2. Emergency Impacts  Patient  Staff  Dentist

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

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

5. Diagnosis

6.  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 for emergency endodontic care?  No prior RCT / initial infection  After RCT initiated  After obturation

9. Initial Presentation  PAIN!  Primary infection

10. After Initiation of Endodontic Therapy

11.  FLARE-UP!

12. After Initiation of Endodontic 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 the Root Canal  Pulp tissue  Bacteria  Bacterial by- products  Endodontic therapy materials

21. Dentist Controlled 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. Dentist Controlled 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’s of Successful Management  Diagnosis  Definitive dental treatment  Drugs

31. Emergency Treatment  Non-surgical  Surgical  Combined

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

33. Surgical Emergency 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’s of Successful Management  Diagnosis  Definitive Dental Treatment  Drugs

42. Remember, there is a Complex Etiology  Microbiologic  Immunologic  Inflammatory

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

44. Breaking the

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 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.

50. 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

51. 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.”

52. Analgesic Doses  Codeine 60mg  Oxycodone 5-6  Hydrocodone 10  Dihydrocodone 60  Propoxyphene HCl (Darvon) 102  Meperidine (Demerol) 90  Tramadol (Ultram) 50

53. Flexible Analgesic Plan

55. Selected NSAID Drug Interactions  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

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

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

58. 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

59. 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

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

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

62. Closely Follow All Infected Patients

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

64. Patient Instructions  By the Clock  NOT PRN

65.  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