Mansoura course Dr. Ragi (01006573035)

1. ENDODONTIC EMERGENCIES
AND MANAGEMENT

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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