Endodontic Emergency – Definition, Classification Diagnosis and Treatment Plan

Endodontic Emergency as the name suggests is the pathology related to Pulp and Periapical tissue which should be addressed immediately to give relief to the patient.

Definition of Endodontic Emergencies:
It is defined as any condition leading to an unscheduled visit associated with Pain or Swelling in relation to pathology of Pulp and Perapical tissue and Traumatic injuries which requires immediate Diagnosis and Treatment.

Classification of Endodontic Emergencies by P Carrotte:

Endodontic Emergencies are classified into 3 main types based on the time of their occurrence related to Endodontic treatment:

Pre Treatment: Patient comes to the dentist for the first time with either a swelling or an Injury
Intra Appointment: This is an emergency which has occurred during the Endodontic Treatment procedure is under way
Post Obturation: This is the Emergency which has taken place after the completion of the Endodontic Procedure performed

Pre Treatment Endodontic Emergencies:

1. Dentin Hypersensitivity
2. Pain of Pulpal Origin:

• Reversible Pulpitis
• Irreversible Pulpitis

3. Acute Apical Periodontitis
4. Acute Periapical Abscess
5. Traumatic Injury: Ellis Fractures
6. Cracked Tooth Syndrome

Intra Appointment or Under Treatment:

1. Mid treatment Flare ups
2. Exposure of pulp
3. Fracture of Tooth
4. Recently placed restoration – Trauma form Occlusion due to high points
5. Periodontal treatment

Post Endodontic Treatment:

1. Over Instrumentation while doing BMP
2. Overextended filling during Obturation
3. Under filling during obturation
4. Root Fracture
5. High points during Restoration

Diagnosis in Endodontic Emergencies:

Diagnosis is a very important aspect in Endodontic Emergencies to properly diagnose the causative factor so that immediate relief can be given to the patient. The three aspects mentioned in the classification should be eliminated each to come to a proper diagnosis depending on whether the symptoms were seen pre treatment or during the treatment or after treatment.

The various Conditions seen as Endodontic Emergencies:

Pre Treatment Endodontic Emergencies:

Dentinal Hypersensitivity: The presence of short and sharp pain occurring in presence of external stimulus thermal, chemical or tactile can be caused due to exposure of the dentinal tubules during endodontic procedure on the adjacent tooth which should be treated by identifying the location and by using  Desensitizer over the tooth surface affected.

Cracked Tooth syndrome:  The presence of fracture lines not deep but which involve the enamel and dentin causing pain in the pulp and periodontal involvement may also be seen. This can be caused by biting on any hard substance or in presence of any para functional habits in case of Trauma. The patient is asked to bite on any substance and if patient complains of Pain during release of pressure it is a classic sign of cracked tooth syndrome. Immediate relief will be by de occluding the tooth and permanent solution can be by Endodontic treatment or Extraction based on the involvement of Fracture line.

Acute Periapical Abscess: The presence of an abscess in the apical portion of the tooth caused due to the inflammation of the periodontal ligament resulting from pulpal infection or Trauma to the affected tooth. Th treatment plan should be incision and drainage of the abscess to give immediate relief and Endodontic treatment.

Acute Irreversible Pulpitis:  This is caused when the caries of infalmmatory process extends to the Pulp causing irreversible pulpitis which can be seen with pain on stimulus and persisting even after removal of stimulus. The treatment for Irreversible Pulpitis is Root Canal Treatment.

Intra Appointment or Under Treatment:

1. Over Instrumentation: Over instrumentation of the pulp chamber can also lead to Endodontic emergencies which should be dealt with immediately. Perforations are a common problem in lower anterior and the Molars which lead to perforation of the furcation.

2. Missed Pulp Canal: Missing a pulp canal after BMP can also lead to severe pain in between appointments. This happens mostly in case of upper first premoalr and all molar which can have additional pulp canals.

3. Inadequate Debridement:

4. Tissue or Air Emphysema: It is the collection of Gas in the Tissue Spacesor the facial planes which is seen during Periapical surgery or Endodontic therapy where Air is forced towards the tissue either with an Air-rotor or the Air pump.

5. Hyper Occlusion or High Point: Presence of excess restoration in between appointments can also lead to severe pain in less than 2 hours of the restoration which should be trimmed and high points removed to relieve the patient.

6. Debris Extrusion:
7. Procedural Complication:

Post Obturation Emergencies:

After the completion of the Root Canal therapy or Obturation the patient complains of pain on biting, chewing or constant pain.

Over Instrumentation: If proper working length is not recorded and the instrumentation extends beyond the Root Apex this leads to over instrumentation leading to pain.

Overfilling: The same problem as seen in over instrumentation where the working length is not recorded properly leading to excess filling.

Persistent Pain: This means that the peri apical lesion is not healed or the presence of vital pulp tissue remnants or infected pulp left in the pulp canals.

Fracture of Root: This can be caused due to three factors – during obturation, during post placement, fracture of crown structure or restoration leading to root fracture.

Hyperocclusion:

Poor Coronal Seal:

These are the various Endodontic Emergencies which are seen before, during or after Endodontic treatments these are related to Endodontic treatments and should be solved immediately to releive the patient of Pain.