Management of a Vital, Irreversibly Inflamed Tooth with Unstoppable Bleeding




  • Patients with recent restorations (e.g., amalgam and resin restorations, crowns) or trauma
  • Medically-compromised patients


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


Pain severity: the patient may experience some pain


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


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


Refer to an endodontist if uncomfortable dealing with this situation.

  1. Ensure that over-instrumentation did not occur.
  2. Place an orthodontic or copper band, or build up the tooth prior to treatment, if adjacent gingival tissues are bleeding in poorly isolated teeth.
  3. 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 thirds.
  4. 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 perform this procedure, refer the patient to an endodontist.
  5. If bleeding stops: Irrigate with NaOCl and leave in the canals and pulp chamber for 10–15 minutes. Dry and place Ca(OH)2 in the canals and close.
    If bleeding does not stop: Place sterile water in the canals for 10–15 minutes, to stop the breakdown of pulpal tissues.
  6. 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.



Dr. Jafine is on staff at the Peel Memorial Hospital in Brampton, Ontario. He also maintains a private practice in endodontics and microsurgical procedures in Scarborough and Bramalea, Ontario. Dr. Jafine was a clinical instructor at the University of Toronto faculty of dentistry for 15 year in both the undergraduate and graduate programs.

Correspondence to: Dr. Jafine, Partners in Endodontics, 709-2075 Kennedy Rd, Scarborough, ON  M1T 3V3. Email:

The author has no declared financial interests.

This article has been peer reviewed.

Suggested Resources

  1. Imura N, Zuolo ML. Factors associated with endodontic flare-ups: a prospective study. Int Endod J. 1995;28(5):261-5.
  2. Morse DR, Koren LZ, Esposito JV, Goldberg JM, Belott RM, Sinai IH, et al. Asymptomatic teeth with necrotic pulps and associated periapical radiolucencies: relationship of flare-ups to endodontic instrumentation, antibiotic usage and stress in three separate practices at three different time periods. Int J Psychosom. 1986;33(1):5-87.
  3. Walton R, Fouad A. Endodontic interappointment flare-ups: a prospective study of incidence and related factors. J Endod. 1992;18(4):172-7.
  4. Harrington GW, Natkin E. Midtreatment flare-ups. Dent Clin North Am. 1992;36(2):409-23.
  5. Harrison JW, Gaumgartner JC, Svec TA. Incidence of pain associated with clinical factors during and after root canal therapy. Part 1. Interappointment pain. J Endod 1983;9(9):384-7.
  6. Fabricius L, Dahlén G, Sundqvist G, Happonen RP, Möller AJ. Influence of residual bacteria on periapical tissue healing after chemomechanical treatment and root filling of experimentally infected monkey teeth. Eur J Oral Sci 2006;114(4):278-85.
  7. Seltzer S, Bender IB, Ziontz M. The dynamics of pulp inflammation: correlations between diagnostic data and actual histologic findings in the pulp. Oral Surg Oral Med Oral Pathol 1963;16:846-71.
  8. Tsesis I, Faivishevsky V, Fuss Z, Zukerman O. Flare-ups after endodontic treatment: a meta-analysis of literature. J Endod 2008;34(10):1177-81.
  9. Torabinejad M, Kettering JD, McGraw JC, Cummings RR, Dwyer TG, Tobias TS. Factors associated with endodontic interappointment emergencies of teeth with necrotic pulps. J Endod 1988;14(5):261-6.