Dealing with various emergencies arising in endodontics which primarily include Pain and Swelling

2. PRESENTED BY:
DR. SOMYA
(PG STUDENT)
ENDODONTIC EMERGENCY

3. CONTENT:
1. INTRODUCTION
2. DEFINITION
3. CLASSIFICATION
4. MANAGEMENT OF ENDODONTIC EMERGENCIES
5. MANAGEMENT OF VARIOUS ENDODONTIC EMERGENCIES
ARISING BEFORE THE TREATMENT
6. EMERGENCIES DURING TREATMENT
7. EMERGENCIES ARISING AFTER TREATMENT
8. ANALGESICS AND ANTIBIOTICS
9. CONCLUSION
10.REFERENCES

4. INTRODUCTION:
• 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).
• While pain due to a severely inflamed pulp is characterized by
dull, throbbing and lingering pain sensations, it can be
spontaneous or in response to an external stimulus, such as hot,
cold or chewing. This makes SIP the bulk of the emergency
cases seen in dental clinics.

5. • The aim of emergency endodontic treatment is to relieve pain
and control any inflammation or infection that may be present.
• Although insufficient time may prevent ideal treatment from
being carried out, the procedures followed should not prejudice
any final treatment plan. It has been reported that nearly 90%
of patients seeking emergency dental treatment have symptoms
of pulpal or periapical disease.

6. • Endodontic emergencies infringe on a tight, planned schedule
of a dentist as well as a of the patient and tend to upset the day
for everyone including the patient, dentist and staff.
• It is but natural that a patient in pain must be rendered painless
and comfortable as soon as possible.

7. DEFINITION:
An endodontic emergency is defined as an “An unscheduled visit
associated with pain or swelling ensuing from pulpoperiapical
pathosis requiring immediate diagnosis and treatment.”
According to Cohen Pathways of pulp :
An endodontic emergency is defined as pain or swelling caused by
various stages of inflammation or infection of pulp or periapical
tissues.

8. Occurrence of severe pain and / or swelling following an
endodontic treatment appointment, requiring an unscheduled visit
and active treatment (Watson and Foud –1992).
According to grossman : An endodontic emergency is defined as
pain and /or swelling caused by inflammation or of the pulp and
/or periradicular tissue necessitating an emergency visit to the
dentist for immediate treatment.

9. EMERGENCY according to Dorland’s Medical dictionary is
defined as a sudden, urgent, usually unforeseen occurrence
requiring immediate action. Life threatening emergencies can and
do occur in the practice of dentistry.
Endodontic emergencies are circumstances associated primarily
with Pain and/or Swelling that require immediate diagnosis and
treatment.

10. According to survey board certified endodontists by Dorn and
associates in 1977 and 1990 and by Lee in 2009, there are seven
clinical presentations that are considered endodontic emergencies:
 Irreversible pulpitis with normal periapex.
 Irreversible pulpitis with symptomatic apical periodontitis.
 Necrotic pulp with symptomatic apical periodontitis ,with no
swelling.
 Necrotic pulp, fluctuant swelling with drainage through the canal.
 Necrotic pulp, fluctuant swelling, with no drainage through the
canal.
 Necrotic pulp, diffuse facial swelling, with drainage through the
canal.
 Necrotic pulp, diffuse facial swelling, with no drainage through
the canal.

11. CLASSIFICATION
According to Walton or Torabinejad
 Pretreatment emergencies
 Inter appointment emergencies
 Post obturation emergencies

12. According to Cohen
 Thermal pain
 Percussion pain
 Swelling
 Spontaneous pain
 Esthetic emergency
Before endodontic treatment
After initiation of endodontic
treatment but before canal
obturation
After canal obturation

13. According to Gutmann
 Depending on the treatment plan.
 Vital pulps
 Reversible pulpitis
Irreversible pulpitis with localized symptoms
 Irreversible pulpitis – symptoms not localized.
 Necrotic pulps
 Acute alveolar abscess
 Localized swelling
 Diffuse swelling

14. According to Grossman:
I. Before Treatment:
 Endodontic emergencies presenting with pain and/or selling
 Cracked tooth syndrome
 Symptomatic reversible pulpitis
 Symptomatic irreversible pulpitis
 Symptomatic apical periodontitis
 Acute exacerbation of asymptomatic apical periodontitis
 Acute alveolar abscess
 Cellulitis

15. II. Traumatic injuries
 Crown/root fracture
 Luxation injuries
 Tooth avulsion
III. During Treatment
Hot tooth
Endodontic flare ups
After treatment
IV. Postobturation pain
Vertical root fracture

16. MANAGEMENT OF VARIOUS
ENDODONTIC EMERGENCIES ARISING
BEFORE THE TREATMENT:

18. According to Grossman it is defined as an incomplete fracture
of a tooth with a vital pulp. The fracture involves enamel and
dentin, often involving the dental pulp.
A more recent attempt to define the nature of this condition
describes it as “a fracture plane of unknown depth and
direction passing through tooth structure that, if not already
involving, may progress to communicate with the pulp and/or
periodontal ligament.

19. Prevelance:
 The condition presents mainly in patients aged between 30
years and 50 years. Men and women are equally affected.
 Mandibular second molars >mandibular first molars and
maxillary premolars,
 Most cases occur in teeth with Class I restorations(39%) or in
those unrestored (25%), but with an opposing plunger cusp
occluding centrically against a marginal ridge.

20. Diagnosis
 Pain on biting that ceases after the pressure has been withdrawn is
a classical sign.
 The patient may have difficulty in identifying the affected tooth
(there are no proprioceptive fibres i.e A alpha fiber in the pulp
chamber).

21.  Vitality testing usually gives a positive response and the tooth is
not normally tender to percussion in an axial direction.
 Significantly, symptoms can be elicited when pressure is applied
to an individual cusp. This is the principle of the so-called “bite
tests” where the patient is instructed to bite on various items
such as a toothpick, cotton roll, burlew wheel, wooden stick, or
the commercially available Tooth Slooth.

22.  Pain increases as the occlusal force increases, and relief occurs
once the pressure is withdrawn.
 The tooth often has an extensive intracoronal restoration. There
may be a history of courses of extensive dental treatment,
involving repeated occlusal adjustments or replacement of
restorations, which fail to eliminate the symptoms.

23.  Recurrent debonding of cemented intracoronal restorations
such as inlays may indicate the presence of underlying cracks.
Heavily restored teeth may also be tested by application of a
sharp probe to the margins.

24.  Other clues evident on examination include the presence of
facets on the occlusal surfaces of teeth (identifies teeth
involved in eccentric contact and at risk from damaging lateral
forces), the presence of localized periodontal defects (found
where cracks extend subgingivally), or the evocation of
symptoms by sweet or thermal stimuli.
 Radiographic examination is usually inconclusive as cracks
tend to run in a mesiodistal direction.

25. Differential Diagnosis:
 Galvanic pain associated with recent placement of amalgam
restorations should also be considered in this differential
diagnosis. Such pain occurs on closing the teeth together but
decreases as full contact is made, unlike CTS where the pain
increases as the teeth close further together, due to increasing
occlusal force.

27. A 22-year-old female patient presented with the
complain of discomfort with the maxillary left premolar
during mastication of soft food
Initial clinical & radiographic view of the nonrestored tooth 24. Bite test revealed pain
A crack was observed under
transillumination
A stainless steel orthodontic band
was cemented to confirm the
diagnosis. The patient could bite
without pain after this procedure.

28. (a): Transillumination was useful to confirm
the defect removal during the cavity
preparation, until no more cracks were
visualized.
(b): Completed MOD cavity preparation
The tooth received a provisional restoration,
and the patient tested the tooth for 21 days.
After the symptoms were eliminated, a
direct bonded MOD composite
restoration was performed.

30. 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
uninflammed state following removal of stimuli.
Clinical characteristics
 Quick, sharp, shooting momentary tooth pain suggesting
involvement of A-delta fibers.
 Sensitivity to mild discomfort.
 Pain is traceable to stimulus such as cold water or a draft of air.

31. Causitive factor:
 Recent history of pulp capping
 Exposed restorations
 Incipient caries or rapidly advancing carious lesions.
 Orthodontic tooth movement
 Periodontal disease
 History of trauma
 Recent restorations
Diagnosis: is by patients’ symptoms and clinical tests.

32. Subjective symptoms: The patient reports of a pain which is sharp,
lasts a few seconds and disappears on removal of stimulus such as
cold, sweet or sour foods. It does not occur spontaneously.
Although the paroxysms of pain are of short duration they may
continue for months.
Dental examination may reveal caries, large restorations, fracture
and deep wear facets, recently placed restorations, exposed dentin.

33. Pulp vitality tests:
Thermal tests: helps to locate the offending tooth. Cold test is
preferable. Percussion, palpation and radiographs give normal
status.
Electric pulp test may give a slightly early response
Radiographic examination are normal

34. Treatment
 Palliative treatment such as placement of a zinc-oxide eugenol
cement as a temporary sedative filling is indicated. If the pain
persists after several days, pulp tissue should be extirpated.
 Removal of noxious stimuli normally suffices. If a recent
restoration has a high point, recontouring the high spot will
relieve the pain.
 If persistent painful episodes occur following cavity preparation,
chemical cleansing of the cavity or leakage of the restoration, one
should remove the restoration and place a sedative dressing such
as zinc oxide eugenol.

35.  If symptoms do not subside then pulpal inflammation should be
regarded irreversible and pulpectomy should be done.
 If an etiology such as caries, exposed cervical margins of
dentin, a fractured cusp, or a fractured restoration is discovered,
the majority of cases will resolve by appropriate restorative
treatment.

36. A: This 20-year-old female with slight sensitivity to temperature
changes was sent for root canal treatment on the mandibular second
molar. All tests were normal, and there were no radiographic
changes.
B: After caries excavation, a sedative restoration was placed. At the
2-week reassessment, the patient was symptom free.
Clinical case presentation:

37. A: This 45-year-old patient complained of significant pain to cold
on a tooth with a newly placed crown and was sent for root canal
treatment. She used her finger to point to the palatal aspect of the
first molar as her source of discomfort.
B: Clinical examination revealed an exposed dentinal margin on the
palatal, where the crown was short of the prepared tooth structure
(arrows). The patient was advised to have the crown replaced
without having root canal treatment

38. A, Mandibular first molar with significantly reduced pulp
chamber, pulp stones, and condensing osteitis. Changes reflect
degenerative pulpitis. No symptoms.
B, Mandibular first molar showing a pulp chamber that is almost
occluded with calcification and canals that also show the same.
While teeth like this may register as “vital,” the pulps are not
healthy, and this is where the diagnostic dilemma lies when it is
difficult to determine the source of the patient’s distress.

39. C, Occlusal surface that depicts questionable restorative margins
and the presence of significant fractures on the distal margin
(arrows). Patient was suffering from vague pain in the maxillary
left quadrant.
D, Crack in tooth dentin showing invasion of bacteria even into the
dentinal tubules. In the presence of long-term defects of this
nature, dental pulps can easily undergo degeneration and be
symptomatic.

41. It is a persistent inflammatory condition of the pulp, symptomatic
or asymptomatic, caused by a noxious stimulus. Acute Irreversible
Pulpitis exhibits pain usually caused by hot or cold stimulus.

42. Clinical characteristics:
• Pain lasts for minutes to hours.
• It is spontaneous.
• 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.
• From packing of food into cavity/food impaction.

43. Causes:
The most common cause of irreversible pulpitis is bacterial
involvement of pulp through caries. Reversible pulpitis may also
deteriorate into irreversible pulpitis.
Diagnosis: is by patients symptoms and clinical conditions.
Pulp Vitality test : In the early stages of irreversible pulpitis,
thermal test may elllicit the pain which persist after removal of
thermal stimulus.
In later stages when the pulp is exposed, it may respond normally
to thermal stimulus but responds feebly to heat and cold.

44. Clinical Challenge #1
In these not-so-rare instances, the clinician must not act based upon
the patient’s insistence that a particular tooth is painful and the
source of their problems, but rather must rely on the objective
findings produced at the time of the emergency visit. If clinical
findings are confusing and do not lend themselves to a rapid or
logical diagnosis, it may be wise to not act upon meaningless data
but wait until valid data can be obtained and an accurate diagnosis
established.

45. In most cases, the symptoms will recur within a short time and the
patient can be reexamined. It is always inappropriate for the
clinician to begin root canal treatment without having a reasonable
diagnosis. Patients have sometimes been subjected to treatment on
multiple teeth in the hope of relieving pain only to discover,
ultimately, that the pain was of non-dental origin.

46. Clinical Challenge #2
It may be necessary to examine clinical findings more
comprehensively:
 How extensive are the restorations that are present?
 How long have they been there?
 Are there marginal discrepancies that may be contributing to
bacterial leakage?
 Are there fracture or significant craze lines?
 Are there changes in the size of the pulp canal spaces and
chamber compared to other teeth?

47.  Are there pulp stones present?
 Is condensing osteitis present?
 Are there subtle changes in the root apex compared to others
that may indicate some evidence of a low-grade resorptive
process?

48. A, Mandibular molar that exhibits narrowed chamber and canals
and the presence of condensing osteitis, indicative of a degenerating
pulp. Symptoms are minimal, and tests could not reproduce the
patient’s discomfort and chief complaint.
B, Mandibular molar that was symptom free, and the patient had no
recollection of any pain or discomfort to function. All tests were
normal but because of the depth of the caries, she was advised that
root canal treatment was likely to be needed along with a crown to
maintain the tooth. Because of cost factors, she opted to have the
tooth extracted.

49. Treatment plan depending on if the pulp is Vital or Non-vital
1.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.
According to many authors like Weine, Walton and Grossman, in
posterior teeth, where time is a factor, PULPOTOMY or removal
of coronal pulp and placement of formocresol or similar dressing
on the radicular pulp should be performed as an emergency
treatment whereas in single rooted teeth, pulpectomy can be
performed directly.

50. 2.Non-Vital Pulp Necrotic pulp rarely causes an emergency
procedure. Most of the time these teeth do not respond to stimuli
such as hot, cold or electric stimulation, they may still contain vital
inflamed tissue in the apical portion of root canal and also
inflamed periapical tissue which causes pain.

52. Definition:-
It is a painful inflammation of periodontium as a result of trauma,
irritation or infection through root canal whether the pulp is vital or
non vital.
There is a complain of the tooth feeling elevated in the socket or
inability to chew on the particular tooth.
Diagnosis: is usually simple, the tooth is tender on percussion.
A radiograph of the tooth may appear normal or exhibit a thickening
of the periodontal ligament space or show a small periapical
radiolucency. An acute condition that occurs before alveolar bone is
resorbed.

53. One of the most difficult emergency condition to treat is acute
pulpitis with apical periodontitis due to difficulty in achieving
required depth of anesthesia in such cases.
Causes:-
• Occlusal trauma
• Wedging of foreign objects
• Blow to tooth
• Over instrumentation or over filling
• Irreversible pulpitis

54. Treatment :
• Removal of causative factors
• If associated with non vital tooth, initiate endodontic therapy.
• Occlusion should be relieved.
• During endodontic therapy, heavy doses of anesthesia may be
required to attain required depth of aneshesia.
• Prescribe analgesics and anti-inflammatory drugs.

56. Also called as:
Acute periapical abscess.
Acute apical pericementitis
Phoenix abscess.
Definition:
It is a localized collection of pus in the alveolar bone at the root
apex following pulp death with extension of infection through
apical foramen into periapical tissues.

57. Causes (Non-vital pulp)
•Bacterial involvement.
•H/O trauma.
•Mechanical or chemical irritation.
The acute episode may result from:
a)PULPITIS that progressively developed into pulp necrosis
affecting the periapical tissues.
b)ACUTE EXACERBATION of a chronic periapical lesion
c)ENDO-PERIO lesion when the periodontal abscess secondarily
affects the pulp through the lateral canals or deep infrabony
pockets.

58. Symptoms
The local reactions like:
•Tenderness of tooth.
•Severe throbbing pain.
•Swelling.
•Sinus tract.
Systemic reactions are:
•Elevated temperature.
•Gastro-intestinal disturbances.
•Malaise.
•Nausea.
•Dizziness.
•Lack of sleep.

59. Treatment :
The main treatment is biphasic in nature i.e.
I – Debridement of canals. II – Drainage of abscess.
The emergency treatment of acute alveolar abscess differs from
acute irreversible pulpitis, as the pulp is necrotic, local
anaesthesia is not required and frequently contraindicated.
Forcing anaesthetic solution into an acutely infected and swollen
area may increase pain and may spread infection.
Most of the pain that occurs during access cavity preparation is
caused by tooth movement resulting from vibration of the bur,
therefore, one should stabilize tooth with finger pressure so that the
pain is reduced.

60. Treatment procedure follows as:
Access cavity preparation.
Profuse irrigation avoiding forcing of any solution or debris into
the periapical tissue.
In most cases PURULENT EXUDATE escapes into the chamber
and indicates that root canal is patent and draining.
If drainage does not occur, the apical constriction is purposefully
violated and enlarged to a minimum of 20/25 no. instrument to
allow for exudate to drain because in most cases the apical
constriction may prevent the drainage.

61. According to GROSSMAN & COHEN leaving the tooth OPEN
for drainage reduces the possibility of continued pain and swelling.
Open root canals permit drainage and frequently eliminate the
need for surgical incision as well as routine administration of oral
antibiotics and analgesics.
According to WALTON, after copious irrigation, the canals are
dried with paper points and a medicated temporary cotton pellet is
kept – in other words – open dressing is given.
Some clinicians suggested acutely abscessed teeth to be sealed
with an intracanal medicament after the initial emergency
treatment is done. According to them, this stops the infiltration of
new microorganisms.

62. As opposed to them, AUGUST found that only 3% out of 311
abscessed teeth which had been left open reacted adversely.
Therefore, the decision to keep the canal patent or closed must be
made depending on the amount of drainage and size of swelling.

63. SWELLINGS ASSOCIATED
If it is slight and localized it will disappear 24 to 48 hours after
drainage.
•If it is extensive, soft and fluctuant, an incision through soft tissue
is a must.
•If swelling is hard – it can be converted to soft fluctuant state by
rinsing with hot saline solution 3-5 minutes at a time repeated
every hour.
Acute Alveolar Abscess Patient may present with no swelling,
with intra oral sinus OR with swelling [facial asymmetry ]

64. WITH SWELLING:-
Three ways to resolve it:
1. Establish drainage through root canal
2. Establish drainage by incising a fluctuant swelling [if the
swelling is hard ,rinse it 3-5 mins with hot saline]
3. Antibiotics use of antibiotics is regarded as an aid to drainage .
Incision and drainage - incise at the site of greatest fluctuance.
The clinician should dissect gently through deeper tissues and
thoroughly explore all parts of abscess cavity. To promote drainage
,the wound should be kept clean with hot water mouth rinses.

65. In cases where periapical drainage cannot be established,
Surgical Trephination is done.
Definition:
Trephination is the surgical perforation of alveolar cortical plate
[over the root end] to release the accumulated tissue exudate that is
causing pain. [A small vertical incision is made adjacent to the
tooth, the mucosa is retracted and No.6 round bur is used to
penetrate cortical plate. This provides a drainage.] Recent
technique involves use of engine driven perforator to enter the
medullary bone with out the need of incision.

67. Potentially life-threatening cellulitis of connective tissue infection,
of the floor of the mouth, usually occurring in adults with
concomitant dental infections, usually develops in
immunocompromised persons bilateral involvement of the
submandibular, sublingual and submental spaces
Treatment involves appropriate antibiotic medications, monitoring
and protection of the airway in severe cases, and, where
appropriate, urgent ENT surgery, maxillo-facial surgery and/or
dental consultation to incise and drain the collections. The
antibiotic of choice is from the penicillin group.

68. Clinical case:
A 65-year-old patient reported to the Department with chief
complaints of inability to open the mouth, pain and difficulty in
swallowing with a swelling in relation to the lower jaw and neck for the
past 4 days .

71. On average, one-third of people suffer a traumatic dental injury
(TDI) of some kind. Injuries must be assessed carefully as the
treatment provided immediately after injury has a major influence
on prognosis.

72. Assessing the traumatized patient:
What are Traumatic dental injury emergencies?
Avulsion, lateral and extrusive luxations require immediate
treatment, as do alveolar fractures and displaced root fractures.
Treatment of avulsed teeth is extremely time sensitive and requires
prompt management, particularly in the first 15 minutes after
trauma.
Immediate tooth replantation should always be encouraged but is not
always possible as most patients are likely traumatized, distressed, in
pain, and bleeding from soft tissues.
If this is not possible, all efforts should be made to place the avulsed
tooth in a medium able to preserve the periodontal ligament (PDL).
Milk remains the most recommended medium.
Uncomplicated crown fractures, tooth concussion and
subluxation are not classified as emergencies.

73. What records are necessary?
As a bare minimum, the following information is necessary
preferably recorded in the patient’s own words (adapted from
Andreasen et al.17):
(1) When did injury occur?
(2) Where did injury occur?
(3) How did injury occur?
(4) Are there legal implications?
(5) Are there insurance implications?
(6) Was a third party involved in the accident?

74. Are there any disturbances or changes in the bite?
Disturbances in a patient’s ‘bite’ are signs of bone fractures or
tooth displacement. Obvious disturbances in the bite or a
premature contact that cannot be explained by this suggest
alveolar or condylar fractures. This requires further radiographic
and clinical assessment and/or referral for specialist management.

75. Can the patient bite together without discomfort?
A simple test at the initial assessment is to ask a patient if they can
bite their teeth together tightly without discomfort. If they are able
to, it is highly unlikely that there is a bone fracture present.
Are any of the teeth loose?
By checking mobility, an assessment can be made of the degree of
luxation and the need for splinting. Documentation should include
the degree of mobility. Where groups of teeth are mobile, an
alveolar fracture is likely to be present.

76. Are any of the teeth painful to touch?
Sensitivity to touching can result from stimulation of exposed
dentine or pulp, movement of a fractured fragment, or an injury to
the supporting tissues.
Where soft tissue damage is extensive, or where there are multiple
fractured teeth, as happens in severe indirect trauma, patients can be
made reasonably comfortable by covering the affected teeth and
fragments with a periodontal pack, until soft tissue healing occurs
and a detailed assessment of the dentition can be made.

77. As an emergency procedure a stomahesive bandage material may
also be used to temporarily cover injured teeth and soft tissues until
appropriate dental management can be performed (personal
communication, Dr Peter Foltyn).
Some teeth that have suffered a concussion injury may be associated
with minor alveolar fractures and can remain sensitive to touch for
many weeks. Pulp removal will not relieve this symptom. Splinting
for 3–5 weeks is usually more helpful.

78. An alveolar fracture should be suspected if pain occurs when
adjacent teeth are moved in opposite directions. Alveolar fractures
can be confirmed with multi-slice computed tomography or cone
beam computed tomography (CBCT) imaging.

79. What about tenderness to percussion?
Teeth that feel ‘soft’ may be mobile and may have been injured.
Teeth that give a characteristic ‘ring’ to percussion may be intruded
or ankylosed.
Teeth that are not sensitive to percussion are unlikely to have
suffered a periodontal injury. Some traumatized teeth can be
exquisitely sensitive.
Thus, tapping or moving the tooth gently first is recommended
before assessing percussion sensitivity using an instrument.

80. Are any teeth sensitive to hot or cold stimuli or to breathing?
Sensitivity to air or thermal stimulation immediately after trauma
is usually a sign of exposure of dentine or the pulp, or cracking of
teeth. Teeth that are sensitive to breathing have live pulps and do
not require pulp testing.

81. Has the colour changed?
(a) Normal colour. (b) Reddish blush immediately after trauma.
(c) Purple colour some months after trauma. These teeth became
responsive to pulp sensibility testing and assumed normal colour
some years after the trauma. (d) Grey discolouration that is
increasing in intensity is a sign of pulp necrosis.

82. (e) Yellowish discolouration is usually a sign of increasing pulp
canal calcification within the crown. (f) Brown discolouration is
usually a sign of pulp necrosis. (g) Palatal view of a tooth
immediately after trauma viewed by transillumination. This tooth
became responsive to pulp sensibility testing and the discolouration
resolved in a few years. (h) Reddish discolouration due to a
resorptive defect.

83. When should pulp sensibility assessment be carried out?
With respect to pulp sensibility testing after trauma, three scenarios
are possible:
(1)The pulp may not respond at the time of the initial assessment nor
at review appointments.
This is not an indication that pulp necrosis has occurred, rather that
the tooth be placed under review. Vascularity can be present even in
the absence of response to sensibility testing.

84. In the absence of a response to testing, pulp necrosis is only
confirmed if the tooth also becomes symptomatic, if there is a
change to a grey colour, if lateral root inflammatory resorption or a
sinus tract develops, or if there is an enlarging periapical
radiolucency.

85. In rare cases, a periapical radiolucency can develop as an initial
sign of healing. Signs of this, termed ‘transient apical breakdown’,
are the development of a small periapical radiolucency associated
with resorption into the apical portion of the root canal, which
resolves over time. Teeth can show a transient pink or purple
discolouration.

86. (2) The second scenario is where a tooth does not respond to early
pulp sensibility testing but does respond later (often after 6–8
weeks). This favourable and positive scenario reflects that
responses to testing may not be immediately definitive, more so
when the tooth has been severely damaged. Pulps can remain in
neurological shock for a number of weeks.

87. (3) The third scenario is where a tooth responds positively to pulp
testing at initial assessment but fails to respond on review. This
negative and unfavourable scenario usually indicates that pulp
necrosis has occurred, but this should be confirmed by further
testing and other clinical examination findings.

88. When should root canal treatment be initiated?
The following influence the decision whether or not to initiate root
canal treatment:
1) Immature teeth generally respond to pulp testing with a reduced
threshold compared with mature teeth.
2) Depending on the time out of the socket, some immature avulsed
teeth revascularize after replantation, but constant review is
necessary to ensure that infection-related root resorption does not
occur.

89. 3) All mature avulsed and replanted teeth and mature intruded
teeth require root canal treatment as soon as possible, preferably as
part of the emergency treatment.
4) Conservative measures, rather than pulp removal should be
undertaken to preserve the pulp in an immature traumatized tooth
to allow root maturation to occur

90. 5) All immature teeth that show signs of infection related
(inflammatory) root resorption require immediate root canal
treatment.
6) The presence of a root fracture is not an indication to initiate root
canal treatment. The decision to initiate treatment in root-fractured
teeth is made on review and only in the presence of other signs
including bone loss at the fracture site, increasing discolouration,
and/or the presence of a draining sinus.

91. Root canal treatment in root-fractured teeth should only be
carried out to the level of the fracture.
Tooth resorption at the fracture site is not a sign of pulp
necrosis in root-fractured teeth.
Pulps in teeth with root fractures and luxation of the coronal
fragment are more likely to become necrotic.
7) Compromised endodontic management is sometimes necessary to
hold a tooth in place until a patient stops growing and more
definitive treatment

93. Endodontic emergencies can occur during the course of treatment.
Most emergencies are reactive phenomenon to pressure and
chemical mediators created as a result of inflammatory response in
periradicular tissues.

95. According to Grossman
The emergencies can be due to:
•Instrumentation beyond the root apex causing trauma to
periradicular tissue.
•When debris and microorganisms are pushed beyond the apical
foramen which can cause an infectious reaction.

96. •Chemical irritants like
- Irrigating solution.
- Intracanal medicament
•Incomplete debridement of all root canals.
•Lost or depressed access cavity seals leading to recontamination.
•Overfilled root canals with subsequent periapical inflammation.

97. The inflammation in the peri-radicular tissue is induced as a result
of release of substances such as vasoactive amines, kinins and
arachadonic acid metabolites. This interappointment emergency as
classified by WALTON is referred to as “FLARE-UP”.
WALTON has suggested the possible factors:
• Irritants within the pulp system.
• Operator controlled or iatrogenic factors.
• Host factors.
• General systemic factors which are related to Flare-up.

98. Patients can accept that pain may continue to a lesser extent when
they come to the dental office for emergency treatment.
What is difficult for patients to comprehend is when they enter
the office having little or no pain before therapy but then
encounter an explosive flare-up after the treatment is done
therefore PREVENTION OF FLARE-UPS can be done by:

99. • The most important preventive measure is preparing the patient to
accept some discomfort which should subside in a day or two i.e.
psychological preparation of patients.
• Using long acting anaesthetic solution.
• Complete cleaning and shaping of root canals.
• Administration of appropriate analgesics, prophylactic analgesics
before next appointment reduces the incidence of discomfort and
flare-ups.

101. Another very important but rare emergency is due to expelling of an
irrigant such as NaOCl beyond the apex. This happens only by
locking the needle of the irrigating syringe in the canal and
forcefully injecting the irrigant.
• Within minutes the patient feels SUDDEN EXTREME PAIN.
• SWELLING within minutes.
• Profuse, prolonged BLEEDING through the root canal. This
bleeding is the body’s reaction to the irrigant.
Remove the toxic fluid with high volume evacuation to encourage
further drainage from periradicular tissue.

102. Treatment:
•Allow the bleeding to continue. If the body rids itself of toxic fluid
healing may be faster.
•If the treated tooth is pulpless consider prescribing an antibiotic
and an analgesic for 5 and 3 days respectively.
•Since this may be hypersensitive reaction consider prescribing an
antihistaminic.

104. A tooth that is difficult to anesthetize is known as a “Hot tooth”.
This is most commonly encountered in a mandibular first molar
tooth wherein after the anesthetic lock, the patient may describe
profound numbeness of the ipsilateral lip and tongue but still may
experience acute pain during access opening.

105. A number of explanations have been present for this
1) Conventional anesthetic techniques do not always give intense
pulpal anesthesia, and patients with pre-existing hyperalgesia
may be unable to bear any noxious input.
2) Inflamed tissue has a lower pH, which bring down the amount of
the base form of anesthetic that invade the nerve membrane.

106. 3) Another theory is that, the nerves arising from the inflamed
tissue have a change resting potentials and low thresholds of
excitability because of which, the prevention of transmission of
nerve impulses by the anesthetic agents is delay.
4) Another factor might be the tetrodotoxin resistant ( TTXR)
sodium channels. These channels are relatively resistant to local
anesthetics, are sensitized by prostaglandins and are more in
inflamed dental pulp.

107. They are four times resistant to close up by lidocaine and their
expression is doubled in the presence of prostaglandins E2
(PGE2).The sensitization of these channels by prostaglandins
propose that, rapid-acting non steroidal anti-inflammatory drugs
(NSAIDs) may be useful in pretreatment to upgrade the efficacy of
local anesthetics in patients with odontogenic pain.

108. 5) Sensitization of TTX-R channels by prostaglandins also reduces
the activation threshold of voltage gated sodium channels
(VGSCs) and hence raised the amount of sodium ions that flow
through the channel.
6) Activation of nociceptors in the occurrence of inflammation is
one of the strongest theories explaining the lower efficacy of
anesthesia. Inflammatory mediators bring down the stimulation
threshold in nociceptor neurons to a level at which the small
stimulators induce a severe neurogenic response (Goodis et al.,
2006).

109. Management of Hot Tooth Prior to procedure for management of
hot tooth certain parameters should be monitored:
1) Patient’s education: Patient should be smart and well-known
about the treatment so that he is mentally aware of procedures
and the terror of unknown is excluding thus reducing anxiety.
2) Role of premedication If required anti-inflammatory can be
prescribed to be taken as 1 hour before the treatment. Providing
sufficient time between anesthetic delivery and beginning of
procedure.

110. 3) Management of anxious patient:
a)Give short morning appointments after good morning breakfast.
b)Premedication with lorazepam 1 mg (after checking interaction
with other drugs) night before sleep followed by 90 minutes before
procedure.
c)No driving & need to be accompanied with friend/relative.
d)Extremely short in waiting area.
e)Duration ,only as much as patient can tolerate Making sure patient
feels he/she is in order.

111. f) Iatrosedation: Vocal sedation- Use of sentences like “I will be
careful”, Talk to them during procedure, Avoid use of words like
hurt,sharp etc, Music, Aroma, Hypnosis, Acupuncture, Relaxation
techniques (deep breathing, guided imagery,progressive relaxation)
will be useful.
4) Before initiating access preparation a small test cavity can be
made to ensure effectiveness of anesthesia.
5) Additional anesthetic or supplemental injections are necessary to
achieve sound anesthesia.

112. Infilltration: It has shown remarkable increase in duration of pulpal
anaesthesia.
Other Supplemental intraligamentary or intraosseous injections
:are most helpful to ensure sound local anesthesia. Special kits have
been evolved that assist drilling a small hole through the mucosa
and cortical plate to allow injection of the anesthetic solution into
the cancellous bone. X-Tips contain a drill to perforate the cortical
plate combined with a guide sleeve. When the drill is pull away the
guide sleeve is left in situ. One more system is Stabident Io delivery
system.

113. Intraligamental: are used to accumulate analgesic directly into
periodontal ligament space. The needle is pushed into the mesial &
distal gingival sulcus and in contact with the tooth. The needle is
hold up by fingers and positioned with maximal penetration
between the root and crestal alveolar bone. Pressure is steadily
applied to the syringe handle for 30 seconds. Backpressure has to be
progressed for this technique to work and blanching of the soft
tissues would be sign of success.

114. Intrapulpal: Major disadvantage of the intrapulpal injection is the
necessity for needle to be pushed into a very sensitive and inflamed
pulp. The approach can, therefore, be painful. Additionally, the pulp
has to be disclosed to give the injection and analgesic problems may
have happened prior to this being achieved. The injection has to be
given under sturdy backpressure.
Importantly, bupivacaine was found to be more strong than
lidocaine in blocking TTXr channels and may be the anesthetic
of choice when managing the "hot tooth".

115. Intraseptal anesthesia: Intraseptal anesthesia can be intended as a
supplemental anesthesia technique for minimizing pain in
endodontic treatment

117. VERTICAL ROOT FRACTURE
Vertical root fracture have been described as longitudinal oriented
fractures of the root, extending from the root canal to the
peridontium. They usually occur in endodontically treated teeth,
although occurance in non restored teeth has been described.

118. Clinical Presentation of Vertical root fracture:

131. MANAGEMENT:
When a longitudinal fracture of a root occurs, the prognosis for that
root is usually hopeless. Endodontically treated teeth have to be
extracted if they cannot be restored. Hence, extraction of such teeth
is the recommended treatment of choice.
In multirooted teeth, hemisection or redisectomy may be indicated.

132. ANALGESICS AND ANTIBIOTICS
ANALGESICS
Analgesics are pain relievers.
NARCOTIC analgesics are used to relieve acute, severe pain.
NON-NARCOTIC or mild analgesics are used to relieve slight to
moderate pain.
The most frequently used non-narcotic analgesics are:
•Aspirin.
•Acetaminophen.
•Naproxen.
•Ibuprofen.

133. ASPIRIN alone or in compound is used most often in the dosage of
600mg. Aspirin should be taken with caution as it can cause an
anaphylactic reaction in an allergic person or an adverse reaction in
persons with gastric ulcers.
Aspirin is contra-indicated in patients receiving anticoagulant
therapy, diabetes and arthritis.
ACETAMINOPHEN is the second most commonly used analgesics
and is effective for mild-to-moderate pain. It has lower incidence of
side effects than aspirin. It lacks anti-inflammatory effect of aspirin.
It is recommended for children and is available in liquid form.

134. IBUPROFEN, a proprionic acid derivative prescribedin doses of
300-400mg, 4 times daily, is more effective in severe pain relief
than aspirin. But it should not be used in patients with h/o peptic
ulcer or aspirin intolerance.
NARCOTIC ANALGESICS like morphine, codine 30mg,
neperidine, hydrocone 5mg with acetaminophen
500mg etc are generally not used or are used with caution as they
may depress the C.N.S. They interact adversely sometimes, fatally
with alcohol, local anaesthetic, antihistaminics etc.

135. ANTIBIOTICS
Antibiotics are life saving therapeutic agents which are used for
prophylactic coverage of medically compromised patients and as
an adjunctive treatment for acute periapical and periodontal
infections.

136. The more lethal the antibiotic, the less likely resistant the
microorganisms will develop to it.
The most effective antibiotics for use in endodontic emergencies is
PENICILLIN.
Penicillin acts by inhibiting the cell wall synthesis during
multiplication of microorganisms and are effective against gm+ve
cocci, viridans strains, many anaerobes which are involved in
endodontic infections.
The standard regime for dental procedures is penicillin V, 2.0g
1 hr before treatment and 1.0gm 6 hourly later.

137. In cases of PENICILLIN ALLERGY, ERYTHROMYCIN may be
prescribed which acts by inhibiting proteins synthesis. The dosage
is 250mg-500mg 6 hourly.
Other antibiotics useful for treating endo-emergencies are:
Cephalexin – 250-500mg 6 hourly.
Clindamycin phosphate – 150-300mg 6 hourly.
Tetracycline HCl – 250-300mg 6 hourly.
Tetracycline is the least effective of all antibiotics for endo
emergencies.

139. Taken together, our mission as endodontists should be to constantly
learn, adapt and elevate the level of care we deliver to our patients.
Effective emergency care can often save the natural tooth and
provide decades of service to our patients. Consultation between
general practitioners and endodontists is an opportunity to provide
the most appropriate care at the most appropriate time. Endodontists
are dental emergency specialists that can utilize all the available
tools to manage challenging emergency situations and are routinely
available to their general practitioner referrals.