endodontic emergencies
DESCRIPTION
TRANSCRIPT
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Management of Nontraumatic, Endodontic Emergencies
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• Patient• Staff• Dentist
Emergency Impacts
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• Pain• Pain and swelling• Trauma (later lecture)
Patient Presentation
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• Diagnosis• Definitive dental treatment• Drugs
3 D’s of Successful Management
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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
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Treatment Plan
toREMOVE
theETIOLOGY
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When do patients present for emergency endodontic care?
• No prior RCT / initial infection• After RCT initiated• After obturation
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Initial Presentation
• PAIN!• Primary
infection
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After Initiation of Endodontic Therapy
FLARE-UP!
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After Initiationof
Endodontic Treatment
Before obturation
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After Obturation
• Recent obturation
• Non-healing endodontic therapy
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Determine aPulpaland
PeriradicularDiagnosis
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• Normal pulp• Reversible pulpitis• Irreversible pulpitis• Necrotic pulp• Pulpless/
previously treated
Pulpal DiagnosisPulpal Diagnosis
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• Normal periradicular tissues
• Acute periradicular periodontitis
• Acute periradicular abscess
Periradicular DiagnosisPeriradicular Diagnosis
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• Chronic periradicular periodontitis• Symptomatic• Asymptomatic
• Chronic periradicular abscess (suppurative periradicular periodontitis)
Periradicular DiagnosisPeriradicular Diagnosis
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• Focal sclerosing osteomyelitis (condensing osteitis): LEO
Periradicular DiagnosisPeriradicular Diagnosis
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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?
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Contents of theRoot Canal
• Pulp tissue• Bacteria• Bacterial by-products• Endodontic therapy materials
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Dentist Controlled Factors
• Over-instrumentation• Inadequate debridement• Missed canal • Hyper-occlusion*• Debris extrusion • Procedural complications*
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Hyperocclusion
• Rosenberg PA, Babick PJ, Schertzer L, Leung A. The effect of occlusal reduction
on pain after endodontic instrumentation. J Endodon 1998;24:492.
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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
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Procedural Complications• Perforation• Separated instrument• Zip • Strip• NaOCl accident• Air emphysema• Wrong tooth
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Dentist Controlled Factors
Dentist’s personalityDentist’s personality
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Host Factors
• Allergies• Age• Sex• Emotional state
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Host Factors
• Complex etiology• Microbiologic• Immunologic• Inflammatory
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Bacteria!
• Bacterial by-products/ endotoxin
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Host Defense is Multi-factorial
C E L L Sn eu trop h ils , lym p h ocytes ,
p lasm a ce lls , m ac rop h ag es ,os teoc las ts , ep ith e lia l ce lls , d en d rit ic ce lls
M O L E C U L A R M E D IA TO R Scytok in es (IL , IF N , C S F , TG F )
e icosan o id s (P G , L T)en zym atic e ffec to r m o lecu les
A N TIB O D IE Sim m u n og lob u lin s (Ig G , e tc .)
p rod u ced b y p lasm a ce lls
M ixed M ic ro flo ra
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• Diagnosis• Definitive dental treatment• Drugs
Three D’sof
Successful Management
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EmergencyTreatment
• Non-surgical• Surgical• Combined
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• Pulpotomy• Partial pulpectomy• Complete pulpectomy• Debridement of the root
canal system*
Non-surgicalEmergency Treatment
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SurgicalEmergency Treatment
Incision for drainage Trephination/apical fenestration
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• 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
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Management
• Inadequate debridement• Debris extrusion• Over-instrumentation• Missed canal• Fluctuant swelling• Severe pain, no swelling
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Treatment
• For severe pain without visible swelling…
• Trephination!
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QUESTIONS
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“Should I leave the tooth
OPEN or CLOSED?”
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“Should I place an Interappointment
Medicament?”
Ca(OH)2
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“Should I prescribe
ANTIBIOTICS?”
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• Diagnosis• Definitive Dental Treatment• Drugs
Three D’sof
Successful Management
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Remember, there is a Complex Etiology
• Microbiologic• Immunologic• Inflammatory
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And, not all can be easily treated...
• Debris extrusion• Over-instrumentation• Over-filling• Over-extension
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Breaking the
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Use a Flexible AnalgesicStrategy
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• Pre - op / loading dose• Long acting anesthesia• Prescription
Drugs
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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
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Codeine
Patients taking 30 mg of codeine report only as much analgesia as placebo
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• 57 patients• Local anesthesia, pulpectomy, post- op
analgesic• Placebo• 600 mg ibuprofen• 600 mg ibuprofen & 1000 mg acetaminophen
Ibuprofen and Acetaminophen
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• 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*
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“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*
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Analgesic Doses
Codeine 60 mgOxycodone 5-6Hydrocodone 10Dihydrocodone 60Propoxyphene HCl(Darvon)
102
Meperidine (Demerol) 90Tramadol (Ultram) 50
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Flexible Analgesic Plan
M IL D2 0 0 -4 0 0 m g ib u p ro fen
or 6 5 0 m g asp irin
M O D E R A TE6 0 0 -8 0 0 m g ib u p ro fen
p lu s com b o an a lg es ic =6 0 m g cod e in e
S E V E R E6 0 0 -8 0 0 m g ib u p ro fen
p lu s com b o an a lg es ic =1 0 m g oxycod on e
A sp irin -like D ru g s a re In d ica ted
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Flexible Analgesic Plan
M IL D6 0 0 -1 0 0 0 ace tam in op h en
M O D E R A TE6 0 0 -1 0 0 0 m g ace tam in op h en
an d op ia te =6 0 m g cod e in e
S E V E R E1 0 0 0 m g ace tam in op h en
an d op ia te =1 0 m g oxycod on e
A sp irin -like D ru g s a re C on tra in d ica ted
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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
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• Systemic involvement• Compromised host resistance• Fascial space involvement• Inadequate surgical drainage
Indications for Antibiotic Therapy
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Select antibiotic with anaerobic spectrum Use a larger dose for a shorter period of time (“hard and fast” rule)
Guidelines forAntibiotic Therapy
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• 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
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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
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Metronidozole(Flagyl)
• Used in conjunction with Penicillin V • 500 mg of Penicillin V with 250 mg
Metronidozole, qid x 7-10 days
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Clindamycin
• Loading dose: 300 mg• 150-300 mg qid x 10 days
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Closely Follow All Infected Patients
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Components of aSuccessful Management
• Appropriate attitude of dentist• Proper patient management• Accurate diagnosis• Profound anesthesia• Prompt and effective treatment
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Patient Instructions
• By the Clock• NOT• PRN
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Questions ?