ENDODONTIC EMERGENCIES

• DEFINITION :

🔸 Endodontic emergencies are usually associated with pain or swelling or both and require immediate diagnosis and treatment.

🔸Emergencies are usually caused by pathoses in the pulp or periapical tissues.

🔸 Emergencies include luxation, avulsion, or fractures of the hard tissues.

• CATEGORIES :

– Pretreatment :

a) Patients usually present with pain or swelling or both.

b) Challenge in this case is the diagnosis and treatment of the offending tooth.

– Emergencies occurring between appointments or after obturation.

a) Also referred to as “flare-up.”

b) Easier to manage because the offending tooth has been identified and diagnosed.

– Diagnosis:

a) A rule of a true emergency is that only one tooth is the source of pain, so avoid overtreatment.

b) Obtain a complete medical and dental history.

c) Obtain a subjective examination relating to the history, location, severity, duration, character, and eliciting stimuli of the pain.

d) Obtain an objective examination including extraoral and intraoral examinations.

🔹Observe swelling, discoloured crowns, recurrent caries, and fractures.

🔹Apical tests include palpation, mobility, percussion, and biting tests.

🔹Pulp vitality tests are most useful to reproduce reported pain.

🔹Probing examination helps differentiate endodontic from periodontal disease.

🔹Radiographic examination is helpful but has limitations because periapical radiolucencies may not be present in acute periapical periodontitis.

– Treatment :

a) Reducing the irritant, through reduction of pressure or removal of the inflamed pulp or apical tissue, is the immediate goal.

b) Pressure release is more effective than pulp or tissue removal in producing pain relief.

c) Obtaining profound anaesthesia of the inflamed area is a challenge.

d) Management of painful irreversible pulpitis.

🔺Complete cleaning and shaping of the root canals are the preferred treatment.

🔺Pulpectomy provides the greatest pain relief, but pulpotomy is usually effective in the absence of percussion sensitivity.

🔺Chemical medicaments sealed in chambers do not help control or prevent additional pain.

🔺Antibiotics are generally not indicated.

🔺Reducing occlusion has been shown to aid in the relief of symptoms if symptomatic apical periodontitis exists.

e) Management of pulpal necrosis with apical pathosis.

(1) Treatment is two-fold.

🔹Remove or reduce pulpal irritants.

🔹Relieve apical fluid pressure when possible.

(2) When no swelling exists, complete canal debridement is the treatment of choice.

(3) When localised swelling exists, the abscess has invaded soft tissues.

🔹Complete debridement.

🔹Drainage to relieve pressure and purulence drainage can occur through the tooth or mucosa (via incision and drainage).

🔹Patients with localised swelling seldom have elevated temperatures or systemic signs, so systemic antibiotics are unnecessary.

(4) When diffuse swelling exists, the swelling has dissected into fascial spaces.

🔹Most important is the removal of the irritant via canal debridement or extraction of the offending tooth.

🔹Swelling may be incised and drained followed by drain insertion for 1 to 2 days.

🔹Systemic antibiotics are indicated for diffuse, rapid swelling.

– “Flare-ups”:

🔹This is a true emergency and is so severe that an unscheduled visit and treatment is required.

🔹A history of preoperative pain or swelling is the best predictor of “flare-up” emergencies.

🔹No relationship exists between flare-ups and treatment procedures (i.e., single or multiple visits).

🔹Treatment generally involves complete cleaning and shaping of canals, placement of intracanal medicament, and prescription of analgesic.

• Antibiotics are generally not indicated except in the instance of systemic symptoms and cellulitis.