Endodontic emergencies

Emergencies in endodontics need to be handled skillfully to prolong the survival of the affected tooth in the oral cavity and the possible emergency situations, their causes and the ways to manage them effectively are discussed here.



1. Why is instrumentation not started in a canal with irreversible pulpitis , unless a pulpectomy is anticipated?

The inflammed vital pulp tissue, when lacerated with files, results in increased discomfort due to the pulp getting shredded and traumatized. Pain may be worsened since the inflammatory process extends into the peri radicular tissues. So complete removal of pulp is the best and advised treatment for emergency.

Ref: Stephen Cohen,Richard C.Burns,Pathways of the pulp, Mosby, 8th Edn,55

2. Why is splinting required for an avulsed tooth and how long is it required?

Stabilizing the replanted tooth is essential until a new periodontal attachment is achieved. It is placed for 1 week and then removed because when kept for too long, it may lead to ankylosis or inflammatory resorption since the periodontal ligament is not functioning.

Ref: Franklin S.Weine,Endodontic therapy, Mosby , 6th Edn,90,91.

3. Why does a tooth become sensitive to percussion , during the course of endodontic treatment sometimes?

This condition is called secondary apical periodontitis which can be due to overinstrumentation, overmedication or forcing the debris into the periapical area. It is treated by placing a corticosteroid antibiotic medication in the periapical area with a paper point at the emergency visit. Routine endo treatment can be performed after 2-5 days.

Ref: Franklin S.Weine,Endodontic therapy, Mosby , 6th Edn,97

4. Why are the chances less for failure for an avulsed tooth that is replanted immediately in the socket?

Replanting the avulsed tooth immediately after the trauma has a good success rate because the presence of original periodontal ligament on the root surface of the replanted teeth improves secondary Cementum deposition and root resorption repair. The tooth may be rinsed under running tap water without scrubbing the tissues that are clinging on to the root surface and replanted in the socket.

Ref: Franklin S.Weine,Endodontic therapy, Mosby , 6th Edn,86,87

5. Why is a transport medium needed to carry an avusled tooth, if it cannot be replaced immediately in to its socket?

A transport medium is needed to allow successful reattachment of the tooth in its socket. Solutions like Hank’s balanced salt solution preserve and reconstitute the cells of the Periodontal ligament. Saliva is the best transport medium since it is a biologically acceptable liquid. Milk is another medium which has many antigens that act negatively from immunologic aspect on the reattachment process. Water is the last resort which can keep the tooth moist atleast.

Ref: Franklin S.Weine,Endodontic therapy, Mosby , 6th Edn,90.

6. Why all horizontally fractured teeth does not need an endodontic therapy?

All horizontally fractured teeth does not require an endodontic management because, though the dentin and the Cementum have been cleaved, the pulp may retain its integrity in a recoverable state and it is only stretched by the injury. No emergency treatment is also needed if there is no mobility. Periodic re-evaluation with radiographs and pulp testing is essential.

Ref: Franklin S.Weine,Endodontic therapy, Mosby , 6th Edn,85.

7. Why does a tooth that is adjacent to a fractured tooth require radiographic examination and pulp testing?

The tooth that has a fracture can undergo pulp recovery later since the force of blow may be dissipated by the fracture . But the adjacent tooth receives the effect of the blow in the periapical area and the apical nerves and blood vessels may be severely damaged. So along with the fractured tooth, the adjacent teeth also have to be examined with radiographs and pulp testing.

Ref: Franklin S.Weine,Endodontic therapy, Mosby , 6th Edn,84.

8. What are the measures taken to prevent hypochlorite accident?

Hypochlorite accident is a an accidental condition that occurs during irrigation of the canals, that results in severe pain, swelling and profuse bleeding. To prevent its oocurance, certain measures are taken like, the needle should not bind against the walls , the needle is bent at the centre, the irrigant is expressed slowly and gently and the tightness of the hub is checked periodically to avoid inadvertant separation. The needle should be oscillated in and out the canal so that there is no resistance for the irrigant and if there is any resistance, irrigation is stopped.

Ref: Stephen Cohen,Richard C.Burns,Pathways of the pulp, Mosby, 8th Edn,69,70.

9. Why Sodium hypochlorite , when used for irrigating the canals, should be used with caution?

When hypochlorite solution is accidentally injected into the periapical tissues, there may be severe pain, swelling and profuse bleeding which may be due to forceful injection of the irrigating solution, a tight irrigating needle in the canal or a tooth with a large apical foramen. The edema and the ecchymosis increase for several days along with tissue necrosis and secondary infection. It may take 1 – 2 weeks for the patient to recover.

Ref: Stephen Cohen,Richard C.Burns,Pathways of the pulp, Mosby, 8th Edn,68

10. Why a closed dressing is preferrable in between appointments, during endodontic management of a tooth with abscess?

When a draining tooth is present, it is allowed to drain for upto 20 mins and after that the exudate should stop. To prevent contamination by the oral cavity, it is best to close the teeth immediately after treatment and it also prevents inter appointment flare ups. It also holds the Intracanal medicament in place.

Ref: Stephen Cohen,Richard C.Burns,Pathways of the pulp, Mosby, 8th Edn,65. Franklin S.Weine,Endodontic therapy, Mosby , 6th Edn,228.

11. Why calcium hydroxide dressing is placed in the canal in between appointments?

Calcium hydroxide is an intra canal medicament which helps in the prevention or treatment of flare- ups. It reduces the bacterial colonies and their toxic by products. The antimicrobial effects of calcium hydroxide are best achieved when it is in the root canal for atleast 1 week.

Ref: Stephen Cohen,Richard C.Burns,Pathways of the pulp, Mosby, 8th Edn,64.