Endodontic Emergencies Introduction An emergency can be defined as a sudden, unforeseen event needing prompt action. Endodontic emergencies are usually associated with pain or swelling originating from the pulp or periapical area. These emergencies, are a challenge in both diagnosis and management. Knowledge and skill in several aspects are required; failure to apply these will result in disastrous consequences. Incorrect diagnosis and incorrect treatment will fail to relieve pain and in fact may aggravate the situation. The clinician must have knowledge of pain mechanisms, patient management, and appropriate treatment measure to both hard and soft tissues. Physiology of Dental Pain The sensory mechanism of the pulp is composed of sensory afferent and autonomic efferent systems. The afferent system conducts impulses perceived by the pulp from a variety of stimuli to the cortex of the brain, where they are interpreted as pain, regardless of the stimulus. The sensibility of dental pulp is controlled by the myelinated (A-delta fibres) and unmyelinated (C fibres) fibres.
- 20% of the nerves of the pulp
- 80% of the innervation
- Diameter – 2-5µm
- Conduction velocity – 6-30m/sec
- Distributed in the odontoblastic and Distributed throughout the pulp tissue subodontoblastic
are and are associated with pain due to
associated with dentinal pain
pulp tissue damage
- Impulses are intercepted as sharp and Conduct throbbing and aching pain pricking pain - Low threshold of excitability
Vitality tests - Electric
High threshold of excitability
A-delta fibres Positive (immediate)
C-fibres Negative ( except of high
levels of stimulation) - Cold (ice) Positive (immediate) Negative - Rapid heat (two Immediate first response Delayed second response phase response) (sharp, localized) (dull radiating) Slow and sustained Negative Positive (after 45°C to 47°C) heat The impulse travels from C or A-delta fibres nerve endings, through the plexus of Raschkow, to the nerve trunk in the central zone of the pulp. In the periapical area, the nerve trunk joins the maxillary or mandibular division of the fifth cranial nerve. Through the 5th cranial N. Pons Thalmus Cortex.
The hydrodynamic theory explains the painful reaction of the pulp to heat, cold, cutting of the dentin and probing of the dentin. Diagnosis Often a diagnostic decision concerning the pulpal status of a particular tooth with respect to endodontic treatment can be made before any clinical tests are performed. An immediate working diagnosis of either an irreversible disease state requiring immediate treatment or a reversible disease state requiring palliative treatment or observation can often be made based on symptoms alone. For example, if the patient reports a histroy of severe, spontaneous pain in a tooth for several days, an irreversible pulpitis is present that requires root canal treatment. However if the patient has had a recent restoration in the sensitive tooth or complains of a recent sensitivity to thermal changes, a more conservative approach is recommended. In general, a wait and watch approach is adopted when the following conditions are present: 1. Short term sensitivity or discomfort (several days or weeks). 2. A history of recent dental treatment, gingival recession, loss of restoration or possible fractured cusp. Definitive pulpal treatment is more
often indicated when these
conditions are present : 1. History of moderate to severe pain, with frequently recurring episodes of spontaneous pain, over long periods of time.
2. Painful symptoms are produced by specific stimuli, such as biting, touching, and hot or cold. The 3 clinical determinants required before instituting endodontic emergency treatment are : 1. Determine the presence or absence of pulp vitality. 2. Analyze the reaction of offending tooth to percussion. 3. Evaluate the radiograph. TREATMENT DIAGNOSIS CONSULT REFERRAL DATA EVALUATION RADIOGRAPHIC INTERPRETATION DIAGNOSIS TESTS PHYSICAL INSPECTION MEDICAL HISTORY DENTAL HISTORY PATIENT INTERACTION CHIEF COMPLAINT Assembling patient data provides the foundation for determining appropriate treatment of acute endodontic emergency. -
Subjective symptoms Pain
Objective symptoms Visual and tactile inspection Percussion Palpation Mobility and depressibility
Radiograph Electric pulp test Thermal tests Anesthetic test Test cavity Classification of Endodontic Emergencies I.
According to Walton or Torabinejad 1. Pretreatment emergencies 2. Inter appointment emergencies 3. Post obturation emergencies
According to Cohen 1. Thermal pain Before endodontic treatment 2. Percussion pain After initiation of endodontic treatment but Before canal obturation 3. Swelling After canal obturation 4. Spontaneous pain 5. Esthetic emergency
According to Gutmann Depending on the treatment plan.
A. Vital pulps
1. Reversible pulpitis 2. Irreversible pulpitis with localized symptoms 3. Irreversible pulpitis â€“ symptoms not localized. B. Necrotic pulps C. Acute alveolar abscess 1. Localized swelling 2. Diffuse swelling Grossman discussed endodontic emergencies under following headings : -
Acute reversible pulpitis
Acute irreversible pulpitis
Acute alveolar abscess
Acute periodontal abscess
Emergencies during treatment
Analgesics and antibiotics
Acute Reversible Pulpitis
Clinical characteristics -
Quick, sharp, shooting momentary tooth pain suggesting involvement of Adelta fibres.
Senstivity to mild discomfort.
Pain is tracable to stimulus such as cold water or a draft of air.
Causative factors -
Recent history of pulp capping
Incipient caries or rapidly advancing carious lesions.
Orthodontic tooth movement
History of trauma
Treatment Since the pulp is inflammed the removal of causative factors usually alleviates the patient discomfort. Sometimes-palliative treatment such as placement of a zinc-oxide eugenol cement as a temporary sedative filling is indicated. If the pain persists after several days, pulp tissue should be extirpated.
Hypersensitive Dentin Etiological factors Exposed dentinal tubules due to : -
Treatment : Treatment modality includes chemical or physical blockage of the patients dentinal tubules to prevent fluid movements from within. Chemical : Chemical desensitizing method attempts to sedate the cellular processes within the tubules with corticosteroids or to occlude the tubules with a protein precipitate, a remineralized barrier, nitrate, fluorides, strontium chloride or a crystallized oxalate deposit. Physical : Attempts to block the dentinal tubules with composite resin, varnishes, sealants, soft tissue grafts and glass ionomer cements. The Iontophoresis techniques electrically drives fluoride ions deep into dentinal tubules to occlude them. Laser technology may provide a definite solution for sealing the dentinal tubules permanently. But this is in the experimental stages and the equipment is expensive.
Recent Restoration Hyperalgesia following restoration procedures especially in young patients is another complaint. Causative factors like : -
Excessive heat generation while cavity preparation.
Improper interproximal contracts.
Premature contact points should be avoided.
Acute Irreversible Pulpitis It is essential that this condition should be distinguished from acute reversible pulpitis which has many similar symptoms because the emergency procedure for each is different. If a patient describes pain that lasts for minutes to hours, or is spontaneous or disturbs sleep or occurs when bending over, then patient will require pulpectomy rather than pallative treatment. Symptoms can be localized or non-localized. The non-localized pulpitis poses one of the most difficult and challenging problem to the practitioner since the patient cannot identify the offending tooth. -
Diagnosis can be achieved through diagnostic tests
Treatment : Pulpectomy The technique for pulpectomy. -
Anesthetize the tooth.
Apply the rubber dam
Prepare an access cavity
Locate the canals and extirpate the pulp.
Irrigate and debride, use a barbed broach.
Dry the canal.
Insert a medicated cotton pledget, moistened with an obtundent such as eugenol into the pulp chamber.
Place a temporary filling.
Prescribe analgesics if necessary. Premedications or post medication with antibiotic is indicated if the patient is medically compromised.
If there is no sufficient time for pulpectomy, pulpotomy is indicated.
Acute Apical Periodontitis -
An acute condition that occurs before alveolar bone is resorbed.
One of the most difficult emergency condition to treat is acute pulpitis with apical periodontitis due to difficulty in achieving required depth of anesthesia in such cases.
There is a complain of the tooth feeling elevated in the socket or inability to chew on the particular tooth.
Diagnosis is usually simple, the tooth is tender on percussion.
A radiograph of the tooth may appear normal or exhibit a thickening of the periodontal ligament space or show a small periapical radiolucency.
Causative factors -
Removal of causative factors
If associated with non vital tooth, initiate endodontic therapy.
Occlusion should be relieved.
During endodontic therapy, heavy doses of anesthesia may be required to attain required depth of aneshesia.
Prescribe analgesics and anti-inflammatory drugs.
Pulp Necrosis -
Rarely causes an emergency procedure. However, the patient may notice a swelling and request emergency treatment.
The proper treatment for pulp necrosis is canal debridement.
No anesthetic is necessary in most instances but in some cases there are still enough pain receptors to cause discomfort during the procedure.
Ensure removal of all necrotic tissue and thorough irrigation of the canals is required.
Acute Alveolar Abscess: (Acute periapical abscess accute apical periodontitis). -
It is a localized collection of pus in the alveolar bone of the root apex of a tooth following death of the pulp, with extension of the infection through the apical foramen into the periapical tissue.
It is accompanied by a severe local reaction of systemic toxicity such as elevated temperature, gastrointestinal disturbance, nausea, dizziness and other symptoms related to continuous pain and lack of sleep.
The acute episode may result from :
1. Pulpitis that progressively developed into pulp necrosis affecting the periapical tissues. 2. May be an excacerbation of a chronic periapical lesion (phoenix abscess).
3. May be caused by an endodontic periodontic lesion when the periodontal abscess secondarily affects the pulp through the lateral root canals or a deep infrabony pocket that extends to or beyond the root apex. Treatment -
Local anesthesia is frequently contraindicated as insinuating a needle and forcing anesthetic solution into an acutely inflammed and swollen area may increase pain and may spread infection. Moreover, it may be ineffective as acutely inflammed tissue has a localized pH that is acidic in spite of bodyâ€™s natural buffering action.
Conduction or block anesthesia may be administered for a few cases in which some pulp vitality persists, as long as the injection route is distant from the inflammed area.
The value of test cavity in treating teeth with acute alveolar abscess is two fold. First, it tests for any remaining, vital pulp that could require anesthesia: and second, it initiates emergency quickly, without waiting for anesthesia to take effect.
Rubber dam application
Complete the acess opening painlessly by stabilizing the tooth with finger pressure or impression compound.
Irrigate profusely, but avoid forcing any solution or debris into the periapical tissue.
Instrument each root canal within 1 mm of the root apex.
Frequently, a purulent exudate escapes into the chamber and indicates that the root canal is patent and draining. Other teeth may appear to be dry within the canal but this may be due to the apical contriction preventing the inflammatory products from draining through the tooth.
To relieve this problem, a procedure called â€˜apical trephinationâ€™ is followed. Apical contriction is purposely violated and enlarged to a minimum of a size 25 instrument to allow for exudate drainage through the tooth.
Aspiration using any mild suction devices such as a wide gauge needle placed in the saliva ejector will give sufficient negative pressure which aids in establishing drainage through the canal.
Leave the tooth open.
Advice the patient to use hot saline rinses for 3 minutes each hour.
Prescribe analgesics or antibiotics if indicated and necessary.
Recently there has been an alteration in most desirable method for treating an acute periapical abscess with drainage. The same regimen allowed for drainage but the appointment ended with the acces cavity closed.
Advantages of this procedure are : -
Prevents additional bacterial contamination.
Prevents contamination with food debris and blockage of canals.
Prevents the need for unnecessary follow-up appointments to close the tooth. The tooth should be re-opened for drainage if symptoms persist or
When a tooth has been left open, if the access is sealed for the first time at the same appointment in which canal enlargement is performed, a high percentage of exacerbation will occur. To avoid this, the following rules are made governing closure, in cases that has been left open for drainage. If you file , donâ€™t close If you close, donâ€™t file
Gutmann describes various modalities of treatment for localized or diffuse swellings associated with acute alveolar abscess.
If the swelling is slight and localized, there is no need for incision and drainage. Advice hot saline rinses in addition to root canal therapy.
If the swelling is soft, extensive and fluctuant â€“ incise and drain.
In diffused swellings, where there is a generalized tissue edema or cellulitis there is no indication for incision and drainage since the purulence is not localized to any one specific area. There is a need for antibiotic coverage and aggressive removal of any necrotic tissue in the pulp canal system.
If the tissue swelling is non-fluctuant Do not incise and drain Consider antibiotics
Advice hot saline rinses A non functional swelling can be converted to a soft fluctuant state by rinsing with hot saline solution 3-5 min at a time repeated every hour. Culturing the exudate -
Culture sample may be taken for antibiotic sensitivity testing.
The culture should not be taken of the initial portion of the exudate when considerable purulence discharges because the majority of the microorganisms at that time are dead and hence incapable of reproduction. The sample should be taken when the exudate starts to change from yellowish to a reddish hue.
Irrigants used in treating acute abscess -
The preferred irrigant in the initial stages of inducing drainage should be warm sterile water or saline as sodium hypochlorite has a tendency to clump the exudate, which might cause plugging of the apical constriction and halt the drainage. When the patency through the apex is maintained, sodium hypochlorite may be used for further canal preparation.
For further appointments, an alternating solutions of sodium hypochlorite and hydrogen peroxide is recommended.
Incision and Drainage -
Incision is performed with a No. 11 or 15 scalpel blade and a pair of hemostats.
Incision is made at the most dependent portion of the swelling to the depth of the bone.
Next, closed hemostats are placed into the incision and opened thus dislodging loculated areas of purulence.
If necessary, a drain placed, it should be secured to prevent it from being either, enclosed in the wound or loosened by normal oral forces and dislodged completely from the incision. Sutures may be used if a rubber type drain is chosen. If a gauge type drain is preferred, the blood clot which forms around the margins of the incision will usually stabilize the drain. Drain should remain in place no longer than 2-3 days.
Trephination â€“ Apical and surgical Apical -
Apical trephination is accomplished by aggressively placing a No.15 to 25 K file beyond the confines of the apex. A radiographic is taken for verification of file position.
Treatment problems with such procedure are : -
Destruction of the natural apical constriction.
Zipping of the canal at the apex in curved canals.
However, the benefits of the procedure far outweigh the potential problems.
However it is a reliable procedure to manage pain when all other methods have failed.
Indicated when the severe pain is due to increase in intracortical pressure in the periradicular tissues, when apical trephination has failed.
Two Approaches Option â€“ 1 1. Proper anesthesia is obtained. 2. A No.-15 scalpel blade is used to make a small (5mm) incision horizontally in the mucosa apical to the root apex. This position is critical to avoid penetration into tooth structures. 3. Retract the mucosa with a tissue retractors, periosteal elevator, or a wide end of a sterile wax spatula. 4. A No.-6 or 8 round bur is used to penetrate the cortical plate at an angle designed to reach the peri-radicular tissues or lesion, avoiding contact with the root apex. 5. Immediate drainage for relieve of intra-cortical pressure is usually obtained.
6. The patient is placed on hot saline rinse. Option â€“ 2 Step 1-3 similar to option 1. 4. No. 6 or 8 round bur is used to penetrate the cortical plate only. 5. A large K-file (No. 40 minimum) is used to bore a path through the cancellous bone to the periradicular tissues or lesion, avoiding contact with the root apex. 6. Immediate drainage or relief of intra cortical pressure is usually obtained. 7. Advise hot saline rinses. -
Option 2 is a safer approach, especially if vital structures are adjacent to the tooth in question, if roots are closely approximated or if the vestibule is shallow.
Failure to adhere to these principles can result in destruction of the root structure and periodontal ligament, with the potential for subsequent external root resorption.
Acute Periodontal Abscess -
It is often mistaken for an acute alveolar abscess as periodontal abscess causes pain and swelling.
It is usually an exacerbation of infection with pus formation in an existing deep infrabony pocket.
If the pulp test indicates pulp vitality within the normal range, then the treatment consists of curettage, debridement and establishment of drainage of the infrabony pocket through the sulcular crevice. At times incision of the soft tissue is necessary.
When the pulp is abnormal and vital, the tooth is treated as if for acute irreversible pulpitis.
If the pulp is necrotic, treat as if for acute alveolar abscess.
In any case, emergency periodontal treatment must be done simultaneously ; otherwise, the patient will not be relieved of the pain and swelling. Emergencies During Treatment Endodontic emergencies can occur during the course of endodontic treatment. There are usually caused by the following : -
Instrumentation beyond the root apex, with resultant trauma to the periapical tissue.
When debris and micro-organisms, are forced through the apical foramina into the periapical tissue and cause an infectious reaction.
Chemical irritants such as irrigating solutions or intracanal medicaments, penetrating the periapical tissues, eg : hypochlorite accident.
Incomplete or inadequate debridement of all root canals.
Lost or depressed access cavity seals, with recontamination of the root canals.
Overfilled root canals with subsequent periapical inflammation.
These emergencies can be avoided if proper care is taken during treatment procedure. -
When severe periodontitis is present, the patients pain can be relieved by re-opening the tooth under the rubber dam, removing the sealed medicament, carefully wiping the root canal dry with sterile absorbent points, and resealing the root canal with a cotton pellet from which a mild obtundent, such as eugenol or cresatin, has been expressed.
Also, a corticosteroid antibiotic medication can be used. A paper point that will reach the periapical tissue is dipped into the medicament and the point is placed in the canal with a pumping action, injecting the inflammed periapical tissue with the anti-inflammtory agent. The antibiotic present prevents any possible overgrowth of micro-organism.
The occlusion should be adjusted if necessary.
If pain or swelling occurs, the sealed medicament should be removed and the tooth opened for drainage.
Antiinflammtory analgesics should be prescribed and antibiotics if indicated.
Incision and drainage of a soft fluctuant swelling should be considered when drainage is insufficient or when severe pain persists.
Post-Obturation Emergencies Post â€“obturation discomfort has been attributed to : -
Periapical irritation by obturating materials.
Poor coronal seal.
Extrusion of sealer or gutta-percha into the periapical tissue.
Obturation combined with cleaning and shaping in the same appointment.
Information about possible discomfort during the first few days, reassurance about the availability of emergency services and administration of mild analgesics significantly reduces the patients anxiety and prevents over reaction to discomfort.
Discomfort due to slight overfilling of the root canals with either the core or cement can be reduced by relieving the occlusion and prescribing anti-inflammatory analgesics and antibiotics.
Retreatment is indicated in persistently painful cases in which treatment has been obviously incomplete.
Apical surgery is required in patients with persistent pain without swelling and overfilled canals or uncorrectable, inadequate root canal treatment.
A patients with acceptable root canal treatment who develop swelling after obturation should undergo incision and drainage.
In some cases surgical trephination (artificial fistulation) may be necessary.
Emergency Treatment of Traumatic injuries â€“ fractures Crown Fracture A traumatic injury to a tooth can cause a cracked crown, a fractured crown, or a fractured root and may result in pain. A cracked tooth can elicit bizarre symptoms such as sharp, piercing pain, especially during mastication. At times, thermal changes cause fleeting painful reactions.
A rubber polishing disc can be used. When the patient bites on the disc, it acts as a wedge on the cracked tooth and causes pain.
Crown fractures without pulp exposure -
Chipping of a small position of enamel needs smoothing of the jagged edge to prevent irritation to the tongue and lips.
If the fracture involves dentin, it should be covered with a sedative dressing and a stainless steel band is cemented in place.
Adjacent teeth should be examined for any fractures.
Regular follow-up is required.
Crown # with vital pulp exposure -
A radiograph should be taken to check the presence or absence of apical closure.
If closure has taken place, treatment is identical to treatment for acute pulpitis.
If apical closure has not yet taken place, a formocresol pulpotomy is performed to aid apexogenosis. At periodic intervals, radiographs are taken to evaluate and routine endodontic treatment may be initiated once apical development has been completed.
Crown # with necrotic pulp exposure -
Treatment follows the pattern of treatment for pulp necrosis or acute periapical abscess.
In the following appointment, radiograph is taken to assess the apical closure. If apical closure has taken place, routine endodontic treatment is performed. If the apex has not developed apexification procedures are instituted.
Fractured Root -
A horizontal # above the alveolar crest has an excellent prognosis. Also, the closer the root # is to the root apex, the more favourable the prognosis.
Emergency Treatment : Consists of stabilization by ligation of the tooth and adjacent teeth if mobility is present. -
Treat any soft tissue lacerations.
Assume that pulp is vital and do not extirpate it. A # root that contains a vital pulp has a better prognosis for root repair than one in
which the pulp has dead or has been extirpated. If later evidence indicates the presence of pulp necrosis endodontic therapy can be instituted. -
If the injury has caused pulpal death treatment consists of ligation for stabilization and root canal therapy.
A horizontal # at the midroot level has a guarded â€“to- poor prognosis unless it is amenable to orthodontic root extrusion. Usually the incisal segment is mobile and requires extraction. When the remaining apical segment is long enough to retain a functional postcore crown and has sufficient bony support, emergency treatment for this segment is pulpectomy. If the pulp is necrotic, then the root should be treated as if for an acute alveolar abscess.
A tooth with a vertical # has a hopeless prognosis and the treatment is extraction. On occasion, a multirooted tooth with vertical fracture of a root can be hemisected and the # segment can be removed. Endodontic therapy can be instituted for the remaining segment.
Tooth Avulsion and Replantation The replacement of a tooth that has been removed from the alveolar socket either intentionally or by accident is called replantation. The longer the luxated tooth is out of its socket, the less likely it will remain in a healthy, functional state after replantation.
Newer philosophies of replantation For many years endodontists enlarged and filled root canals before replanatation of the avulsed tooth. This procedure has been replaced by Andersen based on clinical and experimental research. It has been observed that a relatively good success rate was achieved when patients replanted the avulsed tooth after trauma compared with replantation by a dentist. Suggested Technique Emergency at the site of injury 1. Instruct the patient or parent to wash the tooth in running water without brushing or cleaning it, and examine it to be certain that the tooth is intact. 2. Have the patient rinse mouth. Replace the tooth in its socket using gentle, steady finger pressure. If the patient is co-operative and able, have the patient gently close the teeth together to force the tooth back into its original position. 3. Take the patient to the dentist immediately. 4. If the tooth cannot replaced in its socket, the tooth must be carried to the dentist in a moist vehicle to maintain the viability of the torn periodontal ligament. Emergency at the dental office 1. If the tooth is its socket, ligate, stabilize and disocclude the replanted tooth.
2. If tooth is out of the socket or improperly positioned, do not attempt to curette or sterilize the root surface or socket. Wipe away gross debris gently, irrigate the socket with saline. Handle the tooth all times with a sponge / gauge soaked in saline and handle the crown only. Replant the tooth and stabilize. 3. Take a radiograph to verify the position of the tooth in its socket and to examine it for any root or alveolar bone fracture. Check the adjacent teeth for possible root fracture. 4. Do not attempt endodontic treatment at this time unless the tooth requires venting (drainage). In that case, open the pulp chamber, debride it and the root canals, insert an intracanal medicament and seal the access cavity. Endodontic treatment should be completed at a later date. Completion of endodontic treatment -
One week after replantation prepare access cavity, perform canal debridement and place ZoE temporary filling in the access.
Teeth with undeveloped apices may be watched without pulpextirpation.
Andreasen suggests that the splint should be removed one week after replantation to prevent ankylosis or inflammatory response leading to reposition as the periodontal ligament is not kept in function.
Two weeks after replantation, place, Ca(OH) paste in the canal to inhibit and reduce external resorption. 28
radiographically, institute routine endodontic therapy.
Post operation instructions -
Refer to a physician for antitetanus serum or booster injection.
Transport medium (Referred from the article “Interim storage of avulsed permanent teeth” published in Journal, May 1998). Various transport media that can be used. -
HBSS (Hank’s Balanced Salt Solution).
Viaspan (Transplant Organ Storage Media).
Eagles medium (culture medium).
In the order of preference, HBSS, viaspan and eagles medium for transportation followed by milk and saline, saliva, dry storage, tap water and triton x-100.
Hankâ€™s Balanced Salt Solution Proposed by Krasner and Person. It was highly successful in 85.3% of replantation cases.
The solution contains. Sodium chloride Glucose Potasium chloride Sodium biocarbonate Sodium phosphate Calcium chloride Magnesium chloride Magnesium sulphate Krasner has developed an avulsed tooth storage system, named the Emergency Tooth Preserving System (ETPS), which contains HBSS, a net for holding the tooth atraumatically, and a container for bringing the submerged tooth to the dentist. -
According to Weine, patientâ€™s own saliva is best transport medium for an avulsed tooth.
Andreasen favors milk over saliva as a transport medium. Disadvantage of milk is that it may contain many antigens that could act negatively from an immunologic standpoint on the reattachment process.
Saliva is an immediately available storage medium at all accident location, but its use should be limited to cases where the extraalveolar duration is less than one hour and superior storage media, such as milk, saline, or HBSS or not available.
Regarding the temperature, storage at lower temperature produce best results.
Referred Pain Accurately determining the origin of the patients pain is the first step in emergency endodontic treatment. Although the most frequent cause of dental pain is pulpoperiapical pathosis, the astute clinician knows that pain can originate from many other sources. Various causes Sinusitis may cause pain referred to maxillary posteriors. Myocardial infarction – Toothache on the left side of the mouth. Otitis media – Mandibular molars Basilar artony aneurysm – Lower molars Herpes zoster of maxillary division of fifth cranial N – Maxillary lateral incisors. Other causes Trigeminal neuralgea Atypical facial neuralgea Migrane Cardiac pain Temperomandibular arthrosis
malaria. Muscle spasm
Conversely painful pulpitis may be referred to others areas of the same or opposing arches as well as to the structures remote from the involved tooth.
Site of pain referral Frontal (forehead regin)
Tooth pulp initiating pain Maxillary incisors
Occular pain Temporal region Ear
Maxillary premolars Anterior teeth Maxillary second premolars Mandibular molar
Superior laryngeal area Mandibular premolars
Maxillary molars occassionally Mandibular molars Maxillary canines Maxillary premolars
Obviously, if the pain does not originate from pulpoperiapical disease, emergency endodontic treatment will not relieve it.
Analgesics and Antibiotics The discussion on endodontic emergency will be incomplete without the discussion on analgesics and antibiotics because their role is essential and supportive to the previously described emergency procedures.
Analgesics Analgesics are pain relievers. Generally, the narcotic analgesics are used to relieve acute, severe pain and the non-narcotic or mild analgesics are used to relieve slight to moderate pain. Most frequently used non-narcotic analgesics are : -
Nimuselide â€“ recent inclusion
Has potent anti-inflammatory, analgesic, antipyretic action.
Precaution and contra-indication Contra indicated in patients who are sensitive to it and in peptic ulcers, liver disease, bleeding tendencies, diabetes and 1 week before elective surgery. -
Dispensed as 300 mg and 600mg tablets.
Relieves mild â€“ moderate pain
Lacks anti-inflammatory property.
Lower incidence of side effects
Safer in pregnant patients
Dose â€“ 500 mg tablets
Better tolerated than aspirin.
Side effects are milder but can cause gastric discomfort.
Should be avoided in asthma.
Doses 200, 400, 2600mg tablets
Diclofenac sodium -
Analgesic and anti-inflammatory action is similar to ibuprofen but lesser adverse effects.
Dose : 50 mg tablets.
Safer in asthma patients.
Narcotic analgesics -
Control pain better than other drugs currently available but these drugs must be used with caution.
They may depress the central nervous system, can interact adversely, sometimes fatally, with alcohol, anti-histaminics, local anesthetic and tricyclic antidepressants.
Eg : Morphine â€“ No oral route. Meperidine â€“ 50 to 100 mg.
Antibiotics are life saving therapeutic agents of inestimable value. They are used for prophylactic coverage of medically compromised patients and in special circumstances, an adjunctive treatment of acute periapical or periodontal infection.
Ideally, the selection of a prescribed antibiotic should be based on the result of susceptibility tests.
The most effective antibiotic for use in endodontic emergency is penicillin. It is bactericidal and acts by inhibition of cell wall synthesis during multiplication of micro-organisms.
Recommended drugs Penicillin V- Acid resistant Amoxicillin – Better oral absorption Cloxacillin – Active against penicillin resistant stains
In case of allergy to penicillin erythomycin can be prescribed.
Other antibiotics used are : Cephalexin – 250 – 500 mg every 6 hours Clindamycin phosphate – 150-300 mg every 6 hours Tetracyclines Metranidazole
Conclusion The accurate diagnosis and effective treatment of acute situations are an important responsibility and privilege of dental practice. Effective, caring management of endodontic emergencies not only represent a service to the public, which a dentist can be proud of, but also enhances the positive image of dentistry.