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Review Article

ENDODONTIC EMERGENCIES

Khaly Banea*, Mouhamed Sarra, Koffi Yolande Gnagneb, Babacar Fayea, Babacar Touréa.

aDepartment of Conservative Dentistry and Endodontics, Faculty of Medicine, Pharmacy and

Odontology-Stomatology, Cheikh Anta Diop University of Dakar, Senegal.

bDepartment of Conservative Dentistry and Endodontics, Félix Houphouet Boigny University,

Abidjan, Ivory Cost.

BANE Khaly, Associate Professor, Department of Conservative Dentistry and Endodontics, Cheikh Anta Diop University of Dakar. P.O.Box 5005, Dakar-Fann, Dakar, Senegal.

E-mail address: [email protected]

SARR Mouhamed, Associate Professor, Department of Conservative Dentistry and Endodontics, Cheikh Anta Diop University of Dakar. P.O.Box 5005, Dakar-Fann, Dakar, Senegal.


GNAGNE Koffi Yolande, Associate Professor, Department of Conservative Dentistry and Endodontics, Félix Houphouët Boigny University - Abidjan. BP: 612 Abidjan 22, Ivory Cost.


FAYE Babacar, Full Professor, Department of Conservative Dentistry and Endodontics, Cheikh Anta Diop University of Dakar. P.O.Box 5005, Dakar-Fann, Dakar, Senegal.


TOURÉ Babacar, Full Professor, Department of Conservative Dentistry and Endodontics, Cheikh Anta Diop University of Dakar. P.O.Box 5005, Dakar-Fann, Dakar, Senegal.


Corresponding author: Khaly Bane, Department of Conservative Dentistry and Endodontics, Cheikh Anta Diop University of Dakar. P.O.Box 5005, Dakar-Fann, Dakar, Senegal.

Tel: +221 77550 63 21

E-mail: [email protected]

mailto:[email protected]








ABSTRACT

Endodontic emergencies represent approximately 90% of the emergency consultation reasons. In

particular, they are characterized by violent or disabling pain. In the absence of adequate emergency

treatment, there is a risk of infectious complication. The management of these emergencies in the

dental office requires to be effective the achievement of a precise diagnosis and an emergency act

with or without a prescription.

The objective of this article is to present, according to the data of the current endodontic literature,

the diagnostic and therapeutic elements which make it possible to face effectively all emergency

situations in endodontics.

KEY WORDS: Acute apical abscess, Acute apical periodontitis, Flare up, Pain, Pulpitis

Introduction:

Endodontic emergencies account for

approximately 90% of emergency consultation

reasons1. In particular, they are characterized

by violent or disabling pain. In the absence of

adequate emergency treatment, there is a risk

of infectious complication. While some of them

are vital emergencies (diffuse cellulitis), which

may be hospitalization in intensive care, the

management of the vast majority of endodontic

emergencies is the responsibility of the

odontologist and relies mainly on symptomatic

treatment2. Management of endodontic pain is

one of the challenging aspects in endodontics3.

The aim of this article is to present, according

to the data of the current endodontic literature,

the diagnostic and therapeutic elements which

make it possible to face effectively all

emergency situations in endodontics.

I. PAIN IN ENDODONTICS

1.1. Peripheral mechanisms

involved in the nociception of the

trigeminal sphere

The orofacial region is strongly innervated and

very varied. Pain receptors are located in most

superficial and deep tissues4. The dental and

periodontal sensibility is ensured by the

maxillary nerve (V2, branch of the trigeminal

nerve) which innervates the middle third of the

face and the mandibular nerve (V3, third

branch of the trigeminal nerve) which

innervates the lower stage of the face; the

ophthalmic nerve (V1, first branch of the

trigeminal nerve) innervating the upper stage

of the face. The endings of these three

branches are found in almost all of the

orofacial territories, especially at the dental

level. They are grouped together to constitute

the peripheral ramifications of amyelinic C

fibers and myelinic of Aδ type and also Aβ4.

The fibers found at the level of the dental pulp

consist of 80% of two major types: C fibers,

amyelinic, low conduction velocity (less than

5m / s) and small diameter (less than 1.5μm),

and fibers slightly myelinic, diameter (1 to 5μm)

and conduction velocity (less than 15 - 35m /

s) slightly higher than the first. Aδ fibers differ



from other myelinic fibers in the body due to

the absence of perineural connective sheath5.

All the pulp fibers give fine collateral branches

in the center of the pulp and end with a rich

plexus in the acellular zone under the

odontoblasts, Rashkow's Plexus. Various

external agents (mechanical, chemical,

thermal, electrical) or internal (pro-

inflammatory molecules such as

prostaglandins or neuropeptides) can

stimulate these fibers and give rise to two

different kinds of sensation6. The short and

sharp pain is due to activation of the A fibers

while the dull pain is due to the C fibers. The

action potentials from the peripheral endings

are transmitted to the central ends where they

will cause the release of neurotransmitters

such as the glutamate. Transmission is rapid in

the A fibers (acute pain), slower in the C fibers

(torpid pain) 5.

1.2. Diagnostic tools

In an emergency, the practitioner is required to

perform a quick and effective gesture to relieve

the patient. The nature of this intervention is

dictated by the diagnosis, which as for any

medical treatment is an indispensable and

decisive step. A set of elements are taken into

consideration and make it possible to

determine the nature of the pathology and also

to perform a differential diagnosis.

a. Anamnesis

The reason for the consultation will very

quickly guide the interview of the patient. In

endodontics, the pain is usually concerned and

simple and short questions allow to determine

the origin, nature and characteristics of the

pain. The spontaneous or provoked nature of

pain, triggering factors, duration, persistence,

location, and nature are all necessary

elements to consider7,8.

Medical and surgical history and criteria such

as fatigue, fever, and excessive self-

medication should also be taken into

consideration for the management of the

patient9.

b. Tests

Depending on the patient's grievances,

performing test (s) may be necessary. Among

the many tests at our disposal, the most

appropriate and relevant to confirm or

invalidate a diagnosis should be selected10.

Exobuccal examination allows to highlight

the possible swelling of the mouth, the

presence of fistula or trauma. Careful

palpation of the integuments makes it

possible to detect the presence of

adenopathies.

The intra-oral examination makes it

possible to observe the teeth of the sector

concerned in every detail. The use of

magnifying elements such as magnifying

glass or microscope optimizes the

diagnosis.

Intraoral palpation of the gingiva is often

painful compared to the apices of teeth with

acute apical periodontitis or acute apical

abscess. Axial or vertical percussion with

the handle of an instrument is used to

determine the presence of acute

periodontal or periapical inflammation.



The periodontal survey should be

systematic. The probing of the suspect

tooth allows to establish a differential

diagnosis between an endodontic problem,

a periodontal problem, or the presence of a

fracture.

Pulp vitality tests (hot, cold and electrical)

are always done in comparison with a

healthy tooth and provide information on

the pulp state. They are particularly useful

for establishing a differential diagnosis

between an endodontic problem and a

periodontal problem.

The bite test involves biting the patient,

cuspid by cusp, on a wet cotton swab or a

sheet of dike wrapped around a cement

spatula. A sharp pain on loosening and

occlusion can lead to the diagnosis of

cracking8, 9.

c. Radiographic examination

The panoramic X-ray is a good element for the

emergency clinical examination. It gives a

global vision of the oral cavity and in the

context of the search for a pathology, it makes

it possible to highlight the dental fractures, the

carious attacks and the apical lesions. In

endodontics, the area of interest will be

systematically controlled by a retroalveolar

radiograph8, 9.

1.3. Importance of differential

diagnosis

Before undertaking any emergency

endodontic treatment, it is important to make a

differential diagnosis.

a. Endodontic lesion mimicking a

periodontal lesion

The diagnosis of an endodontic problem is

often easy, its evolution respects the integrity

of the epithelial attachment11. In some cases,

especially in the mandible, an alveolar abscess

of endodontic origin may have a submucosal

or subperiosteal drainage path and lead into

the gingival sulcus of the affected tooth,

reminiscent of periodontal abscess. The

fistular route is established at the expense of

one of the bone tables and may appear in the

form of radiolucency radiography. In this case,

the periodontal sounding is deep and narrow,

located at the level of the fistula, and the pulpal

vitality test is negative. The patient consults

especially because of purulent discharge, and

not for painful symptomatology. These lesions

can sometimes be associated with an acute

inflammatory episode. Emergency treatment is

purely endodontic11, 12.

b. Periodontal lesion mimicking an

endodontic lesion

This situation is quite rare. However, confusion

may exist when there is an abscess of

periodontal origin localized to a single tooth.

The pain is accompanied or not by swelling of

the vestibular portion of the mucosa in the

vicinity of a tooth showing no sign of

endodontic pathology. The tooth can be

sensitive to axial percussion and apical

palpation and normally responds to thermal

sensitivity tests (hot or cold)11, 12.



c. Syndrome septum and endodontic

lesions

The septum syndrome results from a food

settling between two teeth whose point of

contact is deficient. The pain is very severe,

especially after the meal, and the presence of

decay or coronary restoration may suggest an

endodontic origin. The papillary gingiva bleeds

at the slightest touch and the X-ray can show

horizontal bone lysis in the interproximal

space. The simple suppression of food intake

relieves the patient9.

d. Radicular crack/fracture and

endodontic lesions

Radicular cracks and fractures are often

difficult to highlight. The clinical picture may

resemble that of a pulpitis if it occurs on a vital

tooth, and a desmodontitis if it occurs on a

tooth already treated endodontically. The most

reliable way to make an emergency diagnosis

is the bite test8, 9.

II. EMERGENCIES BEFORE

TREATMENT

2.1. Pulpitis

Pulpitis is a result of a bacterial attack most

often related to tooth decay. The aggression

can be triggered also by mechanical irritations,

chemical. The inflammatory reaction of the

pulp is similar to that which occurs in other

connective tissues; the fact that it is enclosed

in a cavity with inextensible walls explains the

local increase in pressure13. The first stage of

inflammation is associated with pulpal

hyperemia, which can evolve either acutely or

chronically to pulpal necrosis with the

possibility of periapex contamination4.

a. Reversible pulpitis

The reversible pulpitis corresponds to an

alteration stage of an inflamed but vital pulp.

External stimuli (hot, cold, sugar ...) cause

painful response but disappears immediately

after stopping the stimulus. The pains are

always provoked and not spontaneous. In

most cases, a carious lesion or recent

obstruction appears to be the cause of the

condition14, 15.

Urgent treatment consists of removing cavities

and providing a tight temporary seal to protect

the underlying pulp and provide sedative

function10, 15. In cases of proven pulpal

proximity, the use of other materials such as

calcium hydroxide or even MTA may be

indicated.

b. Irreversible pulpitis

The irreversible pulpitis corresponds to a

severe inflammation that does not regress,

even if the cause is suppressed; the pulp is

therefore condemned to be eliminated. The

symptomatology associated with irreversible

acute pulpitis is spontaneous, violent and

radiating pain. Pain can also be triggered by

hot, cold and acid and exacerbated by physical

activity and decubitus16. In the most advanced

stages of inflammation, ligament thickening

may be observed on X-ray. Given the extent of

such pain symptomatology, emergency

treatment is required after completion of a

deep anesthesia. The tooth to be treated is

isolated from the rest of the oral cavity, the



decayed dentin completely removed before

seeking access to the pulp, and the access

cavity made.

For multi-rooted teeth, only the cameral

pulp is removed with a bur or excavator.

The pulp is frankly sectioned at the

entrance of each canal. Hemostasis is

performed by compression with a cotton

pellet, previously decontaminated with

sodium hypochlorite. If stopping bleeding is

not achieved, pulpectomy of the bleeding

canal is indicated9.

For monoradiculates, complete

pulpectomy is indicated. It can be

performed with a nerve-puller whose

length and diameter selected according to

the radiological indications. Ideally a first

instrument is put in place, then a second

one is inserted. By simultaneously rotating

the two instruments, the instruments wind

up the connective bundle, which can be

removed from the canal without difficulty.

In all cases, a sterile cotton pellet alone is

placed in the pulp chamber. This dressing is

then covered with a temporary waterproof

cement. In some cases, especially in the most

advanced stages of periodontal inflammation,

the tooth should be placed under occlusion.

The treatment is accompanied by a

prescription of nonsteroidal anti-inflammatory

to block the synthesis of prostaglandins which

are algogenic factors.

All recent endodontic manuals advocate this

emergency treatment to relieve patients with

acute pulpitis17, 18, 19, 20. In addition, a large

number of authors have shown that a tooth

thus treated may remain asymptomatic for a

period of at least one month, and may exceed

6 months21, 22, 23, 24, 25. However, all of them

mention the difficulty of emergency

implementation and poor initial management

can strongly influence the definitive treatment

(accidental bacterial contamination of the

canals during the emergency procedure can

promote or lead to an infection of the

endodontic system which will very often lead to

formation of an inflammatory apical bone

lesion that may progress to abscess.) More

recently, different protocols for the

management of this type of pain syndromes

have been proposed, consisting of a

periradicular intra-osseous injection of

synthetic glucocorticoid26, 27. The anti-

inflammatory action on the inflamed pulp has

been demonstrated by a biochemical

approach28.

Anesthesia of the concerned tooth is

performed. The site of transcortical perforation

is determined after clinical and radiographic

examination: it should ideally be located in the

attached vestibular gingiva, about 5 mm below

the line of the necks, avoiding the dental roots.

The cortical bone is perforated using a sterile

disposable device designed for intra-bone

injection of anesthetic, mounted on a counter-

angle rotating at 10,000 rpm (Dentsply-

Maillefer X-Tip® Needle). The perforator is then

removed leaving in place a catheter for

injection into the medullary bone space. The

methyl-prednisolone acetate (Dépo-Médrol®),

previously conditioned, is injected slowly (1 ml

in 1 to 2 minutes) via a needle placed in the

catheter. The injection site is monitored for



evidence of possible reflux that would lead to

treatment failure. After injection, the guide is

removed using a hemostatic forceps, and if

necessary, hemostasis obtained by

compression. No endodontic procedure or

prescription is required and final endodontic

treatment can be performed later in a single

session to avoid the risk of contamination27.

2.2. Acute apical periodontitis

In the absence of treatment, the bacteria that

cause pulpitis can develop, cause pulp

necrosis and eventually cause bacterial

contamination of the endodontic space10. The

development of this infection usually leads to

the development of an inflammatory bone

lesion in the periapical region of the concerned

root. In most cases the periodontal ligament is

also affected by the inflammation and a

thickening is clearly visible on the X-ray.

Clinically, the pains are dull, continuous,

exacerbated by occlusal contact. The pulpal

vitality tests are negative and the percussion is

very painful9. In extreme cases the contact of

the tongue is unbearable thus putting the

patient in a situation of discomfort.

Emergency treatment is done under

anesthesia because there may still be nerve

fibers in the canals. The canals are rid of all

their contents and the shaping carried out

under abundant irrigation with sodium

hypochlorite. An endodontic medication with

calcium hydroxide is put in place and the tooth

is then closed and imperatively placed under

occlusion. A prescription of ibuprofen

completes the surgical procedure14, 15.

2.3. Acute apical abscess

Acute alveolar abscess results from the

passage of bacteria beyond the endodontic

system with diffusion of infection between the

alveolar bone and the periosteum. In some

cases too, it may follow a chronic inflammatory

reaction of the apical periodontium which, for

various reasons, passes into the acute phase.

In clinical terms, the pains are spontaneous,

continuous and very intense9, 14. The causal

tooth is sensitive to contact and percussion.

Vestibular palpation triggers an exacerbation

of pain. Pulpal vitality tests are negative,

important element for differential diagnosis

with periodontal abscess. In the emergency

treatment of acute alveolar abscess, three

situations are always described1, 9, 14.

- Drainage can be obtained by the canal

After setting up the rubber dam, the access

cavity is made. As soon as access to the pulp

chamber is reached, the pus flows and the

patient feels immediate relief. Once this flow

has dried up, the access cavity is finalized, and

abundantly rinsed with sodium hypochlorite. If

this spontaneous drainage is not obtained

immediately after the creation of the access

cavity, it must be caused by the use of a file

(08 to 15) exceeding controlled beyond the

apical constriction. After rinsing the canals, the

tooth is left open and placed under occlusion

for a maximum of 48 hours. A second

appointment is given to achieve the root canal

shaping and disinfection.

- A fluctuating abscess is present



If trans-canal drainage has not been achieved

and fluctuating abscess is present, the

drainage required to achieve patient relief can

be achieved by open incision to the

periosteum. After performing a superficial

anesthesia of the mucous membrane, a frank

incision until the periosteum is performed with

a scalpel blade n ° 11. The drainage

immediately relieves the patient. The canals

are thoroughly rinsed with sodium hypochlorite

and the tooth is closed and placed under

occlusion. As in the previous case, an

appointment is scheduled as soon as possible

to initiate endodontic treatment.

- Drainage is not obtained

1. If drainage has not been achieved after

the access cavity and instrumental

maneuver and the abscess is not yet

collected, the tooth should be left open

and placed under occlusion. The

patient is also advised to perform hot

and salty mouthwash by focusing on

the affected tooth. The prescription of

antibiotics is essential; it is here an

association of amoxicillin and

metronidazole. The prescription of a

strong analgesic or corticosteroid must

also be done. As soon as the clinical

signs disappear, the patient must be

reviewed and the endodontic treatment

performed14.

III. EMERGENCIES AFTER TREATMENT

3.1. Recent conservative treatment of the pulp

Following a conservative treatment of the pulp,

a post-operative pain can occur in three

situations:

- Biological cause: Exposure of the pulp to

bacteria is the most virulent irritant and the

most likely to cause pulpal reactions. The

virulence of bacterial aggression, the duration

of contamination and the tightness of the teeth

/ obturation are the parameters most frequently

involved in this cause.

- Physical cause: pulpal pain is associated with

excessive heat-up during milling or polishing,

or abnormal mechanical stimulation of the

tooth due to, for example, iatrogenic occlusal

overload.

Chemical cause: it is directly related to the

toxicity of drug products and materials used in

conservative dentistry29.

3.2. Flare up

a. Infectious outbreak

The peculiarity of this type of emergency is that

it occurs in a patient who before his endodontic

treatment did not suffer. It is after the canal

cleaning session that the pain occurs, which

contributes to the frustration of the patient14, 30.

Three hypotheses can explain the appearance

of this pain:

- The presence of debris, bacteria or

endotoxins beyond the apical foramen



propelled into this region during

instrumentation.

- A modification of the intraductal bacterial flora

due to the non-respect of the asepsis-

antisepsis chain.

- A lasting or temporary immunodeficiency of

the patient. The emergency treatment is the

same as that of acute apical periodontitis with

imperatively a prescription of the amoxicillin

and metronidazole combination14, 30.

b. Inflammatory outbreak

The peculiarity of this type of emergency is that

it occurs in a patient who before his endodontic

treatment did not suffer. It is after the canal

cleaning session that the pain occurs, which

contributes to the frustration of the patient14, 31.

Three hypotheses can explain the appearance

of this pain:

- The presence of debris, bacteria or

endotoxins beyond the apical foramen

propelled into this region during

instrumentation.

- A modification of the intraductal bacterial flora

due to the non-respect of the asepsis-

antisepsis chain.

- A lasting or temporary immunodeficiency of

the patient. The emergency treatment is the

same as that of acute apical periodontitis with

imperatively a prescription of the amoxicillin

and metronidazole combination14.

3.3. Accidental injection of

sodium hypochlorite

This type of rare accident occurs when sodium

hypochlorite has been injected into the

periradicular tissues. The reaction is

immediate and violent. The pain is unbearable

and a swelling appears within minutes. At the

level of the canal concerned, prolonged

bleeding appears14. This type of accident often

causes significant necrosis of the surrounding

tissues. The action to take is the following32:

• Stay calm and inform the patient about the

cause and nature of the complication,

• Perform local anesthesia for initial control of

acute pain,

• Rinse immediately with saline to decrease

soft tissue irritation by dilution of sodium

hypochlorite,

• Apply cold compresses immediately to the

facial area to relieve the pain and burning

sensation felt by the patient,

• Leave the tooth open to optimize drainage,

• Recommend that the patient apply an ice

pack for 24 h (15 min intervals) to minimize

edema,

• Recommend that the patient apply warm,

moist compresses after 24 h (15 min intervals)

and rinse with saline for 1 week to improve

circulation in the affected area,

• Control pain with painkillers,

• Avoid nonsteroidal anti-inflammatory drugs,

• Control the inflammatory reaction with the

steroids in the form of tablets at a rate of 1 mg

/ kg or intramuscularly for 3 days,

• Prevent over-infection by prescribing

antibiotics: penicillin is the molecule of choice.

In case of allergy prefer Metronidazole for 7

days,



• Schedule follow-up appointments at regular

intervals: Clinical control is required until

symptoms are resolved,

• In severe cases: hospital care is necessary.

To avoid this type of incident, simply avoid

blocking the needle in the canal during

irrigation. To do this, the needle is lowered into

the canal until it locks, then withdrawn by one

millimeter; the injection of sodium hypochlorite

can then begin14.

CONCLUSION

Emergency consultations are unanimously

described as the last resort for patients who

have given up their care, particularly for socio-

economic reasons. Their consultation is

motivated by pain, which explains the large

number of endodontic emergencies in daily

practice. The dental surgeon must have a

therapeutic arsenal to deal with all these

emergencies. A medicalized approach to our

profession based on a preventive and

ultraconservative odontology would certainly

help to reduce endodontic emergencies in

general and those that occur during treatments

in particular.

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Odontologie, 23-008-A-20, 2006,

Médecine buccale, 28-260-V-10, 2008.

30. Gbadebo SO, Sulaiman AO, Anifowose

OO. Endodontic flare up: incidence and

association of possible risks. Afr J Med

Med Sci 2016;45(2):207-2012.

31. Yang HL, Tang R, Gong Y, Zhang YH.

Clinical evaluation of the presence of

interappointment emergencies during

intracanal medication before and after root

canal preparation. Shanghai Kou Qiang Yi

Xue 2016;25(2):227-230.

32. Ben Rajeb H, douki N. injection

accidentelle d’hypochlorite de sodium au

cours d’un traitement accidentelle : mieux

comprendre pour mieux gérer.

Odontostomatol Trop 2015 ; 38 :50-56.

LISTE OF FIGURES

Figure 1: Emergency treatment of reversible

pulpitis involves removal of decayed tooth tissue

and placement of pulp capping material

.

a. b.

c.

Figure 2 : Opening of the pulpal chamber of a

maxillary molar presenting acute irreversible

pulpitis with significant bleeding (a) which

persisted despite a few minutes of haemostasis

(b); which necessitated the pulpectomy of the

palatal canal (c).

a. b.

Figure 3: Periradicular injection of methyl prednisolone

acetate

a: Transcortical perforation

b: Injection of the product



Figure 4: Emergency treatment of acute

apical periodontitis: access cavity followed

by root canal shaping under heavy

irrigation with sodium hypochlorite.

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