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Endodontic Emergencies

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  • 1. Management of Nontraumatic, Endodontic Emergencies
  • 2. • Patient • Staff • Dentist Emergency Impacts
  • 3. • Pain • Pain and swelling • Trauma (later lecture) Patient Presentation
  • 4. • Diagnosis • Definitive dental treatment • Drugs 3 D’s of Successful Management
  • 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. • Normal pulp • Reversible pulpitis • Irreversible pulpitis • Necrotic pulp • Pulpless/ previously treated Pulpal DiagnosisPulpal Diagnosis
  • 14. • Normal periradicular tissues • Acute periradicular periodontitis • Acute periradicular abscess Periradicular DiagnosisPeriradicular Diagnosis
  • 15. • Chronic periradicular periodontitis • Symptomatic • Asymptomatic • Chronic periradicular abscess (suppurative periradicular periodontitis) Periradicular DiagnosisPeriradicular Diagnosis
  • 16. • Focal sclerosing osteomyelitis (condensing osteitis): LEO Periradicular DiagnosisPeriradicular Diagnosis
  • 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 personalityDentist’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 C E L L S n e u tro p h ils , lym p h o c yte s , p la s m a c e lls , m a c ro p h a g e s , o s te o c la s ts , e p ith e lia l c e lls , d e n d ritic c e lls M O L E C U L A R M E D IA T O R S c yto k in e s (IL , IF N , C S F , T G F ) e ic o s a n o id s (P G , L T ) e n z ym a tic e ffe c to r m o le c u le s A N T IB O D IE S im m u n o g lo b u lin s (Ig G , e tc .) p ro d u c e d b y p la s m a c e lls M ixe d M ic ro flo ra
  • 28. • Diagnosis • Definitive dental treatment • Drugs Three D’s of Successful Management
  • 29. Emergency Treatment • Non-surgical • Surgical • Combined
  • 30. • Pulpotomy • Partial pulpectomy • Complete pulpectomy • Debridement of the root canal system* Non-surgical Emergency Treatment
  • 31. Surgical Emergency Treatment Incision for drainage Trephination/apical fenestration
  • 32. • Decreases number of bacteria • Reduces tissue pressure • Alleviates pain/trismus • Improves circulation • Prevents spread of infection • Alters oxidation-reduction potential • Accelerates healing Rationale for I & D
  • 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. • Diagnosis • Definitive Dental Treatment • Drugs Three D’s of Successful Management
  • 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
  • 43. Use a Flexible Analgesic Strategy
  • 44. • Pre - op / loading dose • Long acting anesthesia • Prescription Drugs
  • 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
  • 46. Codeine Patients taking 30 mg of codeine report only as much analgesia as placebo
  • 47. • 57 patients • Local anesthesia, pulpectomy, post- op analgesic • Placebo • 600 mg ibuprofen • 600 mg ibuprofen & 1000 mg acetaminophen Ibuprofen and Acetaminophen
  • 48. • 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*
  • 49. “The results demonstrate that the combination of ibuprofen and acetaminophen may be more effective than ibuprofen alone for the management of postoperative endodontic pain.” Ibuprofen and Acetaminophen*
  • 50. Analgesic Doses Codeine 60 mg Oxycodone 5-6 Hydrocodone 10 Dihydrocodone 60 Propoxyphene HCl (Darvon) 102 Meperidine (Demerol) 90 Tramadol (Ultram) 50
  • 51. Flexible Analgesic Plan M I L D 2 0 0 - 4 0 0 m g ib u p r o fe n o r 6 5 0 m g a s p ir in M O D E R A T E 6 0 0 - 8 0 0 m g ib u p r o fe n p lu s c o m b o a n a lg e s ic = 6 0 m g c o d e in e S E V E R E 6 0 0 - 8 0 0 m g ib u p r o fe n p lu s c o m b o a n a lg e s ic = 1 0 m g o x y c o d o n e A s p ir in - lik e D r u g s a r e I n d ic a t e d
  • 52. Flexible Analgesic Plan M IL D 6 0 0 -1 0 0 0 a c e ta m in o p h e n M O D E R A T E 6 0 0 -1 0 0 0 m g a c e ta m in o p h e n a n d o p ia te = 6 0 m g c o d e in e S E V E R E 1 0 0 0 m g a c e ta m in o p h e n a n d o p ia te = 1 0 m g o x y c o d o n e A s p irin -lik e D ru g s a re C o n tra in d ic a te d
  • 53. 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
  • 54. • Systemic involvement • Compromised host resistance • Fascial space involvement • Inadequate surgical drainage Indications for Antibiotic Therapy
  • 55. Select antibiotic with anaerobic spectrum Use a larger dose for a shorter period of time (“hard and fast” rule) Guidelines for Antibiotic Therapy
  • 56. • 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 Selecting the Appropriate Antibiotic
  • 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 • 150-300 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 ?

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