Management of Non-traumatic , Endodontic Emergencies

1. Management of Non-traumatic,Endodontic Emergencies

2. Emergency Impacts • Patient • Staff • Dentist

3. Patient Presentation • Pain • Pain and swelling • Trauma (later lecture)

4. 3 D’s ofSuccessful Management • Diagnosis • Definitive dental treatment • Drugs

5. Diagnosis

6. 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

7. Treatment Plan to REMOVE the ETIOLOGY

8. When do patients present foremergency endodontic care? • No prior RCT / initial infection • After RCT initiated • After obturation

9. Initial Presentation • PAIN! • Primary infection

10. After Initiation ofEndodontic Therapy

11. After Initiation ofEndodontic Therapy • FLARE-UP!

12. After InitiationofEndodontic Treatment • Before obturation

13. After Obturation • Recent obturation • Non-healing endodontic therapy

14. Determine a Pulpal and Periradicular Diagnosis

15. Pulpal Diagnosis • Normal pulp • Reversible pulpitis • Irreversible pulpitis • Necrotic pulp • Pulpless/ previously treated

16. Periradicular Diagnosis • Normal periradicular tissues • Acute periradicular periodontitis • Acute periradicular abscess

17. Periradicular Diagnosis • Chronic periradicular periodontitis • Symptomatic • Asymptomatic • Chronic periradicular abscess (suppurative periradicular periodontitis)

18. Periradicular Diagnosis Focal sclerosing osteomyelitis (condensing osteitis): LEO

19. 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?

20. Contents of theRoot Canal • Pulp tissue • Bacteria • Bacterial by-products • Endodontic therapy materials

21. DentistControlled Factors • Over-instrumentation • Inadequate debridement • Missed canal • Hyper-occlusion* • Debris extrusion • Procedural complications*

22. Hyperocclusion Rosenberg PA, Babick PJ, Schertzer L, Leung A. The effect of occlusal reduction on pain after endodontic instrumentation. J Endodon 1998;24:492.

23. 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

24. Procedural Complications • Perforation • Separated instrument • Zip • Strip • NaOCl accident • Air emphysema • Wrong tooth

25. DentistControlled Factors • Dentist’s personality

26. Host Factors • Allergies • Age • Sex • Emotional state

27. Host Factors • Complex etiology • Microbiologic • Immunologic • Inflammatory

28. Bacteria! • Bacterial byproducts/ endotoxin

29. Host Defense is Multi-factorial

30. Three D’sofSuccessful Management • Diagnosis • Definitive dental treatment • Drugs

31. EmergencyTreatment • Non-surgical • Surgical • Combined

32. Non-surgicalEmergency Treatment • Pulpotomy • Partial pulpectomy • Complete pulpectomy • Debridement of the root canal system*

33. SurgicalEmergency Treatment • Incision for drainage • Trephination/apical fenestration

34. 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

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

36. Treatment • For severe pain without visible swelling… • Trephination!

37. QUESTIONS

38. “Should I leave the tooth OPEN or CLOSED?”

39. “Should I place an Inter-appointment Medicament?” Ca(OH)2

40. “Should I prescribe ANTIBIOTICS?”

41. Three D’sofSuccessful Management • Diagnosis • Definitive Dental Treatment • Drugs

42. Remember, there is aComplex Etiology • Microbiologic • Immunologic • Inflammatory

43. And, not all can be easilytreated... • Debris extrusion • Over-instrumentation • Over-filling • Over-extension

44. Breakingthe

45. Use a Flexible Analgesic Strategy

46. Drugs • Pre - op / loading dose • Long acting anesthesia • Prescription

47. 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 33:123.

48. 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.

49. 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. IntEndod J 2004;37:531-41.

50. 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