ENDODONTIC EMERGENCIES

ENDODONTIC EMERGENCIES
PRESENTED BY:
Dr. DEVANSHI SHARMA
MDS 2ND YEAR

INTRODUCTION
• Endodontic emergencies infringe on a tight,
planned schedule of a dentist as well as that of
the patient and tend to upset the day for
everyone including the patient, dentist and staff.
• Endodontic emergency is a condition associated
with pain and/or swelling that requires
immediate diagnosis and treatment.
• Pulpal pathologies and traumatic injuries are the
two most common causes for these emergencies.
Pain can originate from the pulp or the
periradicular area.
Cohen 11th edition

• Pain in endodontic emergencies is mainly
related to two factors, namely, chemical
mediators and pressure.
• Chemical mediators cause pain directly by
lowering the pain threshold of sensory nerve
fibers or by increasing vascular permeability
and producing edema.
• Increased fluid pressure resulting from edema
also stimulates the pain receptors.

DEFINITION
• An endodontic emergency is defined as pain
and/or swelling caused by inflammation or
infection of the pulp and/or periradicular
tissues necessitating an emergency visit to the
dentist for immediate treatment.(Grossman’s
endodontic practice 13th edition)
• An endodontic emergency is defined as pain
or swelling caused by various stages of
inflammation or infection of the pulpal or
periapical tissues. (Cohen 11th edition)

• The fact that is associated with words like
unscheduled and immediate, imply the emergency of
the situation.
• Pain is the most common factor that motivates the
patient to seek dental treatment.
• Approximately 90% of patients requesting dental
treatment for the relief of pain have
pulpal/periapical disease and thus are candidates for
endodontic therapy.
Cohen 11th edition

CLASSIFICATION
According to Grossman

MANAGEMENT OF ENDODONTIC
EMERGENCIES
• Management can be divided into the
following steps:
Proper attitude
Make an accurate diagnosis
Render prompt and effective treatment

Proper attitude: A calm
and confident
professionalism should
be displayed. A positive
attitude to the patient’s
problem can make the
individual aware that an
efficient and effective
treatment will be done

Make an accurate diagnosis:
• acute pain or swelling needs
immediate relief, the essential
diagnosis should be rapid and
accurate.
• Attaining pertinent medical and
dental history to avoid
important medical
complications or allergic
reactions or make modifications
in the treatment.

• Subjective examination
 Questions relating to history, location, severity, duration
character, stimuli eliciting/ relieving pain should be asked.
• Objective examination
 Visual examination of face, oral and hard and soft tissues.
Dental examination should follow to note presence of
defective restoration, discolored teeth, recurrent caries,
fractures etc.
 Perform vitality testing to note pulpal status. Thermal tests
are more useful as they mimic the stimuli which elicit
/relieve the pain.
 Periradicular tests including palpation over apex and light
digital pressure/ percussion should be done to identify
periapical inflammation as the source of pain.
 Periodontal examination to check for pockets should be
done. Probing helps in differentiating endodontic from
periodontal diseases.

 Radiographic examination: helps in detecting recurrent / inter
proximal caries, possible pulpal exposures, resorptions, periapical
pathosis etc.
 A differential diagnosis should be done to consider or rule out
even nonodontogenic sources of pain which mimic odontogenic
pain quite closely.
 After diagnosis, a prompt and effective treatment plan should be
made while keeping in mind about the prognosis.
Periodontal prognosis Restorability

ENDODONTIC
EMERGENCIES BEFORE
TREATMENT

CRACKED TOOTH SYNDROME
• DEFINITION: Cracked tooth is
defined as an incomplete fracture
of the dentine in a vital posterior
tooth that involves the dentine and
occasionally extends into the pulp.
• The term “cracked tooth
syndrome” (CTS) was first
introduced by Cameron in 1964.
• History of pain on release of biting
on a particular tooth, often
occurring with food having small,
harder particles in them.
A Review of the Diagnosis and Management of the Cracked Tooth

Predisposing factors
Excessive forces on a healthy tooth:
•A large proportion of the cracked teeth are seen in unrestored or
minimally restored teeth.
•Masticatory accidents, such as chewing on an unexpectedly hard
food particle, can result in a high concentration of force over a small
area.
•A fall or a blow to the face is a form of excessive trauma
•Parafunctional activities.
•Sport is another common cause of tooth fracture.

Normal forces on a weakened tooth structure:
•Intra-coronal restorations have been significantly
associated with cracked teeth. For instance, teeth with
Class II restorations are seen with cracks
approximately three times more frequently than teeth
with a Class I restoration.
•Endodontic treatment has also been implicated as a
risk factor for CTS.
•Pins or posts that have been placed in teeth for
additional means of retention will almost always result
in additional tooth structure being removed, and this
has been suggested as a precipitating factor for tooth
and root fractures.

Dental materials:
•Water contamination of amalgam, before the advent of high
copper/low gamma-2 phase alloys, resulted in a dimensional
expansion.
•it has been suggested that the curing of a large increment of
composite can result in excessive shrinkage.
•It is the associated stresses caused by the inappropriate
handling of these materials which can result in a cracked
tooth.
•„
Finishing a restoration so that it is ‘high in the bite’, either
with a plastic restoration, such as amalgam, or a cast
restoration, such as an inlay, may also lead to a fractured
tooth due to the wedging effect of the restoration.
•The forces generated during lateral condensation of gutta
percha can be excessive and lead to fracture of the apical
portion of the root.

Rare events:
Pain mechanism:
• The short, sharp pain on biting experienced
with CTS is explained by the fluid movements
in the dentinal tubules when the fracture
fragments separate during the application of
pressure.
•The modern trend for the piercing of body parts has led
to reports of CTS associated with piercing of the tongue.
• A rare cause of a cracked tooth is as a result of loss of
tooth substance due to internal resorption.

• This is due to the stimulation of the
mechanoreceptors in close proximity to the
odontoblastic cell body.
• These then activate the quick acting A-delta
fibres in the pulp.
• Bacterial ingression down the crack may also
result in pulpal inflammation, which causes
the release of neuropeptides, lowering the
pain threshold of the unmyelinated C-type
pain fibres in the pulp chamber.
• This explains the dull ache associated with the
hypersensitivity to cold and, occasionally, hot
stimuli associated with cracked teeth.

SYMPTOMS
•The patient will often complain of pain on biting or on eating,
especially certain types of food that have small hard particles in
them, for example muesli and seeded bread.
• Occasionally, the pain is felt on release of biting. The pain is brief,
sharp.
•There may be an increase in sensitivity to hot and cold, and sweet,
depending on how far the crack has extended into the dentine.
DIAGNOSIS
•Superficial cracks or crazing in the enamel are often seen in teeth
but this enamel crazing is superficial and asymptomatic.
•The tip of a sharp probe can be used to run along the tooth surface
and may catch on the line of the crack.
•The probe can also be used in the fissures or in between the margins
of the tooth and the restoration to open up the crack.
•Magnification, a bright light and a dry field of vision will make it
easier to see a crack.

VISUAL INSPECTION: Transillumination
Special tests

• Magnifying loupes
• Dyes-methylene blue
• Tooth sloth- more
reliable.
• Orthodontic bands

Management
• The emergency and definitive treatment will be dictated by: „
Pulpal status; and „
The restorability of the tooth.
 Pulpal status:
• A tooth exhibiting reversible pulpitis, with an incomplete
fracture that is suspected of communicating with the pulp,
may still be treated conservatively, as preservation of pulpal
health will depend largely on the degree of bacterial
contamination.
• It can be difficult to determine the pulpal status. A short,
sharp pain due to pressure only might be indicative of an
uninfected pulp, while a more lingering ache on hot and cold
stimulation could indicate a greater degree of inflammation
due to bacterial infection. Teeth with this type of pain should
be treated urgently to prevent further movement across the
crack.
• If the pulpal status is uncertain, the tooth should be
stabilized and reassessed before a definitive restoration is
placed.

Restorability:
• The extent of the crack is not usually a factor
where the fracture is incomplete and not
displaced.
• Complete or displaced fractures require the
fragment to be removed and will normally
require the restoration to be placed over the
fracture margins.
• Where the fracture margins are more than 2 mm
below the gingival margin, crown lengthening
may be required. Teeth with a lack of coronal
tooth structure have a poorer prognosis.
• In case if crack is vertical - involving the entire
root – extraction is preferred.

 Emergency treatment:
• The aim of emergency treatment is to relieve pain, to
make the mouth comfortable and to improve function.
• The treatment depends on the diagnosis of the pulpal
status, the extent and the position of the crack. The
tooth should be stabilized to prevent further
propagation of the crack and damage to the tooth.
 Relieving pain:
• Teeth with the symptoms of a reversible pulpitis and
an incomplete fracture are treated with stabilization of
the crack. An irreversible pulpitis or pulpal necrosis
requires an extirpation of the pulp in addition to
stabilization.
• Extraction of the tooth is indicated if the tooth is
unrestorable.

Acute Reversible Pulpitis
• 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.
Pain is always specific to a stimulus.
 Pain is instantly relieved on removal of the stimulus.
 It is more often brought on by cold than hot food or beverages .
Pulpitis: A review (IOSR Journal of Dental and
Medical Sciences)

Causative factors
•Trauma, as from a blow or from a disturbed Occlusal
relationship
•Thermal shock, as from preparing a cavity with a dull bur or
keeping the bur in contact with the tooth for too long, or as
from overheating during polishing a filling
•Excessive dehydration of a cavity or irritation of exposed
dentin at the neck of a tooth
•Placement of a fresh amalgam filling in contact with, or
occluding, a cast restoration.
•Chemical stimulus, as from sweet or sour foodstuffs or from
irritation of a filling; or bacteria, as from caries
Pulpitis: A review (IOSR Journal of Dental
and Medical Sciences)

DIAGNOSIS
• Diagnosis: is by patients’ symptoms and clinical tests.
• 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.
• Pulp vitality tests: Thermal tests: helps to locate the
offending tooth. Cold test is preferable, because the pulp is
sensitive to temperature changes, particularly cold.
Electric pulp test, using less current than on the control
tooth, is an excellent corroborating test.
• Percussion, palpation and radiographs give normal status.
Pulpitis: A review (IOSR Journal of Dental and Medical Sciences)

TREATMENT
•Periodic care to prevent the development of caries,
•early insertion of a filling if a cavity has developed,
•desensitization of the necks of teeth where gingival recession is
marked,
•use of a cavity varnish or cement base before insertion of a
filling, and
•care in cavity preparation and polishing are recommended to
prevent pulpitis.
•When reversible pulpitis is present, removal of the noxious
stimuli will usually bring the pulp back to a healthy state.
•Once the symptoms have subsided, the tooth should be tested
for vitality to make sure that pulpal necrosis has not occurred.
•When pain persists despite proper treatment, the pulpal
inflammation should be regarded as irreversible, the treatment
for which is pulp extirpation.

Hypersensitive Dentin
• It is characterized by short, sharp pain arising from
exposed dentin in response to stimuli – thermal,
tactile, osmotic or chemical and which cannot be
ascribed to any other form of dental defect or
pathology.
Etiological factors
Exposed dentinal tubules due to :
 Periodontal surgery
 Tooth abrasion
 Erosion
 Abfraction
Attrition
Cohen 11th edition

• The mechanisms underlying dentin sensitivity have
been a subject of interest in recent years.
• Converging evidence indicates that movement of fluid
in the dentinal tubules is the basic event in the arousal
of dentinal pain.
• It now appears that pain-producing stimuli, such as
heat, cold, air blasts, and probing with the tip of an
explorer, have in common the ability to displace fluid in
the tubules.
• This is referred to as the hydrodynamic mechanism of
dentin sensitivity.
• The hydrodynamic theory suggests that dentinal pain
associated with stimulation of a sensitive tooth
ultimately involves mechanotransduction.
• Recently, classical mechanotransducers have been
recognized on pulpal afferents, providing a mechanistic
support to this theory.

• Thus fluid movement in the dentinal
tubules is translated into electric signals
by receptors located in the axon
terminals innervating dentinal tubules.
• Indeed, there is a positive correlation
between rate of fluid flow in the tubules
and discharge evoked in intradental
nerves, with outward fluid movements
producing a much stronger nerve
response than inward movements.
• Presumably, heat expands the fluid
within the tubules faster than it expands
dentin, causing the fluid to flow toward
the pulp, whereas cold causes the fluid
to contract more rapidly than dentin,
producing an outward flow.

Treatment
• Treatment modality includes chemical or physical blockage of the
patients dentinal tubules to prevent fluid movements from within.
Cohen 11th edition

Differential Diagnosis
Conditions that produce symptoms namely those of
dentinal hypersensitivity are:
cracked tooth syndrome
 fractured restorations
chipped teeth
Dental caries
post restorative sensitivity
teeth in acute hyper function
palatogingival groove
Cohen 11th edition

Acute Irreversible Pulpitis
• It is essential that this condition should
be distinguished from acute reversible
pulpitis which has many similar
symptoms because the emergency
procedure for each is different.
• Clinically manifested by spontaneous
pain that is exacerbated by in
particular by hot stimuli, never cold. In
fact cold very often brings relief to the
patient.
It is a persistent inflammatory condition of the
pulp, symptomatic/ non-symptomatic, caused by
noxious stimuli with the pulp becoming incapable of healing

• If a patient describes pain that lasts for
minutes to hours, or is spontaneous or
disturbs sleep or occurs when bending
over, then patient will require pulpectomy
rather than palliative treatment.
• Symptoms can be localized or non-
localized. The non-localized pulpitis poses
one of the most difficult and challenging
problem to the practitioner since the
patient cannot identify the offending tooth.
• Based on the patient’s history that the pain
is provoked by the hot foods or beverages,
the application of heat in a controlled
sequential manner to the individual teeth is
undoubtedly helpful in localizing the
diseased tooth.

• Heat by causing dilation of blood vessels, tissues and
gaseous products of proteolysis, the pressure increases,
thus increases the pain.
• In contrast, cold has a contractile effect on the remaining
functional vascular bed, reducing the intra pulp pressure
below the pain threshold of the pain receptors.
• Treatment :
 Pulpectomy followed by insertion of a medicated cotton
pellet, moistened with an obtundent such as eugenol into
the pulp chamber.
 Place a temporary filling.
 Prescribe analgesics if necessary. Premedications or post
medication with antibiotic is indicated if the patient is
medically compromised.
 If there is no sufficient time for pulpectomy, pulpotomy is
indicated.

Acute Apical Periodontitis/ Symptomatic Apical
periodontitis
• 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.
•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.
Grossman’s endodontic practice 13th edition

Causative factors
In vital tooth that has experienced Occlusal trauma by:
Abnormal occlusal contacts.
Recently inserted restorations extending beyond occlusal
plane.
Wedging of a foreign object between the teeth, such as a
toothpick or food.
Traumatic blow to the teeth.
In nonvital tooth it may be caused by:
Sequelae of pulpal disease.
Iatrogenic causes such as:
oRoot canal instrumentation forcing bacteria or debris
beyond the apical foramen.
oOverinstrumentation.
oForcing irrigants and medicaments through the apical
foramen.
oExtension of the obturating material beyond the foramen.

• Treatment
 Removal of causative factors.
 Occlusion should be relieved.
 Adjustment of high points in cases of hyperocclusion.
 Removals of irritants in case of non vital infected pulp and
initiate endodontic therapy .
 Prescribe analgesics and anti-inflammatory drugs.
 Prognosis for tooth is generally favourable.

Pulp Necrosis
 Treatment
 The proper treatment for pulp
necrosis is pulpectomy and
obturation of root canals.
 No anesthetic is necessary in most
instances but in some cases there are
still enough pain receptors to cause
discomfort during the procedure.
 Ensure removal of all necrotic tissue
and thorough irrigation of the canals
is required.
Rarely causes an emergency procedure.
However, the patient may notice a swelling
and request emergency treatment.

Acute Exacerbation of Asymptomatic
Apical Periodontitis (Phoenix Abscess)
• Causes: When chronic periradicular diseases, such as
asymptomatic apical periodontitis, are in a state of
equilibrium, the periradicular tissues are asymptomatic.
Sometimes, noxious stimulus from a diseased pulp can
cause acute inflammatory response in these dormant
lesions. Lowering of body’s defenses due to influx of
bacterial toxins from the root canal or irritation during
root canal instrumentation may also trigger acute
inflammatory response.
Definition: This condition is an acute inflammatory
reaction superimposed on an existing asymptomatic
apical periodontitis.

Symptoms:
• tooth may be tender on palpation.
• As inflammation progresses, the tooth gets elevated from
its socket and becomes sensitive.
• The mucosa over the radicular area may appear red and
swollen and is sensitive to palpation.
Diagnosis:
• most commonly associated with the initiation of root canal
therapy in a completely asymptomatic tooth.
• The radiograph shows a well-defined periradicular lesion.
• The patient gives a history of trauma that lead to
discoloring of the tooth over a period of time or a
postoperative pain that had subsided until then.
• Lack of response to vitality tests diagnoses a necrotic pulp.

•Š
A phoenix abscess is an acute symptomatic
abscess with distinct periradicular radiographic
changes.
•Š
Š
It can be differentiated from an acute alveolar
abscess in which widening of the periodontal
ligament space is the only radiographic change
seen.
Treatment
The treatment of acute exacerbation of a chronic
lesion is the same as that of an acute alveolar
abscess.

Acute Alveolar Abscess: (Acute
periapical abscess )
Microbiology and Treatment of Acute Apical
Abscesses : Clinical Microbiology Reviews

Symptoms
• Local symptom
Tenderness of the tooth.
Patient has throbbing
severe pain with swelling
of the overlying soft
tissue with or without
tooth mobility.
When swelling become
extensive, it result into
cellulitis and the patients
facial changes.
• Systemic symptom
Fever, Irritation, etc

Where to expect swelling from which
tooth???

Ludwig's angina
• Potentially life-threatening
cellulitis or 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.

The acute episode may result from :

Treatment
• Infiltration anesthesia contraindicated
forcing anesthetic
solution into an
Acutely inflammed
and swollen area
localized acidic
pH
•block anesthesia may be administered
•test cavity tests for any remaining, vital pulp that could
require anesthesia and initiates emergency quickly, without
waiting for anesthesia to take effect.

Procedure
• access opening stabilize the tooth with finger
pressure or impression compound (high speed)
• Irrigate profusely
• Instrument within 1 mm of the root apex.
Frequently, a purulent exudate escapes into the chamber and indicates that
the root canal is patent and draining.
(dry canal due to the apical contriction preventing the inflammatory
products from draining through the tooth)
To relieve this problem, a procedure called ‘apical trephination’ is
followed.

• Aspiration using any mild suction devices such as
a wide gauge needle placed in the saliva ejector
will give sufficient negative pressure which aids in
establishing drainage through the canal.
• Leave the tooth open. Current evidence suggests
that leaving teeth open between appointments
(open dressing) is not recommended as it impairs
the prognosis.
• Advice the patient to use warm saline rinses for 3
minutes each hour.
• Prescribe analgesics or antibiotics if indicated and
necessary.

Gutmann describes various modalities of treatment for localized or
diffuse swellings associated with acute alveolar abscess.

Technique
• The clinician should first dry the mucosa
over the affected area and then spray the
tissue with a refrigerant topical anesthetic.
• Some clinicians prefer to anesthetize the
area with conduction anesthesia
(mandibular or infraorbital block), or
peripheral infiltration around but not in the
swollen tissues, prior to incision.
• More often, a topical anesthetic solution is
sprayed over the swollen area immediately
preceding the incision.
• Although a topical anesthetic is minimally
effective, it usually suffices for the quick,
sharp thrust of the No. 11 scalpel through
the center of the soft, fluctuant mass down
to the solid cortical bone plate.

Fluctuant swellings: When the swelling “points,” i.e., it
localizes into a soft, fluctuant, palpable mass, it should
be incised and drained, a procedure that dramatically
reduces the swelling and pain.
Indurated swellings: If the swelling remains hard or
indurated, then the swollen tissue should be bathed in
warm saline rinses for 5 minutes every hour until it
becomes soft, fluctuant, and ready for incision.
• Some clinicians advocate incising even hard tissue
whenever pain is present; they suggest that the tissues
will drain eventually and the pain will disappear
sooner.
• Antibiotics and analgesics can be prescribed as needed.
Finally, the tooth should be disoccluded slightly if it is
extruded from its socket.

Rationale for I & D
• Decreases number of
bacteria
• Reduces tissue pressure
• Alleviates pain/trismus
• Improves circulation
• Prevents spread of
infection
• Accelerates healing

Trephination – Apical and surgical

Surgical
Rarely indicated.
 However it is a reliable procedure to manage
pain when all other methods have failed.
Indicated when the severe pain is due to
increase in intracortical pressure in the
periradicular tissues, when apical trephination
has failed.
Needle tip used in an impression material
gun was modified and sutured into place
as a drain in the palatal tissue.
Trephination and Decompression

Acute Periodontal Abscess
• It is often mistaken for an acute alveolar abscess
as periodontal abscess causes
• pain and swelling.
Etiology
• It is usually an exacerbation of infection with pus
formation in an existing deep infrabony pocket.

Treatment
• Vital pulp periodontal therapy
• When the pulp is abnormal and vital, the tooth is
treated as if for acute irreversible pulpitis.
• If the pulp is necrotic, treat as if for acute alveolar
abscess.
• In any case, emergency periodontal treatment
must be done simultaneously; otherwise, the
patient will not be relieved of the pain and
swelling.

TRAUMATIC INJURIES
• Endodontic treatment may be required as a
result of traumatic injury.
• Most common endodontic emergencies are:
a) Fracture of teeth and alveolar bone
b) Avulsion

Fracture of teeth and alveolar bone
• C++, clinical and radiographic examination;
• S+, splint removal;
• S++, splint removal in cervical third fractures.
• 1 For crown-fractured teeth with concomitant
luxation injury, use the luxation follow-up
schedule.
• 2 Whenever there is evidence of external
inflammatory root resorption, root canal therapy
should be initiated immediately, with the use of
calcium hydroxide as an intra-canal medication
IADT guidelines for the management of
traumatic dental injuries

Avulsion
• Avulsion of permanent teeth
is one of the most serious
dental injuries, and a prompt
and correct emergency
management is very
important for the prognosis.
• Incidence – 3% of all dental
injuries
• True dental emergency –
timely attention to
replantation could save the
tooth.
• Sports and automobile
accidents --- frequent causes.
IADT guidelines for avulsed permanent teeth

• First aid for avulsed teeth at the place of accident: If a tooth is avulsed,
make sure it is a permanent tooth (primary teeth should not be
replanted).
 Keep the patient calm.
 Find the tooth and pick it up by the crown (the white part). Avoid touching
the root.
 If the tooth is dirty, wash it briefly (max 10 s) under cold running water
and reposition it. Try to encourage the patient/guardian to replant the
tooth. Once the tooth is back in place, bite on a handkerchief to hold it in
position.
 If this is not possible, or for other reasons when replantation of the
avulsed tooth is not possible (e.g., an unconscious patient), place the
tooth in a glass of milk or another suitable storage medium and bring with
the patient to the emergency clinic. The tooth can also be transported in
the mouth, keeping it inside the lip or cheek if the patient is conscious. If
the patient is very young, he/she could swallow the tooth – therefore it is
advisable to get the patient to spit in a container and place the tooth in it.
Avoid storage in water!
 Seek emergency dental treatment immediately.

EMERGENCIES
DURING
ENDODONTIC
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.
• A classic example of one type of hot tooth is a
patient who is sitting in the waiting room, sipping
on a large glass of ice water to help control the
pain.
• The inferior alveolar nerve (IAN) block is
associated with a failure rate of 15% in patients
with normal tissue, whereas IAN fails 44-81% of
the time in patients with irreversible pulpitis.
Similarly, it has been reported that the failure
rate of a maxillary infiltration injection is as high
as 30% in teeth with irreversible pulpitis.
Hot tooth – A challenge to endodontists-
International Journal of Biomedical Research
( Review article)

Most common sites of occurrence:
• Primary and permanent teeth
• Sites of recent or defective restorations
•Sites of recent trauma
• Mandibular molars are more challenging to anesthetize.
• Patients with anxiety about dental treatment or patients
who have been in pain for several days usually require a more
sophisticated approach.
Signs
• Deep restorations or caries.
• Coronal fracture lines.
• Increased tooth mobility .
• Thickening of periodontal ligament.
International Journal of Biomedical Research ( Review article)

Symptoms
Pain when biting and in response to percussion test.
Increased sensitivity to temperature extremes.
Earlier presentation: often intense, lingering pain in
response to cold.
Later presentation: intense pain in response to heat;
relieved by cold water. Pain may be spontaneous and
poorly localized (e.g., entire left side is painful), often
radiating from ear to temple for maxillary teeth.
Pain may wander to opposing arch but never over the
midline
( Review article)

Hypotheses to explain the inability to
anesthetize hot tooth
1) Ion trapping : Low pH is responsible for ion trapping of local
anesthetic. According to this hyphothesis, low tissue pH shall
be responsible for a greater proportion of the local
anesthetic being trapped in the charged acid form of the
molecule and thus unable to cross cell membrane. However
ion trapping is for infiltration injections only, block injections
are likely to involve acidotic tissues.
2) Altered Membrane excitability of peripheral nociceptors :
Nerves from inflamed tissue shows decreased excitability
threshold and altered resting potential. Studies show that
lower excitability thresholds are responsible for transmission
of impulses even with action of local anesthetic.

3) Tetrodoxin resistant channels: It is confirmed that, Tetrodoxin
resistant channels (TTXr), a class of sodium channels resist the
action of local anesthesia. Increased expressions of sodium
channels in pulp are responsible for anesthetic failures in hot
tooth. TTX r channels are resistant to lidocaine, thereby
causing incomplete anesthesia.
4) The Central core theory : This theory states that the nerve
situated outside of the nerve bundle supply molar teeth while
the nerve situated inside the nerve bundle supplies the
anterior teeth. The anesthetic solution may not diffuse into
the nerve trunk to reach all the nerves to produce an
adequate block even if deposited at the correct site. This
theory may only be applicable for the higher failure rates in
the anterior teeth with IANB and not for the posterior teeth.

• 5) Central sensitization : Central sensitization
may contribute to local anesthetic failures.
Increased Sensitization may amplify incoming
signals from sensory nerves. In central
sensitization, there is an increased response to
peripheral stimuli and because of this, the IANB
may permit for sufficient enough signaling to
occur thereby leading to the perception of pain.
6) Psychological factors: Patient anxiety is one of
the factor for local anesthetic failure. It is
understood that apprehensive patients have a
reduced pain threshold and more likely to
complain pain during the time of endodontic
treatment.
( Review article)

Management strategies in patients with a hot
tooth
• Even after giving a proper anesthesia, if the patient responds
pain, two treatment strategies could be considered:
I) Supplemental Injections
II) Change in the Anesthetic solution.
I)Supplemental injections : There are several alternative
supplemental injection techniques available in the field of
dentistry.
A. Intraligamentary(Periodontal ligament) Injection
B. Intraosseous Injection
C. Intraseptal anesthesia
D. Intrapulpal Anesthesia
E. Mandibular Buccal Infiltration Injection with Articaine
( Review article)

F. Preemptive Strategies to Improve Success of the IANB
Injection, such as:
1) Use of fast acting anti-inflammatory drugs
2) Reducing pulpal level of inflammatory mediator PGE2
3) Injectable NSAID ketorolac, when injected intraorally or
intra muscularly produce significant analgesia in patient
with severe odontogenic pain.
4) Intra-osseous injection of 40 mg methyl prednisolone in
patients with irreversible pulpitis resulted in less pain.
II. Change in anesthetic solution
a) 1.4% Articaine
Anesthetic efficiency of 4% articaine with 1:100,000
epinephrine shows higher anesthetic efficiency than using
2% lidocaine with 1:100,000 epinephrine when used as
buccal infiltration. Mechanism of action is that articaine
contains a thiophene group, which increases its lipid
solubility.
( Review article)

b) Mandibular Buccal infiltration with articaine
Mandibular buccal infiltration with 4%
articaine could be considered as a
supplemental injection technique. Studies
shows that buccal infiltration of 4% articaine
shows higher anesthetic efficiency as
compared to 2% lidocaine solution.
c) 0.5 M Mannitol
Combination of 0.5 M Mannitol and lidocaine
with epinephrine in Inferior Alveolar Nerve
block shows higher anesthetic efficiency
compared to lidocaine and epinephrine alone.
International Journal of Biomedical Research ( Review article)

ENDODONTIC FLARE – UPS
• An acute exacerbation of peri radicular
pathosis after initiation or continuation
of root canal treatment.
• Inter-appointment flare-up is
characterized by the development of
pain, swelling or both, following
endodontic intervention.
• The causative factors of inter
appointment pain comprise mechanical,
chemical, and/or microbial injury to the
pulp or periradicular tissues, which are
induced during root canal treatment.
Journal of Pharmacy and Bioallied Sciences Vol 4 August 2012
Supplement 2 - Part 3; Harikaran, et al.: Flare-up review

• Regardless of the type of injury, the intensity of
the inflammatory response is directly
proportional to the intensity of tissue injury.
• The frequency of inter appointment pain has
been reported to be significantly higher in teeth
with periradicular lesions as compared to teeth
with vital pulps and normal periradicular tissues.

Cause of Interappointment Pain
 Microbial causes:
• There are some special circumstances in which
microorganisms can cause interappointment pain as a result
of imbalance in host–bacteria relationship induced by
intracanal procedures.
• Development of pain precipitated by infectious agents can be
dependent on several factors. These factors are as follows:
 Presence of pathogenic bacteria:
• The bacterial species can be associated with symptomatic
periradicular lesions. These include Porphyromonas
endodontalis, Porphyromonas gingivalis, and Prevotella
species.
• A recent study revealed that F. nucleatum, Prevotella species,
and Porphyromonas species were frequently isolated from
flare-up cases.

 Presence of virulent clonal types
• Presence of virulent clones of
endodontic pathogens in the root
canal may be a predisposing factor
for interappointment pain, provided
that conditions are created for them
to exert their pathogenicity.
 Microbial synergism or additism:
• Most of the endodontic pathogens
show virulence when they are in
association with other species.
 Number of microbial cells:
• If the host is faced with a higher
number of microbial cells than it is
used to an acute exacerbation of the
periradicular lesion can occur.
Journal of Pharmacy and Bioallied Sciences Vol 4 August
2012 Supplement 2 - Part 3; Harikaran, et al.: Flare-up review

Environmental cues:
• Studies have demonstrated that
environmental changes can influence the
behavior of some putative oral (and
endodontic) pathogens, including P. gingivalis,
F. nucleatum, Prevotella intermedia, and oral
treponemes.
• If the root canal environmental conditions are
altered by intracanal procedures and become
conducive, microbial virulence can be
enhanced and interappointment pain can
ensue. Journal of Pharmacy and Bioallied Sciences Vol 4 August 2012

 Host resistance:
• Individuals who have reduced ability to cope with
infections are more prone to develop clinical symptoms
after endodontic procedures in infected root canals.
• Herpes viruses have the ability to diminish the host
resistance to infection.
There are some situations during the endodontic
treatment that can facilitate microorganisms to cause
interappointment pain. These include:
(a) apical extrusion of debris;
(b) incomplete instrumentation leading to changes in
the endodontic microbiota or in environmental
conditions; and
(c) secondary intraradicular infections.

 Apical extrusion of debris:
• Extrusion of infected debris to the periradicular tissues
during chemomechanical preparation is one of the
principal causes of postoperative pain.
• Forcing microorganisms and their products into the
periradicular tissues can generate an acute
inflammatory response, the intensity of which will
depend on the quantitative (number) and qualitative
(virulence) nature of the extruded microorganisms.
• Iatrogenic overinstrumentation promotes the
enlargement of apical foramen, which may permit an
increased influx of exudate and blood into the root
canal.[18] This will enhance the nutrient supply to the
remaining bacteria within the root canal, which can
then proliferate and cause exacerbation of a chronic
periradicular lesion.

• Steps to prevent the apical extrusion of debris,
crown-down techniques, irrespective of
whether hand- or engine-driven instruments
are used, which extrudes less debris and
should be selected for the instrumentation of
infected root canals. Therefore, the
quantitative factor is more likely to be under
the control of the practitioner. The qualitative
factor is more difficult to be controlled.

 Incomplete chemomechanical preparation leading to the
following:
1. Changes in the endodontic microbiota
• incomplete chemomechanical preparation can disrupt the
balance within the microbial community by eliminating
some inhibitory species and leaving behind other
previously inhibited species, which can then overgrow.
• If overgrown strains are virulent and reach sufficient
numbers, damage to the periradicular tissues can be
intensified. This results in exacerbation of the lesion.
2. Increase of the oxidation–reduction potential
• Another form of environmental change induced by
endodontic intervention refers to the entrance of oxygen in
the root canal. It has been suggested that this can alter the
oxidation–reduction potential (Eh) in the root canal and, as
a consequence, acute exacerbation can occur.

• This theory is based on the fact that the increase in Eh
would induce microbial growth pattern to change from
anaerobic to aerobic.
• Energy yield of facultative anaerobe is more marked in
the presence of oxygen than under anaerobic condition
and a faster growth rate is expected with consequent
overgrowth of facultative anaerobic bacteria.
 Secondary intraradicular infections:
• Secondary intraradicular infections are caused by
microorganisms that were not present in the primary
infection and have gained entry into the root canal
system during treatment, between appointments, or
even after the conclusion of the endodontic
treatment,the most common being a breach of the
aseptic chain during treatment.

Non-microbial causes
• The intensity of pain will depend on several aspects,
including intensity of the injury, intensity of tissue
damage, and intensity of the inflammatory response.
All these three phenomena are interconnected, as one
is directly dependent on the other.
• Mechanical irritation causing periradicular
inflammation includes mainly overinstrumentation and
overextended filling materials.
• Chemical irritation includes apical extrusion of irrigants
or intracanal medications. Most irrigants and
medications are cytotoxic to the host tissues.
• The larger the amount of overextended material, the
greater is the intensity of damage to the periradicular
tissues.

Treatment of interappointment pain
Re-instrumentation:
• Definitive treatment may involve re-entering the
symptomatic tooth. The access cavity should then
be opened.
• Working lengths should be reconfirmed, patency
to the apical foramen obtained and a thorough
debridement with copious irrigation performed.
• Drainage will allow for the exudative components
to be released from the periradicular tissues, thus
reducing localized tissue pressure.

Cortical trephination:
• Cortical trephination is defined as the surgical
perforation of the alveolar bone in an attempt
to release accumulated periradicular tissue
exudates.
• Chestner et al.reported pain relief in patients
with severe and recalcitrant periradicular pain
when cortical trephination was performed.

 Incision and drainage (I and D)
• The rationale for an I and D procedure is to facilitate
the evacuation of pus, microorganisms, and toxic
products from the periradicular tissues.
• Moreover, it allows for the decompression of the
associated increased periradicular tissue pressure and
provides significant pain relief.
• If the abscess occurs after the obturation of the root
canal system, incision of the fluctuant tissue is perhaps
the only reasonable emergency treatment, provided
the root canal filling is adequate.
• Antibiotics are usually not indicated in cases of a
localized abscess, but they can be used to supplement
clinical procedures in cases where there is poor
drainage and if the patient has a concomitant trismus,
cellulitis, fever, or lymphadenopathy.

 Intracanal medicaments:
• Clinical studies have demonstrated that post-treatment
pain is neither prevented nor relieved by medicaments
such as formocresol, camphorated
paramonochlorophenol, eugenol, iodine potassium
iodide, Ledermix, or calcium hydroxide.
• However, the use of intracanal steroids, nonsteriodal
anti-inflammatory drugs (NSAIDs), or a corticosteroid–
antibiotic compound has been shown to reduce post-
treatment pain.
• In a study conducted by Walton et al. steroids and
NSAIDs, when placed within the root canal system after
debridement procedures, can reduce or prevent post-
treatment pain.

Occlusal reduction:
• There appears to be minimal agreement in the
dental literature as to the benefit of reducing the
occlusion to prevent postendodontic pain.
• Rosenburg et al. demonstrated that in teeth with
pain upon biting, occlusal reduction was effective
in reducing postoperative pain.
• Sensitivity to biting and chewing is perhaps due
to increased levels of inflammatory mediators
that stimulate periradicular nociceptors. Occlusal
reduction may therefore alleviate the continued
mechanical stimulation of the sensitized
nociceptors.

VERTICAL ROOT FRACTURE (VRF)
• Vertical root fractures are longitudinal fractures that
originate in the roots of teeth and with few exceptions,
these fractures occur almost exclusively in
endodontically treated teeth.
• The diagnosis is often difficult to establish by
radiograph, percussion, or other means.
• In most cases, the patient complains of discomfort and
may or may not be able to locate the affected tooth.
• In the early stage, when hairline fracture is present and
before separation of the fragments is evident, no
radiographic changes are visible either in the tooth or
in the adjacent bone.
• At times, asking the patient to chew on a tooth slooth,
cotton applicator, or rubber polishing wheel helps in
identifying the tooth.

Etiology
•Root anatomy, amount of remaining sound tooth structure,
loss of moisture in dentin, amount of bony support, pre-
existing cracks, and biochemical properties of root dentin are
predisposing etiological factors
•Traumatic occlusion
•Excessive load on an endodontically treated tooth
•Bruxism
FIG: The vertical root fracture line can
be clearly seen on an extracted tooth.

Clinical Features
•Dull spontaneous pain,
mastication pain, tooth
mobility, periodontal-type
abscesses, and bony
radiolucencies
•Deep osseous defects: The
typical bone loss pattern in
teeth with vertical root
fractures is the loss of alveolar
bone, specifically in relation to
the fracture area
•Sinus tract located near the
cervical area

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 a characteristic J-shaped radiolucent
lesion seen in this radiograph
indicative of a vertical root fracture.

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
radisectomy may be indicated.

HIGH RESTORATION
• Once obturation of the root canal space has
been completed, restoration of the rest of the
tooth should be carried out.
• The occlusion should be checked for
interferences and managed by occlusal
rehabilitation to avoid apical periodontitis or
worse, a fractured tooth.

OVERFILLING
• The most likely cause of pain following obturation of
the root canal space is the presence of infected
material in the periapical region.
• Over filling cause pain more as a result of over
instrumentation and trauma to apical periodontium.
• Management:
- Prescription of analgesics and antibiotics
(infection is present).
- Removal of the root filling and repreparation of
the canal.
- Periradicular surgery and apicectomy, in case
retrieval of the extruded filling is not possible to be
considered only in case of gross extrusion or
persistence of infection due to improper apical seal.

UNDERFILLING
• Underfilling cause pain due to inadequate
debridement.
Management:
• Removal of the root filling and repreparation
of the canal.

Endodontic emergencies: Due to
some medications
• Formaldehyde-containing medications, various compounds
containing arsenic and paraformaldehyde used as pulp
devitalizers.
• Such agents have some clinical benefit, although local soft
and hard tissue necrosis occurs if they are not confined to the
pulp.
• case report describes tissue degeneration and swelling in a
patient treated with formocresol during root canal treatment.

Hypochlorite accident
• A hypochlorite accident 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 symptoms:
• Severe immediate pain
• swelling
• Profuse bleeding both
interstitially and through the
tooth.

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.

Management:
• Immediate aspiration and continuous irrigation with
normal saline.
• Cold pack over the affected area.
• Regional block anesthesia administered. Pain
management difficult because symptoms from distant
anatomic structures will continue to cause discomfort.
• Monitor tooth for the next half hour. Blood exudation
extended from canal denotes the bodies reaction to
the irritant. Remove the fluid with high volume suction
to encourage further drainage. 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 – inflammatory process
• Home care instructions: Cold compress to
minimize pain and swelling.
• Subsequently warm compresses to encourage
healing.

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.

Hydrogen peroxide as a cause of
iatrogenic subcutaneous cervicofacial
emphysema:
• The use of hydrogen peroxide 3% as an irrigant to
newly operated tissue plans may cause
emphysema.
• facial swelling, tenderness and crepitation
• Radiographs will be normal
• paranasal computed tomography (PNCT) – detect
the presence of air within the tissue spaces.
• prophylactic antimicrobial therapy
• Emphysema will recover on its own within a
week.

Air emphysema
• Air introduced into periapical tissues during
invasive root canal treatment --- potential to do
great harm.
• Although rare occurance – but has a risk
• In a study done on pigs – significant pressures
during air drying beyond the apex of the roots
with apical diameters larger than size #20
• Compressed air should never be component in
drying of a root canal that is open to periapical
tissues.

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 lawsuite.
• 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.

Š
Analgesics
•Preoperative NSAID can enhance the effect and
depth of the local anesthetic.
•Š
Š
The first line of management is always restricted
to the use of a non-narcotic analgesic.
•Š
Š
Opioid analgesics are more potent and effective
in pain relief; however, they exhibit adverse side
effects including nausea and drowsiness.
•Š
Š
In acute emergencies, a combination of NSAID
and opioids is preferable.

Antibiotics
• Antibiotics are substances that are produced in very
low concentrations by microorganisms to suppress or
to kill other microorganisms.
• These drugs attack cell structure and metabolic
pathways of bacteria, but not human cells, and play a
key role in controlling bacterial infections.
• The common antibiotics used in endodontic
emergencies are as follows:
 Penicillin G
 Cephalosporins
 Metronidazole
 Erythromycin
 Clindamycin

Indications for Antibiotic
Therapy
• Systemic involvement
• Compromised host resistance
• Fascial space involvement
• Inadequate surgical drainage
Guidelines for Antibiotic Therapy:
• Select antibiotics with anaerobic
spectrum
• Use a larger dose for a shorter
period of time (“hard and fast” rule)

CONCLUSION
• KNOWING WHAT TO DO AND WHEN TO DO ARE AS
IMPORTANT AS HOW TO DO
• More than 80% of pts who reports to dental , clinic are with
emergency symptoms with endodontically related pain.
Therefore the knowledge, skill for the treatment of these
endodontic emergencies is highly required for every clinician.
• An accurate diagnosis and effective treatment of acute
situations are an important responsibility and priviledge of
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 enhances the positive image of
dentistry.

ENDODONTIC EMERGENCIES

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