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Endodontics

How do I manage vital, irreversibly inflamed teeth with unstoppable bleeding?

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This urgent care scenario is presented by the JCDAOasis Team in consultation with Dr. Brian Jafine.

Peer-reviewed content that appeared in the JCDA OASIS “point of care” searchable database at www.jcdaoasis.ca 

Presentation

Population

  • Patients with recent dental restorations (amalgams, resins, crowns) or trauma
  • Medically-compromised patients

Signs

  • Large/deep restorations and crowns (broken down, leaking, open margins)
  • Continuous bleeding after several attempts to dry, close, or fill the root canal spaces

Symptoms

  • Pain severity: the patient may experience some pain

Investigation

  • Thoroughly assess the patient’s medical history: inquire about diabetes mellitus, bleeding disorders, hypertension, history of radiation therapy, etc.
  • Perform an oral examination:
    • Perform a visual examination for any remaining pulp tissue in the canal spaces or trapped under pulp horns.
    • Determine the source of bleeding in canals by placing paper points and locating the blood on the point.
    • Verify if there is bleeding from gingival tissues in poorly isolated teeth.
  • Perform a radiographic examination:
    • Include both periapical and bitewing radiographs.
    • Radiographs can be taken to confirm length (along with apex locator) and determine perforations, strip perforations, or possible missed canals.
  • An apex locator can be used to check if perforation or zipping of the apex is suspected.

Diagnosis

Based on the clinical and radiographic examinations and the patient’s medical history, a diagnosis of irreversibly pulpitis, with bleeding from the root canal system is determined.

Treatment

If Bleeding Does Not Stop:

  • Ensure that over-instrumentation does not occur.
  • Place an orthodontic or copper band, or build up the tooth prior to treatment, if adjacent gingival tissues are bleeding in poorly isolated teeth.
  • Perform a complete and thorough cleaning and shaping, and irrigate to remove all pulpal material.
    • Slot or tear-drop shaped canals often have several foramina.
    • Large isthmus areas between canals can have an apical delta configuration.
    • C-shaped canals often have several portals of exit in the middle and apical one third.
  • Perform a radiographic evaluation to determine length (you can also use an apex locator), possible perforation, strip perforation, or missed canals. If a perforation is noted, repair immediately with mineral trioxide aggregate (MTA) or equivalent material. If unable to do this procedure, refer the patient to an endodontist.
  • If bleeding stops: Irrigate with sodium hypochlorite (NaOCl) and leave in the canals and pulp chamber for 10 to 15 minutes. Dry and place calcium hydroxide [Ca(OH)2] in the canals and close, if bleeding stops.
  • If all else fails, leave the tooth open for a maximum of 24 hours, reappoint for the next day, lightly instrument, irrigate, dry, and close.
  • Refer to an endodontist, if uncomfortable dealing with this situation.

JCDA-OASIS supports clinical decisions. However, it does not provide medical advice, diagnosis or treatment details. JCDA-OASIS is a rapidly accessible, initial clinical resource—not a complete reference.

Suggestions and feedback should be directed to jcdaoasis@cda-adc.ca

3 Comments

  1. Kevin Mark February 27, 2013

    I’ve found ferric sulfate placed in the pulp chamber and then helped down the canals with paper points works well to control seemingly unstoppable bleeding.

    Reply
  2. nasrin karim April 12, 2013

    any tips on how to use and control the consistency and placement of mta ?

    Reply
  3. Amy October 28, 2013

    What to do if there is difficulty in freezing the deeper, apical portion of the root canal system in such cases and it prevents complete instrumentation?

    Reply

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