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.

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A-delta fibres C-fibres

- Myelinated Unmyelinated

- 20% of the nerves of the pulp - 80% of the innervation

- Diameter – 2-5m 0.3-1.2m

- Conduction velocity – 6-30m/sec 0.4-2m/sec

- Distributed in the odontoblastic and

subodontoblastic zones and are

associated with dentinal pain

Distributed throughout the pulp tissue

and are associated with pain due to

pulp tissue damage

- Impulses are intercepted as sharp and

pricking pain

Conduct throbbing and aching pain

- Low threshold of excitability High threshold of excitability

Vitality tests A-delta fibres C-fibres

- Electric Positive (immediate) Negative ( except of high

levels of stimulation)

- Cold (ice) Positive (immediate) Negative

- Rapid heat (two phase response)

Immediate first response

(sharp, localized)

Delayed second response

(dull radiating)

Slow and sustained heat

Negative Positive (after 45°C to 47°C)

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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.

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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.

- History

- Subjective symptoms

Pain

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- 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

II. 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

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III. According to Gutmann

Depending on the treatment plan.

A. Vital pulps

1. Reversible pulpitis

2. Irreversible pulpitis with localized symptoms

3. Irreversible pulpitis – 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

- Crown fracture

- Fractured root

- Tooth avulsion

- Referred pain

- Analgesics and antibiotics

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Acute Reversible Pulpitis

Clinical characteristics

- Quick, sharp, shooting momentary tooth pain suggesting involvement of A-

delta 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

- Exposed restorations

- Incipient caries or rapidly advancing carious lesions.

- Orthodontic tooth movement

- Periodontal disease

- History of trauma

- Recent restorations

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.

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Hypersensitive Dentin

Etiological factors

Exposed dentinal tubules due to :

- Periodontal surgery

- Tooth abrasion

- Erosion etc.

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.

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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

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Treatment : Pulpectomy

The technique for pulpectomy.

- Anesthetize the tooth.

- Apply the rubber dam

- Prepare an access cavity

- Irrigate thoroughly

- 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.

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- 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

- Occlusal trauma

- Irreversible pulpitis

Treatment

- 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.

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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).

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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 body’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.

Procedure

- 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.

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- 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 ‘apical trephination’ 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.

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- Prevents the need for unnecessary follow-up appointments to close the

tooth.

The tooth should be re-opened for drainage if symptoms persist or

worsen.

- 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 , don’t close

If you close, don’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 – 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

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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 micro-

organisms 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.

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- 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 – 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.

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Surgical

- Rarely indicated.

- 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 – 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.

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Option – 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.

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Etiology

- It is usually an exacerbation of infection with pus formation in an

existing deep infrabony pocket.

Treatment

- 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.

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- 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.

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- 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 –obturation discomfort has been attributed to :

- Periapical irritation by obturating materials.

- Poor coronal seal.

- High occlusion

- Extrusion of sealer or gutta-percha into the periapical tissue.

- Obturation combined with cleaning and shaping in the same

appointment.

Treatment

- 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.

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- 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 – 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.

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Diagnosis

- Transillumination method

- Dyes

- 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

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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

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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 –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 post-

core 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.

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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.

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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 pulp-

extirpation.

- 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.

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- After the periodontal ligament and apices have healed

radiographically, institute routine endodontic therapy.

Post operation instructions

- Antibiotic coverage.

- Soft diet

- 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).

- Milk

- Saliva

- Saline

- Tap water

- Triton x-100

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.

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Hank’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, patient’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.

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- Saliva is an immediately available storage medium at all accident

location, but its use should be limited to cases where the extra-

alveolar 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 Intensive radiation

Periodontal abscess Systemic diseases

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Occlusal trauma eg : Typohoid, influenza,

malaria.

Muscle spasm Neurogenic diseases

Pericoronitis Malignant diseases

- 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 Tooth pulp initiating pain

Frontal (forehead regin) Maxillary incisors

Nasolabial area Maxillary canines

Maxillary premolars

Occular pain Anterior teeth

Temporal region Maxillary second premolars

Ear Mandibular molar

Maxillary molars occassionally

Superior laryngeal area Mandibular molars

Mandibular premolars 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.

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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 :

- Aspirin

- Acetaminophen

- Ibuprofen

- Diclofenac sodium

- Nimuselide – recent inclusion

Aspirin

- 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.

Acetaminophen

- Relieves mild – moderate pain

- Lacks anti-inflammatory property.

- Lower incidence of side effects

- Safer in pregnant patients

- Dose – 500 mg tablets

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Ibuprofen

- 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.

Nimuselide

- 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 – No oral route.

Meperidine – 50 to 100 mg.

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Antibiotics

- 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

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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.

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