Republic of Iraq

Ministry of Higher Education

and Scientific Research
University of Baghdad
College of Dentistry

Endodontic Emergencies

A Project Submitted to
The College of Dentistry, University of Baghdad, Department of
Conservative Dentistry in Partial Fulfillment for the Bachelor of
Dental Surgery

By
Nour Aldeen Mohammed Nouri

Supervised by:
Noor Haider Fadhel
B.D.S, MSC. Restorative and Esthetic Dentistry

2023 A.D. 1444 A.H.

I
 Certification of the Supervisor

I certify that this project entitled “Endodontic Emergencies” was

prepared by the fifth-year student Nour Aldeen Mohammed Nouri
under my supervision at the College of Dentistry/University of Baghdad
in partial fulfilment of the graduation requirements for the Bachelor
Degree in Dentistry.

Dr. Noor Haider Fadhel

May, 2023

I
 Dedication
I dedicate this project to all the people that helped me through this part of
my life even with a small gesture.

To my beloved family, they stood by me in all the good and bad times
and provided me the ability to continue studying with the highest quality.

To my friends for being with me inside and outside the college and did
their best to cheer me when I felt down.

II
 Acknowledgement
Firstly and before anyone else, I’m so thankful to ALLAH, the almighty,
for providing me the strength, patience and all blessings that made me
who I am and being able to complete this work.

I want to express my thanks and respect to “Dr. Raghad Abdul-Razaq

Al-Hashimy”, Dean of the Collage of Dentistry, University of Baghdad
for his support to the research student’s program.

I would like to thank “Dr. Anas Falah Mahdee”, the head of

Conservative and Aesthetic Dentistry for its scientific support,
encouragement and advice.

I would like to give my special deep thanks to my supervisor “Dr. Noor

Haider Fadhel”, who has been kind to me, gave away from her time to
answer my questions and supported me. It was a great honor to work
under her guidance.

Finally, I want to express my gratitude to all the seniors that nourished

my mind with great information and tips about Dentistry.

III
 Table of content
Title no. Title Page no.

Certification of the Supervisor I

Dedication II
Acknowledgment III
List of contents IV
List of figures VI
Introduction 1
Aim of the Study 2

Chapter one: Review of Literature

1.1 What is an Endodontic Emergency? 4

1.2 Differentiation of Emergency & Urgency 5

1.3 Treatment Planning 6

1.4 Patient Management 7

1.5 Profound Anesthesia 7

1.6 Categories of Endodontic Emergencies 8

1.6.1 Pretreatment Emergencies 8

1.6.1.a Teeth with vital pulps 9

1.6.1.b Necrotic teeth with symptomatic apical 12

periodontitis

IV
 1.6.1.c Pulpal necrosis with acute apical abscess 15

1.6.2 Inter-appointment Emergencies 17

1.6.2.a Causative Factors 17

1.6.2.b Prevention 18
1.6.2.c Treatment of Flare-Ups 19

1.6.3 Postobturation Emergencies 24

1.6.3.a Causative Factors 24

1.6.3.b Treatment 25
1.7 Drainage 27

1.8 Leaving teeth open 29

1.9 Cracked and fractured teeth 31

Chapter Two
Conclusion 34

References 35

V
 List of Figures
Figure title Page No.
Fig. 1.1 Trephination 14

Fig. 1.2 Drainage of pus through the root canal. 16

Fig. 1.3 Management of pulp necrosis with acute apical 21
abscess with localized intraoral swelling
Fig. 1.4 Management of pulp necrosis with acute apical 22
abscess with localized intraoral swelling
Fig. 1.5 Management of pulp necrosis with acute apical 23
abscess with diffused extraoral swelling
Fig. 1.6 Simplified analgesic strategy to guide drug selection 26
based on patient history and level of present Or anticipated
posttreatment pain
Fig. 1.7 Drainage 27
Fig. 1.8 After opening into the root canal and establishment 28
of drainage, instrumentation should be confined to the root
canal system.
Fig. 1.9 Types of rubber drains 28
Fig. 1.10 Nonvital infected tooth with active drainage from 29
the Periapical area through the canal.
Fig. 1.11 Foreign object in tooth left open to drain. 30
Fig. 1.12 Cracked teeth detection. 31
Fig. 1.13 Checking the prognosis of the tooth. 32

VI
 Introduction
All dentists and endodontists must be able to manage patients who present
with a dental emergency. Emergencies usually involve pain as a result of
inflammation, but they can also involve swelling and other signs of infection. The
aim of this review is to provide an overview of endodontic emergencies.In this
review, the term ‘endodontic treatment’ has been used to include all possible
treatments for pulp, root canal and periradicular conditions—these include indirect
pulp capping, direct pulp capping, partial pulpotomy, pulpotomy, pulpectomy
with root canal treatment, root canal re-treatment and periradicular surgery. The
term ‘root canal treatment’ has been used to specifically refer to pulpectomy and its
associated procedures to clean, disinfect and fill the root canals (Abbott, 2022).

1
 Aims of the Study
This aim of this review about endodontic emergencies is to improve
the management and prevention of acute endodontic problems, which can
cause significant pain and discomfort for patients. By investigating the
prevalence and causes of endodontic emergencies, researchers can develop
effective treatment strategies that address the underlying causes of these
problems. Furthermore, by evaluating the impact of endodontic
emergencies on patient quality of life, researchers can highlight the
importance of prompt and effective management of these conditions in
order to improve patient outcomes.

2
 Chapter One
Review of Literature

3
 Chapter one
Review of Literature

1.1 What is an Endodontic Emergency?

An endodontic emergency can be defined as occurring When a patient has
pain associated with inflammation of the pulp and/or periradicular tissues, or when
there is pain (with or without swelling) caused by infection of the root canal system
and/or the periradicular tissues. This description is somewhat broader than that
proposed by Wolcott et al. (2011) and used by Farmakis et al. (2016),

Where an endodontic emergency was defined as “pain And/or swelling

caused by inflammation or infection of the pulp and/or periapical tissues”.
However, their definition is limited since it does not include teeth that do not have
pulps (e.g. a tooth with a pulpless infected root canal system; a tooth with a root
canal filling, etc.), and it does not include all of the periradicular tissues (e.g. acute
lateral periodontitis associated with a lateral canal or with a tooth that has external
lateral inflammatory resorption) (Abbott, 2022).

Hence, the above broader description is proposed as it is more

comprehensive and representative of all possible emergencies that may occur as a
result of endodontically related conditions.There are many different causes of
dental pain, but the Most common will be associated with dental caries, defective
Restorations and trauma to a tooth (Abbott, 2022).

4
1.2 Differentiation of Emergency & Urgency
Whether a pretreatment, interappointment, or postobturation problem, it is
important to differentiate between a true emergency and the less critical urgency. A
true emergency is a condition requiring an unscheduled office visit with diagnosis
and treatment now! The visit cannot be rescheduled because of the severity of the
problem. Urgency indicates a less severe problem; a visit may be scheduled for
mutual convenience of the patient and the dentist. Key questions (that may be
asked by telephone) to determine severity include the following: (Mahmoud
Torabinejad et al., 2021)

1. Does the problem disturb your sleeping, eating, working, concentrating, or other
daily activities? (A true emergency disrupts the patient's activities or quality of
life.)

2. How long has this problem been bothering you? (A true emergency has rarely
been severe for more than a few hours to 2 days).

3. Have you taken any pain medication? Was the medication ineffective?
(Analgesics do not relieve the pain of a true emergency.)

An affirmative answer to these questions requires an immediate office visit

for management and constitutes a true emergency. Obviously, the patient's
emotional and mental status must also be determined. To some patients, even a
minor problem has major proportions and is disruptive (Mahmoud Torabinejad et
al., 2021).

5
1.3 Treatment Planning
Inflammation and its consequences, that is, increased tissue pressure and
release of chemical mediators in the pulp or peri-radicular tissues, are the major
causes of painful dental emergencies. Therefore, reducing the irritant, or reduction
of pressure or removal of the inflamed pulp or peri-radicular tissue should be the
immediate goal; this usually results in pain relief. Of the two, pressure release is the
most effective (Torabinejad, 1994).

Because pain is both a psychological and biologic entity, the management of

acute dental pain must take into consideration both the physical symptoms and the
emotional status of the patient. The patient’s needs, fears, and coping mechanisms
must be compassionately understood. This assessment and the clinician’s ability to
build rapport with the patient are critical factors (Bender, 2000).

Once it has been determined that endodontic treatment is necessary, it is

incumbent on the clinician to take the proper steps necessary to manage the acute
dental emergency. The clinician has a responsibility to inform the patient of the
recommended treatment plan and to advise the patient of the treatment alternatives,
the risks, and benefits that pertain, and the expected prognosis under the present
circumstances. Given this information, the patient may elect extraction over
endodontics or possibly request a second opinion. The treatment plan should
never be forced on a patient. The informed course of treatment is made jointly
between the patient and the clinician (Gatchel, 1992).
In the event of an endodontic emergency, the clinician must determine the
optimal mode of treatment according to the diagnosis. Treatment may vary
depending on the pulpal or periapical status, the intensity and duration of pain, and
whether there is diffuse or fluctuant swelling (Holmes-Johnson et al., 1986).

6
1.4 Patient Management
Patient anxiety is an important factor in achieving a satisfactory endodontic
outcome, especially at an emergency visit.

More than 200 studies indicate that preemptive behavioral intervention to

reduce anxiety before and after surgery reduces postoperative pain intensity and
intake of analgesics and accelerates recovery (Carr, 1999). A clinical study
determined that the higher the level of anxiety, as measured by a visual analogue
anxiety scale, the less likely it was that pain would be eliminated after
administration of a local anesthetics. A conversation with the patient prior to
treatment, in which the clinician discusses the pain-preventive strategy, including
the use of profound local anesthesia, is an important element of the therapeutic
approach (DiBernardi et al., 2009).

1.5 Profound Anesthesia

Achieving profound local anesthesia for teeth with irreversible pulpitis is
challenging and critical. Maxillary anesthesia is usually achieved by the use of
infiltration or block anesthesia in the buccal and palatal areas. If profound
anesthesia is defined as achieving the complete absence of pain, a single injection
for a mandibular molar is usually insufficient (Reader et al, 2011).

Intraosseous, ligamental, and intrapulpal injections are valuable

supplementary injections that can help achieve this goal. It is important to note that
a numb lip is not adequate proof of complete local anesthesia. The clinician is
advised to recheck the chief complaint prior to initiating treatment. Absence of the
chief complaint, whether it is thermal sensitivity or pain on percussion, is the best
means of determining profound anesthesia (Reader et al. 2011).

7
1.6 Categories of Endodontic Emergencies:
Endodontic emergencies have been classified in several ways by various
authors, but a common system has been to consider endodontic emergencies in
relation to the timing of root canal treatment (Carrotte, 2004), such as:

1. Endodontic emergencies that occur prior to endodontic treatment—this

applies to teeth that have not had any previous endodontic treatment;(Abbott,
2022).

2. Endodontic emergencies that occur during endodontic treatment (usually root

canal treatment or root canal retreatment)—this applies to teeth undergoing
treatment over more than one appointment; these emergencies are often referred to
as a “flare-up” (Azim et al., 2017); and

3. Endodontic emergencies that occur after endodontic treatment—this applies

either to post-operative pain following the root canal filling stage of treatment or to
teeth that have had previous root canal treatment at some time in the past and have
become infected again which has led o acute apical periodontitis or an acute apical
abscess (Abbott, 2022).

1.6.1 Pre-treatment Emergencies:

These are situations in which the patient is seen initially with severe pain
and/or swelling. Problems occur with both diagnosis and treatment. These
emergencies require a diagnosis and treatment sequencing. Each step is important:
(Mahmoud Torabinejad et al., 2021)

1. Categorizing the problem,

2. Taking a medical history,
3. Identifying the source,

8
 4. Making the diagnosis,
5. Planning the treatment,
6. Treating the patient.

Usually, such emergencies are accompanied by a high level of patient

anxiety, which can further complicate diagnosis and treatment.Teeth that cause
pretreatment emergencies may be associated with irreversible pulpitis and/or
symptomatic periodontitis or pulp necrosis with or without apical pathosis and
swelling. Swelling may be localized or diffused. Each of these situations requires a
somewhat different clinical approach based on biologic considerations
(Torabinejad and Walton, 1991).

1.6.1.a Teeth with vital pulps can have one of the following presentations:
(Louis and Kenneth, 2021)

• Normal: The teeth are asymptomatic with no objective pathoses.

• Reversible pulpitis: There is a reversible sensitivity to cold or osmotic
changes (i.e., sweet, salty, and sour).
• Irreversible pulpitis: The sensitivity to temperature changes is more intense
and with a longer duration.
• Reversible pulpitis

Reversible pulpitis can be induced by caries, exposed dentin, recent dental

treatment, and defective restorations. Conservative removal of caries, protection of
dentin, and a proper restoration will typically resolve the symptoms. However, the
symptoms from exposed dentin, specifically from gingival recession and cervically
exposed roots, can often be difficult to alleviate. Topical applications of
desensitizing agents and the use of certain dentifrices have been helpful in the
management of dentin hypersensitivity (Louis and Kenneth, 2021).

9
 • Irreversible pulpitis

Irreversible pulpitis is often the result of inflammation of the pulp due to a

microbial insult from caries or microleakage associated with a defective
restoration. Exacerbation of a tooth with irreversible pulpitis is characterized by
pain, which may be severe. The pain may occur with or without provocation and
tends to increase in severity. A pulp with irreversible pulpitis is usually free of
bacterial colonization in the root canal. Infection is most often confined to the
coronal site of the pulp that is exposed to the oral cavity. As long as the radicular
pulp remains vital, it usually protects itself against microbial invasion and
colonization (Siqueira, 2005) .

It has been demonstrated that removal of the pulp from the pulp chamber
(pulpotomy) is a highly predictable approach to alleviating pain at an emergency
visit (Hasselgren and Reit, 1989).

Since the early 1980s, there seems to have been an increase in the
acceptability of providing endodontic therapy in one visit, especially in cases of
vital pulps, with most studies revealing an equal number, or fewer, flareups after
single-visit endodontic treatment (Eleazer and Eleazer, 1998;Oliet, 1998).

However, this has not come without controversy, with some studies showing
otherwise, contending that there is more posttreatment pain after single-visit
endodontics, and possibly a lower long-term success rate (Weiger et al., 1998).
Unfortunately, time constraints at the emergency visit often make the single-visit
treatment option not practical (Ashkenaz, 1984).

If root canal therapy is completed at a later date, medicating the canal with
calcium hydroxide has been suggested to reduce the chances of bacterial growth in
the canal between appointments in most studies (Chong and Pitt Ford, 1992).

10
 One randomized clinical study showed that a dry cotton pellet was as
effective in relieving pain as a pellet moistened with camphorated
monochlorophenol (CMCP), metacresylacetate (cresatin), eugenol, or saline
(Hasselgren and Reit, 1989). Sources of infection, such as caries and defective
restorations, should be completely removed to prevent recontamination of the root
canal system between appointments (Hasselgren and Reit, 1989).

For emergency management of vital teeth that are not initially sensitive to
percussion, occlusal reduction has not been shown to be beneficial (Gatewood et
al., 1990).

However, the clinician should be cognizant of the possibility of occlusal

interferences and prematurities that might cause tooth fracture under heavy
mastication. In vital teeth in which the inflammation has extended periapically,
which will present with pretreatment pain to percussion, occlusal reduction has
been reported to reduce posttreatment pain (Gatewood et al., 1990;Nusstein et al,.
1998;Rosenberg et al,. 1998).

Antibiotics are not recommended for the emergency management of

irreversible pulpitis (Keenan et al, 2006;Sutherland and Matthews, 2003) as
placebo-controlled clinical trials have demonstrated that antibiotics have no effect
on pain levels in patients with irreversible pulpitis (Nagle et al., 2000).

Most endodontists and endodontic textbooks recommend the emergency

management of symptomatic irreversible pulpitis to involve the initiation of root
canal treatment,(Chong and Pitt Ford, 1992;Hasselgren, 2000;Lee et al,
2009;Torabinejad and Walton, 2009), with complete pulp removal and total
debridement of the root canal system. Unfortunately, in an emergency situation, the
allotted time necessary for this treatment is often an issue. Given the potential time

11
constraints and inevitable differences in skill level between clinicians, it may not be
feasible to complete the total canal cleaning at the initial emergency visit.
Subsequently, especially with multirooted teeth, a pulpotomy (removal of the
coronal pulp) has been advocated for emergency treatment of irreversible pulpitis
(Carrotte ,2004;Hasselgren, 2000).

1.6.1.b Necrotic teeth with symptomatic apical periodontitis

Over the years, the proper methodology for the emergency endodontic
management of necrotic teeth has been controversial. In a 1977 survey of board-
certified endodontists, it was reported that, in the absence of swelling, most
respondents would completely instrument the canals, keeping the file short of the
radiographic apex. However, when swelling was present, the majority of those
polled in 1977 preferred to leave the tooth open, with instrumentation extending
beyond the apex to help facilitate drainage through the canals (Dorn SO et al.,
1977).

Years later and again validated in a 2009 study, most respondents Favored
complete instrumentation regardless of the presence of swelling. Also, it was the
decision of 25.2% to 38.5% of the clinicians to leave these Teeth open in the event
of diffuse swelling; 17.5% to 31.5% left the teeth Open in the presence of a
fluctuant swelling. However, as discussed later, There is currently a trend toward
not leaving teeth open for drainage. There is Also another trend: when treatment is
done in more than one visit, most Endodontists will use calcium hydroxide as an
intracanal medicament (Lee et al., 2009).

Care should be taken not to push necrotic debris beyond the apex during root
canal instrumentation, as this has been shown to promote more posttreatment

12
discomfort (Gatewood et al., 1990;Reddy and Hicks, 1998;Siqueira and Rocas,
2003).

Crown-down instrumentation techniques have been shown to remove most of

the debris coronally rather than pushing it out the apex. The use of positive-
pressure irrigation methods, such as needle-and-syringe irrigation, also poses a risk
of expressing debris or solution out of the apex (Boutsioukis et al, 2014;Desi and
Himel, 2009).

Improvements in technology, such as electronic apex locators and use of the

limited cone-beam computed tomography (CBCT) have facilitated increased
accuracy in determining working length measurements (Metka et al., 2014).

Moreover, new negative-pressure irrigation systems may allow for a more

thorough canal debridement with less apical extrusion of debris (Charara et al.,
2016;Mitchell et al., 2010).

An outcome study indicated that the use of a negative apical pressure

irrigation device significantly reduces the postoperative pain levels in comparison
to conventional needle irrigation (American Association of Endodontics, 2003).

A randomized clinical trial demonstrated final irrigation with 20 mL sterile

cold (2.5°C) saline solution delivered to the working length with a sterile, cold
(2.5°C) EndoVac microcannula (Kerr Endo, Orange Country, CA) for 5 minutes.
They concluded that cryotherapy reduced the incidence of postoperative pain and
the need for medication in patients presenting with a diagnosis of necrotic pulp and
symptomatic apical periodontitis (Vera et al., 2018).

13
 • Trephination

In the absence of swelling, trephination is the surgical perforation of the

alveolar cortical plate to release, from between the cortical plates, the accumulated
inflammatory and infective tissue exudate that causes pain. Its use has been
historically advocated to provide pain relief in patients with severe and recalcitrant
periradicular pain (Dorn et al., 1977).

The technique involves an engine-driven perforator entering through the

cortical bone and into the cancellous bone, often without the need for an incision,
in order to provide a pathway for drainage from the periradicular tissues(as we see
in fig 1.1),(Chestner et al., 1986).

Although more recent studies have failed to show the benefit of trephination
in patients with irreversible pulpitis with symptomatic apical periodontitis (Moos et
al., 1996) or necrotic teeth with symptomatic apical periodontitis, (Nusstein et al
.,1998). there remain some advocates who recommend trephination for managing
acute and intractable periapical pain (Henry and Fraser, 2003).

A B C

Fig.1.1 Trephination. A, Surgical

window into cyst. B, Healed surgical
window. C, Acrylic stint in place for
decompression. (Courtesy Dr. Craig).

Baumgartner.

14
 The clinician should understand that local anesthesia may be difficult for
cases with acute inflammation or infection. Extreme care must be taken when
carrying out a trephination procedure to guard against inadvertent and possibly
irreversible injury to the tooth root or surrounding structures, such as the mental
foramen, intra-alveolar nerve, or maxillary sinus (Horrobin et al., 1997).

• Necrosis and single-visit endodontics

Although single-visit endodontic treatment for teeth diagnosed with

irreversible pulpitis is not contraindicated, (Albahaireh and Alnegrish,
1998;Peters and Wesselink, 2005;Weiger et al., 2000), performing single-visit
endodontics on necrotic and previously treated teeth is not without controversy. In
cases of necrotic teeth, although research has indicated that there may be no
difference in posttreatment pain if the canals are filled at the time of the emergency
versus a later date, (Eleazer and Eleazer, 1998) some studies 105,112 have
questioned the long-term prognosis of such treatment, especially in cases of
symptomatic apical periodontitis (Sjogren et al., 1997). Several studies, (Field et
al., 2004;Kvist et al 2004) including a CONSORT (Consolidated Standards of
Reporting Trials) meta-analysis, have shown no difference in outcome between
single-visit and two-visit treatments (Penesis et al., 2008).

1.6.1.c Pulpal necrosis with acute apical abscess

Tissue swelling may be associated with an acute apical abscess at the time of
the initial emergency visit, or it may occur as an inter-appointment flare-up or as a
postendodontic complication. Swellings may be localized or diffuse, fluctuant or
firm. Localized swellings are confined within the oral cavity, whereas a diffuse
swelling, or cellulitis, is more extensive, spreading through adjacent soft tissues
and dissecting tissue spaces along fascial planes (Sandor et al., 1998).

15
 Swelling may be controlled by establishing drainage through the root canal
or by incising the fluctuant swelling. Antibiotics may be recruited when there are
systemic manifestations of the infection, such as fever and malaise. The principal
modality for managing swelling secondary to endodontic infections is to achieve
drainage and remove the source of the infection (Harrington and Natkin, 1992).

Fig.1.2 Drainage of pus through the root canal. A, Acute apical

Abscess arising from the lower right lateral incisor with
radiographic Radiolucency. B, Initial drainage through the canal.
C, Persistent Drainage through the canal. D, Aspiration of the
content with a plastic Suction tip. E, Irrigation with NaOCl. F,
Mechanical debridement. G, Placement of calcium hydroxide. H,
Obturation of root canals during second visit.( Pathways of the
pulp 12th edition).

When the swelling is localized, the preferred avenue is drainage through the
root canal (see Fig 1.2). Complete canal debridement and disinfection (Turkun
and Cengiz, 1997) are paramount for success regardless of observable drainage,
because the presence of any bacteria remaining within the root canal system will
compromise the resolution of the acute infection (Matusow and Goodall, 1983).

16
 In the presence of persistent swelling, gentle finger pressure to the mucosa
overlying the swelling may help facilitate drainage through the canal. Once the
canals have been cleaned and allowed to dry, calcium hydroxide as the intracanal
medicament (Lee et al., 2009) should be placed and the access properly sealed
(Chong and Pitt Ford, 1992;Gatewood et al., 1990;Hasselgren, 2000).

1.6.2 Inter-appointment Emergencies

The interappointment flare-up is a true emergency that occurs after an

endodontic appointment and is so severe that an unscheduled patient visit and
treatment are required. Despite judicious and careful treatment procedures,
complications such as pain, swelling, or both may occur. Regional temporary
paresthesia has even been reported. As with emergencies occurring before root
canal therapy, these flare-ups are undesirable and disruptive events and must be
resolved quickly. Occasionally flare-ups are unexpected, although they can often be
better predicted according to certain patient presenting factors (Nyerere et al.,
2006).

1.6.2.a Causative Factors

Assessing causality is difficult when reviewing the literature on flareups;

however, certain risk factors have emerged. These factors generally can be
categorized as related to the patient (including pulpal or periapical diagnosis).
Treatment procedures are unrelated to flareups, although this is a popular belief.
Patient factors include gender (more flare-ups are reported to occur in females,
although this circumstance may represent a greater tendency for females to seek
medical care for painful symptoms) (Dao and LeResche, 2000) and preoperative
diagnosis. Flare-ups are uncommon in teeth with vital pulps (Walton and Fouad,
1992;Sim, 1997).

17
 More often, flare-ups occur in teeth with necrotic pulps, and especially in
those with a periapical diagnosis of symptomatic periapical periodontitis or acute
apical abscess (Walton and Fouad, 1992;Sim, 1997;Imura and Zuolo, 1995).
The presence of a periapical radiolucency has also been shown to be a risk factor
(Walton and Fouad, 1992;Imura and Zuolo, 1995), Clearly, the patient who
experiences a flare-up is more likely to have presented with significant preoperative
pain and/or swelling (Trope, 1991).

Treatment factors have also been examined for the potential to cause flare-
ups. Although it would seem intuitive that flare-ups would be related to certain
procedures, such as overinstrumentation, pushing debris beyond the apex, or
completing the endodontic therapy in one visit, no definitive treatment risk factors
have been identified (Genet et al., 1987).

1.6.2.b Prevention

• Procedures

Use of long-acting anesthetic solutions, complete cleaning and shaping of the

root canal system (possibly), analgesics, and psychological preparation of patients
(particularly those with preoperative pain) will decrease interappointment
symptoms in the mild to moderate levels. There are, however, no demonstrated
treatment or therapeutic measures that will reduce the number of interappointment
flare-ups. In other words, no particular relationship has been shown between flare-
ups and specific treatment procedures (Torabinejad et al., 1994).

• Therapeutic Prophylaxis

A popular preventive approach has been the prescribing of antibiotics to

minimize postoperative symptoms. This practice has been demonstrate to be not
useful and needlessly exposes the patient to expensive, potentially dangerous drugs,

18
as described previously (Eleazer and Eleazer, 1998;Walton and Chiappinelli,
1993;Pickenpaugh et al., 2001).

In contrast, certain NSAIDs have been shown to reduce postendodontic

treatment pain. For patients at risk for a flare-up, 400-600 mg of ibuprofen should
be given while the patient is in the chair, and then taken by the clock for the first 24
to 48 hours postoperatively. Although this medication will reduce postoperative
symptoms, it is uncertain whether it will reduce the incidence of flare-ups (Menke
et al., 2000;Gopikrishna and Parameswaran, 2003).

1.6.2.c Treatment of Flare-Ups

Reassurance (the “Big R”) is the most important aspect of treatment. The
patient is generally frightened and upset and may even assume that extraction is
necessary. The explanation is that the flare-up is neither unusual nor irrevocable
and will be managed. Next in importance are restoring the patient’s comfort and
breaking the pain cycle. For extended anesthesia and analgesia, administration of
bupivacaine hydrochloride is recommended (Gordon et al., 1997).

• Previously Vital Pulps with Complete Debridement

If complete removal of the inflamed vital pulp tissues was accomplished at

the first visit, this situation is unlikely to be a true flare-up, and patient reassurance
and the prescription of a mild to moderate analgesic (9.5) often will suffice.
Generally, nothing is to be gained by opening these teeth; the pain will usually
regress spontaneously, but it is important to check that the temporary restoration is
not in traumatic occlusion. Placing corticosteroids in the canal or administering an
intraoral or intramuscular injection of these medications after cleaning and shaping
reduces inflammation and somewhat lowers the level of moderate pain. Flareups,

19
however, have not been shown to be prevented by steroids, whether administered
intracanal or systemically (Calderon, 1993;Liesinger et al., 1993).

• Previously Vital Pulps with Incomplete Debridement

In previously vital pulps with incomplete debridement, it is likely that tissue

remnants have become inflamed and have become a major irritant. The working
length should be rechecked, and the canal(s) should be carefully cleaned with
copious irrigation with NaOCl. A dry cotton pellet is then placed, followed by a
temporary restoration, and a mild to moderate analgesic is prescribed.
Occasionally, a previously vital pulp (with or without complete debridement) will
develop into an acute apical abscess. This problem will occur sometime after the
appointment and indicates that pulpal remnants have become necrotic and are
invaded by bacteria (Trope, 1990).

• Previously Necrotic Pulps with No Swelling

Occasionally teeth with previously necrotic pulps but no swelling develop an

acute apical abscess (flare-up) after the appointment. The abscess is confined to
bone and can be very painful. The tooth is opened, and the canal is gently recleaned
and irrigated with NaOCl. Drainage should be established if possible (see Fig.1.3).
If there is active drainage from the tooth after opening, the canal should be
recleaned (or debridement completed) and irrigated with NaOCl (Campanelli et
al., 2008). The rubber dam is left in place after the tooth is opened; the patient is
allowed to rest pain-free for at least 30 minutes or until drainage stops. Then, the
canals are dried, Ca(OH)2 paste is placed, and the access is sealed. The tooth
should not be left open, If there is no drainage, the tooth should also be lightly
instrumented and gently irrigated, medicated with Ca(OH)2 paste, and then closed.
The symptoms usually subside but do so more slowly than if drainage were present.

20
Again, patient education and reassurance are critical. A long-acting anesthetic and
an analgesic regimen for moderate to severe pain are helpful; antibiotics are not
indicated (Fouad et al., 1996;Henry et al., 2001).

A B C

D E F G

Fig.1.3 Management of pulp necrosis with acute apical

abscess with localized intraoral swelling for a 60-year-old
female patient with pain at 5/5 on visual analog scale
(VAS). A, Preoperative radiograph of #7. B, Drainage
through tooth upon access. C, Radiograph of #7 with
calcium hydroxide [Ca(OH)2]. D, Preoperative photograph
of intraoral swelling. E, Photograph post–incision and
drainage. F, Postoperative Radiograph of completed
obturation and access restoration at second visit. G,
Postoperative radiograph at 2 years post treatment.
(Courtesy Dr. Obadah Austah, UTHSCSA, San Antonio,
TX, USA.)

21
 • Previously Necrotic Pulps with Swelling

These cases are best managed with I&D (see Fig. 1.4). In addition, it is most
important that the canals have been debrided. If not, they should be opened and
débrided, medicated with Ca(OH)2 paste, and sealed. Then I&D with placement of
a drain (if there is continuous drainage) are completed. Occasionally, but rarely, a
flare-up or a presenting acute apical abscess may be serious or even life-threatening
(see Fig. 1.5). These situations may require hospitalization and aggressive therapy
with the cooperation of an oral surgeon (Beus et al., 2018).
A B C D

E G H

Fig. 1.4 Management of pulp necrosis with acute apical abscess with
localized intraoral swelling for a 60-year-old female patient with pain at 5/5
on visual analog scale (VAS). A, Preoperative radiograph of #30 with sulcular
sinus tract. B, Preoperative photograph of intraoral swelling. C, Photograph of
incision. D, Blunt dissection. E, Postoperative radiograph of completed
obturation and access restoration at second visit. F, Curettage. G, Sterile saline
irrigation. (Courtesy Dr. Saeed Bayat, UTHSCSA, San Antonio, TX, USA.)

22
A Fig. 1.5 Management ofBpulp necrosis with acute apical abscess C with diffused
extraoral swelling for a 43-year-old male patient hospitalized for aggressive
therapy with nasal intubation. Pain at 5/5 on visual Analog scale (VAS). A,
Preoperative photograph of extraoral swelling. B, Photograph of syringe aspiration.
C and D, Drainage. E, Postoperative photograph of two drains placed and sutured.
F, Types of extraoral Drains: Covidien Dover Rob-Nel Urethral Catheter and
Penrose drain. (Courtesy Dr. Daniel Perez, UTHSCSA, San Antonio, TX, USA.)

D E F

23
1.6.3 Postobturation Emergencies

True emergencies (flare-ups) postobturation are infrequent, although pain at

the mild level is common. Therefore active intervention is seldom necessary;
usually symptoms will resolve spontaneously. It has been demonstrated
histologically that the most favorable response of periapical tissues occurred when
both instrumentationmand filling were short of the apical constriction (Ricucci and
Langeland, 1998).

A clinical study found that the best treatment outcome in infected teeth with
periradicular lesions occurred when the apical terminus of the filling was 0 to 2 mm
short of the radiographic apex.The same study determined that the prognosis was
less favorable with significant underfill or overfill (Sjogren et al., 1990).

1.6.3.a Causative Factors

Little is known about the etiologic factors involved in postoperative pain

after obturation. Reports of the incidence of postobturation pain vary; however,
most reports show that the pain tends to occur in the first 24 hours (Torabinejad et
al., 1994).

A correlation has been found between the level of obturation and pain
incidence, with overextension associated with the highest incidence of discomfort
(Torabinejad et al., 1994).

Postobturation pain also relates to preobturation pain; levels of pain reported

after obturation tend to correlate to levels of pain before the appointment (Gesiet
al., 2006).

24
1.6.3.b Treatment

Information about possible discomfort for the first few days (especially in
patients who had higher levels of preoperative pain), reassurance about the
availability of emergency services, and administration of analgesics for mild pain
(see Fig.6) significantly control the patient’s anxiety and prevent overreaction. This
support, in turn, decreases the incidence of postobturation frantic telephone calls or
“emergency” visits. Some patients, however, do develop serious complications and
require follow-up treatment. Retreatment is indicated when prior treatment
obviously has been inadequate. Apical surgery is often required when an acute
apical abscess develops, and there is uncorrectable, inadequate root canal treatment.
If root canal treatment was acceptable, I&D of swelling after obturation (an
occasional occurrence) should be performed; usually the swelling resolves without
further treatment. At times, the patient reports severe pain, but there is no evidence
of acute apical abscess, and the root canal treatment has been well done. These
patients are treated with reassurance and appropriate analgesics (see Fig. 1.6);
again, the symptoms usually subside spontaneously. Patients with postobturation
emergencies that do not respond to therapy should be referred to an endodontist for
other treatment modalities, such as surgery (Torabinejad and Walton, 1991).

25
Fig. 1.6 Simplified analgesic strategy to guide drug
selection based on patient history and level of
present Or anticipated posttreatment pain (Endo
principles).

26
1.7 Drainage
Drainage of pus from an abscess can speed recovery (see Fig. 1.7 and 1.8).
The removal of dead lymphocytes and a preponderance of dead bacteria from the
center of an infection can bring rapid resolution of symptoms and head off
worsening of the infection. Return of local vascular flow aids the process of
reaching and maintaining antibiotic levels and also reduces local tissue acidity,
enhancing the action of local anesthetics. Chronic drainage by way of a sinus tract
sharply reduces the occurrence of flare-up because of drainage. Surgical drainage
can be quite helpful in treating infections. An in-dwelling drain to prevent
premature closure of the epithelium is indicated in many situations (see Fig. 1.9).
Foreign bodies and larger amounts of necrotic tissue may call for surgical removal
(Marshall and al Naqqbi, 2009).

A B

Fig. 1.7 Drainage. A, Localized swelling. B, Incision for drainage after

Cleaning and shaping of the offending incisor. (Courtesy Dr.
E.Rivera.)

27
 Fig. 1.8 After opening into the root canal
and establishment of drainage,
instrumentation should be confined to the
root canal system. Release of purulence
removes a potent irritant (pus) and relieves
pressure (Endodontics Principles and
Practice).

Mohammadi and Abbott advocate use of this approach to prevent the tissue
damage characteristic of disinfectants inadvertently introduced into the periapex
(Mohammadi and Abbott, 2009).

Fig. 1.9 Types of rubber drains. Left to right, I drain,

Christmas tree drain, T drain, and Penrose drain with oblique
cuts. These drains are self-retentive and do not require
suturing to the incision margins (Endodontics Principles
and Practice).

28
1.8 Leaving teeth open
On rare occasions, canal drainage may continue from the periapical spaces
(See Fig. 1.10). In these cases, the clinician may opt to step away from the patient
for some time to allow the drainage to continue and hopefully resolve on the same
treatment visit (Torabinejad and Walton, 2009).

Fig. 1.10 Nonvital infected tooth with active drainage

from the Periapical area through the canal. A, Access
opened and draining for 1 Minute. B, Drainage after 2
minutes. C, Canal space dried after 3 Minutes (Pathways
of the pulp 12th edition).

Historically, in the presence of acutely painful necrotic teeth with no

swelling or diffuse swelling, 19.4% to 71.2% of surveyed endodontists would leave
the tooth open between visits (Dorn et al., 1977;Dorn et al., 1977).

29
 However, the more current literature makes it clear that this form of
treatment would impair uneventful resolution and create a more complicated
procedure (Auslander, 1970;Bence et al., 2000;Weine et al., 1975).

For this reason, leaving teeth open between appointments is not

recommended. Foreign objects have been found in teeth left open for drainage (see
Fig. 1.11). There has even been a documented case report of a foreign object being
found to enter the periapical tissues through a tooth that had been left open for
drainage. In addition, leaving a tooth open provides an opportunity for oral
microorganisms to invade and colonize the root canal system if the tooth is left
open for an extended period (Simon et al., 1982).

Fig. 1.11 Foreign object in tooth left open

to drain. Patient used a Sewing needle to
clear out food particles that were blocking the
canal and broke the needle in the tooth
(Pathways of the pulp 12th edition)

30
1.9 Cracked and fractured teeth
Cracks and incomplete fractures can be challenging to locate and diagnose,
but their detection can be an essential component in the management of an acute
dental emergency. In the early stages, cracks are small and difficult to discern.
Removal of filling materials, applications of dye solutions, selective loading of
cusps, transillumination, and magnification are helpful in their detection (see Fig.
1.12). As the crack or fracture becomes more extensive, it can become easier to
visualize. Because cracks are difficult to find and their symptoms can be so
variable, the name cracked tooth syndrome has been suggested, even though it is
not indeed a syndrome (Cameron, 1976).

Fig. 1.12 Cracked teeth detection. A, Preoperative

radiograph. B, Transillumination (Pathways of the
pulp 12th edition)

Cracks in vital teeth often exhibit a sudden and sharp pain, especially during
mastication. Cracks in nonvital or obturated teeth tend to have more of a “dull
ache” but can still be sensitive to mastication (Cameron, 1976).

31
 The determination of the presence of a crack or fracture is paramount
because the prognosis for the tooth may be directly dependent on the extent of the
crack or the longitudinal fracture. Management of cracks in vital teeth may be as
simple as a bonded restoration or a full coverage crown. However, even the best
efforts to manage a crack may be unsuccessful, often requiring endodontic
treatment or extraction. Fractures in nonvital or obturated teeth may be more
challenging. In addition, it must be determined whether the crack or fracture was
the cause of pulpal necrosis and whether there has been an extensive periodontal
breakdown. If so, the prognosis for the tooth is generally poor; thus, extraction is
recommended (see Fig. 1.13), (Cameron, 1976).

Fig. 1.13 Checking the prognosis of the tooth. A,

Preoperative radiograph. B, Clinical view. C,
Transillumination. D, Extracted tooth showing the
extension of them Stained longitudinal fracture
(Pathways of the pulp 12th edition).

32
Chapter Two
Conclusion

33
 Chapter Two
Conclusion
1. Endodontic emergencies are a common presentation to general dentists and
specialist endodontists. The patients usually have significant pain that requires
immediate and comprehensive management.

2. They are generally not something that can be managed quickly and this poses
several challenges to a busy dentist or endodontist.

3. Endodontic emergencies require considerable time to manage them predictably

so the patient and clinician can be confident that the pain will resolve very quickly.

4. The initial management should follow the principles of the 3-D’s—that is,
Diagnosis, Definitive dental treatment and Drugs—in that sequence. If these
principles are followed, then the presenting problem and the pain are highly likely
to resolve to a point where further treatment can be continued when it is convenient
for both the patient and the dentist or endodontist.

5. Once the initial treatment has been provided, the principles of the 3R’s should
then be followed—that is, Review, Reassess and Reconsider. In most cases, only
the first “R” will be required as the pain will usually resolve if appropriate and
comprehensive treatment has been provided. However, if the pain has continued, or
subsequently returned at a later time, then reassessment of the new problem must
be undertaken so that the management can be reconsidered in the light of the
revised diagnosis.

34
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