Management%20of%20Non-traumatic,%20Endodontic%20Emergencies

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Management of Non-traumatic,Endodontic
Emergencies
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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 ofSuccessful Management

• Diagnosis
• Definitive dental treatment
• Drugs

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Diagnosis
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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 foremergency 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 ofEndodontic Therapy
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After Initiation ofEndodontic 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 a
• Pulpal
• and
• Periradicular
• Diagnosis

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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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DentistControlled 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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DentistControlled 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 byproducts/ endotoxin

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Host Defense is Multi-factorial
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Three DsofSuccessful 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
• Inter-appointment
• Medicament?
• Ca(OH)2

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• Should I prescribe
• ANTIBIOTICS?

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Three DsofSuccessful Management

• Diagnosis
• Definitive Dental Treatment
• Drugs

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Remember, there is aComplex Etiology

• Microbiologic
• Immunologic
• Inflammatory

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And, not all can be easilytreated...

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

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Breakingthe
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• Use a Flexible Analgesic
• Strategy

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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 (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 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 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
  200437531-41.

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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

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Ibuprofen andAcetaminophen

• 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

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

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Flexible Analgesic Plan
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Flexible Analgesic Plan
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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

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Indications forAntibiotic Therapy

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

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Guidelines forAntibiotic 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 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

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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 InfectedPatients
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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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• 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
• Analgesics
• Antibiotics

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