The document discusses endodontic emergencies and their management. It describes that approximately 60% of patients with oral pain need emergency endodontic treatment. There are four main types of endodontic emergencies: pre-treatment, intra-appointment, post-obturation, and trauma-related. Common pre-treatment emergencies include reversible/irreversible pulpitis, cracked tooth syndrome, and acute periapical abscesses. Management involves diagnosis, determining the type and source of pain, and providing treatments tailored to each emergency type, such as pulpotomy, root canal treatment, drainage, or antibiotics as needed.

1. ENDODONTIC EMERGENCIES
AND MANAGEMENT

2. INTRODUCTION
•Approximately 60% of patients with oral or
maxillofacial pain are in need of endodontic
emergency treatment (Tronstad, Thieme 2003)
•Nearly 90%of patients seeking emergency dental
treatment have symptoms of pulpal or periapical
disease (Carrotte, Br Dent J 2004)
Pain in endodontic emergencies are related to two factors
Chemical mediators 
lowers pain threshold
increase vascular permeability
edema
edema Pressure

3. SYSTEM OF DIAGNOSIS
 Medical and dental histories
 Subjective examination
 Objective examination
 Periodontal examination
 Radiographic examination

4. Endodontic Emergency Categorized into 4
types:
Pretreatment
Intra appointment
Post obturation
Emergencies related to trauma

5. Before treatment:
 1. Pulpal pain
 a) Reversible pulpitis.
 b) Irreversible pulpitis.
 C)Dentin hypersensitivity.
 2. Cracked tooth syndrome.
 3.Acute periapical abscess.

6. PATIENTS UNDER TREATMENT:
 1. Recent restorative treatment
 2. Periodontal treatment
 3. Exposure of the pulp
 4. Fracture of the root or crown
 5. Pain as a result of instrumentation
 a) acute apical periodontitis
 b) Phoenix abscess

7. Reasons for pain in vital teeth:
•Caries, restored or unrestored--88,6
%
•Cusp fractures (cracked tooth)-- 5,8
%
•Hypersensitive teeth--3,6 %
•Traumatic occlusion--2,0

8. DENTIN HYPERSENSITIVITY
 Attrition: Tooth surface loss by two-body
wear (tooth to tooth contacts)
 Abrasion: Tooth surface loss by three-
body wear (e.g., habits, toothpaste)
 Acidic erosion: Non-carious tooth surface
loss by exogen acids (e.g., acidic foods
and drinks, gastric acids > anorexia
nervosa, bulimia, reflux disease)

10. HYPERSENSITIVITYDESENSITISING AGENTS >
PRIMARY GOAL IS TO CLOSE THE TUBULES BY
INSOLUBLE SALTS

11. TTT HYPERSENSITIVITY
 potassium salts
 potassium-Phosphate
 fluorides
 strontium chlorides
 oxalate
 Seal & Protect Dentsply
 Single Bond 3M Espe
 Sensodyne F,C
 Significant effect after 3 days
active
substances

12. REVERSIBLE PULPITIS
 The pain is of very short duration and does
not linger after the stimulus(hot ,cold,sweets) has
been removed.
 The tooth is not tender to percussion.
except…….
 The pain may be difficult to localize.
 The tooth may give an exaggerated response to
vitality tests.
 The radiographs present wit a normal
appearance, and there is no apparent widening
of the periodontal ligaments

14. REVERSIBLE PULPITIS
Treatment:
 Check the occlusion and remove nonworking
facets.
•Removal of the caries; sealing of exposed dentin
place sedative dressing
•bacteria-tight coronal restoration: either
permanent or temporary restoration (glass
ionomer)
 Apply a fluoride varnish or a dentine bonding
resin to sensitive dentine and prescribe a
desensitizing toothpaste

16. IRREVERSIBLE PULPITIS
 As long as pulpal inflammation has not
spread to the periodontal ligament > pain
radiates and patient is not always able to
pinpoint the source of the symptoms
correctly
 Management?????

17. DIFFERENTIAL DIAGNOSIS REVERSIBLE VS.
IRREVERSIBLE PULPITIS
 Characteristic features for an irreversible
pulpitis are:
 Spontaneous pain
 Pain persists after the stimulus
 Pain triggered by heat later stages relieve by
cold
 Pain at night
 Longer history of pain
 X ray???
 Percussion: (-) or even (+)

18. LOCALIZING THE CORRECT TOOTH
warm water after application of a
rubber dam
gutta-percha
stick
Anaesthetic test

19. TREATMENT:
 aseptic techniques!!
 Access cavity, pulp exposure and (if
possible) removal of the pulp tissue
from the pulp chamber
 -Anodyne medicament (Ledermix or
eugenol) and bacteria-tight seal
 Irrigation of the pulp chamber using a
solution of sodium hypochlorite 5%

20. PULPOTOMY + ANODYNE
MEDICAMENT IN THE PULP CHAMBER +
BACTERIA-TIGHT MEDICAMENT 91%
COMPLETE DEBRIDEMENT +
INTRACANALDRESSING + BACTERIA-
TIGHT SEAL 99%RELIEVING PAIN

21. PAIN RELIEF
 1 Additional infiltration anaesthesia, such as
long-buccal, lingual and palatal.
 2 Intraligamental (intra-osseous) injection.
 3 True intra-osseous injection.
 4 Intrapulpal analgesia.
 5 Inhalational sedation with local analgesia.
 Continous pain after ttt?????

22. CRACKED-TOOTH-SYNDROME
 Up to 20% of patients suffering from
odontogenic pain > cracked tooth
(incomplete fracture) as main cause
(Geurtsen & Garcia-Godoy, Am J Dent 1999)
 •Predisposing factors: masticatory incidents,
bruxism, thermal cycling

24. CRACKED-TOOTH-SYNDROME
 Second premolars and first molar are most often affected (especially
those with extensive restorations)
 Symptoms: pain on chewing (hard food), sensitivity to cold and hot
fluids, pain which is difficult to locate
 Fracture line: from mesial to distal (important: fracture lines in coronal
restoration
 Cracked-tooth-syndrome
 How to detect?
 Ask the patient to bite on a cotton-roll, wood stick, or fracture detector
(Tooth Slooth) > pain on release of pressure > most reliable aid and
most expressive clinical finding
 Visual detection of crack (fiberoptic, staining)
 radiographs are of little value for detection

25. TREATMENT
 Without any signs of pulpitis > stabilization of
the tooth by means of adhesive restorations
or partial or full crowns (full cusp
coverage!)&band of ortho
 Pain when not in use > indication of
irreversible pulpitis > root canal treatment
and full crown
 Fracture lines extending below the alveolar
crest > extraction

27. A crack will block and reflect the light when
transilluminated

28. SYMPTOMATIC APICAL PERIODONTITIS
 Pain:Tooth is sensitive to mastication and
percussion; no swelling is present
 Sensibility: (-)
 Percussion:(+) to (++)

29. Symptomatic apical periodontitis
-Treatment-
 Instrumentation not
possible:
 Access cavity
 Remove necrotic tissue
from the pulp chamber
 Copious irrigation of the
pulp chamber using NaOCl
 Placement of eugenol in
the pulp chamber
 Bacteria-tight seal
 Root canal instrumentation
within the next 2-3 days
 Instrumentation possible:
 Access cavity
 Determination of WL
(electronic apex locator)
 Chemo-mechanical
instrumentation of the root
canals
 ntracanal dressing (mixture
of calcium hydroxide + 2%
CHX)
 Bacteria-tight seal

30. SYMPTOMATIC APICAL PERIODONTITIS
 •Chemo-mechanical instrumentation only
results in pain decrease of 50% within 1 day
and 90% within 2 days (Holstein et al.,
Endodontic Topics 2002).
 •Access cavity + irrigation of the pulp
chamber + placement of eugenol in the pulp
chamber > pain relief in about 70% of
patients within 1 day (Tronstad, Thieme
2003).

31. SYMPTOMATIC APICAL PERIODONTITIS
 Analgesics (ibuprofen)
 Long-acting anaesthetic (bupivacaine) >
duration of analgesia 8-10 h (Keiser &
Hargreaves, Endodontic Topics 2002)
 Fluctuancyof a swelling > incision and
effective drainage
 Further treatment > same day (scheduled)

33. ACUTE PERIAPICAL ABSCESS
 = Apical periodontitis with swelling
 Dd: from lateral PDL abscess
 Swelling &pain
 Feeling of teeth elevated in its socket
 May not have radiographic evidence of tooth
destruction
 Fever &malaise
 Mobility may or may not present

34. Immediate relief is obtained as pus
drains feely from an access cavity.

35. TREATMENT:
 scenario 1: fluctuancy and drainage
through the tooth
Gently grip the tooth and use a small, round,
diamond bur to reduce the trauma of the
operation > drainage
 Chemo-mechanical instrumentation >
exudation has stopped > intracanal dressing
> coronal seal
 optional: if the tissue is fluctuant > incision

36. •TREATMENT
 scenario 2: fluctuancy no drainage through the tooth
 Open the tooth > no drainage
 explore the apical foramen with a very fine
 (size 08 or 10) file
 Chemo-mechanical instrumentation > intracanal dressing >
coronal seal
 incision and effective drainage (optional: drain)
 scenario 3: no fluctuance, drainage through the tooth
 Open the tooth > drainage
 Chemo-mechanical instrumentation > intracanal dressing >
coronal seal
 no indication to incise and drain the soft tissues

38. INCISION TO ESTABLISH DRAINAGE
 copious amounts of surface analgesia
should be applied, for example ethyl chloride or
topical lignocaine ointment.
 Regional anaesthesia !!!!!!!!
 Incise the swelling vertically with . 11 or 15
scalpel blade, & aspirate, using a widebore
needle and disposable syringe.???
 insert a drain(inter , extraorally)

39. ROOT CANAL TREATMENT
 1-access
 2-sodiumhypochlorite
 3-full debrid canal if possible
 4-dry canal
 5-48h complete debride canal
 6-dressing CaOH
 7-ANTIBIOTICS??????

40. PATIENTS UNDER TREATMENT
 1.Recent restorative treatment
 2. Periodontal treatment
 3. Exposure of the pulp
 4. Fracture of the root or crown
 5. Pain as a result of instrumentation
 a) acute apical periodontitis
 b) Phoenix abscess

41. PHOENIX ABSCESS
 Sudden exacerbation of a previously
symptomless periradicular lesion
 Activates the bacterial flora??
 Treatment consists irrigation,debridement of
the root canal and establishing drainage
 it may be necessary to prescribe an
antibiotic

42. POST-ENDODONTIC TREATMENT
 1. High restoration
 2. Overfilling
 3. under filling
 4. Root fracture