major causes of
ledge formation include:
1.
2.
3.
4.

inadequate straight-line access into the canal

inadequate irrigation and/or lubrication
excessive enlargement of a curved canal with files
packing debris in the apical portion of the canal.

Figure 2.17: Ledge formation in a curved canal.

Source: Textbook of Endodotic by Nisha Garg, Amit Garg.
Management of a Ledge

Once created, a ledge is difficult to correct. An initial attempt should be made

to bypass the ledge with a No. 10 steel file to regain working length. The file tip
(2 to 3 mm) is sharply curved and worked in the canal in the direction of the canal
curvature. Lubricants are helpful. A "picking" motion is used to attempt to feel the
catch of the original canal space, which is slightly short of the apical extent of the
ledge. If the original canal is located, the file is then worked with a reaming
motion and occasionally an up-and-down movement to maintain the space and
remove debris, although this may be only partially successful. Once a ledge is
created, even if it is initially bypassed, instruments and obturating materials tend
to be continually directed into the ledge.
If the original canal cannot be located by this method, then cleaning and
shaping of the existing canal space is completed at the new working length. At
times, flaring of the canal may allow the ledge to be bypassed by providing
improved access to the apical canal. Small, curved files are used in the manner
previously described in a final attempt to bypass the ledge. If this is successful,
the apical canal space must be sequentially cleaned and flared to an appropriate
size. Complete removal or reduction of the ledge facilitates obturation.

Figure 2.18 : A No.10 steel file is used to maintain the space and remove debris
Source: Textbook of Endodotic by Nisha Garg, Amit Garg.

2.5.2.2 Creating an Artificial Canal

Cause
Aggressive use of steel files is the most common cause. Deviation from the
original pathway of the root canal system and creation of an artificial canal cause
an exaggerated ledge; it is initiated by the factors that cause ledge formation.
Management
Negotiating the original canal that has an exaggerated ledge is normally very
difficult. Rarely can the original canal be located, renegotiated and prepared. To
obturate, the dentist should determine whether a perforation exists. Methods
include apex locator readings, hemorrhage on paper points while drying and
radiographs with a file in position. If confirmed, the working length is adjusted, an
apical stop is created at the adjusted length with larger files, and obturation is
begun. If there is no perforation, the canal is obturated with a warm or softened

gutta-percha technique in conjunction with a root canal sealer. If there is a

perforation, the defect should be repaired internally or surgically.

2.5.2.3 Root Perforations

Roots may be perforated at different levels during cleaning and shaping.
Location (apical, middle or cervical) of the perforation and the stages of treatment
(cleaning and shaping) affect prognosis. The periodontal response to the injury is
affected by the level and size of the perforation.
Apical perforations

Figure 2.19: Apical perforations.

Source: http://grindentals.blogspot.com/2010/07/root-canal-treatment-and-itsprepration.html

Causes
Occur through the apical foramen (overinstrumentation) or through the body
of the root (perforated new canal). Instrumentation of the canal beyond the apical
constriction results in perforation. Incorrect working length or inability to
maintain proper working length causes zipping or blowing out of the apical
foramen. The appearance of fresh hemorrhage in the canal or on instruments, pain
during canal preparation in a previously asymptomatic tooth, and sudden loss of
the apical stop are indicators of foramen perforation. Extension of the largest
(final) file beyond the radiographic apex is also a sign. An electronic apex locator
may also confirm this procedural accident.
Management
Establishing a new working length, creating an apical seat (taper), and
obturating the canal to its new length. Depending on the size and location of the
apical foramen, a new working length 1 to 2 mm short of the point of perforation
should be established. The canal is then cleaned, shaped and obturated to the new
working length. The master cone must have a positive apical stop at the working
length before obturation. Placement of MTA as an apical barrier can prevent
extrusion of obturation materials.

Lateral (Midroot) Perforations

Figure 2.20 : Midroot Perforation(circled).

Source: http://www.dentistryiq.com/etc/medialib/platform7/dentistryiq/articles/online-exclusive_articles/2009images.Par.73546.Image.400.320.1.gif

Cause
Inability to maintain canal curvature (major cause) of ledge formation.
Negotiation of the ledge canals is not always possible, and misdirected pressure
and force applied to a file may result in formation of an artificial canal and
eventually in an apical or midroot perforation. To avoid these perforations, the
same factors mentioned earlier for prevention of ledge formation should be
considered: 1.degree of canal curvature and size 2.inflexibility of the larger files,
especially stainless steel files.

Management
The optimal goal is to clean, shape and obturate the entire root canal system of the
affected tooth. After the perforation is confirmed, the steps discussed previously
for bypassing of ledged canals are followed. If attempts to negotiate the apical
portion of the canal are unsuccessful, the operator should concentrate on cleaning,
shaping, and obturating the coronal segment of the canal. A new working length
confined to the root is established, and the canal is then cleaned, shaped, and
obturated to the new working length. A low concentration (0.5%) of sodium
hypochlorite or saline should be used for irrigation in a perforated canal.
Extrusion of concentrated irrigant into the surrounding periodontal tissues would
produce severe inflammation.

Coronal Root Perforations

Source: Principles and Practice of Endodontics 3rd Ed.; Walton, Torabinejad.

Causes
Coronal root perforations occur during access preparation as the operator
attempts to locate canal orifices or during flaring procedures with files, GatesGlidden drills, or Peeso reamers.
Management
Repair of a stripping perforation in the coronal third of the root has the poorest
long-term prognosis of any type perforation. The defect is usually inaccessible for
adequate repair. An attempt should be made to seal the defect internally, even
though the prognosis is guarded. Patency of the canal system must be maintained
during the repair process. Referral of the patient to a specialist is recommended.

Separated Instruments

Sourc
e: Principles and Practice of Endodontics 3rd Ed.; Walton, Torabinejad; pg324

Causes
Limited flexibility and strength of intracanal instruments combined with
improper use may result in an intracanal instrument separation. Any instrument
may breaksteel, nickel-titanium, hand or rotary. Overuse or excessive force
applied to files is the main cause of separation. Manufacturing defects in files are
rare.
Management
1. Attempt to remove the instrument
2. Attempt to bypass it
3. Prepare and obturate to the segment.

Initial treatment is similar to that discussed earlier for a ledge. Using a

small file and following the guidelines described for negotiating a ledge, the
operator should attempt to bypass the separated instrument. After bypassing the
separated instrument, ultrasonic files, broaches, or Hedstrom files are used to
remove the segment. If removal of separated piece is unsuccessful, then the canal
is cleaned, shaped, and obturated to its new working length. If the instrument
cannot be bypassed, preparation and obturation should be performed to the
coronal level of the fragment.

Other accidents
Aspiration or Ingestion
The disappearance of an instrument that has slipped from the dentists
fingers followed by violent coughing or gagging by the patient and radiographic
confirmation of a file in the alimentary tract or airway are the chief signs. These
patients require immediate referral to a medical service for appropriate diagnosis
and treatment. According to a survey by Grossman, 87% of these instruments are
swallowed and the rest are aspirated. Surgical removal is required for some
swallowed and nearly all aspirated instruments.
Extrusion of Irrigant
Wedging of a needle in the canal (or particularly out of a perforation) with
forceful expression of irrigant (usually sodium hypochlorite [NaOCl]) causes
penetration of irrigants into the periradicular tissues and inflammation and
discomfort for patients. Extrusion of NaOCl into the periapical tissues can cause a
life-threatening emergency. Loose placement of irrigation needles and careful
irrigation with light pressure or use of a perforated needle precludes forcing the
irrigating solution into the periradicular tissues. Sudden prolonged and sharp pain
during irrigation followed by rapid diffuse swelling (the sodium hypochlorite
accident) usually indicates penetration of solution into the periradicular tissues.
The acute episode will subside spontaneously with time
Initially, there is no reason to prescribe antibiotics or attempt surgical
drainage. Treatment is palliative. Analgesics are prescribed, and the patient is

reassured. Because the outcome is so framatic, evaluation is performed frequently

to follow progress.

2.5.3 Accidents during obturation

Appropriate cleaning and shaping are the keys in preventing obturation
problems because these accidents usually result from improper canal preparation.
In general, adequately prepared canals are obturated without mishap. the quality
of obturation reflects canal preparation. However problems do occur.
2.5.3.1 Underfilling
Some causes include a natural barrier in the canal, a ledge created during
preparation, insufficient flaring, a poorly adapted master cone, and inadequate
condensation pressure. Bypassing (if possible) any natural or artificial barrier to
create a smooth funnel is one key to avoiding an underfill.
Removal of underfilled gutta-percha and retreatment is preferred. Forcing
gutta-percha apically by increased spreader or plugger pressure can fracture the
root. If lateral condensation is the method of obturation, the master cone should
marked to indicate the working length. If displacement of the master cone during
condensation is suspected, a radiograph is made before excess gutta-percha is
removed. Removal can then be accomplished by pulling the cones in the reverse
order of placement. Removal of gutta-percha in canals obturated with lateral
condensation is easier than removal with other obturation techniques. However,

warm gutta-percha techniques allow better obturation of irregularities within the

canal.

2.5.3.2 Overfilling
Extruded obturation material causes tissue damage and inflammation.
Postoperative discomfort (mastication sensitivity) usually lasts for a few days.
Overfilling is usually consequences of overinstrumentation through the apical
constriction or lack of proper taper in prepared canals. When the apex is open
naturally or its constriction is removed during cleaning and shaping, there is no
matrix against which to condense; uncontrolled condensation forces extrusion of
materials. Other causes include inflammation resorption and incomplete
development of the root.
When sign or symptoms of endodontic failure appear, apical surgery may be
required to remove the material from apical tissues and place root end filling
material. Long-term prognosis is dictated by the quality of the apical seal, the
amount and biocompatibility of extruded material, host response, and toxicity and
seal-ability of the root-end filling material
2.5.3.3 Vertical Root Fracture

Figure 2.21 :Facial view of a vertical root fracture, a horizontal cross-section of a

VRF affecting only the lingual root surface, and a horizontal cross section of a
VRF affecting both the buccal and the lingual root surfaces; root canal-filling
material is shown in the canal space.
Source: Rusty Jones. Checking the Cracked tooth Code: Detection and Treatement
of Various Longitudinal Tooth Fractures. Endodontics, Colleagues for Excellence.
2008.

Causative factors include root canal treatment procedures and associated

factors such as post placement. The main cause of vertical root fracture is post
cementation; second in importance is overzealous application of condensation
forces to obturate an under- or overprepared canal.
Complete vertical root fracture predicts the poorest prognosis of the involved
root in multi-rooted teeth and extraction of single-rooted teeth.

2.5.4 Accidents during post space preparation

The indication of perforations and vertical root fractures are somewhat similar.
Appearance of fresh blood during post space preparation is an indication for the
presence of root preparation. The presence of a sinus tract stoma or probing
defects extending to the base of a post is often a sign of root fracture or
perforation. Radiographs often show a lateral radiolucency along the root or
perforation site.
The involved root (or tooth) is hopeless and must be removed. As outlined
earlier, the prognosis of teeth with root perforation during post space preparation
depends on the root size, location relative to epithelial attachment, and
accessibility for repair. Management of the post perforation generally is surgical if
the post cannot be removed. If the post can be removed, nonsurgical repair is
preferred. Teeth with small root perforations that are located in the apical region
and are accessible for surgical repair have a better prognosis than those that have
large perforations, are close to the gingival sulcus, or are inaccessible. Because of
the complexity in diagnosis, surgical techniques, and follow-up evaluation,
patients with post perforations should be referred to an endodontist for evaluation
and treatment.

Figure 2.22: An incisor with incorrect post placement can induce vertical root
fracture.
Source: Endodontics Principles and Practice, Torabinejad, Walton.

CHAPTER 5
CONCLUSION
Endodontic emergencies are a challenge for both diagnosis and management.
Knowledge and skill in several aspects of endodontics are required. Failure to
apply these will result in serious consequences for the patient. Incorrect diagnosis
or treatment will fail to relieve pain and in fact may aggravate the situation.
If general dentists encounter endodontic procedural accidents, the patient
should be considered for referral or an endodontist. In general, a specialist is
better equipped to manage these patients. Also, after long-term evaluation, other
procedures, such as surgery, may be necessary if future failure occurs.

REFERENCES
1. Grag N, Grag A. 2010. Textbook of Endodontics. 2nd ed. Jaypee Brothers
Medical Publishers.
2. http://www.dentalclinicmanual.com/docs/IHS_DentSpecResGuideCh10.pdf
3. Richard E. Walton & Mahmoud Torabinejad, 2002. Principles And Practice Of
Endodontics. Philadelphia : W.B. Saunders Company.
4. TR Pitt Ford, JS Rhodes & HE Pitt Ford, 2002. Endodontics : ProblemSolving in Clinical Practice. London : Martin Dunitz Ltd.
5. George Freedman, Oralhealth and Dental Practice: Clog-Controlled dentin
preparation with Smart Bur 2,2012.
6. Endodontics Principles and Practice, Torabinejad, Walton.
7. Rusty Jones. Checking the Cracked tooth Code: Detection and Treatement of
Various Longitudinal Tooth Fractures. Endodontics, Colleagues for
Excellence. 2008.

DSP 7 ASSIGNMENT
TOPIC 8 ENDODONTIC EMERGENCY

Amira Farhana

160110093001

Chai Min Wei

Cheong Pui Yan
Chew Yuen Huan
Dimple
Fu Soo Ling
Intan Ezzety
Lau Ee Von
Lee Chui Yee
Lee Shy Wen
Lo Xue Li
Low Wai Chian

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FACULTY OF DENTISTRY
UNIVERSITAS PADJADJARAN
JATINANGOR
2012