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Management of Management of Nontraumatic, Endodontic Nontraumatic, Endodontic

EmergenciesEmergenciesDr. Langston D. Smith

Chairman, Department of EndodonticsHoward University College of Dentistry

Washington, D.C.

•PatientPatient•StaffStaff•Dentist Dentist

Emergency ImpactsEmergency Impacts

• PainPain• Pain and swellingPain and swelling• Trauma (later lecture) Trauma (later lecture)

Patient PresentationPatient Presentation

•DiagnosisDiagnosis

•Definitive dental treatmentDefinitive dental treatment

•DrugsDrugs

3 D’s of Successful Management

DiagnosisDiagnosis

• Determine the CCDetermine the CC

• Take an accurate Take an accurate medical historymedical history

• Complete a Complete a thorough exam, thorough exam, with all necessary with all necessary teststests

• Perform a Perform a radiographic examradiographic exam

• Analyze and Analyze and synthesize resultssynthesize results

• Establish a Establish a treatment plantreatment plan

Treatment Plan Treatment Plan to

REMOVEthe

ETIOLOGY

When do patients present for When do patients present for emergency endodontic care?emergency endodontic care?

•No prior RCT / initial infectionNo prior RCT / initial infection

•After RCT initiatedAfter RCT initiated

•After obturationAfter obturation

Initial PresentationInitial Presentation

• PAIN!PAIN!

• Primary Primary infection infection

After Initiation of After Initiation of Endodontic TherapyEndodontic Therapy

FLARE-UP!

After InitiationAfter Initiationofof

Endodontic TreatmentEndodontic Treatment

Before obturation

After ObturationAfter Obturation

• Recent Recent obturationobturation

• Non-healing Non-healing endodontic endodontic therapytherapy

Determine aDetermine aPulpalPulpalandand

PeriradicularPeriradicularDiagnosisDiagnosis

• Normal pulpNormal pulp• Reversible pulpitisReversible pulpitis• Irreversible pulpitisIrreversible pulpitis• Necrotic pulpNecrotic pulp• Pulpless/ Pulpless/

previously treatedpreviously treated

Pulpal DiagnosisPulpal Diagnosis

• Normal periradicular Normal periradicular tissuestissues

• Acute periradicular Acute periradicular periodontitisperiodontitis

• Acute periradicular Acute periradicular abscessabscess

Periradicular DiagnosisPeriradicular Diagnosis

• Chronic periradicular Chronic periradicular periodontitisperiodontitis– SymptomaticSymptomatic– AsymptomaticAsymptomatic

• Chronic periradicular Chronic periradicular abscess (suppurative abscess (suppurative periradicular periodontitis)periradicular periodontitis)


• Focal sclerosing Focal sclerosing osteomyelitis osteomyelitis (condensing osteitis): (condensing osteitis): LEOLEO


EtiologyEtiology• After After listening listening to the patient, begin to to the patient, begin to

determine the etiology of the chief complaint:determine the etiology of the chief complaint:– Contents of the root canal? Contents of the root canal? – Dentist controlled factors?Dentist controlled factors?– Host factors?Host factors?

Contents of theContents of theRoot CanalRoot Canal

• Pulp tissuePulp tissue

• BacteriaBacteria

• Bacterial by-productsBacterial by-products

• Endodontic therapy materialsEndodontic therapy materials

Dentist Dentist Controlled FactorsControlled Factors

• Over-instrumentationOver-instrumentation

• Inadequate debridementInadequate debridement

• Missed canal Missed canal

• Hyper-occlusionHyper-occlusion**

• Debris extrusion Debris extrusion

• Procedural complicationsProcedural complications**

HyperocclusionHyperocclusion

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

on pain after endodontic on pain after endodontic instrumentation. J Endodon 1998;24:492.instrumentation. J Endodon 1998;24:492.

HyperocclusionHyperocclusion

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

• Indiscriminant reduction Indiscriminant reduction of the occlusal surface is of the occlusal surface is not indicatednot indicated

• PRE-OP PAINPRE-OP PAIN• PULP VITALITYPULP VITALITY• PERCUSSION PERCUSSION

SENSITIVITYSENSITIVITY• ABSENCE OF A ABSENCE OF A

PERIRADICULAR PERIRADICULAR RADIOLUCENCYRADIOLUCENCY

• COMBINATION OF COMBINATION OF THESE SYMPTOMSTHESE SYMPTOMS

Procedural Procedural ComplicationsComplications

• PerforationPerforation• Separated instrumentSeparated instrument• Zip Zip • StripStrip• NaOCl accidentNaOCl accident• Air emphysemaAir emphysema• Wrong toothWrong tooth

Dentist Dentist Controlled FactorsControlled Factors

Dentist’s personalityDentist’s personality

Host FactorsHost Factors

• AllergiesAllergies

• AgeAge

• SexSex

• Emotional stateEmotional state

Host FactorsHost Factors

• Complex Complex etiologyetiology– MicrobiologicMicrobiologic– ImmunologicImmunologic– InflammatoryInflammatory

Bacteria!Bacteria!

•Bacterial by-Bacterial by-products/ products/ endotoxinendotoxin

Host Defense is Multi-Host Defense is Multi-factorialfactorial

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

• DiagnosisDiagnosis

• Definitive dental treatmentDefinitive dental treatment

• DrugsDrugs

Three D’sof

Successful Management

EmergencyEmergencyTreatmentTreatment

• Non-surgicalNon-surgical• SurgicalSurgical• CombinedCombined

• PulpotomyPulpotomy• Partial pulpectomyPartial pulpectomy• Complete pulpectomyComplete pulpectomy• Debridement of the root Debridement of the root

canal systemcanal system**

Non-surgicalNon-surgicalEmergency TreatmentEmergency Treatment

SurgicalEmergency Treatment

Incision for drainage Trephination/apical fenestration

• Decreases number of bacteriaDecreases number of bacteria

• Reduces tissue pressureReduces tissue pressure– Alleviates pain/trismusAlleviates pain/trismus– Improves circulationImproves circulation

• Prevents spread of infectionPrevents spread of infection

• Alters oxidation-reduction potentialAlters oxidation-reduction potential

• Accelerates healingAccelerates healing

Rationale for I & D

ManagementManagement

• Inadequate debridementInadequate debridement• Debris extrusionDebris extrusion• Over-instrumentationOver-instrumentation• Missed canalMissed canal• Fluctuant swellingFluctuant swelling• Severe pain, no swellingSevere pain, no swelling

TreatmentTreatment

– For severe pain without visible For severe pain without visible swelling…swelling…

• Trephination!Trephination!

QUESTIONSQUESTIONS

““Should I leave the toothShould I leave the tooth

OPENOPEN or or CLOSEDCLOSED?”?”

““Should I place anShould I place an Interappointment Interappointment

MedicamentMedicament?”?”Ca(OH)2

““Should I prescribe Should I prescribe

ANTIBIOTICSANTIBIOTICS?”?”

• DiagnosisDiagnosis

• Definitive Dental TreatmentDefinitive Dental Treatment

• DrugsDrugs

Three D’sof

Successful Management

Remember, there is aRemember, there is a Complex EtiologyComplex Etiology

•MicrobiologicMicrobiologic

• ImmunologicImmunologic

• InflammatoryInflammatory

And, not all can be And, not all can be easily treated...easily treated...

•Debris extrusionDebris extrusion

•Over-instrumentationOver-instrumentation

•Over-fillingOver-filling

•Over-extensionOver-extension

Breaking Breaking thethe

Use a Flexible Use a Flexible AnalgesicAnalgesicStrategyStrategy

• Pre - op / loading dosePre - op / loading dose

• Long acting anesthesiaLong acting anesthesia

• Prescription Prescription

DrugsDrugs

CodeineCodeine

•Prototype opioid for orally available Prototype opioid for orally available combination drugs combination drugs

•Studies found that 60 mg of codeine (2 T-Studies found that 60 mg of codeine (2 T-3) produces significantly more analgesia 3) produces significantly more analgesia than placebo but less analgesia than 650 than placebo but less analgesia than 650 mg aspirin, or 600 mg acetaminophenmg aspirin, or 600 mg acetaminophen

Troullis E, Freeman R, Dionne R. The scientific basis for analgesic use in dentistry. Troullis E, Freeman R, Dionne R. The scientific basis for analgesic use in dentistry. Anesth Prog 1986 33:123.Anesth Prog 1986 33:123.

CodeineCodeine

Patients taking 30 mg of codeine report Patients taking 30 mg of codeine report only as much analgesia as placeboonly as much analgesia as placebo

Troullis E, Freeman R, Dionne R. The scientific basis for analgesic use in dentistry. Troullis E, Freeman R, Dionne R. The scientific basis for analgesic use in dentistry. Anesth Prog 1986 33:123.Anesth Prog 1986 33:123.

• 57 patients57 patients• Local anesthesia, pulpectomy, post- op analgesicLocal anesthesia, pulpectomy, post- op analgesic

– PlaceboPlacebo– 600 mg ibuprofen600 mg ibuprofen– 600 mg ibuprofen & 1000 mg acetaminophen600 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 *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-ibuprofen or a combination of ibuprofen and acetaminophen in a randomized, double-blind, placebo-controlled study. Int Endod J 2004;37:531-

41.41.

Ibuprofen and Ibuprofen and Acetaminophen*Acetaminophen*

• Visual analogue scale & baseline 4-point category pain scaleVisual analogue scale & baseline 4-point category pain scale• 1 hr, 4 hr, 6 hr, 8 hr1 hr, 4 hr, 6 hr, 8 hr• General linear model analysesGeneral linear model analyses• Significant differencesSignificant differences

– Placebo and combination Placebo and combination – Ibuprofen and combination Ibuprofen and combination

• No significant differenceNo significant difference– Placebo and ibuprofenPlacebo and ibuprofen


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


Analgesic DosesAnalgesic Doses

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

102

Meperidine (Demerol) 90Tramadol (Ultram) 50

Flexible Analgesic PlanFlexible 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 PlanFlexible 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 Selected NSAID Drug InteractionsInteractions

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 involvementSystemic involvement• Compromised host resistanceCompromised host resistance• Fascial space involvementFascial space involvement• Inadequate surgical drainageInadequate surgical drainage

Indications for Antibiotic Therapy

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

Guidelines forAntibiotic Therapy

• Gram stain results available:Gram stain results available: antibiotic- antibiotic-sensitivity chartssensitivity charts

• C & S results available:C & S results available: antibiotic- antibiotic-sensitivity chartssensitivity charts

• No gram stain or C & S results:No gram stain or C & S results: PCN is antibiotic of choicePCN is antibiotic of choice

Selecting the Appropriate Antibiotic

Penicillin VPenicillin V

• Still, the drug of choice for infections Still, the drug of choice for infections of endodontic originof endodontic origin

• Loading dose: 1-2 g then 500 mg qid Loading dose: 1-2 g then 500 mg qid x 7-10 daysx 7-10 days

MetronidozoleMetronidozole(Flagyl)(Flagyl)

• Used in conjunction with Penicillin V Used in conjunction with Penicillin V

• 500 mg of Penicillin V with 250 mg 500 mg of Penicillin V with 250 mg Metronidozole, qid x 7-10 daysMetronidozole, qid x 7-10 days

ClindamycinClindamycin

• Loading dose: 300 mgLoading dose: 300 mg

• 150-300 mg qid x 10 days150-300 mg qid x 10 days

Closely Follow All Infected Closely Follow All Infected PatientsPatients

Components of aComponents of aSuccessful ManagementSuccessful Management• Appropriate attitude of dentistAppropriate attitude of dentist• Proper patient managementProper patient management• Accurate diagnosisAccurate diagnosis• Profound anesthesiaProfound anesthesia• Prompt and effective treatmentPrompt and effective treatment

Patient InstructionsPatient Instructions

• By the ClockBy the Clock

• NOTNOT

• PRNPRN

Questions ?

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