Management of Nontraumatic, Endodontic Emergencies

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Management of Nontraumatic, Endodontic Emergencies

• Dr. Langston D. Smith
• Chairman, Department of Endodontics
• Howard University College of Dentistry
• Washington, D.C.

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Emergency Impacts

• Patient
• Staff
• Dentist

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Patient Presentation

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

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3 Ds of Successful Management

• Diagnosis
• Definitive dental treatment
• Drugs

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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

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Treatment Plan
to REMOVE the ETIOLOGY
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When do patients present for emergency endodontic
care?

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

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Initial Presentation

• PAIN!
• Primary infection

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After Initiation of Endodontic Therapy
FLARE-UP!
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After InitiationofEndodontic Treatment
Before obturation
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After Obturation

• Recent obturation
• Non-healing endodontic therapy

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Determine aPulpalandPeriradicularDiagnosis
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Pulpal Diagnosis

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

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Periradicular Diagnosis

• Normal periradicular tissues
• Acute periradicular periodontitis
• Acute periradicular abscess

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Periradicular Diagnosis

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

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Periradicular Diagnosis

• Focal sclerosing osteomyelitis (condensing
  osteitis) LEO

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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?

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Contents of theRoot Canal

• Pulp tissue
• Bacteria
• Bacterial by-products
• Endodontic therapy materials

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Dentist Controlled Factors

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

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Hyperocclusion

• Rosenberg PA, Babick PJ, Schertzer L, Leung A.
  The effect of occlusal reduction on pain after
  endodontic instrumentation. J Endodon 199824492.

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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

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Procedural Complications

• Perforation
• Separated instrument
• Zip
• Strip
• NaOCl accident
• Air emphysema
• Wrong tooth

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Dentist Controlled Factors
Dentists personality
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Host Factors

• Allergies
• Age
• Sex
• Emotional state

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Host Factors

• Complex etiology
• Microbiologic
• Immunologic
• Inflammatory

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Bacteria!

• Bacterial by-products/ endotoxin

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Host Defense is Multi-factorial
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Three Ds of Successful Management

• Diagnosis
• Definitive dental treatment
• Drugs

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EmergencyTreatment

• Non-surgical
• Surgical
• Combined

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Non-surgicalEmergency Treatment

• Pulpotomy
• Partial pulpectomy
• Complete pulpectomy
• Debridement of the root canal system
  

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SurgicalEmergency Treatment

• Incision for drainage
• Trephination/apical fenestration

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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

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Management

• Inadequate debridement
• Debris extrusion
• Over-instrumentation
• Missed canal
• Fluctuant swelling
• Severe pain, no swelling

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Treatment

• For severe pain without visible swelling
• Trephination!

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QUESTIONS
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Should I leave the tooth OPEN or CLOSED?
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Should I place an Interappointment Medicament?
Ca(OH)2
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Should I prescribe ANTIBIOTICS?
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Three Ds of Successful Management

• Diagnosis
• Definitive Dental Treatment
• Drugs

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Remember, there is a Complex Etiology

• Microbiologic
• Immunologic
• Inflammatory

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And, not all can be easily treated...

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

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Breaking the
PAIN CHAIN
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Use a Flexible AnalgesicStrategy
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Drugs

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

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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 33123.

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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 33123.

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Ibuprofen and Acetaminophen

• 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
  200437531-41.

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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

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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.

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Analgesic Doses
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Flexible Analgesic Plan
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Flexible Analgesic Plan
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Selected NSAID Drug Interactions
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Indications for Antibiotic Therapy

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

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Guidelines for Antibiotic Therapy

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

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Selecting the Appropriate Antibiotic

• Gram stain results available
  antibiotic-sensitivity charts
• C S results available antibiotic-sensitivit
  y charts
• No gram stain or C S results
• PCN is antibiotic of choice

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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

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Metronidozole(Flagyl)

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

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Clindamycin

• Loading dose 300 mg
• 150-300 mg qid x 10 days

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Closely Follow All Infected Patients
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Components of aSuccessful Management

• Appropriate attitude of dentist
• Proper patient management
• Accurate diagnosis
• Profound anesthesia
• Prompt and effective treatment

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Patient Instructions

• By the Clock
• NOT
• PRN

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Questions ?