Management of Nontraumatic, Endodontic

EmergenciesDr. Langston D. Smith

Chairman, Department of EndodonticsHoward University College of Dentistry

Washington, D.C.

• Patient• Staff• Dentist

Emergency Impacts

• Pain• Pain and swelling• Trauma (later

lecture)

Patient Presentation

• Diagnosis• Definitive dental treatment• Drugs

3 D’s of Successful Management

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 Plan to

REMOVEthe

ETIOLOGY

When do patients present for emergency endodontic care?

• No prior RCT / initial infection• After RCT initiated• After obturation

Initial Presentation

• PAIN!• Primary

infection

After Initiation of Endodontic Therapy

FLARE-UP!

After Initiationof

Endodontic Treatment

Before obturation

After Obturation

• Recent obturation

• Non-healing endodontic therapy

Determine aPulpaland

PeriradicularDiagnosis

• Normal pulp• Reversible pulpitis• Irreversible pulpitis• Necrotic pulp• Pulpless/

previously treated

Pulpal Diagnosis

• Normal periradicular tissues

• Acute periradicular periodontitis

• Acute periradicular abscess

Periradicular Diagnosis

• Chronic periradicular periodontitis– Symptomatic– Asymptomatic

• Chronic periradicular abscess (suppurative periradicular periodontitis)

Periradicular Diagnosis

• Focal sclerosing osteomyelitis (condensing osteitis): LEO

Periradicular Diagnosis

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

Dentist Controlled Factors

• Over-instrumentation• Inadequate debridement• Missed canal • Hyper-occlusion*• Debris extrusion • Procedural complications*

Hyperocclusion

• Rosenberg PA, Babick PJ, Schertzer L, Leung A. The effect of occlusal

reduction on pain after endodontic instrumentation. J Endodon

1998;24:492.

Hyperocclusion

• Researchers have found that patients most likely to benefit from occlusal reduction are those whose teeth initially present with symptoms.

• Indiscriminant reduction of the occlusal surface is not 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

Dentist Controlled Factors

Dentist’s personality

Host Factors

• Allergies• Age• Sex• Emotional state

Host Factors

• Complex etiology– Microbiologic– Immunologic– Inflammatory

Bacteria!• Bacterial by-

products/ endotoxin

Host Defense is Multi-factorial

C E L L Sn eu trop h ils , lym p h ocytes ,

p lasm a ce lls , m ac rop h ag es ,os teoc las ts , ep ith e lia l ce lls , d en d rit ic ce lls

M O L E C U L A R M E D IA TO R Scytok in es (IL , IF N , C S F , TG F )

e icosan o id s (P G , L T)en zym atic e ffec to r m o lecu les

A N TIB O D IE Sim m u n og lob u lin s (Ig G , e tc .)

p rod u ced b y p lasm a ce lls

M ixed M ic ro flo ra

• Diagnosis• Definitive dental treatment• Drugs

Three D’sof

Successful Management

EmergencyTreatment

• Non-surgical• Surgical• Combined

• Pulpotomy• Partial pulpectomy• Complete pulpectomy• Debridement of the

root canal system*

Non-surgicalEmergency Treatment

SurgicalEmergency Treatment

Incision for drainage Trephination/apical fenestration

• Decreases number of bacteria• Reduces tissue pressure

– Alleviates pain/trismus– Improves circulation

• Prevents spread of infection• Alters oxidation-reduction potential• Accelerates healing

Rationale for I & D

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 an Interappointment

Medicament?”Ca(OH)2

“Should I prescribe

ANTIBIOTICS?”

• Diagnosis• Definitive Dental Treatment• Drugs

Three D’sof

Successful Management

Remember, there is a Complex Etiology

• Microbiologic• Immunologic• Inflammatory

And, not all can be easily treated...

• Debris extrusion• Over-instrumentation• Over-filling• Over-extension

Breaking the

Use a Flexible AnalgesicStrategy

• Pre - op / loading dose• Long acting anesthesia• Prescription

Drugs

Codeine

• Prototype opioid for orally available combination drugs

• Studies found that 60 mg of codeine (2 T-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 in dentistry. Anesth Prog 1986 33:123.

• 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 and Acetaminophen*

• 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 and Acetaminophen*

“The results demonstrate that the combination of ibuprofen and acetaminophen may be more effective than ibuprofen alone for the management of postoperative endodontic pain.”

Ibuprofen and Acetaminophen*

Analgesic Doses

Codeine 60 mgOxycodone 5-6Hydrocodone 10Dihydrocodone 60Propoxyphene HCl(Darvon)

102

Meperidine (Demerol) 90Tramadol (Ultram) 50

Flexible Analgesic Plan

M IL D2 0 0 -4 0 0 m g ib u p ro fen

or 6 5 0 m g asp irin

M O D E R A TE6 0 0 -8 0 0 m g ib u p ro fen

p lu s com b o an a lg es ic =6 0 m g cod e in e

S E V E R E6 0 0 -8 0 0 m g ib u p ro fen

p lu s com b o an a lg es ic =1 0 m g oxycod on e

A sp irin -like D ru g s a re In d ica ted

Flexible Analgesic Plan

M IL D6 0 0 -1 0 0 0 ace tam in op h en

M O D E R A TE6 0 0 -1 0 0 0 m g ace tam in op h en

an d op ia te =6 0 m g cod e in e

S E V E R E1 0 0 0 m g ace tam in op h en

an d op ia te =1 0 m g oxycod on e

A sp irin -like D ru g s a re C on tra in d ica ted

Selected NSAID Drug Interactions

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

• Systemic involvement• Compromised host resistance• Fascial space involvement• Inadequate surgical drainage

Indications for Antibiotic Therapy

Select antibiotic with anaerobic spectrum Use a larger dose for a shorter period of time (“hard and fast” rule)

Guidelines forAntibiotic Therapy

• 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

Selecting the Appropriate Antibiotic

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 Infected Patients

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

Questions ?