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Endodontic Emergencies

Ahmed Abuahimed

EE

Definition
By definition, endodontic emergencies are usually associated with pain and/or swelling and require immediate diagnosis and treatment. And they can result from infection or inflammation of the pulp or periradicular tissues.

Diagnosis
Complete medical and dental history, in addition to clinical and radiographic examinations are essential for correct diagnosis and management.
Siqueira JF (2010) Endodontic Emergencies of Infectious Origin Treatment of Endodontic Infections, 1st edn; pp. 363-79: Quintessence Publishing Co Ltd.

Diagnostic tools
EPT Thermal tests. Percussion. Palpation. Translumination. Radiographs.

Diagnostic tools
Review the patients chief complaint and select the test that is most appropriate to reproduce that complaint.
Abou-Rass M (1982) Endodontics. The endodontic emergency problem. Alpha Omegan 75, 18- 34.

Pain
A and C nerve fibers are responsible for pain sensation. A-fibers :
Fast, myelinated, sensitive to oxygen, and located the periphery of the pulp.

C-fibers :
Slow, unmyelinated, less sensitive to oxygen, located in the center.

Classification

Before

During

After

Classification

Pulpal

Periapical

Emergency vs. Urgency


Emergency visit
Urgency

Can not be rescheduled, due to the severity of symptoms.

Can be rescheduled, due to less severity of symptoms.

Purpose of treatment
Elimination of the causative factor. Reduction of pulpal and periapical pressure. Prevention of spread of infection. Pain control with analgesics if necessary.
Abou-Rass M (1982) Endodontics. The endodontic emergency problem. Alpha Omegan 75, 18- 34.

Treatment options
Pulpotomy. Pulpectomy. Incision and drainage. Trephination. Occlusal reduction.

Treatment options

Dorn SO, Moodnik RM, Feldman MJ, Borden BG (1977a) Treatment of the endodontic emergency: a report based on a questionnaire--part I. Journal of Endodontics 3, 94-100.

Treatment options
Preferred treatment was complete instrumentation. File location:
No swelling: short of the radiographic apex. Swelling: pass the apex

Majority tend to do occlusal reduction. With swelling, tendency to prescribe antibiotics and leave the tooth open. Analgesics were used in all emergency conditions.
Dorn SO, Moodnik RM, Feldman MJ, Borden BG (1977a) Treatment of the endodontic emergency: a report based on a questionnaire--part I. Journal of Endodontics 3, 94-100.

Treatment options

Gatewood RS, Himel VT, Dorn SO (1990) Treatment of the endodontic emergency: a decade later. Journal of Endodontics 16, 284-91.

Treatment options
A greater tendency toward complete instrumentation of the root canals to the apex regardless of the emergency condition. Dramatic decrease in the number of clinicians who leave the tooth open. Increase in the use of CaOH dressing.

Gatewood RS, Himel VT, Dorn SO (1990) Treatment of the endodontic emergency: a decade later. Journal of Endodontics 16, 284-91.

Treatment options

Lee M, Winkler J, Hartwell G, Stewart J, Caine R (2009) Current trends in endodontic practice: emergency treatments. Journal of Endodontics 35, 35-9

Before

SYMPTOMATIC IRREVERSIBLE PULPITIS

Diagnosis
Cold test is more predictable than EPT. The use of EPTs followed by thermal testing is a commonly recommended sequence of testing.
Dummer PMH, Hicks R, Huws D (1980) Clinical signs and symptoms in pulp disease. International Endodontic Journal 13, 2735.

Late irreversible pulpitis will be relieved by cold application due to contraction of the dentinal fluid decrease the pressure within the pulp rapid transient reduction of pain.
Cecic PA, Hartwell GR, Bellizzi R. Cold as a diagnostic aid in cases of irreversible pulpitis. Report of two cases. Oral Surg Oral Med Oral Pathol. 1983 Dec;56(6):647-50

Management
Pulpectomy
No time constraints. Can finish the RCT in one visit.

Pulpotomy
Time constraints or any other limiting factors. Multirooted teeth.

Analgesics are not recommended. Pain releife is mainly achieved by the removal of the inflamed pulpal tissues.
Keiser K (2003) Strategies for managing the endodontic pain patient. Texas dental journal 120, 250-7.

Management
Antibiotics are not recommended because the irreversibly inflamed pulp is still vital and able to resist bacterial infection, therefore, antibiotics do not help in relieving postoperative pain
Keenan JV, Farman AG, Fedorowicz Z, Newton JT (2006) A Cochrane systematic review finds no evidence to support the use of antibiotics for pain relief in irreversible pulpitis. Journal of Endodontics 32, 87-92

Before

NECROTIC PULP WITH APICAL PERIODONTITIS


With swelling Without

Diagnosis
Tooth is usually very sensitive to touch and patient reports the sensation that the tooth has grown up, due to the edema in the periodontal ligament.
Siqueira JF (2010) Endodontic Emergencies of Infectious Origin Treatment of Endodontic Infections, 1st edn; pp. 363-79: Quintessence Publishing Co Ltd.

Negative response to cold test and EPT.

Management
In the past, treatment would include complete instrumentation short of the radiographic apex if there is no swelling Dorn et al (1977a). Later, Gatewood et al. (1990) and Lee et al. (2009) favored complete instrumentation to the apex regardless of the presence of swelling. Care should be taken during cleaning and shaping not to push any debris beyond the apex, because this may cause postoperative discomfort.
Siqueira JF, Jr. (2003) Microbial causes of endodontic flare-ups. International Endodontic Journal 36, 453-63

Management
If associated with swelling:
Localized fluctuant swellings should be incised. Drainage can also be achieved through the canal. The incision provides a drainage passageway, not only for bacteria and their products but also for the inflammatory mediators associated with the spread of abscess and/or cellulitis (Siqueira 2010). Penicillin and amoxicillin are suitable antibiotics for treatment of endodontic infection when conventional root canal treatment alone is insufficient. Clindamycin could be advised for penicillinallergic patients with primary endodontic infections.
Skucaite N, Peciuliene V, Vitkauskiene A, Machiulskiene V (2010) Susceptibility of endodontic pathogens to antibiotics in patients with symptomatic apical periodontitis. Journal of Endodontics 36, 1611-6.

During

FLARE-UPS BETWEEN VISITS

What is it?
When patients experience significant pain and/or swelling within a few hours to a few days after an endodontic procedure, and the problem is of such severity that the patient will initiate contact with the dentist. The dentist then determines that the patient must be seen the same day and active treatment is rendered at that visit.
Walton R, Fouad A (1992) Endodontic interappointment flare-ups: a prospective study of incidence and related factors. Journal of Endodontics 18, 172-7

Incidence
3.17 %.
Walton R, Fouad A (1992) Endodontic interappointment flare-ups: a prospective study of incidence and related factors. Journal of Endodontics 18, 172-7

5.5 %
Barnett F, Tronstad L (1989) The incidence of flare-ups following endodontic treatment. Journal of Dental Research 68, 338

20 %
Morse DR, Koren LZ, Esposito JV et al. (1986) Endodontic flare-ups: induction and prevention, Part 2 : 1978-1983. International Journal of Psychosomatics 33, 18-30

Aetiology
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Figure 3: Bacterial, chemical, and physical irritants. Adopted from Walton (2002). Interappointment flare-ups: incidence, related factors, prevention, and management. Endodontic Topics 3, 67-76.

Aetiology

Hypotheses
Although the reasons for flare-ups are not always clear, a number of hypotheses may explain some of the etiological factors:
(a) alteration of the local adaptation syndrome; (b) changes in periapical tissue pressure; (c) microbial factors; (d) effects of chemical mediators; (e) changes in cyclic nucleotides; (f) immunological phenomena; and (g) various psychological factors.
Seltzer S, Naidorf IJ (2004) Flare-ups in endodontics: I. Etiological factors. Journal of Endodontics 30, 476-81

1. Alteration of the local adaptation syndrome


Connective tissues of the pulp and periapical area become inflamed when exposed to irritants. If irritants are not removed, the inflammation persists in the form of chronic inflammation. However, when a new irritant is introduced to the inflamed tissues, a violent reaction may occur (flare-up).
Selye H (1953) The part of inflammation in the local adaptation syndrome. Revue canadienne de biologie / editee par l'Universite de Montreal 12, 155-75

2.

Microbial factors

Sundqvist (1976) was able to isolate anaerobic bacteria, and found that, in teeth with painful symptoms, bacteroides melaninogenicus (an anaerobic, gramnegative rod) was present, while, in teeth without symptoms, there was no bacteroides melaninogenicus. Bacteroides melaninogenicus produces endotoxin 1.activate Hageman factor leads to production of bradykinin (potent pain mediator)
2.Activate alternate complement system C3 enhances the inflammatory process.
Sundqvist G (1976) Bacteriological studies of necrotic dental pulps. Umea Un. Odont Dissertations no 7, intro and summary.

3.

Chemical mediators

Chemical mediators include histamine, serotonin, prostaglandins, and lymphokines, all of which are capable of causing pain. These mediators are usually released during inflammation due to physical, chemical, or bacterial insults.

4.

Immunological factors:

In patients with acute symptoms, the level of circulating immune complexes are found to be almost three times greater than normal.
Kettering JD, Torabinejad M (1984) Concentrations of Immune complex, IgG, IgM, IgE, and C3 in patients with acute apical abscesses. Journal of Endodontics 10, 417

Following endodontic therapy, a reduction of circulating immune complexes, IgG and C3, was noted.

Management

Therapeutic management
For management of severe pain, a combination approach is the most effective. This combination was found to be effective in the management of emergency patients: flurbiprofen (100 mg loading +50 mg each 6h) and tramadol (100 mg each 6h).
Doroschak AM, Bowles WR, Hargreaves KM (1999) Evaluation of the combination of flurbiprofen and tramadol for management of endodontic pain. Journal of Endodontics 25, 660-3.

Therapeutic management
The systemic use of antibiotics should be restrained generally but appears to have some value when the patient exhibits signs of systemic involvement, such as cellulitis, fever, malaise, and toxemia. The overuse of antibiotics risks the induction of hypersensitivity or anaphylactic reactions, systemic side effects, and the development of resistant strains of microorganisms.
Seltzer S, Naidorf IJ (2004) Flare-ups in endodontics: II. Therapeutic measures. 1985. Journal of Endodontics 30, 482-8

Therapeutic management
Corticosteroid: Intramuscular injection of 4 mg of dexamethasone significantly reduced both the incidence and severity of pain 4 h after single-appointment endodontic therapy.
Marshall JG, Walton RE (1984) The effect of intramuscular injection of steroid on posttreatment endodontic pain. Journal of Endodontics 10, 584-8.

After

POST-TREATMENT FLARE-UPS

Aetiology
Post-treatment endodontic emergencies are infrequent; pain is usually mild to moderate, and can be associated with swelling. In addition, pain usually occurs in the first 24 hours after root canal treatment.
Torabinejad M, Dorn SO, Eleazer PD et al. (1994) Effectiveness of various medications on postoperative pain following root canal obturation. Journal of Endodontics 20, 427-31

Overextended root canal filling is associated with the highest rate of post-treatment discomfort.
Harrison JW, Baumgartner JC, Svec TA (1983) Incidence of pain associated with clinical factors during and after root canal therapy. Part 2. Postobturation pain. Journal of Endodontics 9, 434-8

Management
Reassurance of patients plays an important psychological role. Adjustment of high occlusal contacts. Fluctuant swelling should be incised and drained. Underfilled roots should be retreated. Overfilled teeth can be managed by analgesics, and if pain is persistent, retreatment is recommended. Periapical surgery is indicated if retreatment is not successful.
Torabinejad M, Walton RE (2009) Endodontic Emergencies and Therapeutics Endodontics Principles and Practice, 4th edn; pp. 148-62: Saunders Elsevier.

FREQUENTLY ASKED QUESTIONS

Open vs. Closed leave abscessed In the past, many endodontists would
teeth with swelling open (Dorn et al. 1977a, Dorn et al. 1977b). The number of endodontists who leave the tooth open has decreased dramatically over time (Gatewood et al. 1990). Leaving the tooth open may also introduce new bacteria to the root canal, causing secondary infection that can be hard to resolve.
Siren EK, Haapasalo MP, Ranta K, Salmi P, Kerosuo EN (1997) Microbiological findings and clinical treatment procedures in endodontic cases selected for microbiological investigation. International Endodontic Journal 30, 91-5.

Open vs. Closed


Even if the patient has presented to the emergency clinic with a previously opened tooth, it should be cleaned, disinfected and closed in the same appointment.
August DS (1977) Managing the abscessed tooth: instrument and close? Journal of Endodontics 3, 316-19. August DS (1982) Managing the abscessed open tooth: instrument and close--part 2. Journal of Endodontics 8, 364-6.

Weine FS, Healey HJ, Theiss EP (1975) Endodontic emergency dilemma: leave tooth open or keep it closed? Journal of Oral Surgery 40, 531-6.

Trephination
It is advocated to provide pain relief in patients with severe and unmanageable periradicular pain (Chestner et al. 1968, Dorn et al. 1977a, Dorn et al. 1977b).
Chestner SB, Selman AJ, Friedman J, Heyman RA (1968) Apical fenestration: solution to recalcitrant pain in root canal therapy. Journal of the American Dental Association 77, 846-8.

Recent reports show that pulpectomy with trephination can cause more pain than pulpectomy alone (Moos et al. 1996).
Moos HL, Bramwell JD, Roahen JO (1996) A comparison of pulpectomy alone versus pulpectomy with trephination for the relief of pain. Journal of Endodontics 22, 422-5

Occlusal reduction
Routine occlusal reduction to prevent postoperative pain and flare-ups is ineffective (Creech et al. 1984).
Creech JL, Walton RE, Kaltenbach R (1984) Effect of occlusal relief on endodontic pain. Journal of the American Dental Association 109, 64-7

However if there is pain on mastication, occlusal adjustment may help in reducing pain (Rosenberg et al. 1998).
Rosenberg PA, Babick PJ, Schertzer L, Leung A (1998) The effect of occlusal reduction on pain after endodontic instrumentation. Journal of Endodontics 24, 492-6