Endodontic emergencies and mid term flare ups

Endodontic
emergencies
-DR POOJA

CONTENTS
• Introduction
• Classifications
• Different Types Of Endodontic Emergencies And
Their Management
1.PRETREATMENT ENDODONTIC
EMERGENCIES
(i) Cracked tooth syndrome
(ii) Symptomatic reversible pulpitis
(iii) Symptomatic irreversible pulpitis
(iv) Symptomatic apical periodontitis
(v) Acute exacerbation of asymptomatic
apical periodontitis (phoenix abscess)
(vi) Acute alveolar abscess

CONTENTS
2. DURING TREATMENT
(a) Hot tooth
(b) Endodontic flare-ups
(c) Hypochlorite accident
(d) Air emphysema
(e) Aspiration/ ingestion of instruments
(f) Perforation
3. AFTER TREATMENT
(a) Postobturation pain
(b) Vertical root fracture (VRF)
• CONCLUSION

An endodontic emergency is defined as
pain and/or swelling caused by
inflammation or infection of pulp and/or
periradicular tissue necessitating an
emergency visit to the dentist for
immediate treatment.
The main causative factors responsible for occurrence of
endodontic emergencies are:
Pathosis in pulp and periradicular tissues
Traumatic injuries
Grossman endodontic practice 13th edi chapter 7, pg 146

Recent studies report a 60-82% incidence of endodontic emergencies
among all dental emergencies.
Within this group, 20-42% of patients seek care for teeth with
symptomatic irreversible pulpitis (SIP) .
Additionally, about 60% of SIP patients also complain of
symptomatic apical periodontitis (SAP)
The goal of management of endodontic emergencies is to quickly and
effectively manage pain and infections thereby also minimizing the
development of persistent pain and the formation of periapical
pathology
Management of endodntic emergencies. www.aae.org Fall 2017

ACCORDING TO
GUTMANN TREATMENT OF VITAL PULP
Acute reversible pulpitis
Hypersensitive dentin.
Recurrent decay.
Recent restoration.
Cracked tooth syndrome.
ESTHETIC
EMERGENCY
Fracture of crown.
Fracture of root.
Avulsed tooth
TREATMENT OF
NON VITAL PULP
Acute apical periodontitis.
Necrotic pulp.
Acute alveolar abscess.
Phoenix abscess.
Acute irreversible pulpitis
Localized.
Non-localized

ACCORDING TO P. CARROTTE
PRETREATME
NT
• Dentin
hypersensitivity
• Pain of pulpal origin
• a. Reversible pulpitis
• b. Irreversible
pulpitis
• Acute apical
periodontitis
• Acute periapical
abscess
• Traumatic injury
• Cracked tooth
syndrome
PATIENTS
UNDER
TREATMENT
• Mid treatment flare-
ups
• Exposure of pulp
• Fracture of tooth
• Recently placed
restoration
• Periodontal treatment
POST
ENDODONTIC
TREATMENT
• Overinstrumentation
• Overextended filling
• Underfilling
• Fracture of root
• High restoration

ACCORDING TO GROSSMAN
BEFORE
TREATMENT
DURING
TREATMENT
AFTER
TREATMENT

ENDODONTIC EMERGENCIES
PRESENTING WITH PAIN OR
SWELLING
• Cracked tooth syndrome
• Symptomatic reversible
pulpitis
• Symptomatic irreversible
pulpitis
• Symptomatic apical
periodontitis
• Acute exacerbation of
asymptomatic apical
periodontitis
( Phoenix abscess )
• Acute alveolar abscess
• Cellulitis
TRAUMATIC
INJURIES
• Crown / Root Injuries
• Luxation injuries
• Tooth avulsion
BEFORE
TREATMENT

• Hot tooth
• Endodontic flare-ups
DURING
TREATMENT
AFTER
TREATMENT
• Post obturation pain
• Vertical Root Fracture

PRETREATMENT ENDODONTIC
EMERGENCIES

• ‘Cuspal fracture odontalgia’
was first used by Gibbs in
1954
• ‘Cracked tooth syndrome’ or
‘Cracked cusp syndrome’.
coined by Cameron in 1964.
• Also called-
Split tooth syndrome , or
Green-stick fracture
BRITISH DENTAL JOURNAL VOLUME 208 NO. 11
JUN 12 2010. Cracked tooth syndrome. Part 1. Cracked
tooth syndrome. Part 1: aetiology and diagnosis S. Banerji

• Crack tooth syndrome is defined as
“incomplete tooth fracture extending through
body of the tooth causing pain of idiopathic
origin.”
• Most distinct clinical Features:
»Rebound pain
»Sharp pain on eating or drinking
hot/sugary substances
TEXTBOOK OF ENDODONTICS;
NISHA GARG

Inconsistent ability to localise affected tooth
Sensitivity to cold thermal stimuli; in some cases hyper-
reactivity to hot/sugary stimuli may also occur
Pain may be elicited by lateral cusp pressure, as evoked by ‘bite
tests’ and tooth grinding. Pain at initiation or release of biting
pressure
Fracture lines may be seen clinically (sometimes upon
removal of the restoration), aided by magnification, dyes or
transillumination
Positive response to vitality tests; exaggerated
response to cold thermal stimuli
Sudden sharp pain on release of
bite: rebound pain SIGNS &
SYMPTOMS

Lynch et al. have subdivided the
causes of cracks into four major
causative categories, hence:
Restorative procedures
Occlusal factors
Developmental conditions , and
Miscellaneous factors

When the fractured portions of the
tooth move independently of each other,
it causes sudden movement of fluid
present in the dentinal tubules.
This causes activation of myelinated A-
type fibers within the dental pulp and
results in acute pain.
Hypersensitivity to cold may occur due
to the seepage of toxic irritants through
the crack.
This leakage of toxic irritants cause the
release of neuropeptides, and a
concomitant lowering in the pain
threshold of unmyelinated C-type fibers
within the dental pulp.
the symptoms are caused by the
alternating stretching and
compressing of the odontoblast
processes located within the crack
Int J Appl Basic Med Rest.2015 Sep-Dec; 5(3): 164–168. Cracked tooth syndrome: Overview of literature Shamimul Hasan
THEORIES
ASSOCIATED
WITH CTS

CLASSIFICATION:
American Association of endodontists classification
of cracked teeth
NISHA GARG

• FIBRE OPTIC LIGHT:
transillumination of fracture line
• DYE: such as gentian violet or
methylene blue
• Use Of Wooden Sticks, Cotton
Rolls, rubber plungers of
anaesthetic carpules suspended from
a length of floss.
• The Tooth slooth is placed either
between the cusps of a tooth or onto
the cusp tip and the patient is asked to
close together.
• Pain on biting or release on the
specific cusp identifies the
offending/involved cusp
BRITISH DENTAL JOURNAL VOLUME 208 NO. 11 JUN
12 2010. Cracked tooth syndrome. Part 2: restorative
options for the management of cracked tooth syndrome S.
Banerji

TREATMENT
URGENT CARE!!
• Immediate reduction of
occlusal contacts by
selective grinding of tooth
at the site of crack or its
antagonists
NISHA GARG

It is a mild to moderate inflammatory condition of the
pulp caused by noxious stimuli in which the pulp is
capable of returning to the uninflamed state following
removal of the stimulus
• Characterized by sharp pain lasting for a moment, more
often brought on by cold than hot food or beverages.
• The patient can identify the tooth.
• Momentary pain that subsides on removal of stimulus
Cohen pathways of pulp

CAUSES
1. Trauma-disturbed occlusal relationship
2. Thermal shock- too long contact of bur during cavity preparation or
overheating due to polishing of a filling.
3. Excessive dehydration-chloroform or alcohol
4. Galvanic shock-fresh amalgam filling in contact with gold
restoration
5. Chemical irritation-sweet of sour food stuff or irritation of silicate
or self cure acrylic
MANAGEMENT
1. Removal of the cause.
2. Recontouring of recently placed restoration which causes pain.
3. Removal of the restoration and replacing it with the sedative
dressing if painful symptoms still persist following the tooth
preparation.
4. Relieving the occlusion.

DEFINITION: It is a persistent inflammatory condition of the pulp,
symptomatic or asymptomatic, caused by a noxious stimulus.
SYMPTOMS:
• Pain lasts for minutes to hours.
• It often continues even when the cause is removed.
• Pain is present even on bending over.
• Patient complains of disturbed sleep.
• Pain is experienced on sudden temperature change.
• On taking sweets or acidic foodstuff.

PAIN –
• sharp, piercing, or shooting in nature,
• it may be intermittent, continues depending on degree of pulp
involvement, related to external stimuli
• Later stages- bowing, gnawing & throbbing
• Pain-increased by heat relieved by cold
CAUSES-
• Bacterial involvement of pulp through caries. Other factors-chemical ,
thermal, mechanical
MANAGEMENT-
• Vital pulp According to Grossman, the preferable emergency
treatment is ‘PULPECTOMY’ - complete removal of the pulp and
placement of an intracanal medicament to act as a disinfectant or
obtundent.

• Defined as a painful inflammation of the periodontium as a result
of trauma, irritation, or infection through the root canal,
regardless of whether the pulp is vital or nonvital.
• Pressure on tooth (Occlusion/percussion) is transmitted to the fluid
which pushes on nerve endings in the periodontal ligament.
• It is characterized by:
Tooth may be elevated out of its socket because of the build up in
fluid pressure in the periodontal ligament.
Discomfort to biting or chewing.
Sensitivity to percussion is a hallmark diagnostic test.
Management of endodontic emergencies
chapter 2, Cohen pathways of pulp 10th
edition

• Radiographic examination may show a thickened periodontal
ligament or a small area of rarefaction if a pulp less tooth is
involved and it may show normal periradicular structures if a vital
pulp is present in the tooth
TREATMENT:
• Adjustment of high points (in hyperocclusion cases) and removal of
irritants (in case of nonvital infected pulp) is the immediate line of
management.
• Root canal treatment
Management of endodontic emergencies chapter 2, Cohen pathways of pulp 10th edition

• It is a localized collection of pus in the alveolar bone at
the root apex of a tooth following death of the pulp,
with extension of the infection through the apical
foramen into the periradicular tissues.
SYMPTOMS:
tenderness of the tooth, relieved by
continued slight pressure on the
extruded tooth to push it back into
the alveolus.
severe, throbbing pain, with
attendant swelling of the overlying
soft tissue.
Management of endodontic emergencies chapter 2,
Cohen pathways of pulp 10th edition

• the pain may subside or cease entirely while the adjacent tissue
continues to swell.
• If left unattended, chronic apical abscess sinus tract
(opening in the labial or buccal mucosa)
• It may further progress on to osteitis, periostitis, cellulitis, or
osteomyelitis.
• Systemic features such as fever and malaise may also be present.
a radiograph may help
determine the tooth affected by
showing a cavity, a defective
restoration, thickened
periodontal ligament space, or
evidence of breakdown of bone
in the region of the root apex.
edition

Management
Biphasic treatment:
a. Pulp debridement
b. Incision and drainage
• Do not leave tooth open between appointments.
• In case of localized infections, antibiotics provide
no additional benefit.
• In case of systemic features, antibiotics should
be given.
• Relieve the tooth out of occlusion in cases of
hyperocclusion.
• To control postoperative pain, NSAIDs should be
prescribed.
• Speed of recovery will rely on canal debridement.
LA is contraindicated in such cases
because of following reasons:
1. Pain caused by injection in distended
area.
2. Chances of dissemination of virulent
organisms.
3. Ineffectiveness of local anesthetics.
Acutely inflamed tissue has a localized
pH that is acidic inspite of the body's
natural buffering action.
Local anesthetics are effective in tissues
with a more alkaline pH and, as a result,
are ineffective when injected into
acutely inflamed tissue.
edition

Nonvital infected tooth with active drainage from the periapical area through the
canal.
A, Access opened and draining for 1 minute.
B, Drainage after 2 minutes.
C, Canal space dried after 3 minutes.

Pulpal Necrosis With Acute
Apical Abscess
1977 preferred to leave the
tooth open, with instrumentation extending
beyond the apex
to help facilitate drainage through the canals.
Until 1977 preferred to leave the tooth open, with
instrumentation extending beyond the apex to help
facilitate drainage through the canals.
there is currently a trend toward not leaving teeth open
for drainage.
another trend: when treatment is done in more than one
visit, most endodontists will use calcium hydroxide as an
intracanal medicament.
Care should be taken not to allow necrotic debris to be
pushed beyond the apex, because this has been shown to
promote more posttreatment discomfort
Trephination
In the absence of swelling, trephination is the surgical perforation of the alveolar
cortical plate to release from between the cortical plates the accumulated tissue
exudate that causes pain.
No Swelling
edition

Pulpal Necrosis With Acute
Apical Abscess
Swelling may be controlled by establishing drainage
through the root canal or by incising the fluctuant
swelling.
When the swelling is localized, the preferred avenue is
drainage through the root canal. Complete canal
debridement and disinfection are paramount to success
presence of persistent swelling, gentle finger pressure
to the mucosa overlying the swelling may help facilitate
drainage
Incision for Drainage
Swelling
Management of endodontic emergencies chapter 2, Cohen
pathways of pulp 10th edition

• A non functional swelling can be converted to a soft fluctuant
state by rinsing with warm saline solution 3-5 min at a time
repeated every hour.
Irrigants used in treating acute abscess
• Initial stages sterile water and saline/ (NaOCl clumping debris)
• When the patency through the apex is maintained, sodium hypochlorite
may be used for further canal preparation.
• For further appointments, an alternating solutions of sodium hypochlorite
and hydrogen peroxide is recommended
Textbook of endodontics 4th edition chapter 10 Management of acute emergencies and traumatic dental injuries
K Gulabivala, Y-L Ng

(10) Pre-op buccal abscess
over tooth No. 14.
(11) Buccal incision made with
No. 15 scalpel.
(12) Purulence draining from incised fluctuant abscess.
(13) Curved hemostat used to open incised site.
(14) Monoject (Medtronic)
syringe used to irrigate inside
incision site.
Textbook of endodontics 4th edition chapter 10 Management of acute emergencies
and traumatic dental injuries K Gulabivala, Y-L Ng

A, Localized fluctuant abscess as a result of
periradicular pathosis after trauma.
B, Radiographic appearance. C, Drainage was
spontaneous when the tooth was opened. D,
Christmas tree–shaped rubber drain placed after
soft tissue incision.
Different shapes of rubber drains. From
left to right: I drain, Christmas tree
drain, T drain, and Penrose drain with
oblique cuts. These designs are self-
retentive and do not require suturing to
the incision margins.
Endodontic
Principles &
Practise 4th Edi.
Torabinejad &
Walton

Acute Exacerbation of Chronic
Periodontitis
6

• It is an acute inflammatory reaction superimposed on an existing
chronic apical periodontitis.
• Also c/d: Exacerbating apical periodontitis , PHOENIX
ABSCESS.
CAUSES:
• noxious stimulus from a diseased pulp can cause acute inflammatory
response in dormant lesions.
• Lowering of body s defenses due to influx of bacterial toxins from the
root canal or,
• irritation during root canal instrumentation triggers acute
inflammatory response.
edition

tender on palpation
tooth gets elevated from its socket and becomes sensitive.
The mucosa over radicular area may appear red and swollen and is
sensitive to palpation.
Lack of response to vitality tests
a tooth may respond to the electric pulp test because of fluid in the
root canal or in a multirooted tooth.
Well-defined periradicular lesion evident in a
case of acute exacerbation of chronic
periodontitis.

Grossman 13th edition Chapter 7

TRAUMATIC INJURIES
CROWN
FRACTURE
ROOT
FRACTURE
AVULSION

CROWN FRACTURE
• Uncomplicated crown fracture can be
defined as fracture of the enamel only or
enamel and dentin without pulp exposure
Treatment:
• Reattachment of the separated enamel-
dentin fragment or conservative restoration
with composite resin
Management of endodontic
emergencies chapter 2, Cohen

• CROWN FRACTURE INVOLVING PULP
• crown fractures involving enamel, dentin & pulp are called
‘complicated crown” fractures by Andreasen & class 3 by Ellis.
• Degree of pulp exposure--- pinpoint exposure to total unroofing of
coronal pulp.
TREATMENT:
• Treatment options for complicated crown fracture are
(1) Vital pulp therapy, comprising pulp capping, partial pulpotomy, or
full pulpotomy;
(2) Pulpectomy.
Choice of treatment depends on the stage of development of the
tooth, the time between trauma and treatment, concomitant
periodontal injury, and restorative treatment plan.
edition

ROOT FRACTURE
• < 3% of all dental injuries
• Since root fractures are usually oblique (facial to
palatal) , one periapical radiograph may easily miss its
presence.
• It is imperative to take at least three angled
radiographs (45, 90, 110 degrees)
edition

Radiographs showing the importance of different vertical angulations
for diagnosis of root fracture.
Radiographic technique
used for suspected root
fractures. At least two
angulations are made: the
conventional (90 degree)
view and a steep vertical (45
degree) view.
Principles & practise of endodontics 3rd edit, walton & torabinejad

• Re-approximation of the two segments done by releasing the coronal
segment from the bone by gently pulling it slightly downward
with finger pressure or extraction forceps, and then once it is
loose, rotate it back to its original position
• The traditionally recommended splinting protocol has been changed
from 2 to 4 months with rigid splinting to a semirigid splint to
adjacent teeth for 2 to 4 weeks.
Textbook of endodontics 4th edition chapter 10 Management of acute emergencies and traumatic dental injuries
K Gulabivala, Y-L Ng

Healing with calcified tissue. Radiographically, the fracture line is
discernible, but the fragments are in close contact
Healing with interproximal connective tissue. Radiographically,
the fragments appear separated by a narrow radiolucent line, and the fractured
edges appear rounded
Healing with interproximal bone and connective tissue.
Radiographically, the fragments are separated by a distinct bony ridge
Interproximal inflammatory tissue without healing.
Radiographically a widening of the fracture line and/or developing radiolucency
corresponding to the fracture line becomes apparent

Principles & practise of endodontics 3rd edit, walton
& torabinejad

Types of luxation injury:
1. Concussion implies no displacement, normal mobility, and
sensitivity to percussion.
2. Subluxation implies sensitivity to percussion, increased mobility,
and no displacement.
3. Lateral luxation implies displacement labially, lingually, distally,
or incisally.
4. Extrusive luxation implies displacement in a coronal direction.
5. Intrusive luxation implies displacement in an apical direction into
the alveolus.
Management of endodontic emergencies chapter 2, Cohen pathways of
pulp 10th edition

• Initial treatment : avoid use of the tooth.
• serious luxation: slight occlusal adjustment OR repositioning
(reduction) and splinting (stabilization) for 2 to 6 weeks.
edition

Avulsion of permanent teeth:
theory to practice
• Avulsion is defined as complete displacement of a tooth from the
socket.
• Tooth avulsion results in attachment damage and pulp necrosis.
• The tooth is “separated” from the socket mainly due to tearing of
the periodontal ligament that leaves viable periodontal ligament
cells on most of the root surface.
• The incidence is < 3% of all dental injuries
Guidelines for the Management of Traumatic Dental Injuries: 2. Avulsion of
Permanent Teeth Dental Traumatology 2012;28:88-96

When the patient arrives:
1. The tooth is placed in a cup of physiologic saline.
2. The area of injury is radiographed, looking for evidence of alveolar
fracture.
3. The avulsion site is examined carefully for any loose bone fragments
that may be removed.
4. The socket is gently irrigated with saline to remove contaminated
coagulum.
5. In the cup of saline, the tooth is grasped with extraction forceps by the
crown to avoid handling the root.
6. The tooth is examined for debris, which, if present, is gently removed
with gauze moistened with saline.
REPLANTATION WITHIN 1 HOUR OF AVULSION.
Principles & practise of endodontics 3rd edit,
walton & torabinejad

7. The tooth is replaced into the socket; after partial insertion using the
forceps, gentle finger pressure is used or the patient bites on gauze
until the tooth is seated.
8. Proper alignment is checked, and hyperocclusion is corrected. Soft
tissue lacerations are tightly sutured, particularly cervically.
9. The tooth is stabilized for 1 to 2 weeks with a splint
10. It has been suggested that antibiotics be prescribed in the same
dosage as that used for mild to moderate oral infections,
A tetanus booster injection is recommended if the last one was
administered more than 5 years previously
11. Supportive care is given; a soft diet and mild analgesics are
suggested as needed.
• Root canal treatment is indicated for mature teeth and should be
done optimally after 1 week and before the splint is removed

• Debris and pieces of soft tissue adhering to the root surface are
removed.
• The tooth is soaked in a 2.4% solution of sodium fluoride
(acidulated to pH 5.5) for 5 to 20 minutes.
• The pulp is extirpated, and the canal is cleaned, shaped, and filled
while the tooth is held in a fluoride-soaked piece of gauze. Often the
procedure can be accomplished from an apical direction if the root is
immature.
• The alveolar socket is carefully suctioned to remove the blood clot.
The socket is irrigated with saline. Anesthesia may be necessary first.
• The tooth is gently replanted into the socket, checking for proper
alignment and occlusal contact.
• The tooth is splinted for 3 to 6 weeks
REPLANTATION AFTER 1 HOUR

Replantation of a tooth with closed apex within 1 hour of avulsion in a 14-year-old boy. A, The avulsed
central incisor was brought to the dentist in a cup of milk. B, Clinical appearance of the avulsion site.
C, A wire-composite splint is used after repositioning the tooth. D, Radiographic examination after
splinting. The roots appear short, probably due to history of previous trauma to the anterior teeth. E,
Calcium hydroxide is placed in the root canal 8 days later and left in place for 2 months. F-G, Clinical
and radiographic appearance at 2 months follow-up control. Root canal treatment with gutta-percha

I. healing with a normal periodontal ligament. Clinically the tooth exhibits a
normal position and mobility. Radiographically the periodontal ligament
space is evident and displays no signs of bone or root resorption
II. healing with surface resorption. The resorptive process is self-limiting, and
clinically the tooth is normal. The resorptive defects are usually not evident
radiographically
III. healing with ankylosis or replacement resorption. It is characterized by
osteoclastic activity and resorption of the root followed by deposition of bone
into the defect. Clinically the tooth is immobile and percussion elicits a clearly
different sound compared with normal teeth. The radiographic appearance is
consistent with the replacement of root structure by bone and the loss of a
visible periodontal membrane. No known treatment is available for
replacement resorption.
IV. healing with inflammatory resorption. Clinical evaluation may detect signs
and symptoms of inflammation, infection, and mobility.
Radiography reveals radiolucent areas in the root and adjacent bone.
Endodontic treatment may arrest inflammatory resorption.
Guidelines for the Management of Traumatic Dental Injuries: 2. Avulsion of Permanent Teeth Dental Traumatology
2012;28:88-96

ENDODONTIC EMERGENCIES DURING
TREATMENT

HOT TOOTH
• The term ‘‘hot’’ tooth generally refers to a pulp that has been
diagnosed with irreversible pulpitis, with spontaneous, moderate-
to-severe pain
• Patients in pain as a result of a tooth diagnosed with irreversible
pulpitis have additional difficulties attaining pulpal anesthesia.
Management of endodontic emergencies chapter 2, Cohen pathways
of pulp 10th edition

Theories related to hot tooth
inflamed tissue has a lowered pH, which
reduces the amount of the base form of
the anesthetic needed to penetrate the
nerve sheath and membrane.
Therefore, there is less ionized form of
the anesthetic within the nerve to
produce anesthesia.
nerves arising from the inflamed tissue have
altered resting potentials and reduced
thresholds of excitability.
anesthetic agents were not able to prevent the
transmission of nerve impulses because of the
lowered excitability thresholds of inflamed
nerves
• Sodium channel expression on C fibers
shifts from TTX sensitive to TTX resistant
• TTX resistant channels are five times
more resistant to anesthetic (lidocaine)
• Bupivacaine found to be more potent
• Alternate and supplementary injection
sites: intraosseous, intraligamentory Dent Clin N Am 2010 Nusstein etal
Local anaesthesia strategies for hot
tooth

• The key to giving a successful PDL injection
remains the attainment of back-pressure during
the injection.
• The development of computer-controlled
anesthetic delivery systems (the Wand or the
Single Tooth Anesthesia [Milestone Scientific,
Livingston, NJ, USA] devices) have been found
to be able to deliver a PDL injection.
INTRALIGAMENTARY (PERIODONTAL LIGAMENT)
INJECTION
Dent Clin N Am 2010 Nusstein
etal Local anaesthesia strategies
for hot tooth
Dent Clin N Am 2010 Nusstein etal
tooth

INTRAOSSEOUS ANAESTHESIA
Allows the practitioner to deliver local anesthetic solutions directly
into the cancellous bone surrounding the affected tooth.
several IO systems available
• Stabident , X-Tip, IntraFlow handpiece
• Key to success: deposition into the cancellous space;
• In 0-48% --- transient moderate to severe pain on perforation and
deposition of anesthetic
• Perforator breakage
• Optimal site: DISTAL to the problematic tooth
• Except second molars: MESIAL to the tooth
• Immediate onset
tooth

INTRAPULPAL ANAESTHESIA
• Moderately to severe painful
• Immediate onset
• Short (15 - 20 min) duration of action
• Pulp must be exposed
• Predictable under back-pressure.
• Indicated when PDL & IO injections fail.
tooth

Preemptive stategies to improve success of IANB injection:
• Use pretreatment oral doses of acetaminophen or a
combination of acetaminophen and ibuprofen versus
placebo in patients undergoing endodontic therapy.
• an IO injection of 40mg of methyl-prednisolone (Depo-
Medrol) and found that it significantly reduced pain.
• Give short morning appointments followed by good
morning breakfast.
• Premedication with lorazepam 1mg (after checking
interaction with other drugs) night before sleep followed by 90
minutes prior to procedure
Local anaesthesia strategies for hot tooth

• A non-pharmacological method for
pain control is the use of
transcutaneous electrical nerve
stimulation [TENS]
• Stimulate superficial nerves for
localized pain relief
Dent Clin N Am 2010 Nusstein
etal Local anaesthesia strategies
for hot tooth

ENDODONTIC FLARE- UP
According to American Association of Endodontics (1998):
• An acute exacerbation of peri radicular pathosis after initiation or
continuation of root canal treatment
• Studies report 1.8-3.2 % flare-ups
• Flareup is described as the occurrence of pain, swelling or the
combination of these during the course of root canal therapy, which
results in unscheduled visits by patients (Gerald W Harrington,1992)
Stomatologija, Baltic Dental and Maxillofacial Journal, 16:25-30, 2014 Pain and flare-up after endodontic treatment procedures
Predisposing
Factors

Result of imbalance in host-
bacteria relationship.
F. nucleatum, Prevotella species
and Porphyromonas species
were frequently isolated from
flare-up cases.
Enterococcus faecalis is present
in retreatment cases.

INTERAPPOINTMENT
FLARE UPS
• Apical periodontitis
secondary to treatment
• Incomplete removal of the
pulp tissue
• Phoenix abscess
• Recurrent periapical abscess
• Flare ups related to necrotic
pulp
POSTOBTURATION
FLARE UPS

Previously Vital Pulps with Complete
Debridement - situation is unlikely to
be a true flare-up, and patient
reassurance and the prescription of a
mild to moderate analgesic
Previously Vital Pulps with
Incomplete Debridement- The
working length should be rechecked,
and the canal(s) should be carefully
cleaned with copious irrigation of
sodium hypochlorite.
A dry cotton pellet is then placed,
followed by a temporary filling, and a
mild to moderate analgesic is
prescribed
Previously Necrotic Pulps with No Swelling
Occasionally, these teeth develop an acute
apical abscess (flare-up) after the
appointment.
The tooth is opened and the canal is gently
recleaned and irrigated with sodium
hypochlorite the canals are dried, calcium
hydroxide paste is placed, and the access is
sealed.
The tooth should not be left open.
analgesic regimen for moderate to severe
pain are helpful; antibiotics are not
indicated.
Previously Necrotic Pulps with Swelling –
incision and drainage indicated.
Canals should be opened and debrided,
medicated with calcium hydroxide paste,
and closed
Treatment
of Flare-ups
Principles & practise of endodontics 3rd edit, walton & torabinejad

HYPOCHLORITE ACCIDENT
• It refers to any event in which sodium
hypochlorite extruded beyond the apex of a
tooth and the patient immediately manifests a
combination of some of the following:
• Severe immediate pain
• swelling
• Profuse bleeding both interstitially and
through the tooth.
edition

• Causes :
• Forceful injection of Naocl due to wedging of the irrigating needle
into the root canal.
• Irrigating a tooth with a large apical foramen, apical resorption or an
immature apex.
• Features :
• Edema and ecchymosis, accompanied by tissue necrosis, paraesthesia
and secondary infection.
• Although most patients recover within 1-2 weeks.
• Long-term paraesthesia and scarring have
been reported.
edition

• Management:
• Immediate aspiration
• Cold pack over the affected area followed by
warm compresses to encourage healing.
• Regional block anesthesia administered.
• Monitor tooth for the next half hour.
• Bloody exudation extended from canal
denotes the bodies reaction to the irritant.
• Remove the fluid with high volume suction
to encourage further drainage.
Sodium Hypochlorite Accident: A Systematic Review Article in Journal of Endodontics · October 2016

• If drainage is persistent consider leaving the tooth open.
• Antibiotic coverage to prevent secondary infection
• Analgesics prescribed. Because of possible bleeding complication
with aspirin and NSAIDs an acetaminophen-narcotic combination
may be more appropriate.
• Corticosteroids – antiinflammatory process
• Prevention :
• Bend the irrigating needle at centre to confine the tip of the needle to
higher/coronal levels of root canal.
• Never bind the needle in the canal
• Oscillate the needle in and out to ensure that the tip is free to express
the irrigant with out resistance
• express the irrigant slowly and gently

• Clinical Note
• Š
Š
Always use passive irrigation and never force the irrigant into the
pulp space
• Š
Š
Sodium hypochlorite should be handled carefully as its
inadvertent seepage under the rubber dam can result in multiple
ulcers and leave the gingiva painfully inflamed
Š
Š
The recommended endodontic
irrigation needle is a 30-gauge
side-vented, close-ended needle
placed passively at:
3 mm short of working length in
posterior teeth
1 mm short of working length in
anterior teeth

AIR EMPHYSEMA
Air introduced into periapical tissues during invasive root
canal treatment - potential to do great harm.
Although rare occurence – but has a risk
Compressed air should never be used in drying of a root canal
that is open to periapical tissues
Textbook of endodontics Nisha garg
2nd edition chapter 21, pg 311
Through stenson’s duct

ASPIRATION / INGESTION OF ENDODONTIC
INSTRUMENTS
Aspiration of endodontic hand instruments happens only when
rubber dam is not in place.
Grossman had aptly stated (1955) that if an instrument is
swallowed by the patient, the dentist is likely to be confronted
law-suite.
High power suction along with rubber dam help in
prevention of aspiration of instruments.
Aspiration of endodontic instruments can be a clinical disaster
ending up in life threatening situations or ending up in the
need of major surgery to remove instrument

• EMERGENCIES DURING ENDODONTIC SURGERY
• Excessive uncontrolled bleeding
• Due to rebound phenomenon
• MEDICAL EMERGENCIES DURING ENDODONTIC
TREATMENT
• Syncope
• Hypoglycemic shock
Endodontic Principles & Practise 4th Edi. Torabinejad & Walton

ENDODONTIC EMERGENCIES AFTER
TREATMENT

• Following completion of root canal treatment,
patients usually complain of pain especially on
biting and chewing.
• The painful episodes are usually caused by
pressure exerted by insertion of root canal filling
materials or by chemical irritation from
ingredients of root canal cements and pastes.
OVERINSTRUMENTATION is directly
proportional to post operative pain.
If care of working length is not properly taken
overobturation or overfilling may result.

OVEREXTENDED OBTURATION leads to pain. Periapical
inflammation results in firing of proprioceptive nerve fibers in the
periodontal ligament.
• These results are short lived and abate in 24-48 hours. No treatment is
usually necessary in these cases.
PERSISTENT PAIN: Persistence of
pain or sensitivity for longer periods
may indicate failure of resolution of inflammation.
• In rare cases, inflamed but viable pulp tissue may be left in root canal.
• Retreatment is then indicated in such cases.

According to the AAE :
“ A true VRF is defined as a
complete or incomplete
fracture initiated from the
root at any level, usually
directed buccolingually ”
2.3% of total fractured teeth

Etiology
Root anatomy
Amount of remaining tooth structure
Presence of pre existing cracks
Overzealous application of condensation
forces to obturate an under- or overprepared
canal (wedging forces)
Bruxism

Pathogenesis
VRF
As it progresses to the PDL, soft tissue grows into
this fragment causing separation of these fragments
When it communicates with the oral cavity bacteria
enter into this area and initiate inflammatory
response
Disintegration of PDL, alveolar bone loss and
formation of granulation tissue

chapter 2, Cohen pathways of pulp 10th edition

Dhawan A, Gupta S, Mittal R.
Vertical root fractures: An update
review . J Res Dent 2014;2:107-13

Clinical Features
Pain in mild to moderate usually
accompanied by bad taste.
The swelling is usually broad-based, and
mid-root in position
In VRF, sinus tract is located close to the
gingival margin as opposed to non-vital
teeth where sinus tracts are located more
apically (differential diagnosis from
endodontic infections).
The presence of two sinus tracts (at both
buccal and lingual aspects) or multiple
sinus tracts is almost pathognomonic for
a VRF.
Dhawan A, Gupta S, Mittal R. Vertical root fractures: An update review . J Res Dent 2014;2:107-13

Radiographic Features
Separation of root segments associated
with
• a radiolucency surrounding the bone
• between the roots
Hairline fracture–like radiolucency
Halo appearance—a combined
periapical
and periradicular radiolucency on one
or both
sides of the involved root(J type lesion)
Widening of periodontal ligament space:
Around the whole length of the root may
indicate VRF
Dhawan A, Gupta S, Mittal R. Vertical root fractures: An update review . J Res Dent 2014;2:107-13

Vertical root fracture.
After flap reflection and visualization, the
pattern of bony changes tends to be
consistent with oval or oblong "punched-
out" defects filled with granulomatous
tissue (VRF). This is differentiated from
the normal bony fenestration.
Endodontic Principles & Practise 4th Edi.
Torabinejad & Walton
As VRF progresses to the periodontal
ligament, soft tissue growth into the
fracture space increases the separation of
the root segments.
Along the fracture line the periodontal
ligament disintegrates, followed by bone
loss, which is progressive especially in thin
buccal bone plate.

Management:
When a longitudinal fracture of a root occurs, the prognosis for that
root is usually hopeless.
Hence, extraction of such teeth is the recommended treatment of
choice.
In multirooted teeth, hemisection or radisectomy may be indicated.
Š
Additional imaging techniques such as CBCT
(cone beam computed tomography) to detect
and visualize VRFs have been introduced.
Management of endodontic emergencies chapter 2, Cohen

• Bonding the fractured segments with glass ionomer bone cement
and replanting the tooth in conjunction with an e-PTFE
membrane
• Two-stage surgical procedure of bonding with silver glass ionomer
cement, placement of a bone graft material and GTR therapy.
• Use of dual-cured adhesive resin cement is preferred for bonding
the fractured fragments
• Use of orthodontic elastics to join the buccal and palatal segments
of fractured tooth followed by sealing with a photocured resin
liner to allow the tooth to be endodontically treated and restored
with a cast crown
• Fitting of orthodontic bands before endodontic treatment to
prevent propagation of a crack or fracture
• Use of CO2 and Nd.YAG laser to fuse fractured tooth roots.
Other alternative attempts at treating VRF include:
Dhawan A, Gupta S, Mittal R. Vertical root fractures: An update review . J Res Dent 2014;2:107-

Repair of root fracture has been tried by binding
them with the help of adhesive resins, glass
ionomers and lasers.
But till date no successful technique has been
reported to correct this probem.

CONCLUSION
• The aim of emergency endodontic treatment is to relieve
pain and control any inflammation or infection that may
be present.
• The swift and correct diagnosis of emergency problems is
essential when providing treatment, especially in a busy
dental practice
• Effective caring and management of endodontic
emergencies not only represents a service to the public,
which the dentist can be proud of but also enhaces the
positive image of dentistry

Endodontic emergencies and mid term flare ups

Endodontic emergencies and mid term flare ups

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