Approximately 60% of patients with oral or maxillofacial pain are in need of endodontic emergency treatment. The immediate goal of the emergency treatment is to mitigate the patient’s symptoms and, if possible, it should also constitute the first phase in the permanent treatment of the condition. Since emergency treatment usually takes place between regular patients in a busy schedule, the therapeutic procedures should be as simple as possible and in keeping with the objective of relieving the patient’s pain.
About 90% of vital teeth that need endodontic emergency treatment are carious teeth or teeth previously restored because of caries (Table 7.1). Approximately 2% of the teeth will have symptoms because of traumatic occlusion. Exposed dentin and tooth fractures are other conditions causing pain in vital teeth.
In teeth with symptomatic pulpitis, either carious dentin must be excavated or existing restorations removed, or both. The subsequent treatment will then depend on the clinical findings, mainly on whether the pulp is exposed or not.
Symptomatic teeth without pulp exposure. When carious dentin and possible restorations have been removed, the cavity is cleansed with a spray of water and air, and while still wet is filled with zinc oxide–eugenol cement (see p. 86). This is a simple, rapid, and effective method which, over a 5-year period, has been found to give relief from pain in 97% of the teeth (Table 7.2). Remember, however, that when the final treatment is planned, absence of symptoms does not in any way guarantee a healthy pulp.
Symptomatic teeth with pulp exposure. If the pulp is found to be exposed after excavation of carious dentin or removal of a restoration (or both), there are three possible methods for emergency treatment. While the three procedures are not equally effective, they are all acceptable and provide a reasonable choice according to the time available for the emergency treatment.
Anodyne medicament. The simplest treatment method is to apply a cotton pellet with a medicament with an anodyne effect, preferably eugenol, directly on the exposed pulp. The cavity is subsequently filled temporarily with a material which gives a bacteria-tight seal, usually a zinc oxide–eugenol cement. This treatment is simple, rapid, and amazingly effective, and gives temporary relief from pain in about 90% of these cases until a pulpectomy can be performed (Table 7.2).
Emergency pulpotomy. The second method is to amputate and remove the coronal pulp of the symptomatic tooth. The bleeding is controlled and a cotton pellet with an anodyne medicament (eugenol) is applied on the remaining pulp stump. The cavity is then sealed bacteria-tight as described above. This method is most effective and will give relief from pain in more than 95% of these cases (Table 7.2). It is somewhat more time-consuming than the first method, but it is still a simple procedure in that no root canal instrumentation is performed. The emergency pulpotomy should be regarded as the routine method in emergency treatment of vital teeth with exposed pulp.