Hot Tooth Endodontic Nontraumatic Emergencies Svetlana Berman, DDS, MSD Indiana University School of Dentistry National Oral Health Care Conference Dallas, TX November, 2008

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

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

Endodontic Pain Management Preoperative: Diagnosis Anxiety reduction Intraoperative: Effective local anesthetics Operative techniques Postoperative: Pharmacologic agents

Preoperative Differential 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?

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?

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

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

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

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

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

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)

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

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

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

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: Munchausen’s syndrome

Anxiety Reduction Reflective listening: - a dialogue of trust between the dentist and the patient - cannot be delegated to a staff member Patient’s feeling of fear are acknowledged: “Sounds like you have had some unpleasant experiences in the past”

Anxiety Reduction: Dentist’s 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”

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

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 2008;34:1167

Anesthesia 90% of dentists have anesthetic difficulties Al Reader & John Nusstein Endo topics 2002; 3:14 (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

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)‏

Local Anesthesia IANB Gow-Gates & Akinosi-Vasirani methods Stabident: - effective in 89% Parente & Welte, 1998 - 2% lido with epi 1:100,000 increased heart rate in 67% of patients to 97 bpm Replogle & Reader, 1999

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

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 1:50,000: no advantage 3% mepivacaine is as effective as 2% lidocaine with 1:100,000 epinephrine

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)4:296 4% Articaine with epinephrine 1:200,000 Paresthesias?

IANB Long-acting anesthetics: Bupivacaine (Marcaine): 4 hours of lip numbness, ask patient 0.5% Ropivacaine with 1:200,000 epinephrine (Naropin): lower potential for CNS and cardiovascular toxic effects

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

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

Supplemental Injections Intraligamentory Anesthesia STA (CompuDent): intraligamentory single tooth anesthesia 2% lidocaine with epinephrine 1:100,000 or 4% articaine with epinephrine 1:200,000

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

Intraosseous Anesthesia Irreversible pulpitis: IANB 44-81% failures Mandibular intraosseous anesthesia of 1.8 ml of 2% lidocaine with 1:100,000 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

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

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

Clinical Management of 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

Irreversible Pulpitis Maxillary 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 1:50,000 epinephrine Less failures, but can occur Intraosseous anesthesia Repeat infiltration during the treatment

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

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

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

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

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

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

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

Irreversible Pulpitis with 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

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

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

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

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

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)‏

NSAIDs: Mechanism of Action for 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

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

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

The Most Effective Analgesics Combination of flurbiprofen and tramadol Combination of preoperative and postoperative flurbiprofen Doroshak et al. J Endod 1999;25:660 Tramadol hydrochloride: an opioid agonist and a reuptake inhibitor of serotonin and norepinephrine

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

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

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.)‏

Flexible Analgesic Plan Aspirin-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

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

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

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

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

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

Steroids Intracanal Ledermix (triamcinolone and tetracycline derivative) or dexamethasone 0.1 ml per canal: significantly less pain Liesenger et al. J Endod 1993:19:35 Symptomatic necrotic teeth; pulpectomy with intraosseous methylprednisolone (Depo- Medrol 40 mg/ml): significantly less pain Bramy et al.

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

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

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

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

Case #1 Sinusitis No definitive treatment plan until the diagnosis is confirmed

Case #2 Irreversible Pulpitis with Acute Apical Periodontitis Tooth #18

Case #2 Irreversible 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

Case #3 Necrotic Pulp with Acute Apical Abscess Tooth #18

Case #3 Necrotic 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

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

Case #4 Treatment 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

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