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  1. 1. Management of Nontraumatic, Endodontic Emergencies Dr. Langston D. Smith Chairman, Department of Endodontics Howard University College of Dentistry Washington, D.C.
  2. 2. <ul><li>Patient </li></ul><ul><li>Staff </li></ul><ul><li>Dentist </li></ul>Emergency Impacts
  3. 3. <ul><li>Pain </li></ul><ul><li>Pain and swelling </li></ul><ul><li>Trauma (later lecture) </li></ul>Patient Presentation
  4. 4. <ul><li>Diagnosis </li></ul><ul><li>Definitive dental treatment </li></ul><ul><li>Drugs </li></ul>3 D’s of Successful Management
  5. 5. Diagnosis <ul><li>Determine the CC </li></ul><ul><li>Take an accurate medical history </li></ul><ul><li>Complete a thorough exam, with all necessary tests </li></ul><ul><li>Perform a radiographic exam </li></ul><ul><li>Analyze and synthesize results </li></ul><ul><li>Establish a treatment plan </li></ul>
  6. 6. Treatment Plan to REMOVE the ETIOLOGY
  7. 7. When do patients present for emergency endodontic care? <ul><li>No prior RCT / initial infection </li></ul><ul><li>After RCT initiated </li></ul><ul><li>After obturation </li></ul>
  8. 8. Initial Presentation <ul><li>PAIN! </li></ul><ul><li>Primary infection </li></ul>
  9. 9. After Initiation of Endodontic Therapy FLARE-UP!
  10. 10. After Initiation of Endodontic Treatment Before obturation
  11. 11. After Obturation <ul><li>Recent obturation </li></ul><ul><li>Non-healing endodontic therapy </li></ul>
  12. 12. Determine a Pulpal and Periradicular Diagnosis
  13. 13. <ul><li>Normal pulp </li></ul><ul><li>Reversible pulpitis </li></ul><ul><li>Irreversible pulpitis </li></ul><ul><li>Necrotic pulp </li></ul><ul><li>Pulpless/ previously treated </li></ul>Pulpal Diagnosis
  14. 14. <ul><li>Normal periradicular tissues </li></ul><ul><li>Acute periradicular periodontitis </li></ul><ul><li>Acute periradicular abscess </li></ul>Periradicular Diagnosis
  15. 15. <ul><li>Chronic periradicular periodontitis </li></ul><ul><ul><li>Symptomatic </li></ul></ul><ul><ul><li>Asymptomatic </li></ul></ul><ul><li>Chronic periradicular abscess (suppurative periradicular periodontitis) </li></ul>Periradicular Diagnosis
  16. 16. <ul><li>Focal sclerosing osteomyelitis (condensing osteitis): LEO </li></ul>Periradicular Diagnosis
  17. 17. Etiology <ul><li>After listening to the patient, begin to determine the etiology of the chief complaint: </li></ul><ul><ul><li>Contents of the root canal? </li></ul></ul><ul><ul><li>Dentist controlled factors? </li></ul></ul><ul><ul><li>Host factors? </li></ul></ul>
  18. 18. Contents of the Root Canal <ul><li>Pulp tissue </li></ul><ul><li>Bacteria </li></ul><ul><li>Bacterial by-products </li></ul><ul><li>Endodontic therapy materials </li></ul>
  19. 19. Dentist Controlled Factors <ul><li>Over-instrumentation </li></ul><ul><li>Inadequate debridement </li></ul><ul><li>Missed canal </li></ul><ul><li>Hyper-occlusion * </li></ul><ul><li>Debris extrusion </li></ul><ul><li>Procedural complications * </li></ul>
  20. 20. Hyperocclusion <ul><li>Rosenberg PA, Babick PJ, Schertzer L, Leung A. The effect of occlusal reduction on pain after endodontic instrumentation. J Endodon 1998;24:492. </li></ul>
  21. 21. Hyperocclusion <ul><li>Researchers have found that patients most likely to benefit from occlusal reduction are those whose teeth initially present with symptoms. </li></ul><ul><li>Indiscriminant reduction of the occlusal surface is not indicated </li></ul><ul><li>PRE-OP PAIN </li></ul><ul><li>PULP VITALITY </li></ul><ul><li>PERCUSSION SENSITIVITY </li></ul><ul><li>ABSENCE OF A PERIRADICULAR RADIOLUCENCY </li></ul><ul><li>COMBINATION OF THESE SYMPTOMS </li></ul>
  22. 22. Procedural Complications <ul><li>Perforation </li></ul><ul><li>Separated instrument </li></ul><ul><li>Zip </li></ul><ul><li>Strip </li></ul><ul><li>NaOCl accident </li></ul><ul><li>Air emphysema </li></ul><ul><li>Wrong tooth </li></ul>
  23. 23. Dentist Controlled Factors Dentist’s personality
  24. 24. Host Factors <ul><li>Allergies </li></ul><ul><li>Age </li></ul><ul><li>Sex </li></ul><ul><li>Emotional state </li></ul>
  25. 25. Host Factors <ul><li>Complex etiology </li></ul><ul><ul><li>Microbiologic </li></ul></ul><ul><ul><li>Immunologic </li></ul></ul><ul><ul><li>Inflammatory </li></ul></ul>
  26. 26. Bacteria! <ul><li>Bacterial by-products/ endotoxin </li></ul>
  27. 27. Host Defense is Multi-factorial
  28. 28. <ul><li>Diagnosis </li></ul><ul><li>Definitive dental treatment </li></ul><ul><li>Drugs </li></ul>Three D’s of Successful Management
  29. 29. Emergency Treatment <ul><li>Non-surgical </li></ul><ul><li>Surgical </li></ul><ul><li>Combined </li></ul>
  30. 30. <ul><li>Pulpotomy </li></ul><ul><li>Partial pulpectomy </li></ul><ul><li>Complete pulpectomy </li></ul><ul><li>Debridement of the root canal system * </li></ul>Non-surgical Emergency Treatment
  31. 31. Surgical Emergency Treatment <ul><li>Incision for drainage </li></ul><ul><li>Trephination/apical fenestration </li></ul>
  32. 32. <ul><li>Decreases number of bacteria </li></ul><ul><li>Reduces tissue pressure </li></ul><ul><ul><li>Alleviates pain/trismus </li></ul></ul><ul><ul><li>Improves circulation </li></ul></ul><ul><li>Prevents spread of infection </li></ul><ul><li>Alters oxidation-reduction potential </li></ul><ul><li>Accelerates healing </li></ul>Rationale for I & D
  33. 33. Management <ul><li>Inadequate debridement </li></ul><ul><li>Debris extrusion </li></ul><ul><li>Over-instrumentation </li></ul><ul><li>Missed canal </li></ul><ul><li>Fluctuant swelling </li></ul><ul><li>Severe pain, no swelling </li></ul>
  34. 34. Treatment <ul><ul><li>For severe pain without visible swelling… </li></ul></ul><ul><ul><ul><li>Trephination! </li></ul></ul></ul>
  35. 35. QUESTIONS
  36. 36. “ Should I leave the tooth OPEN or CLOSED ?”
  37. 37. “ Should I place an Interappointment Medicament ?” Ca(OH) 2
  38. 38. “ Should I prescribe ANTIBIOTICS ?”
  39. 39. <ul><li>Diagnosis </li></ul><ul><li>Definitive Dental Treatment </li></ul><ul><li>Drugs </li></ul>Three D’s of Successful Management
  40. 40. Remember, there is a Complex Etiology <ul><li>Microbiologic </li></ul><ul><li>Immunologic </li></ul><ul><li>Inflammatory </li></ul>
  41. 41. And, not all can be easily treated... <ul><li>Debris extrusion </li></ul><ul><li>Over-instrumentation </li></ul><ul><li>Over-filling </li></ul><ul><li>Over-extension </li></ul>
  42. 42. Breaking the PAIN CHAIN
  43. 43. Use a Flexible Analgesic Strategy
  44. 44. <ul><li>Pre - op / loading dose </li></ul><ul><li>Long acting anesthesia </li></ul><ul><li>Prescription </li></ul>Drugs
  45. 45. Codeine <ul><li>Prototype opioid for orally available combination drugs </li></ul><ul><li>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 </li></ul><ul><li>Troullis E, Freeman R, Dionne R. The scientific basis for analgesic use in dentistry. Anesth Prog 1986 33:123. </li></ul>
  46. 46. Codeine <ul><li>Patients taking 30 mg of codeine report only as much analgesia as placebo </li></ul><ul><ul><li>Troullis E, Freeman R, Dionne R. The scientific basis for analgesic use in dentistry. Anesth Prog 1986 33:123. </li></ul></ul>
  47. 47. <ul><li>57 patients </li></ul><ul><li>Local anesthesia, pulpectomy, post- op analgesic </li></ul><ul><ul><li>Placebo </li></ul></ul><ul><ul><li>600 mg ibuprofen </li></ul></ul><ul><ul><li>600 mg ibuprofen & 1000 mg acetaminophen </li></ul></ul><ul><li>*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. </li></ul>Ibuprofen and Acetaminophen*
  48. 48. <ul><li>Visual analogue scale & baseline 4-point category pain scale </li></ul><ul><li>1 hr, 4 hr, 6 hr, 8 hr </li></ul><ul><li>General linear model analyses </li></ul><ul><li>Significant differences </li></ul><ul><ul><li>Placebo and combination </li></ul></ul><ul><ul><li>Ibuprofen and combination </li></ul></ul><ul><li>No significant difference </li></ul><ul><ul><li>Placebo and ibuprofen </li></ul></ul>Ibuprofen and Acetaminophen*
  49. 49. <ul><li>“ The results demonstrate that the combination of ibuprofen and acetaminophen may be more effective than ibuprofen alone for the management of postoperative endodontic pain.” </li></ul>Ibuprofen and Acetaminophen*
  50. 50. Analgesic Doses
  51. 51. Flexible Analgesic Plan
  52. 52. Flexible Analgesic Plan
  53. 53. Selected NSAID Drug Interactions
  54. 54. <ul><li>Systemic involvement </li></ul><ul><li>Compromised host resistance </li></ul><ul><li>Fascial space involvement </li></ul><ul><li>Inadequate surgical drainage </li></ul>Indications for Antibiotic Therapy
  55. 55. <ul><li>Select antibiotic with anaerobic spectrum </li></ul><ul><li>Use a larger dose for a shorter period of time (“hard and fast” rule) </li></ul>Guidelines for Antibiotic Therapy
  56. 56. <ul><li>Gram stain results available: antibiotic-sensitivity charts </li></ul><ul><li>C & S results available: antibiotic-sensitivity charts </li></ul><ul><li>No gram stain or C & S results: </li></ul><ul><li>PCN is antibiotic of choice </li></ul>Selecting the Appropriate Antibiotic
  57. 57. Penicillin V <ul><li>Still, the drug of choice for infections of endodontic origin </li></ul><ul><li>Loading dose: 1-2 g then 500 mg qid x 7-10 days </li></ul>
  58. 58. Metronidozole (Flagyl) <ul><li>Used in conjunction with Penicillin V </li></ul><ul><li>500 mg of Penicillin V with 250 mg Metronidozole, qid x 7-10 days </li></ul>
  59. 59. Clindamycin <ul><li>Loading dose: 300 mg </li></ul><ul><li>150-300 mg qid x 10 days </li></ul>
  60. 60. Closely Follow All Infected Patients
  61. 61. Components of a Successful Management <ul><li>Appropriate attitude of dentist </li></ul><ul><li>Proper patient management </li></ul><ul><li>Accurate diagnosis </li></ul><ul><li>Profound anesthesia </li></ul><ul><li>Prompt and effective treatment </li></ul>
  62. 62. Patient Instructions <ul><li>By the Clock </li></ul><ul><li>NOT </li></ul><ul><li>PRN </li></ul>
  63. 63. Questions ?

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