2013 Toronto Winter Clinic, Endodontic Pain by Drs. Cherkas & Dorfman

3,338 views

Published on

2013 Toronto Academy of Dentistry, 76th Annual Winter Clinic
New Approaches in Management of Endodontic Pain by
Dr. Pavel S. Cherkas, Endodontist-Neuroscientist and
Dr. Ruslan Dorfman, Molecular Geneticist

Published in: Health & Medicine
1 Comment
13 Likes
Statistics
Notes
  • Спасибо вам Руслан и Павел за прекрасную презентацию! :0)
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
No Downloads
Views
Total views
3,338
On SlideShare
0
From Embeds
0
Number of Embeds
459
Actions
Shares
0
Downloads
189
Comments
1
Likes
13
Embeds 0
No embeds

No notes for slide

2013 Toronto Winter Clinic, Endodontic Pain by Drs. Cherkas & Dorfman

  1. 1. New Approaches in Management of Endodontic Pain-- Making Sense of Evidence, Technology and Pharmacogenetics Pavel S. Cherkas DMD, PhD, MMedSc, MSc, BSc Ruslan Dorfman PhD, MBA, MSc, BSc Faculty of Dentistry, University of Toronto, Canada
  2. 2. Agenda for today’s course • Anatomical structures in pain signaling • NSAIDs for analgesia • Pain modalities • Break - 10 min • Antiepileptic drugs for pain control • Acute pain as risk factor of chronic • Anesthesia – maximum results pain • Technologies for root canal • Levels of evidence treatment • Pain as diagnostic tool • Antibiotics in endodontic treatment • Evidence based pain management • Statin-macrolide drug interactions • Anthropologic risk factors of pain • Differences in NSAID response • Pre-op pain – local anesthetics • Use of steroids • Opioids – when and what is appropriate • Outlook into future • Conclusions
  3. 3. Do we know more today? Can we treat better?
  4. 4. Peripheral innervation patterns cannot explain pain referral
  5. 5. Acute vs. Chronic Dental Pain Pain: An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (IASP) Acute Pain: Transient, usually sharp, pain that serves a protective function : warns the organism of actual or impending tissue injury
  6. 6. Chronic Pain Chronic Pain: Persistent, often dull or aching pain, that continues long after an injury has apparently healed (> 3 months duration); serves no protective function and apparently no biologic role Some of most common pains occur in oro-facial region, e.g. 10-15% prevalence of toothache or TMD
  7. 7. Uncontrolled acute pain increases the risk of chronic pain P(T) 60 12% 50 10% 40 8% 30 Series2 P(T) 6% 20 4% 10 2% 0 0% 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 P(T) = GB * Int[I(t)dt] where P(T) is the probability of developing chronic condition by time T Cherkas, 2013
  8. 8. Uncontrolled acute pain increases the risk of chronic pain P(T) 60 12% 50 10% 40 8% 30 Series2 20 P(T) 6% 4% 10 2% 0 0% 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 P(T) = GB * Int[I(t)dt] where P(T) is the probability of developing chronic condition by time T Cherkas, 2013
  9. 9. Pain control: what works and what does not? • • • • • Pre-op anesthesia – and NSAIDs Local anesthesia Post-op anesthesia – and NSAIDs vs opioids Antibiotics Steroids Each treatment is associated with benefits and risks – need to balance both
  10. 10. Levels of evidence Systematic Reviews Evidence Synthesis & Guidelines Critically Apprised Individual Articles Filtered information Randomized Controlled Trials Case-control Studies & Case Series and reports Background information / Expert Opinion Unfiltered information
  11. 11. AAE Definitions of Pulpitis Reversible pulpitis – A clinical diagnosis based upon subjective and objective findings indicating that the inflammation should resolve and the pulp return to normal
  12. 12. AAE Definitions of Pulpitis Irreversible pulpitis – A clinical diagnosis based on subjective and objective findings indicating that the vital inflamed pulp is incapable of healing Additional descriptions: Symptomatic – Lingering thermal pain, spontaneous pain, referred pain Asymptomatic – No clinical symptoms but inflammation produced by caries, caries excavation, trauma, etc. Take home message!
  13. 13. “Hot tooth” • pulp diagnosed with irreversible pulpitis, with spontaneous, moderate-to-severe pain • patient who is sitting in the waiting room, sipping on a large glass of ice water to help control the pain
  14. 14. “Hot tooth” • Chronic inflammation takes on an acute exacerbation • Influx of neutrophils • Release of inflammatory mediators • Release of proinflammatory neuropeptides • Peripheral and central sensitization of nociceptors • Increased neuronal excitability
  15. 15. Pain as a Diagnostic Tool Barodontalgia Affects air crew and aircraft passengers, underwater divers Pain or injury affecting teeth due to changes in pressure gradients Boyle’s Law: “at a given temperature, the volume of a gas is inversely proportional to the ambient pressure” Robichaud & McNally, 2005
  16. 16. Pain as a Diagnostic Tool Lack of knowledge concerning the type, characterization and variety of fractures may lead to misunderstanding with incorrect diagnosis and inappropriate treatment • • • • • Craze Lines Split Tooth Fractured Cusp Vertical Root Fracture Cracked Tooth
  17. 17. Craze Lines, Fractured and Split Teeth Craze lines affect only the enamel, while fractured cusps, cracked teeth and split teeth begin on the occlusal surface and extend apically, affecting enamel, dentin, and possibly, the pulp
  18. 18. Craze Lines, Fractured and Split Teeth Craze lines affect only the enamel, while fractured cusps, cracked teeth and split teeth begin on the occlusal surface and extend apically, affecting enamel, dentin, and possibly, the pulp Craze lines Fractured cusp Take home message! Cracked tooth
  19. 19. Case 1
  20. 20. Radiographic Examination
  21. 21. Radiographic Examination
  22. 22. Apical surgery and bone grafting
  23. 23. Apical surgery and bone grafting
  24. 24. Apical surgery and bone grafting
  25. 25. Apical surgery and bone grafting
  26. 26. Case 2 (Apical surgery)
  27. 27. Case 3 (Apical surgery)
  28. 28. Q: The teeth with irreversible pulpitis that are the most difficult to anesthetize are: 1. the mandibular molars followed by mandibular premolars, maxillary molars, and maxillary premolars 2. the maxillary molars, and maxillary premolars, mandibular molars followed by mandibular premolars 3. the mandibular molars followed by maxillary molars, mandibular premolars and maxillary premolars 4. maxillary anterior teeth
  29. 29. Q: What anthropologic factors contribute to response to opioid anesthesia ? a. Age, Gender, Body weight b.Race c. Hair color d.a+b e.a+b+c
  30. 30. Q: Who has higher pain sensitivity, and stronger response to opioid anesthesia? A B C D E F
  31. 31. Q: Who has higher pain sensitivity, and stronger response to opioid anesthesia? A Red hair = 2 mutations in MC1R gene melanocortin 1 receptor
  32. 32. Red-haired women are more sensitive to morphine black vs yellow (e/e) MC1R mutant mice MC1R gene function and morphine (M6G) mediated inhibition of thermal nociception in mice and electrical current pain in humans. Mogil J S et al. J Med Genet 2005;42:583-587 2 variants = red hair Women are more sensitive 10 mg/kg morphine
  33. 33. Anesthetic efficacy of the inferior alveolar nerve block in red-haired women • Red hair and the MC1R gene were significantly linked to higher levels of dental anxiety • but were unrelated to success rates of the IAN block in women with healthy pulps Droll et al., 2012
  34. 34. Pre-Operative Pain Control • Local anesthesia Blocks (short and long-lasting) Infiltration Intraosseous Intrapulpal
  35. 35. Intravenous cocaine increases plasma epinephrine and norepinephrine in humans • Epinephrine is contraindicated in patients who have used cocaine within the last 24-48 hours Take home message! Sofuoglu et al., 2001
  36. 36. ABSOLUTE CONTRAINDICATIONS Uncontrolled hyperthyroidism The main reason for dentists to avoid local anesthetic with vasoconstrictors in untreated hyperthyroidism has been the possibility that sympathomimetic amines could potentiate the vascular effect of thyroid hormone. Take home message!
  37. 37. ABSOLUTE CONTRAINDICATIONS Pheocromocytoma Pheocromocytoma is a rare but serious disorder characterized by the presence of catecholamineproducing tumors. The use of vasoconstrictors puts these patients at high risk for lethal cardiac or cerebrovascular complications and should be strictly avoided. Perusse and Goulet, 1992 Take home message!
  38. 38. Success of the inferior alveolar nerve block in patients with irreversible pulpitis • Clinical studies in endodontics in patients with irreversible pulpitis have found success with the inferior alveolar nerve block occurred between 15% and 57% of the time Take home message! Al Reader et al; 2011
  39. 39. Combination of preoperative ibuprofen/acetaminophen and inferior alveolar nerve block in patients with symptomatic irreversible pulpitis • a combination dose of 800 mg ibuprofen and 1000 mg acetaminophen given 45 minutes before administration of the IAN block did not result in a statistically significant increase in anesthetic success Simpson et al., J Endod. 2011
  40. 40. Is a dose of 3.6 mL better than 1.8 mL for inferior alveolar nerve blocks in patients with symptomatic irreversible pulpitis? • For patients presenting with irreversible pulpitis, success was not significantly different between a 3.6-mL volume and a 1.8-mL volume of 2% lidocaine with 1:100,000 epinephrine. Fowler and Reader, J Endod., 2013 Take home message!
  41. 41. Why do we get anesthetic failures? 1. Anatomical variations – central core theory – Spread of the solution within the pterygomandibular space Hargraves 2002
  42. 42. Lip numbness • Lip numbness can be obtained in 100% of the time • Successful anesthesia in 15% -57% of the time • The lack of lip numbness following IANB indicates the injection was missed- no anesthesia • Once lip numbness is achieved, lack of pulpal anesthesia is not due to an inaccurate inferior alveolar nerve block Take home message! Al Reader et al; 2011
  43. 43. Tachyphylaxis 2. Tachyphylaxis appears neither to be linked to structural or pharmacological properties of the local anesthetics nor to the technique or mode of their administration The mechanisms underlying tachyphylaxis are open to debate and include changes in pharmacokinetics or pharmacodynamics Kottenberg-Assenmacher & Peters, 1999 Take home message!
  44. 44. Why do we get anesthetic failures? 3. Effect of Inflammation on local tissues (pH) 4. Effect of Inflammation on blood flow – vasodilation 5. Effect of Inflammation on nociceptors – allodynia 6. Effect of Inflammation on central sensitization 7. Psychological factors Hargreaves 2002 7. Genetic factors - variations in drug metabolic genes
  45. 45. WHO Analgesic Ladder Analgesic Ladder. World Health Organization; 1986
  46. 46. Typical situation Patient comes back within 24 hours after a treatment and complains of severe pain. You prescribe Tylenol 3. Next morning the patient is back in your office with acute pain and asks for stronger pain killer • Is this real or he/she is a drug seeker? • What should I prescribe to alleviate the pain ?
  47. 47. Q : Patient on Tylenol 3 reports only minor pain relief Next best treatment options: A. Tylenol 4 B. Percocet C. Oxycontin or Tramadol D. Celecoxib
  48. 48. Tylenol 3 = acetaminophen (500mg) +codeine (30mg) Non-responders are poor CYP2D6 metabolizers http://pharmgkb.blogspot.ca/2013/02/fda-to-post-black-box-warning-on-codeine.html
  49. 49. Tylenol 3 non-responders • Poor CYP2D6 metabolizers CANNOT convert codeine to morphine, thus do not experience pain relief. • Oxycodone and Tramadol are metabolized by CYP2D6 • Percocet (acetaminophen and oxycodone) – the same! • These patients do not benefit from Oxycodone, Tramadol, Tramacet and Percocet • Respond well to morphine and fentanyl, and COX-2 inhibitors Take home message!
  50. 50. Q: Patient on Tylenol 3 reports short-term pain relief Next best treatment option is: A. Tylenol 4 B. Oxycontin or Tramadol C. Morphine D. Celecoxib
  51. 51. Q: Patient on Tylenol 3 reports short-term pain relief Next best treatment option is: A. Tylenol 4 B. Oxycontin or Tramadol C. Morphine D. Celecoxib R
  52. 52. Patient on Tylenol 3 reports only short term pain relief Most likely the patient is ultrafast CYP2D6 metabolizer Stamer & Stüber Expert Opin. Pharmacother. (2007)
  53. 53. Ethnic variability of CYP2D6 alleles Stamer & Stüber Expert Opin. Pharmacother. (2007)
  54. 54. Acute Post-Endodontic Pain Reported incidence – 1.6% to 6.6% within one week Typically treated with shortterm analgesics Analgesics ineffective in 3% of affected patients Al-Negrish et al. 2006, Imura et al. 1995, Morse et al. 1987, Trope 1991, Walton & Fouad 1992
  55. 55. Persistent Post-Endodontic Pain Reported incidence – 5.5 % (range of 3-12%) beyond six months Estimated 3.4% is of nonodontogenic origin In the US – 870,000, in Canada –96,000 -new cases/year; In the US – 550,000, in Canada –61,000 non-odontogenic pain Campbell et al. 1990, Marbach et al. 1982, Polycarpou et al. 2005, Keenan 2010, Nixdorf et al. 2010, Cherkas &Sessle 2012
  56. 56. Analgesia Postoperative analgesia is no different from other areas of medicine, in that we all have strong opinions, and often the stronger the opinion the weaker is the underlying evidence. HJ McQuay, DM, University of Oxford
  57. 57. Adverse side effects are rare and underreported • Collecting evidence about harm in postoperative pain receives much less attention than evidence about efficacy…. • Rare (serious) adverse effects are not likely to be detected in small randomised trials • Adverse side effects create liability risk for your practice!
  58. 58. Levels of evidence Systematic Reviews Evidence Synthesis & Guidelines Critically Apprised Individual Articles Filtered information Randomized Controlled Trials Case-control Studies & Case Series and reports Background information / Expert Opinion Unfiltered information
  59. 59. The 2007 Oxford league table of analgesic efficacy Numbers needed to treat - the proportion of patients with at least 50% pain relief over 4-6 hours compared with placebo in randomised, double-blind, singledose studies in patients with moderate to severe pain. http://www.medicine.ox.ac.uk/bandolier/boot h/painpag/Acutrev/Analgesics/lftab.html Analgesic Number Percent of with at patients least in 50% comparis pain on relief NNT Dipyrone 1000 Ibuprofen 600/800 Ketorolac 20 Ketorolac 60 IM Diclofenac 100 Piroxicam 40 Celecoxib 400 113 165 69 116 545 30 298 79 86 57 56 69 80 52 1.6 1.7 1.8 1.8 1.8 1.9 2.1 Paracetamol 1000 + Codeine 60 197 57 2.2 Oxycodone IR 5 + Paracetamol 500 150 60 2.2 370 675 60 279 247 288 5456 51 54 73 61 53 73 55 2.2 2.3 2.3 2.4 2.4 2.4 2.5 Bromfenac 25 Rofecoxib 50 Oxycodone IR 15 Aspirin 1200 Bromfenac 50 Dipyrone 500 Ibuprofen 400
  60. 60. What may work for Tylenol 3 non-responders? 1. COX2 inhibitors (valdecoxib, celecoxib) 2. Higher doses of ibuprofen 3. Anti-epileptic (carbamazepine or pregabalin) 4. Morphine R
  61. 61. Effect of Acetaminophen on Head Withdrawal Response (Animal Model) Cherkas et al., 2013
  62. 62. Effect of Pregabalin on Head Withdrawal Response (Animal Model) 0.18 0.14 0.12 0.1 Naïve 0.08 * 0.06 * 0.04 0.02 Time Cherkas et al., 2013 Day 56 180m 120m 60m Day 49 Pre Day 42 Day 35 Day 28 Day 22 180m 120m 60m Day21 Pre Day 21 Day 14 Day 10 180m 120m 60m Day7 Pre Day 5 Day3 Day 1 0 Pre Head withdrawal threshold 0.16 Aceta 100mg/Kg PG 75mg/kg IONX
  63. 63. Break - 10 min
  64. 64. Post-Endodontic Pain Terminology Phantom tooth pain Idiopathic periodontalgia Idiopathic odontalgia Atypical odontalgia Pain in a tooth or tooth-bearing area Not related to any dental cause Often mistaken for toothache and treated as such Marbach 1978, Harris 1978, Graff-Radford et al. 1986, Rees & Harris 1978, BaadHansen 2008, Zakrzewska 2010, 2011
  65. 65. Atypical Odontalgia Specific mechanisms not yet established Sub-set of trigeminal neuropathic pain: ”pain arising as a direct consequence of any lesion or disease affecting the somatosensory system” Incidence can be as high as 3% to 6% International Association for the Study of Pain 2011 Take home message!
  66. 66. What do we do for better anesthesia? Alternate injection locations • Gow-Gates and Vazirani-Akinosi • Incisive nerve block at the mental foramen • Mandibular infiltration following IANB Supplemental LA • Intraligamental • Intrapulpal • Intraosseus
  67. 67. Anesthetic efficacy of X-tip intraosseous injection using 2% lidocaine with epinephrine in patients with irreversible pulpitis after inferior alveolar nerve block • 93% of X-tip injections were successful Verma et al., 2013 Take home message!
  68. 68. Al Reader et al; 2011
  69. 69. Al Reader et al; 2011
  70. 70. Q: In which of the following teeth it is highly unlikely to have profound anesthesia after the IANB and intraosseous injection? 1. 2. 3. 4. 5. Tooth with symptomatic irreversible pulpitis Tooth with asymptomatic irreversible pulpitis Tooth with reversible pulpitis Asymptomatic tooth with necrotic pulp Symptomatic tooth with necrotic pulp and PA radiolucency
  71. 71. Painful teeth with necrotic pulp and PA radiolucencies courtesy of Kamil Kolosowski
  72. 72. Painful teeth with necrotic pulp and PA radiolucencies • In this condition, intraosseous and intrapulpal injections are painful and may not be effective • Intraosseous and intrapulpal injections should not be used in painful teeth with necrotic pulps and radiolucent areas Al Reader et al; 2011
  73. 73. Flare-up  As specifically defined by Walton (2002), interappointment flare-up has the following 4 criteria:  1. Within a few hours to a few days after an endodontic procedure, a patient has significant increase in pain or swelling or a combination of the two.  2. The problem is of such severity that the patient initiates contact with the dentist.
  74. 74. Flare-up • 3. The dentist determines that the problem is of such significance that the patient must come for an unscheduled visit. • 4. Active treatment is rendered. That may include incision for drainage, canal debridement, opening the tooth, prescribing appropriate medications, or doing whatever is necessary to resolve the problem.
  75. 75. Flare-up - Frequency • Overall incidence low • Best evidence suggest true frequency ranges from 1.5% to 5.5% • Some studies showing frequency high as 16% • Variation due at least in part to study design (prospective, retrospective), how cases defined, sample size, etc. Walton 2002, Siqueira and Barnett 2004
  76. 76. Causes of Post-op Pain • Central sensitization • Microbial • Non-microbial (mechanical or ‘physical’, chemical) Seltzer and Naidorf 1985, Siqueira and Barnett 2004
  77. 77. Causes of Post-op Pain • Microbial causes are the most common and most important cause of post-operative pain in endodontics • Non-microbial causes (mechanical, chemical, even thermal in rare instances) are typically iatrogenic Seltzer and Naidorf 1985, Siqueira and Barnett 2004
  78. 78. Clinical/Risk Factors for Post-op Pain or Flare-Up Related to Presenting Signs/Symptoms – With pre-op pain  increased risk – With pre-op swelling  increased risk • With pre-op pain, increased stress levels may lead to impaired immune capabilities Logan et al 2001, Walton 2002
  79. 79. Clinical/Risk Factors for Post-op Pain or Flare-Up • Related to Treatment Procedures – Single visit versus multi-visit – no difference in risk (Sathorn 2008, Figini 2008) – Incomplete debridement or overinstrumentation? increased risk – Obturation – decreases the risk? May be due to fact that operators won’t obturate cases with extreme presenting signs/symptoms Walton 2002
  80. 80. Post-Operative Pain Control – Operative Treatment Choices: – Re-instrumentation – Cortical trephination – Incision and drainage – Intracanal medicaments – Occlusal reduction Siqueira and Barnett 2004
  81. 81. I think, the adequate working length is shown in ___? A B 1. A 2. B 3. C 4. B+C 5. None C
  82. 82. I think, the adequate working length is shown in ___? A B C
  83. 83. What is the best cell phone for my family?
  84. 84. EndoVac
  85. 85. Negative pressure irrigation Plazas-Garzon and Cherkas, 2013
  86. 86. Postoperative pain after the application of two different irrigation devices in a prospective randomized clinical trial Use of a negative apical pressure irrigation device can result in a significant reduction of postoperative pain levels in comparison to conventional needle irrigation. Gondim E Jr et al., 2010
  87. 87. Post-Operative Pain Control – Pharmacological Treatment • Antibiotics • Local Anesthetics • Analgesics – Acetaminophen – NSAIDs – Opioid analgesics
  88. 88. Q: Post-Operative Pain Control Antibiotics • Are systemtic antibiotics effective in relieving ‘untreated’ pulpal pain? • Answer: NO • Nagle et al 2000 (penicillin had no analgesic effect in cases of irrversible pulpitis) Fouad 2002
  89. 89. Q: Post-Operative Pain Control Antibiotics • Question: Are systemtic antibiotics effective in relieving localized post-op periapical symptoms? • Answer: NO – In patients with pulp necrosis and symptomatic AP, addition of systemic penicillin provided no added benefit to the painful condition beyond that of chemomechanical canal instrumentation alone Fouad 2002, Henry et al 2001
  90. 90. What DOESN’T Work for Post-Op Pain? 1. Antibiotics Walton and Chiappinelli (JOE ’97), Fouad, Rivera and Walton (OOOO, 96), Henry, Reader and Beck (JOE, 2001) Effect on incidence of flare ups, Pickenpaugh, Reader et al (JOE, 2001) 2. Narcotics as a first choice medication Systematic reviews (Moore et al, 2005-13)
  91. 91. Indications for Antibiotics Use in Endodontics • AHA Prophylaxis • Diffuse swelling (cellulitis) • Localized swelling without drainage • Rapidly increasing swelling • Systemic signs (fever, lymphadenopathy, unexplained trismus) • Trauma • Regeneration Take home message!
  92. 92. Q: You are considering to prescribe a macrolide antibiotic Your major concerns are: a) Patient's prior sensitivity to clarithromycin or azithromycin b) Kidney and liver function c) Use of statins d) a+b e) a+b+c
  93. 93. Q: You are considering to prescribe a macrolide antibiotic Your major concerns are: a) Patient's prior sensitivity to clarithromycin or azithromycin b) Kidney and liver function c) Use of statins d) a+b e) a+b+c
  94. 94. Antibiotics : Be aware of statins rs4149056 p.Val174Ala SLCO1B1 18% of statin users experience muscle pain as a result of rhabdomyolysis that may lead to kidney failure Macrolides can exacerbate the risk of kidney failure especially in elderly, and patients with reduced kidney function Link E, Parish S, Armitage J, Bowman L, Heath S, Matsuda F, Gut I, Lathrop M, and Collins R. (2008) The SEARCH Collaborative Group. " N. Engl. J. Med. 359:789-799.
  95. 95. Azythromycin has a lower risk of statin interaction Azithromycin Clarithromycin Erythromycin http://www.pharmgkb.org/pathway/PA145011109
  96. 96. Statins and microlides can lead to kidney failure Statin toxicity from macrolide antibiotic coprescription: a populationbased cohort study. Patel AM, Shariff S, Bailey DG, Juurlink DN, Gandhi S, Mamdani M, Gomes T, Fleet J, Hwang YJ, Garg AX Ann Intern Med. 2013 Jun 18;158(12):869-76 “Compared with azithromycin, coprescription of a statin with clarithromycin or erythromycin was associated with a higher risk for hospitalization with rhabdomyolysis or with acute kidney injury” • Patients reporting muscle pain while taking statins are at increased risk of kidney damage while on macrolides • thus should temporarily discontinue statins
  97. 97. Can We Predict Patients More Likely to Experience Pain After an Endodontic Therapy? 1. 2. 3. 4. Preoperative hyperalgesia Females Apical Periodontitis Necrotic Pulp Hutter and Hargreaves, (2011)
  98. 98. Can We Predict Patients More Likely to Experience Pain After an Endodontic Therapy? 1. Pre-op pain is a good predictor or post-op pain 2. On average pain is maximal in first 24-48 hrs – no need to give pain meds for more than a few days with proper clean and shape of the canal Torabinejad et al., (JOE, 2002)
  99. 99. Post-Operative Pain Control – Local Anesthetics • LA can be used for sole purpose of pain relief or in conjunction with operative/surgical procedures to reduce post-op pain • Most useful in cases involving mandibular teeth where bupivacaine (long-acting LA) is administered by mandibular block injection
  100. 100. Post-Operative Pain Control – Local Anesthetics • bupivacaine 0.5% – available with 1:200,000 epinephrine – trade name Marcaine (Vivacaine – new, U.S. only) www.kodakdental.com
  101. 101. Post-Operative Pain Control – Local Anesthetics Haas 2002
  102. 102. Bupivacaine-induced cardio toxicity Minimum Intravenous Toxic Dose of Local Anesthetic Agent Minimum Toxic Dose (mg/kg) Procaine 19.2 Tetracaine 2.5 Chloroprocain e 22.8 Lidocaine 6.4 Mepivacaine 9.8 Bupivacaine 1.6 Etidocaine 3.4 Excessive plasma concentrations due to: – inadvertent intravascular injection, – excessive dose or rate of injection, – administration into vascular tissue, – delayed drug clearance (CYP3A4). Myocardial depression and bradycardia, and cardiovascular collapse Goldfrank LR, et al. 1507-17. In: Goldfrank's Toxicologic Emergencies. 6th ed. New York: McGraw-Hill; 1998:897-903.
  103. 103. The 3D Strategy for Treating Endodontic Pain 1. Differential Diagnosis of non odontogenic pain: P – Psychogenic – Munchausen's I – Inflammatory – Sinusitis N – Neurovascular – Cluster headaches S – Systemic – Myocardial Infarct M – Musculoskeletal – Myofacial pain (TMD) Hargreaves 2011
  104. 104. The 3D Strategy for Treating Endodontic Pain 2. Definitive Dental Treatment • anesthesia (anatomy, all current evidence based techniques) • EndoVac (negative pressure), Bupivacaine, etc. 3. Drugs • NSAIDs • Opioids Hargreaves, 2011
  105. 105. Post-Operative Pain Control: Analgesics – Algorithm Hargreaves and Seltzer 2002
  106. 106. Preferred for patients on warfarin or other blood thinners Poor CYP2C9 metabolizers experience better pain relief vs CYP2E1 converts acetaminophen into N-acetyl-p-benzoquinoneimine (NAPQI) • NAPQI is the active metabolite • increases risk of liver toxicity Inactivated by CYP2C9 • • • • Celecoxib Lornoxicam Diclofenac Naproxen • • • • Ketoprofen Piroxicam Meloxicam Suprofen
  107. 107. Acetominophen and Ibuprofen Substantially greater analgesia than either drug alone AND avoids the side effects of opiates Cooper et al: combined Ibuprofen 200 mg + APAP 650 (Compendium) was better than either alone Derry et al., 2011(Br Dent j, 2011) Mehninick (IEJ, 2004)
  108. 108. Cox-2 specific inhibitors • Very effective in controlling inflammatory pain • Long term exposure leads to increased risk of heart failure • Most effective Cox-2 blockers were pulled off the market • How to balance benefits and risks?
  109. 109. Coxibs: pain relief and risk of CVD and GI bleed • Coxibs metabolized by CYP2C9 • Poor metabolizers have increased exposure to celecoxib • better pain control • increased risk of heart attack and GI bleeding • Warfarin is metabolized by CYP2C9 • Co-administration can increase risk of intracranial bleeding • Need to check the INR http://www.pharmgkb.org/pathway/PA165816736 Gong Li, et al. 2012
  110. 110. Post-Operative Pain Control – ASA (low dose) and ibuprofen Because of an interaction between ibuprofen and ASA, an alternative NSAID should be used, or ibuprofen should be taken at least 30 min after or at least 8 h before ASA AHA, 2007
  111. 111. Before recommending NSAIDs for pain control Ask the patient whether: a. Suffering from ulcers or GI bleeding b. Abusing alcohol or has reduced liver function c. Taking aspirin or antiplatelet medication (Plavix, Effient) d. Warfarin or another anticoagulant (Xarelto) • Advise to check INR with family physician to adjust warfarin dose to reduce the risk on intracranial bleed • Seek advise if pain persists over 3 days Take home message!
  112. 112. Post-Operative Pain Control – Steroids • Glucocorticoids inhibit many cells and factors present in inflammatory response • Inhibition of gene transcription for inflammatory factors • Inhibition of pro-inflammatory cytokine production Marshall 2002
  113. 113. Post-Operative Pain Control – Steroids “The administration of systemic steroids is efficacious as an adjunct to but not replacement for appropriate endodontic treatment in the attenuation of endodontic post treatment pain” “Systemic steroids are also highly effective in those patients who present for treatment with moderate/ severe pain and a clinical diagnosis of pulpal necrosis with associated periapical radiolucency.” Marshall 2002
  114. 114. Post-Operative Pain Control – Steroids Is the benefit worth the risk, given the side effect profile (ex. avascular necrosis of the hip from a single oral steroid dose) and given the efficacy of available analgesics?
  115. 115. Atypical odontalgia Cherkas and Sessle, 2012
  116. 116. Pain Associated with Irreversible Pulpitis What is the best time for treatment? Acute inflammation Acute inflammation
  117. 117. Today (2013-14) Today’s patients are under the impression that only classic methods of pain control apply to endodontics We now have “molecular approaches” that offer us different methods of pain control
  118. 118. Today (2013-14) http://www.personalizedmedicinecoalition.org/
  119. 119. DNA tests – can predict drug response and the risk of side effects
  120. 120. Conclusion  Post-operative pain and flare-up      Definitions/Frequency (25-40% vs 2-6%) Causes – bacterial, chemical, physical Clinical / Risk Factors Prevention – may not be entirely possible Temporal summation (central sensitization)  Post-Operative Pain Control (Management)     Operative/surgical – reinstrumentation, I&D, etc. Pharmacological – analgesics, LA (steroids, Ab) Patients respond differently to treatments Adverse side effects are preventable
  121. 121. Future directions • More targeted pain treatments (minocycline?) • Proactive interventions to reduce the risk of chronic pain • Implementation of new endodontic techniques • Personalized approach to pain management • Reduced incidence of adverse side effects • Happier and healthier patients!
  122. 122. Thank you Pavel Cherkas pavel@endoart.ca EndoArt.ca Ruslan Dorfman ruslan@geneyouin.ca www.geneyouin.ca Phone: 647-868-1812 Please fill the feedback form after completing your test!

×