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IN THE NAME OF ALLAH THE MOST GRACIOUS THE MOST MERCIFUL

Niagra Falls

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Prof. Abdelhamied Y. Saad, BDS, MS (Egypt), Endo. Cert., Ph.D. Prof. Abdelhamied Y. Saad, BDS, MS (Egypt), Endo. Cert., Ph.D. (U.S.A.)(U.S.A.)

The reason for endodontic emergency The reason for endodontic emergency is pain and at times, swelling ensuing is pain and at times, swelling ensuing from pulpal-periradicular pathosis.from pulpal-periradicular pathosis.

Most dental emergencies are Most dental emergencies are unscheduled intrusion into the routine unscheduled intrusion into the routine of daily practice.of daily practice.

Therefore, the clinician must diagnose Therefore, the clinician must diagnose the origin of pain as quickly as the origin of pain as quickly as possible, to render rapid and effective possible, to render rapid and effective relief.relief.

Classif ication of Classif ication of Endodontic Endodontic

EmergenciesEmergencies

Classif ied according to Classif ied according to the time of occurrencethe time of occurrence

I.I. Pre-endodonticPre-endodontic

II.II. During endodonticDuring endodontic

III.III. Post-endodonticPost-endodontic

I. Pre-treatment I. Pre-treatment EmergenciesEmergencies

Acute Reversible Acute Reversible Pulpit is (Hyperemia)Pulpit is (Hyperemia)

The best treatment is prevention.The best treatment is prevention.

Locate the involved teeth.Locate the involved teeth.

This can be confirmed by visual, This can be confirmed by visual, tactile, thermal, and radiographic tactile, thermal, and radiographic examination.examination.

CO2 Stick (-50º C)

It transforms from a solid to a gaseous state

No stimulation of adjacent teeth

(An excellent method of thermal testing)

Hot Gutta-Percha

Place a pulp-protective base under Place a pulp-protective base under restorations.restorations.

Avoid marginal leakage.Avoid marginal leakage.

Reduce occlusal trauma in a recent Reduce occlusal trauma in a recent restoration.restoration.

Avoid excessive heat while preparing Avoid excessive heat while preparing or polishing a metallic restoration.or polishing a metallic restoration.

TreatmentTreatment

Remove the restoration and replace it Remove the restoration and replace it with a sedative cement (ZOE).with a sedative cement (ZOE).

Remove the recurrent decay under old Remove the recurrent decay under old restoration.restoration.

Carious lesion

The pain should disappear within few The pain should disappear within few days. If persists or worsens, the pulp days. If persists or worsens, the pulp should be extirpated.should be extirpated.

Acute Irreversible Acute Irreversible Pulpit isPulpit is Abnormal response to thermal and Abnormal response to thermal and

electric pulp tests.electric pulp tests.

Pain lasts for minutes to hours, Pain lasts for minutes to hours, spontaneous, disturbs sleep, or occurs spontaneous, disturbs sleep, or occurs when bending over. when bending over.

Inflammatory cells and vasodilatation of b.vs.

Irreversible Pulpit is

TreatmentTreatment

1.1. Pulpectomy (if possible).Pulpectomy (if possible).2.2. An analgesic with antibiotics only if An analgesic with antibiotics only if

pain recurs or if systemic toxicity pain recurs or if systemic toxicity occurs subsequently.occurs subsequently.

3.3. Emergency pulpotomy (no sufficient Emergency pulpotomy (no sufficient time).time).

4.4. The patient should be rescheduled The patient should be rescheduled for additional treatment.for additional treatment.

Severe pain from irreversible pulpitis

Pulpotomy & placement of cotton pellet with medication & a temporary filling result in pain relief

PDL Inf i l trat ion can be useful when anaesthesia is dif f icult to achieve

Necrotic PulpNecrotic Pulp Pain may be localized or diffuse.Pain may be localized or diffuse.

Thermal or electric pulp tests are Thermal or electric pulp tests are required.required.

Sensitivity to mastication.Sensitivity to mastication.

Previous extensive restorations.Previous extensive restorations.

Pulp Necrosis

RadiographicallyRadiographically

1.1. Size and extent of caries.Size and extent of caries.

2.2. Loss of PDL.Loss of PDL.

3.3. Thickening of theThickening of the

PDL space.PDL space.

4. 4. Bone loss.Bone loss.Chronic Apical Periodontitis

TreatmentTreatment

1.1. Remove the necrotic tissue from the Remove the necrotic tissue from the pulp chamber.pulp chamber.

2.2. The tissue in the RC must also be The tissue in the RC must also be removed, if not totally, then as much removed, if not totally, then as much as you can.as you can.

3.3. Copious irrigation with sodium Copious irrigation with sodium hypochlorite.hypochlorite.

Measuring the irr igating needle to prevent extrusion of sodium hypochlorite

TreatmentTreatment

4.4. Total debridement is the ideal Total debridement is the ideal treatment for symptomatic anterior treatment for symptomatic anterior teeth and single rooted posterior teeth and single rooted posterior teeth with patent canal (not easy with teeth with patent canal (not easy with multi-rooted teeth.multi-rooted teeth.

Localized swell ing Incision for drainage after cleaning and shaping

Treatment Treatment

5.5. Avoid pushing some debris past the Avoid pushing some debris past the apical foramen by maintaining the file apical foramen by maintaining the file 2 to 3 mm from the apex.2 to 3 mm from the apex.

Instrumentation should be confined to the RC system(release of purulence, removes pus & relieves pressure)

Treatment Treatment

6.6. Temporarily seal the access Temporarily seal the access opening.opening.

7.7. Use analgesics and antibiotics as Use analgesics and antibiotics as necessary.necessary.

Acute Periradicular Acute Periradicular Abscess (Phoenix Abscess (Phoenix Abscess)Abscess) Is a localized collection of pus at the Is a localized collection of pus at the

root apex following death of the pulp.root apex following death of the pulp.

May be an exacerbation of a chronic May be an exacerbation of a chronic periradicular lesion.periradicular lesion.

May be caused by an endodontic May be caused by an endodontic periodontic lesion when the periodontic lesion when the periodontal abscess secondarily periodontal abscess secondarily affected the pulp, oraffected the pulp, or

A deep infrabony pocket extends to or A deep infrabony pocket extends to or beyond the root apex.beyond the root apex.

ClinicallyClinically Severe pain.Severe pain. Swelling may or may not occur.Swelling may or may not occur. Systemic toxicity such as:Systemic toxicity such as:

– Elevated temperatureElevated temperature– Gastrointestinal disturbanceGastrointestinal disturbance– MalaiseMalaise– NauseaNausea– DizzinessDizziness– Lack of sleepLack of sleep Acute Periradicular Abscess

(Phoenix Abscess)

Infection arise fromupper right canine

Emergency TreatmentEmergency Treatment

1.1. Drainage through root canal (apical Drainage through root canal (apical trephination) using nerve block trephination) using nerve block anesthesia (not infiltration) and anesthesia (not infiltration) and rubber dam.rubber dam.

2.2. Complete chemomechanical Complete chemomechanical debridement (if possible) with debridement (if possible) with copious irrigation.copious irrigation.

Apical Trephination

One day after drainage and initial treatment

Emergency TreatmentEmergency Treatment

3.3. Frequently, a purulent exudate Frequently, a purulent exudate escapes into the chamber (patent escapes into the chamber (patent canal) and relief follows quickly.canal) and relief follows quickly.

Emergency TreatmentEmergency Treatment

4.4. If no drainage appears, according to If no drainage appears, according to some investigators, leave the tooth some investigators, leave the tooth open, or close only with a cotton open, or close only with a cotton pellet if the canal patent (relief within pellet if the canal patent (relief within a short time).a short time).

Emergency TreatmentEmergency Treatment

5.5. Hot saline rinse for 3 – 5 min. each Hot saline rinse for 3 – 5 min. each hour to assist drainage.hour to assist drainage.

6.6. Analgesics or antibiotics if indicated.Analgesics or antibiotics if indicated.

7.7. In mild cases, seal the tooth with an In mild cases, seal the tooth with an antiseptic after biomechanical antiseptic after biomechanical preparation.preparation.

Emergency TreatmentEmergency Treatment

8.8. Many clinicians suggest:Many clinicians suggest:• Seal the tooth with intracanal Seal the tooth with intracanal

medication (IKI or Ca hydroxide) after medication (IKI or Ca hydroxide) after initial emergency instrumentation.initial emergency instrumentation.

• Leaving the tooth open increases the Leaving the tooth open increases the risk of adverse reaction when the tooth risk of adverse reaction when the tooth is sealed.is sealed.

• Bacterial contamination prolongs the Bacterial contamination prolongs the treatment time.treatment time.

• Reopen the tooth for drainage.Reopen the tooth for drainage.

Mode of Application of Mode of Application of Ca(OH)2Ca(OH)2 Introduced with a lentulo spiral or file Introduced with a lentulo spiral or file

and packed with pluggers (repeated and packed with pluggers (repeated to give a dense fill).to give a dense fill).

The paste can also be placed into the The paste can also be placed into the cleaned canal by injection.cleaned canal by injection.

Barium freeBarium free

Emergency TreatmentEmergency Treatment

9.9. Incision through soft and fluctuant Incision through soft and fluctuant swelling using ethyl chloride may be swelling using ethyl chloride may be necessary.necessary.

10.10. Trephination through the bone if Trephination through the bone if necessary.necessary.

Incision for drainageIncision for drainage (abscess)(abscess)

Surgical trephination throughSurgical trephination through the bone to relief pressurethe bone to relief pressure

Post & core

Inaccessible RC due to post and crown

Approximate position of the root apex

Vertical incision placed near approximate apex position

Area of weakened cortical density (pathological fenestration)

Bur is directed into the center of lesion near the apex.

Six months postoperative One year postoperative. Patient is asymptomatic

Trauma followed by acute apical abscess

Submental space swelling

Pulpectomy followed by extraoral incision & placement of a drain

Acute Periodontal Acute Periodontal AbscessAbscess Often mistaken for an acute periapical Often mistaken for an acute periapical

abscess.abscess.

Causes pain and swelling.Causes pain and swelling.

Pulp is vital or necrotic.Pulp is vital or necrotic.

Its origin is usually an exacerbation of Its origin is usually an exacerbation of infection with pus fomation in an infection with pus fomation in an existing deep pocket.existing deep pocket.

Emergency TreatmentEmergency Treatment

1.1. If the pulp is normalIf the pulp is normal• Curettage.Curettage.• Establish drainage of the pocket through Establish drainage of the pocket through

the gingival sulcus.the gingival sulcus.• Incision may be necessary.Incision may be necessary.

1.1. If the pulp is affected If the pulp is affected • Pulp extirpation.Pulp extirpation.

II . Interappointment II . Interappointment Emergencies Emergencies (Midtreatment Flare-(Midtreatment Flare-Ups)Ups)

Emergencies During Emergencies During TreatmentTreatment Occurs during the course of RCT.Occurs during the course of RCT.

The cause is usually iatral, andThe cause is usually iatral, and

Results in acute apical periodontitis.Results in acute apical periodontitis.

Can be avoided if:Can be avoided if:

1.1. Instruments, irrigating solution, Instruments, irrigating solution, medicaments, sealers, and filling medicaments, sealers, and filling material are confined to the root canals.material are confined to the root canals.

2.2. The teeth under treatment are properly The teeth under treatment are properly sealed between visits.sealed between visits.

3.3. The teeth are recontoured to prevent The teeth are recontoured to prevent trauma.trauma.

When severe periodontitis is present, When severe periodontitis is present, an immediate injection of a long-an immediate injection of a long-lasting local anesthesia will relieve the lasting local anesthesia will relieve the pain.pain.

With a dam in place, the tooth should With a dam in place, the tooth should be reopened and cleared of any liquid be reopened and cleared of any liquid contents using paper points, andcontents using paper points, and

Resealing with a cotton pellet with Resealing with a cotton pellet with eugenol or cresatin.eugenol or cresatin.

If pain or swelling occurs, the sealed If pain or swelling occurs, the sealed medicament should be removed and the medicament should be removed and the tooth opened for drainage.tooth opened for drainage.

Analgesics and antibiotic should be Analgesics and antibiotic should be prescribed.prescribed.

Trephine through the apical foramen to Trephine through the apical foramen to reduce pressure.reduce pressure.

Hydrocortison combined with Hydrocortison combined with neomycin (anti-inflammatory anti-neomycin (anti-inflammatory anti-bacterial medicament) is teased out bacterial medicament) is teased out the trephine apex with a sterile the trephine apex with a sterile instrument.instrument.

Incision and drainage of a soft Incision and drainage of a soft fluctuant swelling should be fluctuant swelling should be considered when:considered when:

1.1. Drainage is insufficient.Drainage is insufficient.

2.2. Severe pain persists.Severe pain persists.

Localized fluctuant swelling

Rubber drain placed after soft t issue incision.Antibiot ics are unnecessary, but analgesics are indicated

When the canals have already been When the canals have already been filled and pain is present:filled and pain is present:

1.1. The occlusion should be checked.The occlusion should be checked.

2.2. Complete treatment re-evaluated.Complete treatment re-evaluated.

When occlusal relief had no effect When occlusal relief had no effect after a week or so, a prescription for:after a week or so, a prescription for:

1.1. A corticosteroid as dexmethasone A corticosteroid as dexmethasone (Decadron – 0.50 mg).(Decadron – 0.50 mg).

2.2. An antibiotics (erythromycin – 250 mg) An antibiotics (erythromycin – 250 mg) each taken 4 times a day for 4 to 5 each taken 4 times a day for 4 to 5 days.days.

Corticosteroid should not be Corticosteroid should not be prescribed for patient with prescribed for patient with hypertension, gastric or duodenal hypertension, gastric or duodenal ulcers, or diabetes.ulcers, or diabetes.

At times, the root canal filling must be At times, the root canal filling must be removed, to relieve the pain and to removed, to relieve the pain and to establish drainage.establish drainage.

III. Post-obturation III. Post-obturation EmergenciesEmergencies

Directly, after RCT:Directly, after RCT:

1.1. Pain.Pain.

2.2. Swelling.Swelling.

3.3. Severe tenderness.Severe tenderness.

4.4. Tooth mobility.Tooth mobility.

Usually, patient who had suffered Usually, patient who had suffered from interappointment pain had from interappointment pain had higher incidence of suffering from higher incidence of suffering from post-obturation pain.post-obturation pain.

It occurs due to:It occurs due to: Apical extrusion of filling material or Apical extrusion of filling material or

debris.debris.

Missed canal.Missed canal.

Hyperocclusion of filling.Hyperocclusion of filling.

Tooth fracture.Tooth fracture.

Spaghetti phenomenon Sealer extruded to the sinus. Immediate surgery is needed

Fractured Crown

This kind of emergency may also This kind of emergency may also occur in old RCT (flare-ups of occur in old RCT (flare-ups of endodontic failures) due to breakdown endodontic failures) due to breakdown of the seal of poorly condensed root of the seal of poorly condensed root canal filling.canal filling.

Failure after 20 yr, si lver point, breakdown of sealer and perculat ion.

Pain usually subside spontaneously Pain usually subside spontaneously within the first few days in case with within the first few days in case with an acceptable endodontic treatment.an acceptable endodontic treatment.

Analgesics will reduce the pain.Analgesics will reduce the pain.

Incision of the swelling and drainage Incision of the swelling and drainage following acceptable RCT will resolve following acceptable RCT will resolve the problem without further treatment.the problem without further treatment.

In case of endodontic In case of endodontic fai lures:fai lures:1.1. Retreatment is indicated.Retreatment is indicated.

2.2. Apicoectomy with retrograde filling Apicoectomy with retrograde filling may be needed.may be needed.

Retreatment ; gutta-percha was removed using Gates-Glidden, Hedstreom f i les, & chloroform

Obturation ; the 2 nd mesialcanal was located

Apical corrosion of s. points

removed during retreatment

Tooth sensit ive to percussion

Late failure

Silver points

In abil i ty to remove si lver points

Tooth st i l l symptomatic after retreatment

Apicoectomy with retrograde f i l l ing