Management of Nontraumatic, Endodontic Emergencies Dr. Langston D. Smith Chairman, Department of Endodontics Howard University College of Dentistry Washington, D.C.

Emergency Impacts Patient Staff Dentist

Patient Presentation Pain Pain and swelling Trauma (later lecture)

Successful Management 3 D’s of Successful Management Diagnosis Definitive dental treatment Drugs

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

Treatment Plan to REMOVE the ETIOLOGY

When do patients present for emergency endodontic care? No prior RCT / initial infection After RCT initiated After obturation

Initial Presentation PAIN! Primary infection

After Initiation of Endodontic Therapy FLARE-UP!

After Initiation of Endodontic Treatment Before obturation

After Obturation Recent obturation Non-healing endodontic therapy

Determine a Pulpal and Periradicular Diagnosis

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

Periradicular Diagnosis Normal periradicular tissues Acute periradicular periodontitis Acute periradicular abscess

Periradicular Diagnosis Chronic periradicular periodontitis Symptomatic Asymptomatic Chronic periradicular abscess (suppurative periradicular periodontitis)

Periradicular Diagnosis Focal sclerosing osteomyelitis (condensing osteitis): LEO

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?

Contents of the Root Canal Pulp tissue Bacteria Bacterial by-products Endodontic therapy materials

Dentist Controlled Factors Over-instrumentation Inadequate debridement Missed canal Hyper-occlusion* Debris extrusion Procedural complications*

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

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

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

Dentist Controlled Factors Dentist’s personality

Host Factors Allergies Age Sex Emotional state

Host Factors Complex etiology Microbiologic Immunologic Inflammatory

Bacteria! Bacterial by-products/ endotoxin

Host Defense is Multi-factorial

Successful Management Three D’s of Successful Management Diagnosis Definitive dental treatment Drugs

Emergency Treatment Non-surgical Surgical Combined

Non-surgical Emergency Treatment Pulpotomy Partial pulpectomy Complete pulpectomy Debridement of the root canal system*

Surgical Emergency Treatment Incision for drainage Trephination/apical fenestration

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

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

Treatment For severe pain without visible swelling… Trephination!

QUESTIONS

“Should I leave the tooth OPEN or CLOSED?”

“Should I place an Interappointment Medicament?” Ca(OH)2

“Should I prescribe ANTIBIOTICS?”

Successful Management Three D’s of Successful Management Diagnosis Definitive Dental Treatment Drugs

Remember, there is a Complex Etiology Microbiologic Immunologic Inflammatory

And, not all can be easily treated... Debris extrusion Over-instrumentation Over-filling Over-extension

Breaking the PAIN CHAIN

Use a Flexible Analgesic Strategy

Drugs Pre - op / loading dose Long acting anesthesia Prescription

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 33:123.

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.

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 2004;37:531-41.

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

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.”

Analgesic Doses

Flexible Analgesic Plan

Flexible Analgesic Plan

Selected NSAID Drug Interactions

Indications for Antibiotic Therapy Systemic involvement Compromised host resistance Fascial space involvement Inadequate surgical drainage

Guidelines for Antibiotic Therapy Select antibiotic with anaerobic spectrum Use a larger dose for a shorter period of time (“hard and fast” rule)

Appropriate Antibiotic Selecting the Appropriate 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

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

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

Clindamycin Loading dose: 300 mg 150-300 mg qid x 10 days

Closely Follow All Infected Patients

Components of a Successful Management Appropriate attitude of dentist Proper patient management Accurate diagnosis Profound anesthesia Prompt and effective treatment

Patient Instructions By the Clock NOT PRN

Questions ?