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

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