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Clinical Guide to Treating Endodontic Emergencies
Avoiding common mistakes to provide optimal outcomes
James Bahcall, DMD, MS | Bradford Johnson, DDS, MPHE
An endodontic emergency “is defined as pain and/or swelling caused by various stages of inflammation or infection of the pulpal and/or periapical tissues.”1 An American Dental Association 2010 survey stated that general dental practitioners averaged 230.7 walk-in/emergency patients per year.2 Approximately 85% of all dental emergencies arise from pulpal or periapical disease.3
The patient with an endodontic emergency requires a clinician to be skilled in diagnosis, endodontic treatment, and clinical pharmacology.4 With the correct implementation of these skills, a dentist can be efficient and effective in treating a patient with an endodontic emergency. This article will discuss the clinical management of an endodontic (non-trauma, adult patient) emergency from diagnosis through treatment.
After reviewing the patient’s medical and dental history, the determination of the pain etiology must be made prior to performing any emergency treatment. The first step in determining etiology is understanding the patient’s perception of the issue (subjective), followed by clinical tests (objective) to reproduce the patient’s subjective pain symptoms.
There are five objective clinical tests that need to be performed in a patient’s endodontic diagnostic evaluation:
1. cold, electric pulp tester (EPT) and/or heat tests for pulp vitality
2. percussion testing to determine the status of the periodontal ligament (PDL) 3. palpation testing to evaluate the gingival tissue and cortical and trabecular bone for infection or inflammation
4. periodontal examination that includes probing and tooth mobility evaluation
5. radiographic examination of current periapical and bitewing films, along with a CBCT (cone-beam computed tomography) when indicated.
These objective tests enable a dentist to make a proper pulpal and periradicular diagnosis. Using only a dental radiograph to determine the etiology of tooth pain can lead to treatment of the wrong tooth (Figure 1).
Pulpal and Periradicular Diagnoses
The pulpal nerve fibers A-delta (respond to cold and EPT) and C-fibers (respond to hot and patient’s report of spontaneous tooth pain) are nociceptors, which are sensory receptors that respond to stimuli by sending nerve signals to the brain. This stimulus can cause the perception of pain in an individual.5 By testing the pulpal nerve fibers, a dentist can determine the pulpal status.
Current pulpal diagnosis terminologies include:
• Reversible pulpitis: Pain from an inflamed pulp that can be treated without the actual removal of the pulp tissue. This is not a disease, but rather a symptom. The classic clinical symptom is a sharp, quick pain that subsides as soon as the stimulus (cold) is removed.
• Symptomatic irreversible pulpitis: Pain resulting from an inflamed pulp for which the only treatment is removal. Classic clinical symptoms include lingering of cold/hot stimulus for more than 5 seconds and/or patient reporting spontaneous tooth pain.
• Pulpal necrosis: The pulp does not respond to cold tests, EPT, or heat test. Pulpal necrosis can result from an untreated irreversible pulpitis or immediately after a traumatic injury that disrupts the vascular system of the pulp.
A periradicular diagnosis is just as important as a pulpal diagnosis. A study by McCarthy and colleagues6 demonstrated that patients presenting with periradicular pain can localize the painful tooth (89%) in comparison to patients that present with tooth pain without periradicular pain (30%). Current periradicular diagnosis terminologies are described in Table 1.
Odontogenic vs Non- Odontogenic Pain
When performing objective clinical endodontic tests to diagnose an emergency endodontic patient, there can be many non-odontogenic pain symptoms that mimic endodontic symptoms.7 If a patient describes his or her pain as tingling, electric-like, burning, or hurting on both sides of the face, the etiology may be non-odontogenic in origin.
Whenever the objective endodontic diagnostic tests either do not correlate with the subjective patient symptoms or are within normal limits, a clinician must re-evaluate the etiology of pain and proper diagnosis before providing any dental treatment.
When confirming endodontic pain, primary pain is when the reported and actual site and source of the pain are the same. For example, this occurs if patients report that their tooth pain is brought on when they eat or drink anything cold and you test the specific tooth to cold and they have a painful lingering response (pulpal diagnosis: symptomatic irreversible pulpitis).
Heterotopic pain or secondary pain is perceived to originate from a site that is different from the actual source of the pain.7 From an endodontic diagnostic perspective, the dentist must consider that the source of the pain is different from the site of the pain when the tooth perceived as the pain source tests within normal limits to the objective tests. In this case, endodontic treatment on the tooth will result in no change in the patient’s pain.
Selective anesthesia can be useful to either isolate odontogenic pain or help differentiate between odontogenic and non-odontogenic pain. As a clinical guide, if the tooth pain subsides after anesthesia is placed, the etiology is most likely odontogenic pain. If the patient’s pain does not subside after injection of local anesthesia, the clinician should consider a non-odontogenic etiology.8 Although selective anesthesia can be a useful clinical aid in diagnosis, it should be performed as a last objective test after all the tooth and periradicular testing has been completed.