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

2. Emergency Impacts
Patient
Staff
Dentist

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

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

5. 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

6. Treatment Plan to
REMOVE
the
ETIOLOGY

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

8. Initial Presentation
PAIN!
Primary infection

9. After Initiation of Endodontic Therapy
FLARE-UP!

10. After Initiation of Endodontic Treatment
Before obturation

11. After Obturation
Recent obturation
Non-healing endodontic therapy

12. Determine a Pulpal and Periradicular Diagnosis

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

14. Periradicular Diagnosis
Normal periradicular tissues
Acute periradicular periodontitis
Acute periradicular abscess

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

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

17. 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?

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

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

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

21. 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

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

23. Dentist Controlled Factors
Dentist’s personality

24. Host Factors
Allergies
Age
Sex
Emotional state

25. Host Factors
Complex etiology
Microbiologic
Immunologic
Inflammatory

26. Bacteria!
Bacterial by-products/ endotoxin

27. Host Defense is Multi-factorial

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

29. Emergency Treatment
Non-surgical
Surgical
Combined

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

31. Surgical Emergency Treatment
Incision for drainage
Trephination/apical fenestration

32. 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

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

34. Treatment
For severe pain without visible swelling…
Trephination!

35. QUESTIONS

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

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

38. “Should I prescribe ANTIBIOTICS?”

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

40. Remember, there is a Complex Etiology
Microbiologic
Immunologic
Inflammatory

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

42. Breaking the
PAIN CHAIN

43. Use a Flexible Analgesic Strategy

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

45. 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 :123.

46. 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 :123.

47. 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:

48. 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

49. 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.”

50. Analgesic Doses

51. Flexible Analgesic Plan

52. Flexible Analgesic Plan

53. Selected NSAID Drug Interactions

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

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

56. 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

57. 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

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

59. Clindamycin
Loading dose: 300 mg
mg qid x 10 days

60. Closely Follow All Infected Patients

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

62. Patient Instructions
By the Clock
NOT
PRN

63. Questions ?