This document discusses various endodontic emergencies including pre-treatment emergencies like cracked tooth syndrome and acute irreversible pulpitis, mid-treatment flare-ups, and post-treatment emergencies. It defines endodontic emergencies and classifies them according to different authors. It also describes the management of various emergencies through accurate diagnosis, effective pain relief treatments, and addressing the underlying causes. Key procedures discussed include pulpectomy, apical trephination, incision and drainage, and irrigation with appropriate solutions.

1. 1

2. CONTENTS
 INTRODUCTION
 DEFINITION
 PRE-TREATMENT EMERGENCIES
 PULPAL PAIN
 TRAUMATIC INJURIES
 CRACKED TOOTH SYNDROME
 CROWN FRACTURE
 ROOT FRACTURE
 AVULSION
 MID-TREATMENT FLARE-UPS
 HYPOCHLORITE ACCIDENT
 HYDROPEROXIDE ACCIDENT
 AIR EMPHYSEMA
 POST-TREATMENT EMERGENCIES
 REFERRED PAIN
 CONCLUSION
2

3. INTRODUCTION
 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.
 Nevertheless they are practice builders as a dentist if often judged by
the swiftness he sees a patient in pain, and his skill is judged by the
speed by which he can alleviate pain.
 It is but natural that a patient in pain must be rendered painless and
comfortable as soon as possible.
3

4. 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.”
or
 Occurrence of severe pain and / or swelling following an endodontic
treatment appointment, requiring an unscheduled visit and active
treatment (Watson and Foud –1992).
4

5.  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.
A true emergency is the condition which requires unscheduled visit with
diagnosis & treatment at that time.
But urgency indicates a less severe problem in which next visit may be
scheduled for mutual convenience of both patient as well as clinician.
5

6. CLASSIFICATION
According to Walton or Torabinejad
 Pretreatment emergencies
 Inter appointment emergencies
 Post obturation emergencies
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
6

7. 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
7

8. MANAGEMENT OF ENDODONTIC
EMERGENCIES
Management can be divided into the following
steps:
 Proper attitude
 Make an accurate diagnosis
 Provide profound anesthesia
 Render prompt and effective treatment
8

9. Proper attitude:
A calm and confident professionalism
should be displayed . a positive attitude to
the patients 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
histories to avoid important medical
complications or allergic reactions or make
modifications in the treatment.
9

10. 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 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 elecit /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.
10

11.  Radiographic examination: helps in detecting recurrent / inter proximal
caries, possible pulpal exposures, resorptions, periapical pathosis etc. Remember
radiographs are an aid to diagnosis. Learn to use them and not abuse them.
 A differential diagnosis should be done to consider or rule out even non-
odontogenic sources of pain which mimic odontogenic pain quite closely.
Periodontal prognosis Restorability
12

12. 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.
 Sensitivity to mild discomfort.
 Pain is traceable to stimulus such as cold water or a draft of air.
13

13. 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.
Recent history of pulp capping
Exposed restorations
Incipient caries or rapidly advancing carious lesions.
Orthodontic tooth movement
Periodontal disease
History of trauma
Recent restorations
Causative factors
14

14.  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.
Percussion, palpation and radiographs give normal status.
 Electric pulp test may give a slightly early response
 Radiographic examination are normal
15

15.  Treatment:
 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.
 If symptoms do not subside then pulpal inflammation should be regarded
irreversible and pulpectomy should be done.
16

16. 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
17

17. Treatment : Treatment modality includes chemical or physical blockage of
the patients dentinal tubules to prevent fluid movements from within.
 Attempts to block the dentinal
tubules with composite resin,
varnishes, sealants, soft tissue
grafts and glass ionomer
cements. The Iontophoresis
techniques electrically drives
fluoride ions deep into dentinal
tubules to occlude them.
 Chemical desensitizing method
attempts to sedate the cellular
processes within the tubules with
corticosteroids or to occlude the
tubules with a protein
precipitate, a remineralized
barrier, nitrate, fluorides,
strontium chloride or a
crystallized oxalate deposit.
Physical : Chemical :
Laser technology provides a definite solution for sealing the dentinal tubules
permanently. But this is in the experimental stages and the equipment is
expensive.
18

18. 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
19

19. Acute Irreversible Pulpitis
It is a persistent inflammatory condition of the
pulp, symptomatic/ non-symptomatic, caused by
noxious stimuli
 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.
 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.
20

20.  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.
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.
21

21. Acute 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.
22

22. Causative factors
 Occlusal trauma
 Irreversible pulpitis
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.
23

23. Pulp Necrosis
Rarely causes an emergency procedure. However, the
patient may notice a swelling and request emergency
treatment.
Treatment
 The proper treatment for pulp necrosis is canal debridement.
 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.
24

24. Acute Alveolar Abscess: (Acute
periapical abscess )
It is a localized collection of pus in the alveolar bone of the root apex of a tooth
following death of the pulp, with extension of the infection through the apical
foramen into the periapical tissue.
25

25. Symptoms
Local symptom
 Tenderness of the tooth remove by continuous slight process.
 Patient has throbbing sever pain with swelling of the overlying soft tissue with or
wothout tooth mobility.
 When swelling become extensive ,it result into cellulitis and the patients facial
changes.
Systemic symptom
Fever, Irritation, etc
26

26. 27
Where to expect swelling from which tooth???

27. Ludwig's angina
28
 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.

28. The acute episode may result from :
Pulpitis 
pulp necrosis
 abscess
phoenix
abscess
Periodontic-
endodontic
lesion
29

29. Treatment
 Infiltration anesthesia  contraindicated
 Conduction or block anesthesia may be administered
 test cavity  tests for any remaining, vital pulp that could require
anesthesiaand initiates emergency quickly, without waiting for anesthesia to
take effect.
forcing anesthetic
solution into an
acutely
inflammed and
swollen area
localized acidic
pH
30

30. 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 within the 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.
31

31.  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.
 Advice the patient to use warm saline rinses for 3 minutes each hour.
 Prescribe analgesics or antibiotics if indicated and necessary.
Advantages of closed dressing are :
Prevents additional bacterial contamination.
Prevents contamination with food debris and blockage of canals.
Prevents the need for unnecessary follow-up appointments to close the tooth.
32

32. Gutmann describes various modalities of treatment for localized or diffuse
swellings associated with acute alveolar abscess.
33
• no need for incision and drainage. Advice warm
saline rinses in addition to root canal therapy
swelling is slight and
localized
• incise and drain
swelling is soft, extensive
and fluctuant
• antibiotic coverage and aggressive removal of
any necrotic tissue in the pulp canal system
diffused swellings, where
there is a generalized
tissue edema or cellulites
• Consider antibiotics and advice hot saline rinses
If the tissue swelling is
non-fluctuant

33.  A non functional swelling can be converted to a soft fluctuant state by rinsing
with warm saline solution 3-5 min at a time repeated every hour.
34
alkalinize the
mouth
astringent
heat of the
solution 
increase in
blood flow
prevents
destruction of
the cells

34. Irrigants used in treating acute abscess
 Initial stages  sterile water and saline (NaOCl clumping debris)
 When the patency through the apex is maintained, sodium hypochlorite may be
used for further canal preparation.
 For further appointments, an alternating solutions of sodium hypochlorite and
hydrogen peroxide is recommended.
35
Culturing the exudate
Culture sample may be taken for antibiotic sensitivity testing.
The culture should not be taken of the initial portion of the exudate.

35. Incision and Drainage
36

36. Rationale for I & D
 Decreases number of bacteria
 Reduces tissue pressure
 Alleviates pain/trismus
 Improves circulation
 Prevents spread of infection
 Alters oxidation-reduction potential
 Accelerates healing
37

37. Trephination – Apical and surgical
Apical
 Apical trephination is accomplished by aggressively placing a No.15 to 25 K
file beyond the confines of the apex.
 A radiographic is taken for verification of file position.
Treatment problems with such procedure are :
 Destruction of the natural apical constriction.
 Zipping of the canal at the apex in curved canals.
 However, the benefits of the procedure far outweigh the potential
problems.
38

38. 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.
39

39.  Proper anesthesia is obtained.
 A No.-15 scalpel blade is used to
make a small (5mm) incision
horizontally in the mucosa apical
to the root apex.
 A No.-6 or 8 round bur is used to
penetrate the cortical plate at an
angle designed to reach the peri-
radicular tissues or lesion,
avoiding contact with the root
apex.
 No. 6 or 8 round bur is used to
penetrate the cortical plate only.
 A large K-file (No. 40 minimum)
is used to bore a path through
the cancellous bone to the
periradicular tissues or lesion,
avoiding contact with the root
apex.
40
Option – 1 Option – 2
Two Approaches

40. 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.
41

41. 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.
42

42. HOT TOOTH
 A hot tooth is a tooth that is difficult to anesthetize.
 There is special class of sodium channels on C fibers, known as tetradotoxin-
resistant (TTXr).
 Sodium channel expression shifts from TTX-sensitive to TTXr during neuro
inflammatory reactions, and the TTXr resistant sodium channels play a role in
sensitizing C fibers.
 These sodium channels - resistant –lignocaine & is 5 times more resistant to
anesthetic than TTX sensitive channels.
 Bupivacaine – potent..
 Supplementary intraligamentary or intraosseous injections have been found to
ensure profound anesthesia.
44

43. CRACK TOOTH SYNDROME
 DEFINITION: A fracture plane of unknown depth and direction passing
through tooth structure, if not already involving, may progress to
communicate with the pulp and/or periodontal ligament.
* History of pain on release of biting on a particular tooth, often occurring with
food having small, harder particles in them.
45

44. VISUAL INSPECTION: Transillumination
46

45. Magnifying loupes
Dyes-methylene blue
Tooth slooth- more
reliable.
47

46. Cracks in vital teeth
48
 Urgent care -- immediate reduction of tooth from its
occlusion by selective grinding
 Sharp, intense pain of short duration during chewing and on
release of food- even as no pulpal involvement.
 Treatment for cracks not involving pulp: Compromised
portion removed- occlusal adjustment, cuspal protection.-
Restoration-Composite -Pinned amalgam-Cast restoration
•Full coverage restoration- as permanent treatment.
•If crack involves pulp-causes pulpal inflammation &
necrosis- RCT is advised followed by full coverage
restoration.

47. As a rule of thumb, if the crack involves a root canal, extract the tooth.
If the crack involves the pulp chamber only, RCT and restore
Cracks in root filled or nonvital teeth:
 cracks in teeth without a living pulp gives vague symptoms & origin is difficult
to locate-& pain receptors in the pdl may be involved or bacteria may invade
through the craze line causing periodontal inflammation – tooth tender to
percussion.
 Treatment: location of the crack-even surgical exposing of the crack is done
and removal of the source of pain(infection)- followed by full coverage
restoration if tooth can be saved.
 In case if crack is vertical - involving the entire root – extraction is preferred.
49

48. REFERRED PAIN
 Referred pain may be initiated from inflamed pulp-other parts of body on
same side or in close proximity to another tooth
 Eg: infection of max ant teeth- referred to ocular pain, mandi molars to
back of ear.
 pain from other parts of body- referred to tooth.
 Otitis media- refer pain- mandibular molars, tmj dysfunction-toothache.
 Accurately determine the origin of pain – radiograph is often useful here
and in any case if pulpal pain is diagnosed – start with routine endodontic
treatment.
50

49.  Refered pain should be differentiated from other :
 MPDS
 Tmj problems
 Otitis media -- ear pain, fever , upper respiratory tract infection with cough
and nasal discharge
 Ocular pain --- eye irritation , fever , reduced vision, sharp throbbing pain
in eye , pain worsened by light.
51

50. TRAUMATIC INJURIES
Endodontic treatment may be required as a result of traumatic injury.
Most common endodontic emergencies are:
a) Crown fracture.
b) Root fracture
c) Avulsion
52

51. CROWN FRACTURE
 If a green stick # of crown is present and crown segment doesn’t shear off
under pressure, a steel band is cemented around the tooth.
 Relieve the occlusion- eliminates pain & re-evaluate status pulp later.
CROWN FRACTURE INVOLVING PULP:
 crown fractures involving enamel, dentin & pulp are called ‘complicated
crown” fractures by Andreasen & class 3 by Ellis.
 Degree of pulp exposure--- pinpoint exposure to total unroofing of coronal
pulp.
 Initial reaction --- hemorrhage --- inflammatory response --- destructive
(necrotic) / proliferative (polyp)
53

52. 54
TREATMENT:
Depends on maturity of the pulp……
 Preservation of the pulp by vital pulp therapy--- pulp capping /
pulpotomy
 Pulpectomy
Pulp Capping Modified pulpotomy technique
(“Cvek type”)

53. FOLLOW – UP AND PROGNOSIS:
Acceptable results of evaluation following pulpotomy should be all of the following:
1. No clinical signs or symptoms
2. No evidence of periradicular pathologies
3. No evidence of resorption – internal / external
4. Evidence of continued root formationin developing tooth.
55

54. ROOT FRACTURE:
 DESCRIPTION: fracture involves the root only; cementum , dentin, and
pulp.
 INCIDENCE: account 2% of all dental injuries
56

55. DIAGNOSIS :
 Missed in conventional radiographs
 With conventional radiograph… 90 degree angulation ….if fracture diagonal
… missed
 Additional film angulation of 45 degree + 90 degree ---- reveal root
fracture.
57

56. Management:
SPLINTING:
 Repositioning the coronal fragment
 Fragments with close proximity --- splinting does not make difference
 Semirigid splinting --- favour healing
 splinting after4 wks– does not make difference
 Delaying treatment for 24 hrs --- does not make difference
58

57. TREATMENT OF CORONAL FRAGMENT:
 most simplistic
 Fracture site located more coronally on the root --- “new
apex” which is wide and open--- open apex
 Establishment of working length ---- radiographically
 Conventional apexification
- Calcium hydroxide ---- 3 to 12 months for barrier
formation
- MTA --- immediate restoration
59

58. TREATNG CORONAL FRAGMENT & REMOVAL OF APICAL
FRAGMENT:
signs and symptoms of non-healing after
coronal RCT.
 SWELLING / radiolucent area at the
site / apically.
 Assuming coronal fragment stable---
surgical removal of apical fragment.
 68% success rate
 Notable mobility of coronal fragment ---
implant through coronal fragment &
into bone = endosseous implant.
60

59. TREATING CORONAL & APICAL FRAGMENTS AT THE SAME
TIME:
 It is difficult to get apical seal when endodontically treating only coronal
fragment.
 To achieve this seal --- treatment of both coronal & apical fragment
simultaneously which is almost impossible.
 low success rate
 Favorable approximation of fragments --- intra radicular splint --- rigid
type of post (cobalt – chromium alloy [vitallium])
61

60. REMOVING THE CORONAL FRAGMENT & TREATING THE
APICAL SEGMENT
CROWN ROOT FRACTURE:
- Coronal fragment attached only by gingiva
- Acceptable crown :root ratio  1:1 (for planning post and
core)
- Endodontic treatment of apical segment .
- Followed by crown lengthening --- orthodontic/
periodontal
- Placement of appropriate crown.
62

61. SEQUELE OF ROOT FRACTURE
63

62. Extrusive Luxation
 Displacement of tooth in coronal direction results in
partial avulsion.
 Tooth – mobile & continually traumatized by contact with
opposing tooth --- premature occlusion
 Radiographically --- “empty” radiolucent space
 Immediate treatment – repositioning the tooth &
stabilizing by functional splint for 4 to 8 wks.
 Definitive treatment –vitality test RCT --- NECROSIS/
INFLAMATORY ROOT RESORPTION SEEN
64

63. Lateral Luxation
 Traumatic injury --- displacement of tooth labially ,
distally or mesially --- lateral luxation.
 Very painfull --- premature occlusion e.g :
max.incisor pushed palatally.
 Crown makes contact long before centric occlusion.
 Treatment plan depends on ---presence or absence
of apical displacement at the time of injury.
65

64. LATERAL LUXATION WITHOUT APICAL DISPLACEMENT:
 Teeth pushed only in facial / lingual direction with apical root
remaining in its original position within the socket.
 Teeth loose enough – slight digital pressure to reposition the tooth.
 Some sulcular bleeding --- typically seen
 If there is no widening of PDL space as confirmed by radiographs ---
good prognosis --- endodontic treatment may not be necessary.
 Tooth is initially unresponsive to EPT and cold test.
66

65. LATERAL LUXATION WITH APICAL DISPLACEMENT:
 Tooth is frequently pushed palatally / lingually and firmly located in its new
position.
 Tooth will elicit dull metallic sound on percussion.
 palpating alveolar bone --- reveal new location of apex.
 Radiographically – PDL space widened around the midportion and coronal
portion of root.
 If apex moved out of its original position --- damage to neurovascular bundle.
 negative response to cold and EPT .
 Closed apex cases --- advice endodontic treatment
REPOSITIONING THE TOOTH IN ITS SOCKET
SPLINTING --- 3 TO 4 WEEKS
PROGNOSIS GOOD --- if endodontic treatment done when indicated.
67

66. 68
TOOTH
AVULSION/
EXARTICULATION
 Incidence – 3% of all dental injuries
 True dental emergency – timely attention to replantation could save the
tooth.
 Sports and automobile accidents --- frequent causes.
 Examine --- tooth is replanted before coming to dental office.
 See for any debris / contaminants.
 Record the time of avulsion.

67. Storage media
69

68. 70

69. 71

70. TREATMENT :
IMMEDIATE TREATMENT
Radiographs --- fracture of alveolar bone
- Socket --- foreign bodies and debris --- scrape gently from bony walls.
- Blood clot – gently suctioned and irrigated with saline
- Avulsed tooth --- debris gently rinsed off
- Do not hold the in hands --- always use some twizer / forceps to hold the
tooth
- Gently and slowly insert the into socket --- aneasthesia may not be
necessary.
72

71.  Check the alignment --- no hyperocclusion .
 Splinting not necessary if tooth fits firmly in socket.
 Mobility --- splinting recommended
 Orthodontic wire ( 0.3 mm) attached with composite on the labial surface
of tooth.
 Splinting should left for 1 to 2 wks
 Initial antibiotic course, tetanus prevention & RCT ( after 10 to 14 days).
 Calcium hydroxide is recommended as an intracanal medicament --- 2 wks
, during RCT.
73

72. DURING
ENDODONTIC
TREATMENT
74

73. Flare – ups
American Association of Endodontics
Definition :An acute exacerbation of peri radicular pathosis after
initiation or continuation of root canal treatment.(1998).
> Studies reports 1.8-3.2 % flare-ups.
 Inter-appointment flare-up is characterized by the development of pain,
swelling or both, following endodontic intervention.
75

74.  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.
 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.
76

75. Medical status of patient :
 Diabetic patient --- they are more prone for flare ups because increased
sugar content in blood – uncontrolled diabetics--- treared only when there
is an emergency
 Hypertensive patients – care should be taken during giving local
anesthesia– epinephrine contraindicateds
 Pregnant patient – second trimester is the best time to treat --- first and
third risk to foetus and patient. --- only emergency treatment given ---
continuation of treatment after pregnancy
78

76. Result of imbalance in host-bacteria relationship.
F. nucleatum, Prevotella species and Porphyromonas species were frequently
isolated from flare-up cases.
- Enterococcus faecalis is present in retreatment cases.
Contributing factors:
1)Inadequate debridement
2)debris extrusion
3) over instrumentation
79

77. Inadequate debridement
Residual pulp in inadequately instrumented canal
b) Undetected canals.
c) Teeth with necrotic pulps (with / with out associated peri radicular
lesions)–more prone to mid endodontic flare-ups than vital teeth
Rx: Through debridement of entire root canal space- removal of entire pulpal
tissue with broaches + irrigants.
80

78. Debris extrusion
Conventional hand instrumentation was shown to extrude the more debris
than rotary instrumentation.
 Pulpal remnants, necrotic tissue, dentin filings, canal irrigants
( forced irrigation of NaoCl beyond apex-violent tissue reactions),
microorganisms and their toxins may extrude beyond the apical foramen
during instrumentation.
More likely to cause flare up if pulp is necrotic and infected.
81

79.  Debris extrusion occurs with all techniques of root canal instrumentation.
 The crown down technique and balanced force technique shows
significantly less debris extrusion.
 The presence of an apical dentinal plug may prevent debris extrusion, over
instrumentation and over obturation. But since it may harbor infectious
material, the long term prognosis is compromised.
82

80. Over instrumentation
 Incident of moderate –severe pain
 Gross O.I – causes acute apical periodontitis producing
primary inflammatory pain
 Over instrumentation beyond the apical foramen results
in intra-operative or post operative pain.
 apical periodontium is crushed producing pain and
inflammation.
 overinstrumentation can be prevented by proper w.l-
 Endodontic therapy may be continued, analgesics relieve
pain.
 Occlusal reduction is necessary.
83

81.  TESTING FOR OVERINSTRUMENTATION:
 grasp the paper point 2mm more than the working length, the paper point
will pass easily without any obstruction and on withdrawal there will be a
reddish
brown discoloration of the tip indicating presence –inflamed tissue &
absence of stop in apical preparation.
84

82. Secondary apical periodontitis
 Term applied to severe tenderness to percussion immediately
after the treatment was initiated.
 Extremely uncomfortable- causes throbbing, gnawing, pounding pain.
Preoperative cond is either acute or chronic pulpitis.
 If the access is opened, no productive exudate or escape of gas is noted-
culture tests negative –as no infection present.
 Main Cause is over instrumentation but may also occur due to over
medication(too caustic or too much ICM), forcing debris into periapex.
 Sympathomitic pain relief: access cavity opened, saline irrigation and use
of corticosteriod-antibiotic paste as an intracanal medicament – pt recalled
later for completion of endo treatment- thus avoiding painfull episode.
85

83.  PREVENTION:
 The canals are normally instrumented too close to the apex in an attempt ,
to ‘completely clean the canal’
 Most studies on apical anatomy are of the opinion that over instrumentation
0.5mm beyond the radiographic apex may lead to secondary apical
periodontitis.
 If over-instrumentation has occurred- take remedial steps at the same
sitting to avoid a flare–up.
 A intracanal medicament+antibiotic coverage.
86

84. Endodontic emergencies: Your medication may be the cause
J Conserv Dent. 2009 Apr-Jun; 12(2): 77–79.
Promila Verma
87
• 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.

85. Treatment & Prevention Of Flare-
ups:
1. Occlusal reduction.
2. Antibiotic prophylaxsis
3. I & D ---Leaving tooth open for complete drainage- 20 min – complete
removal of pulp tissue and debris -followed by closed dressing
4. Calcium hydroxide therapy: intra canal dressing
 MOA:- hydrolyses lipid moiety of bacterial lipopolysaccharides.
 Disadvantages: Unable to kill enterococcus species which is commonly
associated with failed r.c.t.-
5. Antibiotics & Analgesics(releive pain)
6. Corticosteroids – antiinflammatory action.
88

86. 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.
89

87. 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.
90

88.  Management:
 Immediate aspiration
 Cold pack over the affected area.
 Regional block anesthesia administered. Pain management difficult
because symptoms from distant anatomic structures will continue to
cause discomfort.
91

89.  Monitor tooth for the next half hour. Bloody exudation extended from
canal denotes the bodies reaction to the irritant. Remove the fluid with
high volume suction to encourage further drainage. If drainage is
persistent consider leaving the tooth open.
 Antibiotic coverage to prevent secondary infection
92

90.  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.
93

91. 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
94

92. 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.
95

93. 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.
96

94. 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.
97

95. PERFORATION
 Perforation is an artificial opening in the tooth or root, created by clinician
during entry to the canal system or by a biologic event such as pathologic
resorption or caries that results in communication between the root canal and
periodontal tissues.
 Time --- time elapsed between seal of the perforation and its inception ---
important in determining prognosis . --- immediate treatment --- better
prognosis.
 Location :
 Subgingival – during access cavity prepation for search of canal
 Midroot – during post space preparation and aggressive BMP
 Apical --- during instrumentation – using large inflexible files violating apical
constriction
 Size of perforation --- smaller the defect better is prognosis
98

96.  Coronal third furcation management:
 Materials – Cavit, amalgam, calcium hydroxide,
GIC or haemostatic agent such as Gelform.
Barrier technique:
 Artificial barrier (floor) using either calcium
sulphate and hydroxyapatite  improves sealing
ability & provides successful barrier against its
over extension.
Calcium hydroxide:
 Control bleeding
 placed in the area of perforation and left for at
least few days will leave the area dry and allow
for inspection of perforation.
99

97. MIDROOT PERFORATIONS
 Lateral perforation at midroot level tends to occur in curved canals when a
ledge has formed or along inside curvature of root as canal is straightened
out.
 MB canal of lower molar >>>
100

98. STRIPPING
 a “lateral”perforation caused by
overinstrumentation through a thin
wall of the root & mostly happens
along the inside curvature of the
root as the canal is straightened out
 Distal wall of mesial roots in
mandibular 1st molars>>
101

99.  Recognition:Sudden appearance of blood or
complaint from patient.
 Access is difficult, Repair- unpredictable.
 Prognosis is poor. Lack of tooth
structure & integrity of wall may eventually
lead to fractures & microleakage due to
inability to seal the perforation.
102

100. Two Step method to repair midroot
perforations
Root canals are first obturated, then the defect is repaired surgically.
 removal of excess GP using a hot spatula & then cold burnishing the site.
 To Prevent Stripping:
 anticurvature filing
 maintaining mesial pressure.
 Careful use of rotary instruments inside the canal
103

101. APICAL PERFORATIONS
Maybe due to….
 Not negotiating a curved canal or..
 Not establishing WL &
overinstrumentation.
 Instrumentation beyond apical
confines
104

102. 105
Emergencies during endodontic surgery
 Excessive uncontrolled
bleeding
 Due to rebound phenomenon
Medical emergencies during endodontic
treatment
 Syncope
 Hypoglycemic shock

103. POST ENDODONTIC
TREATMENT
 Over extension
 Under extension
 Hyperocclusion
 Missed canals
106

104.  UNDERFILLING
ETIOLOGY-
- natural barrier in canal
- ledge
- insufficient flaring
- poorly adapted master cone
- inadequate condensation
pressure
TREATMENT-
-removal and retreatment
107

105. TREATMENT:
 Sealer – no treatment required as it removed from body by action of
macrophages.
 Gutta percha – re- rct / apical surgery followed by retrograde filling
OVERFILLING- can either gutta percha or
sealer
etiology-
- sequel of over instrumentation
- uncontrolled condensation pressure
- inflammatory resorption
- incomplete development of root
- open apex
108

106. Analgesics and Antibiotics
109

107. Flexible Analgesic Plan
110
When aspirin
like drugs are
indicated
severe
600-800mg
ibuprofen + 10
mg oxycodone
moderate
600-800 mg
ibuprofen + 60
mg codeine
Mild
200-400 mg
ibuprofen or
650 mg aspirin

108. 111
Aspirin like
drugs are
contraindicated
Mild
600-1000 mg
acetaminophen
Moderate
600-1000 mg
acetaminophen
+opiate 60 mg
codeine
Severe
600-1000 mg
acetaminophen
+ opiate 10 mg
oxycodone

109. Indications for Antibiotic
Therapy
112
 Systemic involvement
 Compromised host resistance
 Fascial space involvement
 Inadequate surgical drainage
Select antibiotic with anaerobic spectrum
Use a larger dose for a shorter period of time (“hard and fast” rule)
Guidelines for Antibiotic
Therapy

110. Penicillin V
 Still, the drug of choice for infections of endodontic origin
 Penicillin, is a bactericidal antibiotic with good oral absorption. It also has a
good spectrum of coverage against the main oral virulent microflora. It is
well tolerated by patients and has a low toxicity profile.
 Loading dose: 1-2 g then 500 mg qid x 7-10 days
 Amoxicillin, has a more broad spectrum of coverage than penicillin, but it is
an acceptable alternative. Its dosing regimen (three times daily) may lead
to better compliance.
113

111. Metronidozole (Flagyl)
 Used in conjunction with Penicillin V
 500 mg of Penicillin V with 250 mg Metronidozole, qid x 7-10 days
 Covers anaerobic spectrum
114
Other antibiotics:
Cephalosporins
Clindamycin  penetrates well into abscesses

112. 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
enhaces the positive image of dentistry.
115

113. 116