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Patient Presentation Pain Pain and swelling Trauma (later lecture)
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Emergency Impacts
Patient Staff Dentist
Patient Presentation
Pain Pain and swelling Trauma (later lecture)
3 D’s ofSuccessful Management
Diagnosis Definitive dental treatment Drugs
Diagnosis
Diagnosis Determine the CC Take an accurate
medical history Complete a
thorough exam, with all necessary tests
Perform a radiographic exam
Analyze and synthesize results
Establish a treatment plan
Treatment Planto
REMOVEthe
ETIOLOGY
When do patients present foremergency endodontic care? No prior RCT / initial infection After RCT initiated After obturation
Initial Presentation
PAIN!
Primary infection
After Initiation ofEndodontic Therapy
After Initiation ofEndodontic Therapy FLARE-UP!
After InitiationofEndodontic Treatment Before obturation
After Obturation
Recent obturation
Non-healing endodontic therapy
Determine aPulpal
andPeriradicular
Diagnosis
Pulpal Diagnosis Normal pulp Reversible pulpitis Irreversible pulpitis Necrotic pulp Pulpless/ previously treated
Periradicular Diagnosis Normal periradicular tissues Acute periradicular periodontitis Acute periradicular abscess
Periradicular Diagnosis Chronic periradicular periodontitis
Symptomatic Asymptomatic
Chronic periradicular abscess (suppurative periradicular periodontitis)
Periradicular DiagnosisFocal sclerosing
osteomyelitis(condensing osteitis):
LEO
Etiology After listening to the patient, begin to
determine the etiology of the chief complaint:
Contents of the root canal? Dentist controlled factors? Host factors?
Contents of theRoot Canal Pulp tissue Bacteria Bacterial by-
products Endodontic therapy
materials
DentistControlled Factors Over-instrumentation Inadequate debridement Missed canal Hyper-occlusion* Debris extrusion Procedural complications*
HyperocclusionRosenberg PA, Babick PJ, Schertzer L,
Leung A. The effect of occlusalreduction on pain after endodontic
instrumentation. J Endodon1998;24:492.
Hyperocclusion Researchers have
foundthat patients most likelyto benefit from occlusalreduction are thosewhose teeth initiallypresent with symptoms. Indiscriminant
reductionof the occlusal surface isnot indicated
PRE-OP PAIN PULP VITALITY PERCUSSION
SENSITIVITY ABSENCE OF A
PERIRADICULAR RADIOLUCENCY
COMBINATION OF THESE SYMPTOMS
Procedural Complications Perforation Separated instrument Zip Strip NaOCl accident Air emphysema Wrong tooth
DentistControlled Factors Dentist’s
personality
Host Factors Allergies Age Sex Emotional state
Host Factors
Complex etiology
Microbiologic Immunologic Inflammatory
Bacteria! Bacterial
byproducts/ endotoxin
Host Defense is Multi-factorial
Three D’sofSuccessful Management
Diagnosis Definitive dental treatment Drugs
EmergencyTreatment
Non-surgical Surgical Combined
Non-surgicalEmergency Treatment
Pulpotomy Partial pulpectomy Complete pulpectomy Debridement of the root canal
system*
SurgicalEmergency Treatment
Incision for drainage
Trephination/apical fenestration
Rationale for I & D Decreases number of bacteria Reduces tissue pressure
Alleviates pain/trismus Improves circulation
Prevents spread of infection Alters oxidation-reduction potential Accelerates healing
Management Inadequate debridement Debris extrusion Over-instrumentation Missed canal Fluctuant swelling Severe pain, no swelling
Treatment For severe pain without visible
swelling… Trephination!
QUESTIONS
“Should I leave the tooth OPEN or CLOSED?”
“Should I place anInter-appointment
Medicament?”Ca(OH)2
“Should I prescribeANTIBIOTICS?”
Three D’sofSuccessful Management
Diagnosis Definitive Dental Treatment Drugs
Remember, there is aComplex Etiology
Microbiologic Immunologic Inflammatory
And, not all can be easilytreated...
Debris extrusion Over-instrumentation Over-filling Over-extension
Breakingthe
Use a Flexible AnalgesicStrategy
Drugs Pre - op / loading dose Long acting anesthesia Prescription
Codeine Prototype opioid for orally available
combination drugs Studies found that 60 mg of codeine
(2T-3) produces significantly more analgesia than placebo but less analgesia than 650 mg aspirin, or 600 mg acetaminophen
Troullis E, Freeman R, Dionne R. The scientific basis for analgesic use in dentistry.
Anesth Prog 1986 33:123.
Codeine
Patients taking 30 mg of codeine report only as much analgesia as placebo
Troullis E, Freeman R, Dionne R. The scientific basis for analgesic use indentistry. Anesth Prog 1986 33:123.
Ibuprofen andAcetaminophen* 57 patients Local anesthesia, pulpectomy, post- op analgesic
Placebo 600 mg ibuprofen 600 mg ibuprofen & 1000 mg acetaminophen
*Menhinick KA, Gutman JL, Regan JD, Taylor SE and Buschang PH. The efficacy of pain control following nonsurgical root canal treatmnent using ibuprofen or a combination of ibuprofen and acetaminophen in a randomized, double-blind, placebo-controlled study. Int Endod J 2004;37:531-41.
Ibuprofen andAcetaminophen* Visual analogue scale & baseline 4-point category pain scale
1 hr, 4 hr, 6 hr, 8 hr General linear model analyses Significant differences
Placebo and combination Ibuprofen and combination
No significant difference Placebo and ibuprofen
Ibuprofen andAcetaminophen*
“The results demonstrate thatthe combination of ibuprofenand acetaminophen may be
more effective than ibuprofenalone for the management of
postoperative endodonticpain.”
Analgesic Doses Codeine 60mg Oxycodone 5-6 Hydrocodone 10 Dihydrocodone 60 Propoxyphene HCl (Darvon) 102 Meperidine (Demerol) 90 Tramadol (Ultram) 50
Flexible Analgesic Plan
Flexible Analgesic Plan
Selected NSAID DrugInteractions Anticoagulants Increased prothrombin time or
bleeding time ACE Inhibitors Reduced antihypertensive
effectiveness Beta Blockers Reduced antihypertensive effects Cyclosporine Increased risk of nephrotoxicity Lithium Increased serum levels of lithium Sympathomimetics Increased blood pressure Thiazide Reduced antihypertensive
effectiveness
Indications forAntibiotic Therapy Systemic involvement Compromised host
resistance Fascial space involvement Inadequate surgical
drainage
Guidelines forAntibiotic Therapy
Select antibiotic with anaerobicspectrum
Use a larger dose for a shorterperiod of time (“hard and fast”
rule)
Selecting theAppropriate Antibiotic Gram stain results available:
antibiotic-sensitivity charts C & S results available:
antibiotic-sensitivity charts No gram stain or C & S results:
PCN is antibiotic of choice
Penicillin V Still, the drug of choice for infections of
endodontic origin Loading dose: 1-2 g then 500 mg qid x
7-10 days
Metronidozole(Flagyl) Used in conjunction with
Penicillin V 500 mg of Penicillin V with
250 mg Metronidozole, qid x 7-10 days
Clindamycin Loading dose: 300 mg 150-300 mg qid x 10 days
Closely Follow All InfectedPatients
Components of aSuccessful Management Appropriate attitude of dentist Proper patient management Accurate diagnosis Profound anesthesia Prompt and effective
treatment
Patient Instructions By the Clock NOT PRN
E Evaluate the case M Make diagnosis E Evacuate swelling R Rubber dam and local anasthetic G Gain access and remove caries E Eliminate pulpal content and irrigate N No canal instrumentation if time
limited C Canal dressing and coronal seal. Y You have to give post-op instructions:
AnalgesicsAntibiotics