Hot Tooth Endodontic Nontraumatic Emergencies

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Hot ToothEndodontic Nontraumatic Emergencies

• Dr shabeel pn

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Dental Emergencies

• 30 of all dental emergencies are endodontic
• In 90 of painful emergencies, pain is pulpal or
  periapical

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Pathophysiology of Pain

• Pain is a psychobiological phenomenon.
• It consists of
• - Perception of pain influenced by anesthesia
• - Reaction to pain (fear, anxiety) influenced
  by drugs and emotions and contributes to
  hyperalgesia

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Endodontic Pain Management

• Preoperative
• Diagnosis
• Anxiety reduction
• Intraoperative
• Effective local anesthetics
• Operative techniques
• Postoperative
• Pharmacologic agents

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PreoperativeDifferential Diagnosis

• Chief Complaint
• Listen to your patient and the patient will
  give you the diagnosis
• Sir William
  Osler
• Etiology
• - Contents of the root canal?
• - Dentist controlled factors?
• - Host factors?

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History of Chief Complaint

• 1. What is the nature of the pain? When did the
  pain begin?
• Pulpal rapid onset, spontaneous, gets more
  intense and more localized
• 2. What
• provokes pain?

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Interview

• 3. What drugs have you taken for the pain?
• Drug addicts last pill before the weekend

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Interview

• 4. Does the pain awaken you?
• 5. Where does it hurt, and where does the pain
  radiate to?
• - Temporal region premolars and molars
• - Ear mandibular or maxillary (less) molars
• - Neck/Shoulder mandibular molars, heart

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Medical and Dental History

• SBE prophylaxis
• Referred pain
• Patient motivation to retain dentition
• Restorative treatment plan
• Blood pressure and temperature

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Clinical Examination

• Visual swelling, sinus tract, aphthous ulcers,
  caries, cracks
• TRY TO FIND A REASONABLE CAUSE FOR PULPAL
  DISEASE!
• In the absence of odontogenic source, look for
  non-odontogenic etiology

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Diagnostic Tests

• Pulp Tests
• - Cold (Endo Ice on cotton pellets)?
• - Heat (impression compound, warm water with
  rubber dam)?
• - Electric pulp test
• Periodontal Probing
• Periapical Tests
• - Percussion, palpation, ToothSlooth

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Radiographic Examination

• Parallel Periapical Radiograph
• Angled horizontally PA
• Bitewing
• Follow PDL and lamina dura
• Superimposed anatomical structures maxillary
  sinus, mental foramen, lingual salivary gland
  depression, IAN canal (mandibular second molars)

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DIAGNOSIS

• REPRODUCTION OF THE CHIEF COMPLAINT IS THE
  MAJOR FACTOR IN REDUCING THE MISDIAGNOSIS of
• ODONTOGENIC VS.
• NON-ODONTOGENIC PAIN

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Odontogenic Diagnoses

• Dentinal Hypersensitivity
• Reversible Pulpitis
• Irreversible Pulpitis
• Necrotic pulp
• Acute Apical Periodontitis
• Acute Apical Abscess
• Cellulitis

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Non-odontogenic Pain

• No apparent odontogenic etiology
• Pain not relieved by local anesthesia
• Bilateral pain, multiple teeth
• Chronic pain, not responsive to dental treatment
• Specific qualities burning, stabbing, concurrent
  with headache
• Trigger points, muscles
• Stress, head position

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Non-Odontogenic Diagnoses

• Musculoskeletal myofascial pain
• Neuropathic trigeminal neuralgia, atypical
  odontalgia, glossopharyngeal neuralgia
• Neurovascular migraine, cluster headaches
• Inflammatory allergic or bacterial sinusitis
• Systemic cardiac, herpes zoster, sickle cell
  anemia, neoplastic disease
• Psychogenic Munchausens syndrome

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Anxiety Reduction

• Reflective listening
• - a dialogue of trust between the dentist and
  the patient
• - cannot be delegated to a staff member
• Patients feeling of fear are acknowledged
• Sounds like you have had some unpleasant
  experiences in the past

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Anxiety Reduction Dentists Role

• Safe environment, reassurance I will do
  whatever can be done to make your treatment
  comfortable
• Ask patient to summarize
• Mix of open and closed questions
• Nonverbal Strategies face the patient at the
  same chair level, steady and frequent eye
  contact, mutual respect and concern, no promises
  of painless treatment, frequent review of
  accomplishments
• Control during treatment time out, music
  choice, nothing will happen that we have not
  agreed upon

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Anxiety Reduction

• Office tone staff attitude
• Distraction music, office décor, TV
• Relaxation techniques muscular and mental, deep
  breathing 2-4 min with heart rate monitor
• Hypnosis (special training) and guided imaginery
• Referral to a mental health professional

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Anxiety Reduction

• Conscious sedation does not treat anxiety, just
  facilitate treatment
• Benzodiazepines orally Lorazepam, Triazolam
  (short duration, no metabolites), and Diazepam
  (active metabolites)?
• Reversal agent Flumazenil (Romazicon)?
• Contraindications and drug interactions (
  Triazolam and protease inhibitors for HIV
  treatment)?
• Nitrous oxide
• Monitoring
• Profound anesthesia is still required
• Lindemann et al. J Endod 2008341167

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Anesthesia

• 90 of dentists have anesthetic difficulties
• Al Reader John Nusstein Endo topics 2002
  314
• (17 years of research on endodontic pain
  anesthesia)?
• A challenge for inflammed tissue
• Local acidic inflammatory byproducts lower the
  pH, so most anesthetic molecules remain in
  inactive cationic form
• Local prostaglandins and bradykinin can
  antagonize local anesthetics

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TTX-resistant channels

• Sodium channel expression on C fibers shifts from
  TTX sensitive to TTX resistant
• TTX resistant channels are five times more
  resistant to anesthetic (lidocaine)?
• Bupivacaine found to be more potent
• Alternate and supplementary injection sites
  intraosseous, intraligamentory
• Anatomic limitations dense bone, accessory
  innervation (mylohyoid nerve branch)?

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Local Anesthesia

• IANB
• Gow-Gates Akinosi-Vasirani methods
• Stabident
• - effective in 89
• Parente Welte,
  1998
• - 2 lido with epi 1100,000 increased heart
  rate in 67 of patients to 97 bpm
• Replogle
  Reader, 1999

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Mandibular Anesthesia

• IANB most failures 25 of accurate blocks fail
  central core theory
• EPT is predictable for pulpal anesthesia
• Lip sign is not predictable, but lack of it (5)
  predicts failure requires re-administration
• Noncontinuous anesthesia 12-20 man
• Slow onset 19-27 after 15min 8 after 30min
• Duration 2.5 h

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Inferior Alveolar Nerve Block

• Double volume (2 cartridges) of 2 lidocaine with
  epinephrine does not increase the incidence of
  pulpal anesthesia
• Increase epinephrine concentration to 150,000
  no advantage
• 3 mepivacaine is as effective as 2 lidocaine
  with 1100,000 epinephrine

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IANB

• Articaine as effective, but no advantage
• Contraindications Sulfa allergy
• Mandibular buccal infiltration with 4 articane
  is more effective that 2 lidocaine with
  epinephrine
• Kanaa et al. J Endod (32)4296
• 4 Articaine with epinephrine 1200,000
• Paresthesias?

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IANB

• Long-acting anesthetics
• Bupivacaine (Marcaine) 4 hours of lip numbness,
  ask patient
• 0.5 Ropivacaine with 1200,000 epinephrine
  (Naropin) lower potential for CNS and
  cardiovascular toxic effects

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Mandibular Teeth

• Infiltration with 2 lidocaine and epinephrine
  no advantage
• Gow-Gates no advantage in anesthesia, less
  possibility for the intravascular injection
• Akinosi-Vasirani technique trismus
• Incisive nerve block at mental foramen premolar
  teeth

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Needle Deflection and STA

• Bi-directional needle rotation technique
• Computer-assisted Wand or STA (Single Tooth
  Anesthesia)
• no significant differences in success for IANB
• Pain perception less painful with STA

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Supplemental InjectionsIntraligamentory
Anesthesia

• STA (CompuDent)
• intraligamentory
• single tooth anesthesia
• 2 lidocaine with
• epinephrine 1100,000 or
• 4 articaine
• with epinephrine 1200,000

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Intraosseous Injection

• Stabident
• X-Tip
• Key to success deposition into the cancellous
  space 10 constricted spaces
• In 0-48 transient moderate to severe pain on
  perforation and deposition of anesthetic
• Perforator breakage
• Optimal site DISTAL to the problematic tooth
• Except second molars MESIAL to the tooth
• Immediate onset

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Intraosseous Anesthesia

• Irreversible pulpitis IANB 44-81 failures
• Mandibular intraosseous anesthesia of 1.8 ml of
  2 lidocaine with 1100,000 epinephrine gives 91
  success (Nusstein et al.)?
• Transient increase in heart rate (4 min)?
• Supplemental 1.8 ml 3 mepivacaine produces 80
  success repeated injection increases success to
  98 no increase in heart rate

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Intraosseous Anesthesia

• Long-acting anesthetic are not long-acting with
  this technique and have cardiotoxic effects no
  advantage
• Large volumes overdose reactions
• Should not be considered intravascular
• Postoperative discomfort 2-15
• Less than 5 swelling/exudate on perforation
  site may take weeks to heal bone overheating

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Intrapulpal Anesthesia

• 5-10 of irreversible pulpitis cases do not
  respond to supplemental anesthesia
• Moderately to severe painful
• Short (20 min)?
• Pulp must be exposed
• Predictable under back-pressure

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Clinical Managementof Endodontic Anesthesia

• Irreversible pulpitis
• IANB for mandibular teeth, observe lip sign,
  inform patient, intraosseous anesthesia 1.8 ml 3
  mepivacaine apply rubber dam if painful,
  administer intraosseously another carpule of 3
  mepivacaine
• Use 2 sharp round bur to make a channel into the
  pulp chamber. If pulp is entered and painful,
  proceed with intrapulpal anesthesia

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Irreversible PulpitisMaxillary Teeth

• Double the initial anesthetic dose for the buccal
  infiltration
• PSA for molars
• Small amount 0.5 ml palatally for the clamp and
  palatal canals avoid 150,000 epinephrine
• Less failures, but can occur
• Intraosseous anesthesia
• Repeat infiltration during the treatment

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Symptomatic Teeth with Pulpal Necrosis and
Periapical Radiolucencies

• Mandible inferior alveolar nerve block
• Maxilla infiltration or block
• Swelling injection on either side
• SLOWLY access
• DO NOT use intraosseous, periodontal ligament, or
  intrapulpal injections painful and ineffective,
  introduce bacteria periapically

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Intraoperative Management Combined Approach

• Pharmacological (not drugs alone)?
• Non-pharmacological
• Pulpectomy
• Pulpotomy reduces pain in 90 of patients
• Incision for drainage, trephination/apical
  fenestration
• Occlusal reduction
• Informed Consent Form

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Pulpotomy

• Case of acute pain of pulpal origin, NO
  periapical pathology, and not enough time for
  pulpectomy
• Goal to remove coronal pulp place rubber dam,
  use slow speed round bur to the canal orifice
• Bleeding is managed with sterile cotton pellet
• With or without dressing cavity should be sealed
  
• High level of success alteration of pulpal
  hemodynamics, reduction of interstitial fluid
  pressure and inflammatory mediator concentrations

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Pulpotomy vs. Partial Pulpectomy

• Pulpotomy is preferable when there is lack of
  time for complete pulpectomy with accurate canal
  length measurements
• Partial pulpectomy may result in a profuse
  hemorrhage and more postoperative pain
  traumatizes already inflammed tissue

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Pulpectomy

• Reduction of inflammatory mediators levels and
  interstitial tissue pressure to relieve
  peripheral terminals of nociceptors
• With/without I D provides predictable pain
  reduction in endodontic emergencies

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Pulpectomy

• Intracanal medications
• Calcium hydroxide (Ultracal) effective
  antibacterial, not analgesic
• Leave tooth open or closed? Closed!
• Open tooth additional bacterial
  contamination, foreign body reaction, blockage
  with food, and complications

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Incision Drainage Rationale

• Decreases number of bacteria
• Reduces tissue pressure, which alleviates pain
  trismus and improves circulation
• Prevents spread of infection
• Alters oxidation-reduction potential
• Accelerates healing
• Trephination 3 spreader in patients with pain,
  radiolucencies, and no swelling
• Results in more pain, routinely not justified
• Moss et al. 1996

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Irreversible Pulpitiswith Periapical Inflammation

• PULPECTOMY anterior teeth posterior teeth on
  all roots
• Occlusal reduction
• Rubber dam
• Instrumentation to a size 25 minimum
• Irrigation with 2.6 or 5.25 NaOCl

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Necrotic Pulp, No Swelling

• Complete debridement
• Estimated working length (1 mm short of
  anatomical length)?
• Instrument crown-down to a size 25 minimum or 3
  sizes larger than the first file that binds
• Copious irrigation with 2.6-5.25 NaOCl
• Calcium hydroxide intracanal dressing

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Necrotic Pulp, Localized Swelling

• Complete debridement determine working length
  for all canals, rotary Ni-Ti files
• If drainage through the tooth is obtained,
• I D is optional antibiotic is not indicated
• Do NOT leave tooth open
• Fluctuation anesthesia around it and I D
• Warm saline rinses for 48 h
• No fluctuation I D is contraindicated

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Cellulitis

• Diffuse extraoral or intraoral swelling
• Rapid spread into spaces
• Systemic signs of infection
• Lymphadenopathy, fever
• Difficulty swallowing, mouth opening
• Sublingual and palatal aspects
• Referral to an oral surgeon or ER

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Long-acting Anesthetics

• Bupivacaine, ropivacaine blocks up to 8-10h
• Block the activation of unmyelinated C
  nociceptors (anesthesia)?
• Decrease potential for central sensitization

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Postoperative management

• Non-narcotic analgesics
• Pretreatment is effective for post treatment
  pain
• Ibuprofen (800mg) (Advil Liquid Gel) or
  Flurbiprofen (100mg)?
• Patients who cannot tolerate NSAIDs
• GI disorders, active asthma, hypertension
  (renal effects of NSAIDs or interactions with
  anti-HTN drugs)
• Acetaminophen (1000mg) (also, COX-3 enzyme
  inhibition)?

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NSAIDs Mechanism of Actionfor Irreversible
Pulpitis

• Reduction of pulpal levels of the inflammatory
  mediator PGE-2 causes
• - Decrease in pulpal nociceptor sensitization
• - Decrease of a prostanoid-induced stimulation
  of TTX-resistant sodium channel activity
• - Decrease in resistance to local anesthetics

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Ibuprofen and Acetaminophen

• Combination may be more effective than ibuprofen
  alone for the management of postoperative
  endodontic pain
• Menhinick et al.
  2004
• Ibuprofen 400 mg and Acetaminophen 1000 mg
• Timing Q6-8 h for the first few days

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Codeine

• Patients taking 30 mg of codeine have as much
  analgesia as with placebo
• Troullis
  et al. 1986
• 60 mg of codeine (2 Tylenol-3) produce
  significantly more analgesia than placebo, but
  less that 650 mg of aspirin, or 600 mg
  acetaminophen

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The Most Effective Analgesics

• Combination of flurbiprofen and tramadol
• Combination of preoperative and postoperative
  flurbiprofen
• Doroshak et al. J Endod 199925660
• Tramadol hydrochloride an opioid agonist and a
  reuptake inhibitor of serotonin and
  norepinephrine

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Analgesic Doses

• Codeine 60 mg
• Oxycodone 5-6 mg
• Hydrocodone 10 mg
• Dihydrocodone 60 mg
• Propoxyphene HCl (Darvon) 102 mg
• Meperidine (Demerol) 90 mg
• Tramadol (Ultram) 50 mg

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NSAIDs Drug Interactions

• Anticoagulants increased prothrombin time or
  bleeding time
• ACE inhibitors, Beta Blockers, Thiazide reduced
  antihypertensive effects
• Cyclosporine increased risk of nephrotoxicity
• Lithium increased serum levels of lithium
• Sympathomimetics increased blood pressure

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Flexible Prescription Plan

• Goal to obtain maximal analgesic benefits with
  minimal side effects
• First, maximize the dose of non-narcotics before
  prescribing narcotics
• If patient still has pain
• 1. NSAIDs with acetaminophen over a short period
  of time
• 2. NSAIDs with opioid or with acetaminophen/opioid
  
• Flurbiprofen with Tramadol (Holstein et
  al.)?

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Flexible Analgesic PlanAspirin-like Drugs are
Indicated

• Mild pain 200-400 mg ibuprofen or 650 mg aspirin
• Moderate 600-800 mg ibuprofen plus combo
  analgesic 60 mg codeine
• Severe 600-800 mg ibuprofen plus combo analgesic
  10 mg oxycodone

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Aspirin-like Drugs are Contraindicated

• Mild pain 600-1000 mg acetaminophen
• Moderate 600-1000 mg acetaminophen and opiate
  60 mg codeine
• Severe 1000 mg acetaminophen and opiate 1 mg
  oxycodone

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Indications for Antibiotic Therapy

• Systemic involvement or fascial space involvement
• Compromised host resistance
• Inadequate surgical drainage
• Select antibiotic with anaerobic spectrum or
  antibiotic-sensitivity charts (C S available)?
• Contraindicated as a preventive measure
• Use a larger dose for a shorter period of time
• Pseudomembranous colitis

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Penicillin V

• When Gram stain and C S results are not
  available, PCN is antibiotic of choice
• Loading dose 1-2 g, then 500 mg qid for 7-10
  days
• Metronidazole 250 mg qid 7-10 days
• Used in conjunction with Penicillin V

61
Clindamycin

• Loading dose 300 mg
• 150-300 mg qid for 7-10 days
• Cephalexin (Keflex)?
• Loading dose 1 g
• 500 mg qid for 7-10 days

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Steroids

• Multiple sites of action
• Reduce pulpal concentrations of PGE2
• Reduction of bradikinin (proinflammatory)?
• Produce vasocortin (decreases edema)?
• Inhibit nitric oxide synthase (amplifier of
  inflammatory response)?
• Single large dose or short course up to 1 week is
  harmless
• Contraindications systemic fungal infections,
  renal insufficiency, ulcerative colitis,
  diabetes, others

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Steroids

• Intracanal Ledermix (triamcinolone and
  tetracycline derivative) or dexamethasone 0.1 ml
  per canal significantly less pain
• Liesenger et al. J Endod
  19931935
• Symptomatic necrotic teeth pulpectomy with
  intraosseous methylprednisolone (Depo-Medrol 40
  mg/ml) significantly less pain
• Bramy et al.
  
  

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Steroids

• Antibiotics are NOT routinely required in
  conjuction to prevent infection secondary to
  reduced inflammation in healthy patient
• Steroids are effective as an adjunct to but not
  replacement for appropriate endodontic treatment
• Systemic steroids are highly effective for
  patients with moderate/severe preoperative pain
  and pulpal necrosis with periapical radiolucency

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Causes of Flare-Ups

• Overinstrumentation, overmedication
• Debris extruded into periapical tissue
• Incomplete debridement or missed canal
• Exacerbation of chronic apical periodontitis
• Over-irrigation, NaOCl accident
• Hyperocclusion occlusal reduction benefit
  symptomatic patients (vital pulp, no PARL)?
• Root fracture
• Wrong tooth
• Air emphysema air syringe into root canal
  Stropko syringes
• Pasteur effect (overgrowth of facultative
  anaerobes)?
• Seltzer Naidrof
  J Endod 1985

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Predictors of Post-Endo Pain

• Preoperative pain or swelling
• Walton and Fouad 1992
• Preoperative pain and anxiety
• Torabinejad 1994
  
• Preoperative pain, necrotic, PARL, females
• Genet
  1987

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Treatment of Flare-Ups

• Psychological (reassurance), localized operative,
  and pharmacological
• Necrotic pulp with swelling open, re-debride, I
  D, adjust occlusion
• Analgesics
• Antibiotics rapid increase S S, anatomical
  danger zone, disease/drug that compromises immune
  status, systemic involvement (LAD, fever,
  malaise)?
• Steroids effective for lower levels of pain
  single dose dexamethasone 4-6 mg

68
Case 1

• Sinusitis
• No definitive treatment plan until the diagnosis
  is confirmed

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Case 2Irreversible Pulpitis with Acute Apical
Periodontitis

• Tooth 18

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Case 2Irreversible Pulpitis with Acute Apical
Periodontitis

• Preoperative NSAID (ibuprofen 800 mg or
  flurbiprofen 100 mg) possibly with tramadol
  (50mg) or acetaminophen (500mg) augmentation for
  the next 2 days
• IANB intraosseous 3 mepivacaine distally
• Occlusal reduction
• Endo 2 round bur access into the chamber
  intrapulpal anesthesia complete pulpectomy

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Case 3Necrotic Pulp with Acute Apical Abscess

• Tooth 18

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Case 3Necrotic Pulp with Acute Apical Abscess

• Preoperative NSAIDs or acetaminophen
• IANB avoid intraosseous in necrotic teeth and
  PARLs or distal to the adjacent tooth (Reader,
  Nusstein)?
• Complete pulpectomy avoid intrapulpal injections
• Postoperative flexible analgesic plan
• Occlusal reduction?
• Antibiotics are not required and do not reduce
  postoperative pain

73
Case 4Postendodontic Flare-Up

• Repeat vitality tests (missed canals)?
• Contributing risk factors female, necrotic pulp,
  acute apical periodontitis
• Patient did not respond to NSAIDs pain is due to
  non-prostaglandin mediators

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Case 4Treatment

• Reassurance in a favorable prognosis
• Effective local anesthesia infiltration or block
  with bupivacaine
• Steroid injection dexamethasone 4-6mg
  (immune-mediated hypersensitivity reaction
  inhibition)?
• Daily contact
• Postoperative analgesics flurbiprofen 100 mg tid
  with tramadol 50-100 mg q6h
• Endodontically conservative care, may or may not
  remove the fill

75
Summary

• Accurate diagnosis
• Successful anesthesia
• Timely and effective
• treatment
• QUESTIONS?
• THANK YOU!