Endodontic Emergencies / orthodontic courses by Indian dental academy

ENDODONTIC EMERGENCIES

INTRODUCTION

EMERGENCY according to Dorland’s Medical dictionary is

defined as a sudden, urgent, usually unforeseen occurrence requiring

immediate action. Life threatening emergencies can and do occur in the

practice of dentistry.

Although, all forms of medical emergency may develop in dental

practice, some are seen with greater frequency. These are situations

produced entirely by stress or those that are acutely exacerbated when

the patient is under stress.

These situations include:

- Vasodepressor syncope.

- Respiratory difficulty.

- Airway obstructions.

- Hyperventilation syndrome.

- Asthma.

- Acute cardiovascular emergencies.

Effective management of STRESS in the dental office will

minimize the occurrence of these situations.

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Other life threatening situations that occur with greater

frequency in dental practice are those reactions associated with the

administration of DRUGS.

The most frequently observed reactions are those associated with

administration of local anesthetics.

Others are:

- Drug overdose.

- Drug allergy.

Most dental emergencies are unscheduled intrusions into the

routine of daily practice. Nevertheless the dentist must provide speedy

and effective relief because such care is essential part of daily practice.

The reason for endodontic emergency treatment is PAIN and at times

SWELLING ensuing from pulpoperiapical pathosis. Because dental

pain has many causes, the adept clinician must diagnose the origin of

pain as quickly as possible to render rapid and effective relief.

“Knowing what to do and when to do it are as important as knowing

how to do it”.

DIAGNOSIS

In an ACUTE pain emergency, the PHYSICAL as well as the

EMOTIONAL state of the patient should be considered. The doctors

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reactions to the patient is important for both pain and patient

management. The patients needs, their fears about the immediate

problem and their defenses for coping with the situation must be

understood.

The chief tool in establishing a correct diagnosis remains in

careful history taking followed by a thorough but quick clinical

examination.

According to Grossman – The diagnostic methods available to

clinicians are:

I. SUBJECTIVE SYMPTOMS : Which is the chief complaint of

patient eliciting either:

(A) 1) Pain

2) Swelling

3) Lack of function

4) Esthetics

II. DENTAL HISTORY

III. MEDICAL HISTORY

IV. OBJECTIVE SYMPTOMS

Which are determined by tests and observations performed

by clinicians.

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The tests are as follows:

1. Visual and Tactile Inspection.

2. Percussion.

3. Palpation.

4. Mobility and Depressibility.

5. Radiographs.

6. Electric pulp test

7. Thermal tests - Hot

- Cold

8. Anesthetic test

9. Test cavity

CLASSIFICATION OF ENDODONTIC EMERGENCIES

(A) According to WALTON

a) Pretreatment emergencies.

b) Interappointment emergencies.

c) Post-obturation emergencies

(B) According to GROSSMAN

1) Acute Conditions

1. Reversible pulpitis

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2. Irreversible pulpitis.

3. Alveolar abscess.

4. Periodontal abscess

2) Emergencies During Treatment

3) Fractures

Crown

Root

4) Avulsed tooth

5) Referred pain

(C) According to GUTTMAN

I] TREATMENT OF VITAL PULP

- Acute reversible pulpitis

- Hypersensitive dentin.

- Recurrent decay.

- Recent restoration.

- Cracked tooth syndrome.

II] TREATMENT OF NON-VITAL PULP

- Acute apical periodontitis.

- Necrotic pulp.

- Acute alveolar abscess.

- Phoenix abscess.

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- Acute irreversible pulpitis - Localized.

- Non-localized

III] AESTHETIC EMERGENCY

- Fracture of crown.

- Fracture of root.

- Avulsed tooth.

Coming to the PRE-TREATMENT EMERGENCIES

ACUTE PULPITIS

ACUTE REVERSIBLE PULPITIS [HYPEREMIA]

Definition:

Reversible pulpitis is a mild-to-moderate inflammatory

condition of the pulp caused by noxious stimuli in which the pulp is

capable of returning to the uninflamed state following removal of the

stimuli.

Symptoms:

A.R.P. is characterized by:

1. Sharp pain lasting for a moment.

2. Shooting pain lasting for short-duration.

3. Pain brought on by cold beverages and sweets.

4. Clinically – the patient can identify the tooth by pointing to it.

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Causes and Treatment

1) Caries Lesion which are close to pulp can cause mild

to moderate sensitivity to patients.

Treatment Caries excavation and placing a sedative cement like

dycal and zinc oxide eugenol (IPC).

2) Recent restoration which has a premature contact

point.

Treatment Recontouring or removal of high points.

3) Persistent pain and severe sensitivity after cavity

preparation Suggesting chemical leakage.

Treatment Removal of restoration and placing sedative cement

like ZOE.

4) Recurrent caries -> under an old restorations.

Treatment Remove all caries and replace with a sedative cement.

5) Thermal shock from preparing a cavity with a dull bur or

keeping the bur in contact with the tooth for a long time can cause

acute reversible pulpitis which exaggerates on placing a metallic

restoration over the tooth.

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Treatment Removal of metallic restoration and palliative

treatment by placing the cement.

Because the best treatment of reversible pulpitis is removal of

irritants of any sorts.

Prognosis: The prognosis is favourable if early removal of irritant is

achieved otherwise the condition may develop into irreversible

pulpitis.

ACUTE IRREVERSIBLE PULPITIS

Definition:

Irreversible pulpitis is a persistent inflammatory condition of the

pulp, caused by a noxious stimuli.

As opposed to that of reversible pulpitis, irreversible pulpitis is

caused by both hot / or cold stimuli.

Therefore, the difference between reversible and irreversible

pulpitis is distinguished by the duration of pain experienced by the

patient.

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Symptoms:

- Pain lasts for minutes to hours.

- It is spontaneous.

- It often continuous even when the cause is removed.

- Pain is present even on bending over.

- Patient complains of disturbed sleep.

- Pain is experienced on sudden temperature change.

- On taking sweets or acidic foodstuff.

- From packing of food into cavity/food impaction.

Causes:

1. The most common cause of irreversible pulpitis is bacterial

involvement of pulp through caries.

2. Reversible pulpitis may also deteriorate into irreversible

pulpitis.

In irreversible pulpitis the pulp may be Vital

Non-vital

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A) Vital pulp

According to Grossman, the preferable emergency treatment is

‘PULPECTOMY’ i.e. complete removal of the pulp and placement of

an intracanal medicament to act as a disinfectant or obtundent.

According to many authors like Weine, Walton and Grossman,

in posterior teeth, where time is a factor, PULPOTOMY or removal of

coronal pulp and placement of formocresol or similar dressing on the

radicular pulp should be performed as an emergency treatment whereas

in single rooted teeth pulpectomy can be performed directly.

Procedure:

- After administration of local anaesthesia.

- Access cavity is prepared.

- With a spoon excavator and round bur the coronal pulp is

removed.

- A cotton pellet moistened with formocresol is placed in the

cavity and it is sealed with ZnOE cement.

After removal of the tissue the site of inflammation precipitating

a painful response is gone.

The formocresol fixes the non-inflammed tissues in the canal

until the subsequent treatment of endodontics is followed.

The tooth involved is then relieved out of occlusion.

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B) Non-Vital Pulp

Necrotic pulp rarely causes an emergency procedure.

Most of the time these teeth do not respond to stimuli such as

hot, cold or electric stimulation, they may still contain vital inflamed

tissue in the apical portion of root canal and also inflamed periapical

tissue which causes pain.

Radiographically:

A) If a lesion is seen – ACUTE APICAL ABSCESS.

B) If no lesion is seen – ACUTE APICAL PERIODONTITIS

ACUTE ALVEOLAR ABSCESS

Also called as:

- Acute periapical abscess.

- Acute apical pericementitis

- Phoenix abscess.

Definition:

Is defined as a localized collection of pus in the alveolar bone at

the root apex of the tooth following death of pulp with extension of

infection through the apical foramen into the periapical tissue.

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Causes (Non-vital pulp)

a) Bacterial involvement.

b) H/O trauma.

c) Mechanical or chemical irritation.

The acute episode may result from:

1) PULPITIS that progressively developed into pulp necrosis

affecting the periapical tissues.

2) ACUTE EXACERBATION of a chronic periapical lesion

3) ENDO-PERIO lesion when the periodontal abscess

secondarily affects the pulp through the lateral canals or deep

infrabony pockets.

SYMPTOMS

There are local reactions like:

- Tenderness of tooth.

- Severe throbbing pain.

- Swelling.

- Sinus tract.

Systemic reactions are:

- Elevated temperature.

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- Gastro-intestinal disturbances.

- Malaise.

- Nausea.

- Dizziness.

- Lack of sleep.

TREATMENT

The main treatment is biphasic in nature i.e.

I – Debridement of canals.

II – Drainage of abscess.

The emergency treatment of acute alveolar abscess differs from

acute irreversible pulpitis, as the pulp is necrotic, local anaesthesia is

not required and frequently CONTRAINDICATED.

Forcing anaesthetic solution into an acutely infected and

swollen area may increase pain and may spread infection.

“BLOCK MAY BE USED IN SUCH CASES”

Most of the pain that occurs during access cavity preparation is

caused by tooth movement resulting from vibration of the bur therefore

one should stabilize tooth with finger pressure so that the pain is

reduced.

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Treatment procedure follows as:

1) Access cavity preparation.

2) Profuse irrigation avoiding forcing of any solution or debris into

the periapical tissue.

3) In most cases PURULENT EXUDATE escapes into the chamber

and indicates that root canal is patent and draining.

4) If drainage does not occur, the apical constriction is purposefully

violated and enlarged to a minimum of 20/25 No. instrument to

allow for exudate to drain because in most cases the apical

constriction may prevent the drainage.

According to GROSSMAN & COHEN leaving the tooth OPEN

for drainage reduces the possibility of continued pain and swelling.

Open root canals permit drainage and frequently eliminate the need for

surgical incision as well as routine administration of oral antibiotics

and analgesics.

According to WALTON, after copious irrigation, the canals are

dried with paper points and a medicated temporary cotton pellet is kept

– in other words – open dressing is given.

Some clinicians suggested that acutely abscessed teeth be sealed

with an intracanal medicament after the initial emergency treatment is

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done. According to them this stops the infiltration of new

microorganisms.

As opposed to them AUGUST found that only 3% out of 311

abscessed teeth which had been left open reacted adversely.

Therefore, the decision to keep the canal patent or closed must

be made depending on the amount of drainage and size of swelling.

SWELLINGS ASSOCIATED

1) If it is slight and localized it will disappear 24 to 48 hours after

drainage.

2) If it is extensive, soft and fluctuant an incision through soft

tissue is a must.

3) If swelling is hard – it can be converted to soft fluctuant state by

rinsing with hot saline solution 3-5 minutes at a time repeated

every hour.

ACUTE PERIODONTAL ABSCESS

It is often mistaken for an acute alveolar abscess.

Cause

It can occur with either Vital pulp

Necrotic pulp

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1) Its origin usually is an ACUTE EXACERBATION of infection

with pus formation in an existing deep infrabony pocket.

If the pulp is VITAL

Treatment Consists of curettage, debridement and establishment of

drainage of the infrabony pocket through sulcus.

If the pulp is NECROTIC

Treatment – extirpation and pulpectomy, similar to acute alveolar

abscess.

If the pulp is ABNORMAL and VITAL.

Treatment is same as acute alveolar abscess.

In any case, emergency periodontal treatment must be done

simultaneously otherwise the patient will not be relieved of pain and

swelling.

EMERGENCIES DURING TREATMENT

Endodontic emergencies can occur during the course of

treatment.

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Most emergency are reactive phenomenon to pressure and

chemical mediators created as a result of inflammatory response in

periradicular tissues.

According to Grossman

The emergencies can be due to:

1) Instrumentation beyond the root apex causing trauma to

periradicular tissue.

2) When debris and microorganisms are pushed beyond the apical

foramen which can cause an infectious reaction.

3) Chemical irritants like - Irrigating solution.

- Intracanal medicament

4) Incomplete debridement of all root canals.

5) Lost or depressed access cavity seals leading to recontamination.

6) Overfilled root canals with subsequent periapical inflammation.

The inflammation in the peri-radicular tissue is induced as a

result of release of substances such as vasoactive amines, kinins and

arachadonic acid metabolites. This interappointment emergency as

classified by WALTON is referred to as “FLARE-UP”.

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WALTON has suggested the possible factors related as

discussed before as:

1) Irritants within the pulp system.

2) Operator controlled or iatrogenic factors.

3) Host factors.

4) General systemic factors which are related to Flare-up.

Patients can accept that pain may continue to a lesser extent

when they come to the dental office for emergency treatment. What is

difficult for patients to comprehend is when they enter the office

having little or no pain before therapy but then encounter an explosive

flare-up after the treatment is done.

Therefore PREVENTION OF FLARE-UPS Can be done by:

1) The most important preventive measure is preparing the patient

to accept some discomfort which should subside in a day or two

i.e. psychological preparation of patients.

2) Using long acting anaesthetic solution.

3) Complete cleaning and shaping of root canals.

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4) Administration of appropriate analgesics, prophylactic

analgesics before next appointment reduces the incidence of

discomfort and flare-ups.

HYPOCHLORITE ACCIDENT

Another very important but rare emergency is due to expelling

of an irrigant such as NaOCl beyond the apex.

This happens only by locking the needle of the irrigating syringe

in the canal and forcefully injecting the irrigant.

Within minutes the patient feels SUDDEN EXTREME PAIN.

SWELLING within minutes.

Profuse, prolonged BLEEDING through the root canal.

This bleeding is the body’s reaction to the irrigant.

Remove the toxic fluid with high volume evacuation to

encourage further drainage from periradicular tissue.

Treatment:

1) Allow the bleeding to continue. If the body rids itself of toxic

fluid healing may be faster.

2) If the treated tooth is pulpless consider prescribing an antibiotic

and an analgesic for 5 and 3 days respectively.

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3) Since this may be hypersensitive reaction consider prescribing

an antihistaminic.

TRAUMATIC & ESTHETIC EMERGENCY

It can be broadly classified as:

1) Crown fracture.

2) Root fracture.

3) Tooth avulsion.

A traumatic injury to a tooth can cause a: - Cracked crown

- Fracture crown.

- Fracture root

And all this results in pain.

Coming to ‘CRACKED TOOTH SYNDROME’

Causes:

1) Intact tooth that has an opposing plunger cusp occluding

centrically against a marginal ridge.

2) Biting unexpectedly on a hard object like stone.

3) Trauma / blow.

Symptoms:

1. Sharp, piercing pain during mastication.

2. Fleeting pain on thermal changes.

3. Hypersensitivity.

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DETECTION is made by:

1) Dental history.

2) Transillumination.

3) Placing a disc and making the patient bite, the disc acts like a

wedge on the cracked tooth and causes pain.

4) Dye.

5) When a visible crack is found, lateral pressure, either digital or

from the handle of an instrument is applied to see if the segment

shears off or not.

TREATMENT

1) Immediate treatment is covering the exposed dentin with a

sedative cement like ZnOE and cementing a stainless steel band.

2) If a green stick fracture of the crown is present and the crown

segment does not shear off under pressure, one should cement

stainless steel band.

3) If the pulp is exposed, a band should be placed and cemented

and a pulpectomy should be performed.

4) This should be immediately followed by relieving of occlusion

by grinding the cusps of the tooth.

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Because any traumatic accident can temporarily affect the usual

responses to the electric pulp test, cold test and test cavity, negative

test responses for pulp vitality are non diagnostic and should not be the

basis for selecting endo emergency treatment. It is wiser to assume that

pulp is vital as vital pulp in the root canal of fractured tooth can

enhance the prognosis of healing.

CROWN FRACTURES

Crown fractures can be divided into 4 major groups:

1) Only enamel.

2) Enamel and dentine without pulp exposure.

3) Enamel and dentin with pulp exposure.

4) Untreatable.

ONLY ENAMEL

Can be treated by composite restoration.

ENAMEL AND DENTINE WITHOUT PULP EXPOSURE

Can be treated by early placement of restoration with pulpal

protection like sandwich technique.

ENAMEL AND DENTINE WITH PULP EXPOSURE

These fall into two categories Developing apex

Open apex

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It apex is developed pulpectomy.

If apex is open pulpotomy – patient is checked for apical

closure after every 3 months and then routine endodontic treatment.

UNTREATABLE

These imply to crown fracture in which an aesthetic and

periodontally healthy condition is impossible.

ROOT FRACTURE

Can be divided as : - Vertical

- Horizontal

Coronal third.

Middle third

Apical third.

Vertical fractures have hopeless prognosis because it is not

possible to either stabilize the fragments or remove one part surgically

and leave the other in situ.

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Horizontal fractures

Above alveolar crest excellent prognosis.

The closer the root fractures to the apex the more favourable the

prognosis as sufficient root length is seen if fracture fragment is to be

removed.

Treatment stabilize by ligation to adjacent teeth.

Check pulp vitality after 6 weeks as the pulp will be in a

“stunned” state.

If the fracture is at mid root or below the alveolar crest poor

prognosis.

If remaining root portion is left post and core can be given.

TOOTH AVULSION

The avulsed or luxated tooth is both a dental and an emotional

problem.

Cause:

Result of trauma to an anterior tooth of a young adult or child.

The longer the luxated tooth is out of its socket, the less likely it

will remain in a healthy, functional state after replantation.

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The instruction to the patients are:

1) To carry the avulsed tooth in a moist vehicle preferably in the

patients mouth i.e. saliva to maintain the viability of periodontal

ligament. Others are milk, saline etc.

The tooth should not be dried.

The extra-oral time for a tooth should not exceed 30 minutes.

Procedure

The tooth is placed in the socket

Ligated.

Stabilised and disoccluded.

Radiograph to verify the position should be taken.

This procedure was first given by ANDREASON

REFERRED PAIN

Although the most frequent cause of pain is pulpoperiapical

pathosis, the clinician knows that the pain can originate from many

other sources.

According to Hurwitz dental pain can have its origin in:

- Trigeminal neuralgia.

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- Atypical facial neuralgia.

- Migrane.

- Cardiac pain.

- Temporomandibular arthrosis.

Sinusitis or cold may refer to maxillary posterior teeth.

Pain arising from periodontal problems:

- Periodontal abscess.

- Occlusal trauma.

- Muscle spasm.

- Bruxism and clenching.

- Pericoronitis may be confused as pulpoperiapical pain.

Spicer reported pain referred to a lower molar from a basilar

artery aneurysm that produces pressure in the trigeminal nerve.

Verbin and colleagues described odontalgia in a maxillary lateral

incisor due to herpes zoster of trigeminal nerve.

Sanubai and Richardson described vascular neck pain referred to

mandibular posterior teeth.

Otitis Media may refer to mandibular molars.

Myocardial infarction or angina pectoris may cause tooth ache

on left side especially if it occurs while patient is exercising.

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Other causes of referred or unusual pain are:

- Intensive radiation.

- Malaria, typhoid, influenza.

- Menstrual pain.

- Some malignant diseases and tumors.

Thus, the role of diagnosing a true endo emergency cannot be

over emphasized.

ANALGESICS AND ANTIBIOTICS

The use of analgesics and antibiotics is important in endodontic

emergency treatment. Every clinician should be familiar with their:

- Mode of action.

- Dosage.

- Indications.

- Interactions with other drugs.

- Route of administration.

- Toxicity

- Contraindications.

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ANALGESICS

Analgesics are pain relievers

NARCOTIC analgesics are used to relieve acute, severe pain.

NON-NECROTIC or mild analgesics are used to relieve slight to

moderate pain.

The most frequently used non-narcotic analgesics are:

- Aspirin.

- Acetaminophen.

- Naproxen.

- Ibuprofen.

ASPIRIN alone or in compound is used most often in the dosage

of 600mg. Aspirin should be taken with caution as it can cause an

anaphylactoid reaction in an allergic person or an adverse reaction in

persons with gastric ulcers.

Aspirin is contra-indicated in patients receiving anticoagulant

therapy, diabetes and arthritis.

ACETAMINOPHEN, the second most commonly used

analgesics is effective for mild-to-moderate. It has lower incidence of

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side effects than aspirin. It lacks anti-inflammatory effect of aspirin. It

is recommended for children and is available in liquid form.

IBUPROFEN a proprionic acid derivative prescribed in doses of

300-400mg 4 times daily is more effective for severe pain relief than

aspirin. But it should not be used in patients with h/o peptic ulcer or

aspirin intolerance.

NARCOTIC ANALGESICS like morphine, codine 30mg

neperidine, hydrocone 5mg with acetaminophen 500mg etc are

generally not used or are used with caution as it may depress the

C.N.S. They interact adversely sometimes fatally with alcohol, local

anaesthetic, antihistaminics etc.

ANTIBIOTICS

Antibiotics are life saving therapeutic agents which are used for

prophylactic coverage of medically compromised patients and as an

adjunctive treatment for acute periapical and periodontal infections.

Ideally, the selection of antibiotics should be based on the

susceptibility tests that indicate effectiveness against the infecting

microorganisms. Therefore, the more lethal the antibiotic the less likely

resistant the microorganisms will develop to it.

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The most effective antibiotics for use in endodontic emergencies

is PENICILLIN.

Penicillin acts by inhibiting the cell wall synthesis during

multiplication of microorganisms and are effective against gm+ve

cocci, viridans strains, many anaerobes which are involved in

endodontic infections.

The standard regime for dental procedures is penicillin V, 2.0gm

1 hr before treatment and 1.0gm 6 hourly later.

This is quite feasible according to the European standards owing

to their larger physique and body wt and higher BMR, but according to

Indian Standards this regime works out to be on a larger scale owing to

its less body wt. Therefore, the dosage reduces in accordance to the

body wt which is 250mg to 500mg tid.

In case of PENICILLIN ALLERGY, ERYTHROMYCIN may be

prescribed which acts by inhibiting proteins synthesis. The dosage in

250mg-500mg 6 hourly.

Other antibiotics useful for treating endo-emergencies are:

- Cephalexin – 250-500mg 6 hourly.

- Clindamycin phosphate – 150-30mg 6 hourly.

- Tetracycline Hcl – 250-300mg 6 hourly.

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Tetracycline is the least effective of all antibiotics for endo

emergencies.

CONCLUSIONS

A satisfying and rewarding experience is to successfully manage

a distraught patient who initially presented with severe pain for an

emergency appointment.

Proper operators attitude, patient control, accurate diagnosis, and

profound anaesthesia as well as prompt and effective treatment are all

integral components of management of endo-emergencies.

REFERENCES:

- Grossman.

- Weine.

- Walton.

- Cohen.

- Ingle.

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