In this brief lecture I will discuss most common endodontic emergencies that occur while practicing endodontics. The lecture is directed to the mind of undergraduate level. I hope you enjoy it.

1. Patient History
Diagnostic Tools
Classification Of Endodontic Emergencies
Pretreatment Emergencies
Reversible Pulpitis
Irreversible Pulpitis
Periapical Abscess
Phoenix Abscess
Cracked Tooth Syndrome
Occlusion
Perioperative Emergencies (Flare-Up)
Post-Obturation Emergencies
PATIENT HISTORY
Dental and medical history can help in the diagnostic
procedure. Patient should be asked about the nature of
his pain:
• Where is the pain located?
• When the pain first noticed?
• Describe the pain
• Under what circumstances the pain occur?
• Does anything relieve it?
• Is there any associated swelling or tenderness?
• Previous dental history
• Recent treatment
• Periodontal treatment
• Any history of trauma to the teeth
Also odontogenic pain should be differentiated from
non-odontogenic pain.
DIAGNOSTIC TOOLS
These instruments and techniques are the equipments
needed for accurate and definitive diagnosis.
• Perapical radiograph with paralleling technique
• Electric pulp tester
• Ice sticks, hot gutta-percha, ethyl chloride
• Periodontal probe
CLASSIFICATION OF ENDODONTIC
EMERGENCIES
Endodontic emergencies can be classified into three
main groups:
• Emergencies that occur prior to introduction of
treatment
• Emegencies that occur during treatment (between
visits)
• Emegencies that occur after treatment, when canal
has been obturated.
Each of these group is subclassified and each one is
managed differently.
PRETREATMENT EMERGENCIES
It is further divided into:
• Reversible pulpitis
• Irreversible pulpitis
• Periapical abscess
• Cracked tooth syndrome
• occlusion
REVERSIBLE PULPITIS
The pulp has been exposed to irritant, but the condition
of the pulp is reversible and treatment is feasible with-
out need for RCT.
endodontic emergencies
Osama Asadi, B.D.S, Published for Iraqi Dental Academy Blog
Endodontic emergencies represent an important part of dental practice. Proper diagnosis and treatment is
necessary in order to relieve pain, stop an infection, and reduce swelling. Emergencies may occur prior to
introduction of treatment, during the treatment visits, or occur after the canal system has been obturated.
LECTURE OUTLINE
CHAPTER
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2. The patient usually present with deep caries, exposed
dentin, recent dental treatment, defective restoration,
gingival recession or exposed cervical dentin.
One should differentiate between reversible and irre-
versible pulpitis.
Reversible pulpitis characterize by:
• Pain that is intense
• Always triggered by stimuli (hot, cold, sweet)
• Pain is stopped when the stimuli is removed
• Tooth may give exaggerated response to vitality
tests
• Tooth is not tender to percussion
• Pain may be difficult to locate
• Normal radiographic appearance, but occasionally
widened PDL may be seen
Treatment options for such cases:
• Removal of deep caries and placement of protective
layer of capping material, then restoration
• Check occlusion and remove high spots if present
• Apply fluoride varnish or dentin bonding agent to
sensitive dentin, and prescribe desensitizing tooth-
paste.
IRREVERSIBLE PULPITIS
In this case the pulp has been irreversibly damaged be-
yond repair. Patient usually present with deep caries,
exposed dentin, recent dental treatment, defective res-
toration.
Patient history reveals that:
• Pain is spontaneous, but also occur with stimuli
• Lasts for hours
• Worsen at night
• In early stage of pulpitis, hot and cold stimuli both
elicit prolonged pain, while in later stages, the pain
mainly aggravated by hot, relieved by cold
• Pain is difficult to localize, patient can tell if it is
on his left or right side, but he can not identify the
offending tooth, and can not identify the position of
tooth in relation to arches.
• Radiographically, widened PDL may be seen
• Tooth is tender to percussion only if inflammation
has reached to the periapical area.
Also irreversible pulpitis can be asymptomatic, in
which patient present with no pain. This condition
is temporary and the pulp condition can be turn into
symptomatic any time.
Treatment
This condition is indicated for RCT. But sometimes, es-
pecially in molar teeth, the time does not permit com-
plete pulp extirpation. In this case we do pulpotomy
(removal of the coronal pulp) and place a dry cotton
pellet inside the pulp chamber and restore with tempo-
rary filling. This will relieve patient’s pain. Patient is
recalled within 48 hours for complete pulp extirpation
and further endodontic treatment.

PERIAPICAL ABSCESS
In this case, pulp is necrotic, and the infection has
reached to the periapical area. This case can be pre-
sented with or without swelling. It should be differen-
tiated from periodontal abscess, in which the abscess
is lateral and tooth is vital.
Symptoms of periapical abscess:
• Tooth is not vital
• Patient feel as if the tooth elongated
• Pain on percussion and/or palpation
• Tooth may be slightly mobile due to extrusion
from the socket
• Radiographically, widened PDL can be seen. Peri-
apical radiolucency can be present only if the ab-
scess is chronic.
• Tooth may present with swelling (indurated or
fluctuant)
Without swelling:
Treatment option for such case is complete extirpation
of pulp, and further endodontic treatment. Pulpecto-
my should be done in the emergency visit, regardless
of the time factor. However, certain criteria should be
followed:
• Do not leave tooth open
• If treatment to be completed in multi-visits, in-
tracanal medicament (preferably calcium hydrox-
ide) should be placed in the canal.
• Accurate working length determination
• Thorough canal debridment
• Avoid over-instrumentation, and extrusion of ne-
crotic tissue beyond apical constriction.
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Figure 1. pulpotomy procedure for irreversibly inflammed pulp, in
order to relieve pain

3. • Use crown-down technique
• Do not prescribe antibiotics, only if the patient has
systemic signs of infection
With swelling:
Patient will present with swelling. Pus should be
drained. Treatment options for such cases are:
• Root canal drainage and RCT.
• Incision, drainage and RCT
Root canal drainage
It is indicated for localized swelling. Area is anesthe-
tized and access opening is made. Then tooth is left to
drain. Upon completion of drainage, root canal further
instrumented and cleaned either in this visit, or within
48 hours. Never leave tooth open between visits. If pus
did not appeared after access opening, use small file
and insert it beyond the working length by 2-3 mm, to
stimulate pus extrusion.
Incision and Drainage:
In this case, the swelling is incised with scalpel verti-
cally at the site of most fluctuant swelling. If drainage
is not complete, drain is placed inside the swelling to
prevent healing of incision site. Patient is allowed to
visit on next day to remove drain and complete root
canal treatment. Drains are either rubber dam drains, or
iodoform gauze drain. Different form of drains present,
such as I, T, Christmas tree drains.
PHOENIX ABSCESS
It is defined as sudden exacerbation of previously sym-
pompless periapical lesion. It occur after instrumen-
tation of root canal. This phenomenon is not well un-
derstood, however, it thought to be due to alteration of
internal environment of root canal space during instru-
mentation which activate bacterial flora.
Treatment
Irrigation, debridement of root canal and establishing
drainage.
CRACKED TOOTH SYNDROME
Tooth with cracks that involve the pulp often presented
with:
• Sharp Pain on mastication
• Sensitivity to hot and cold
• Pain is difficult to localize
• Abscess may formed
• Chronic cracks are characterized by dull pain
Diagnosis of cracked tooth can be difficult. Certain di-
agnostic aids can help such as dye solutions, selective
cusp loading, transillumination, and magnification.
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4. Vertical tooth fracture present with poor prognosis and
most likely indicated for extraction. Horizontal and di-
agonal fractures have better prognosis, and their treat-
ment depend on their location on the tooth.
OCCLUSION
High fillings can lead to apical periodontitis and possi-
bly tooth fracture. Check for any high filling with artic-
ulating paper and correct area with insufficient contact.
Also look on the tooth from opposite arch. Overerupted
third molars can cause pain.
FLARE UP
Flare up can be defined as occurrence of pain or swell-
ing after initiation of endodontic treatment. It occur for
many reasons:
• Preparation beyond the apical terminus
• Over-instrumentation
• Pushing dentinal and pulpal debris into periapical
area
• Incomplete removal of pulp tissue
• Overextended root canal filling
• Aggressive irrigation, extrusion beyond apex
• Extrusion of intracanal medicaments or sealer
• hyperocclusion
• Root fracture
• Procedural accidents which prevent complete de-
bridment of the canals
• Microbiological factors
Treatment
Such cases require repreparation and cleaning. If swell-
ing is present, drainage is indicated. Analgesics could
also help relieve symptoms that will subside and disap-
pear within 1-2 weeks. Periapical surgery is indicated
for persistent cases.
POST-OBTURATION EMERGENCIES
In addition to the reasons mentioned previously for
flare-up, it occur due to:
• Overfilling or underfilling
• Obturation a tooth with concurrent pain present
• High restoration
• Root fracture
Treatment
If endodontic principles has been followed correctly,
apical surgery is not indicated. Prescribe analgesic to
relieve the symptoms. Otherwise, apical surgery should
be performed to correct obturation errors.
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REFERENCES:
• Cohen’s Pathway of Pulp
• Endodontic Principles and Practice
• A Clinical Guide to Endodontics, P. Carrote