management of nontraumatic, endodontic emergencies dr. langston d. smith chairman, department of...
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Management of Nontraumatic, Endodontic
EmergenciesDr. Langston D. Smith
Chairman, Department of EndodonticsHoward University College of Dentistry
Washington, D.C.
• Patient• Staff• Dentist
Emergency Impacts
• Pain• Pain and swelling• Trauma (later
lecture)
Patient Presentation
• Diagnosis• Definitive dental treatment• Drugs
3 D’s of Successful Management
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
Treatment Plan to
REMOVEthe
ETIOLOGY
When do patients present for emergency endodontic care?
• No prior RCT / initial infection• After RCT initiated• After obturation
Initial Presentation
• PAIN!• Primary
infection
After Initiation of Endodontic Therapy
FLARE-UP!
After Initiationof
Endodontic Treatment
Before obturation
After Obturation
• Recent obturation
• Non-healing endodontic therapy
Determine aPulpaland
PeriradicularDiagnosis
• Normal pulp• Reversible pulpitis• Irreversible pulpitis• Necrotic pulp• Pulpless/
previously treated
Pulpal Diagnosis
• Normal periradicular tissues
• Acute periradicular periodontitis
• Acute periradicular abscess
Periradicular Diagnosis
• Chronic periradicular periodontitis– Symptomatic– Asymptomatic
• Chronic periradicular abscess (suppurative periradicular periodontitis)
Periradicular Diagnosis
• Focal sclerosing osteomyelitis (condensing osteitis): LEO
Periradicular Diagnosis
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?
Contents of theRoot Canal
• Pulp tissue• Bacteria• Bacterial by-products• Endodontic therapy materials
Dentist Controlled Factors
• Over-instrumentation• Inadequate debridement• Missed canal • Hyper-occlusion*• Debris extrusion • Procedural complications*
Hyperocclusion
• Rosenberg PA, Babick PJ, Schertzer L, Leung A. The effect of occlusal
reduction on pain after endodontic instrumentation. J Endodon
1998;24:492.
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
Procedural Complications
• Perforation• Separated instrument• Zip • Strip• NaOCl accident• Air emphysema• Wrong tooth
Dentist Controlled Factors
Dentist’s personality
Host Factors
• Allergies• Age• Sex• Emotional state
Host Factors
• Complex etiology– Microbiologic– Immunologic– Inflammatory
Bacteria!• Bacterial by-
products/ endotoxin
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
• Diagnosis• Definitive dental treatment• Drugs
Three D’sof
Successful Management
EmergencyTreatment
• Non-surgical• Surgical• Combined
• Pulpotomy• Partial pulpectomy• Complete pulpectomy• Debridement of the
root canal system*
Non-surgicalEmergency Treatment
SurgicalEmergency Treatment
Incision for drainage Trephination/apical fenestration
• 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
Management
• Inadequate debridement
• Debris extrusion• Over-instrumentation• Missed canal• Fluctuant swelling• Severe pain, no
swelling
Treatment
– For severe pain without visible swelling…
• Trephination!
QUESTIONS
“Should I leave the tooth
OPEN or CLOSED?”
“Should I place an Interappointment
Medicament?”Ca(OH)2
“Should I prescribe
ANTIBIOTICS?”
• Diagnosis• Definitive Dental Treatment• Drugs
Three D’sof
Successful Management
Remember, there is a Complex Etiology
• Microbiologic• Immunologic• Inflammatory
And, not all can be easily treated...
• Debris extrusion• Over-instrumentation• Over-filling• Over-extension
Breaking the
Use a Flexible AnalgesicStrategy
• Pre - op / loading dose• Long acting anesthesia• Prescription
Drugs
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
Troullis E, Freeman R, Dionne R. The scientific basis for analgesic use in dentistry. Anesth Prog 1986 33:123.
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.
• 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.
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
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.”
Ibuprofen and Acetaminophen*
Analgesic Doses
Codeine 60 mgOxycodone 5-6Hydrocodone 10Dihydrocodone 60Propoxyphene HCl(Darvon)
102
Meperidine (Demerol) 90Tramadol (Ultram) 50
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
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
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
• Systemic involvement• Compromised host resistance• Fascial space involvement• Inadequate surgical drainage
Indications for Antibiotic Therapy
Select antibiotic with anaerobic spectrum Use a larger dose for a shorter period of time (“hard and fast” rule)
Guidelines forAntibiotic Therapy
• 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
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
Metronidozole(Flagyl)
• Used in conjunction with Penicillin V • 500 mg of Penicillin V with 250 mg
Metronidozole, qid x 7-10 days
Clindamycin
• Loading dose: 300 mg• 150-300 mg qid x 10 days
Closely Follow All Infected Patients
Components of aSuccessful Management• Appropriate attitude of
dentist• Proper patient management• Accurate diagnosis• Profound anesthesia• Prompt and effective
treatment
Patient Instructions
• By the Clock• NOT• PRN
Questions ?