PDF: Management of Endodontic Emergencies: Pulpotomy Versus Pulpectomy

Recent studies report a 60-82% incidence of endodontic emergencies among all dental emergencies (1, 2). Within this group, 20-42% of patients seek care for teeth with symptomatic irreversible pulpitis (SIP) (1-3). Additionally, about 60% of SIP patients also complain of symptomatic apical periodontitis (SAP) (3). 

While pain due to a severely inflamed pulp is characterized by dull, throbbing and lingering pain sensations, it can be spontaneous or in response to an external stimulus, such as hot, cold or chewing. This makes SIP the bulk of the emergency cases seen in dental clinics.

The goal of management of endodontic emergencies is to quickly and effectively manage pain and infections thereby also minimizing the development of persistent pain and the formation of periapical pathology. 

Pharmacological management such as intramuscular or infiltration injection of ketorolac trimethamine (injectable NSAID) can significantly attenuate pain in patients with moderate to severe pulpal pain over a three-hour tested time (4, 5) or oral administration of ibuprofen sodium dihydrate over a one-hour time period (6). These treatments have yet to be evaluated over days or weeks after drug administration but before completion of endodontic therapy. Therefore, until research becomes available substantiating the long-term effectiveness of pharmacological management, procedural interventions remain the gold standard.

On the other hand, procedural interventions such as pulpotomies and pulpectomies have been the first line of emergency treatments with pulpectomy being the preferred choice of treatment (Figure 1). As seen in Figure 1, a survey of Diplomates of the American Board of Endodontics demonstrated that more endodontists were inclined towards pulp extirpation/pulpectomy compared to pulpotomy-only procedures for both vital and necrotic cases (7-9). Moreover, more than 50% of endodontists preferred complete instrumentation compared to pulpectomy-only procedures, especially in necrotic cases. 

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