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Hot Tooth
Endodontic Nontraumatic
Emergencies
Svetlana Berman, DDS, MSD
Indiana University School of Dentistry
National Oral Health Care Conference
Dallas, TX
November, 2008
Dental Emergencies
30% of all dental emergencies are
endodontic
In 90% of painful emergencies, pain is
pulpal or periapical
Pathophysiology of Pain
Pain is a psychobiological phenomenon.
It consists of:
- Perception of pain: influenced by
anesthesia
- Reaction to pain (fear, anxiety):
influenced by drugs and emotions and
contributes to hyperalgesia
Endodontic Pain Management
Preoperative:
Diagnosis
Anxiety reduction
Intraoperative:
Effective local anesthetics
Operative techniques
Postoperative:
Pharmacologic agents
Preoperative
Differential Diagnosis
Chief Complaint:
“Listen to your patient and the patient
will give you the diagnosis”
Sir William Osler
Etiology:
- Contents of the root canal?
- Dentist controlled factors?
- Host factors?
History of Chief Complaint
1. What is the nature of the pain?
When did the pain begin?
Pulpal: rapid onset, spontaneous, gets
more intense and more localized
2. What
provokes pain?
Interview
3. What drugs have you taken for the
pain?
Drug addicts: last pill before the weekend
Interview
4. Does the pain awaken you?
5. Where does it hurt, and where
does the pain radiate to?
- Temporal region: premolars and molars
- Ear: mandibular or maxillary (less) molars
- Neck/Shoulder: mandibular molars, heart
Medical and Dental History
SBE prophylaxis
Referred pain
Patient motivation to retain dentition
Restorative treatment plan
Blood pressure and temperature
Clinical Examination
Visual: swelling, sinus tract, aphthous
ulcers, caries, cracks
TRY TO FIND A REASONABLE CAUSE
FOR PULPAL DISEASE!
In the absence of odontogenic source,
look for non-odontogenic etiology
Diagnostic Tests
Pulp Tests:
- Cold (Endo Ice on cotton pellets)
- Heat (impression compound, warm
water with rubber dam)
- Electric pulp test
Periodontal Probing
Periapical Tests:
- Percussion, palpation, ToothSlooth
Radiographic Examination
Parallel Periapical Radiograph
Angled horizontally PA
Bitewing
Follow PDL and lamina dura
Superimposed anatomical structures:
maxillary sinus, mental foramen,
lingual salivary gland depression, IAN
canal (mandibular second molars)
DIAGNOSIS
REPRODUCTION OF THE CHIEF
COMPLAINT IS THE MAJOR FACTOR
IN REDUCING THE MISDIAGNOSIS of
ODONTOGENIC VS.
NON-ODONTOGENIC PAIN
Odontogenic Diagnoses
Dentinal Hypersensitivity
Reversible Pulpitis
Irreversible Pulpitis
Necrotic pulp
Acute Apical Periodontitis
Acute Apical Abscess
Cellulitis
Non-odontogenic Pain
No apparent odontogenic etiology
Pain not relieved by local anesthesia
Bilateral pain, multiple teeth
Chronic pain, not responsive to dental
treatment
Specific qualities: burning, stabbing,
concurrent with headache
Trigger points, muscles
Stress, head position
Non-Odontogenic Diagnoses
Musculoskeletal: myofascial pain
Neuropathic: trigeminal neuralgia, atypical
odontalgia, glossopharyngeal neuralgia
Neurovascular: migraine, cluster headaches
Inflammatory: allergic or bacterial sinusitis
Systemic: cardiac, herpes zoster, sickle cell
anemia, neoplastic disease
Psychogenic: Munchausen’s syndrome
Anxiety Reduction
Reflective listening:
- a dialogue of trust between the dentist
and the patient
- cannot be delegated to a staff member
Patient’s feeling of fear are
acknowledged:
“Sounds like you have had some
unpleasant experiences in the past”
Anxiety Reduction:
Dentist’s Role
Safe environment, reassurance: “I will do whatever
can be done to make your treatment comfortable”
Ask patient to summarize
Mix of open and closed questions
Nonverbal Strategies: face the patient at the same
chair level, steady and frequent eye contact, mutual
respect and concern, no promises of painless
treatment, frequent review of accomplishments
Control during treatment: “time out”, music choice,
“nothing will happen that we have not agreed upon”
Anxiety Reduction
Office tone: staff attitude
Distraction: music, office décor, TV
Relaxation techniques: muscular and
mental, deep breathing 2-4 min with
heart rate monitor
Hypnosis (special training) and guided
imaginery
Referral to a mental health professional
Anxiety Reduction
Conscious sedation: does not treat anxiety, just
facilitate treatment
Benzodiazepines orally: Lorazepam, Triazolam (short
duration, no metabolites), and Diazepam (active
metabolites)
Reversal agent: Flumazenil (Romazicon)
Contraindications and drug interactions ( Triazolam
and protease inhibitors for HIV treatment)
Nitrous oxide
Monitoring
Profound anesthesia is still required
Lindemann et al. J Endod 2008;34:1167
Anesthesia
90% of dentists have anesthetic difficulties
Al Reader & John Nusstein Endo topics 2002; 3:14
(17 years of research on endodontic pain anesthesia)
A challenge for inflammed tissue:
Local acidic inflammatory byproducts lower
the pH, so most anesthetic molecules remain
in inactive cationic form
Local prostaglandins and bradykinin can
antagonize local anesthetics
TTX-resistant channels
Sodium channel expression on C fibers
shifts from TTX sensitive to TTX resistant
TTX resistant channels are five times more
resistant to anesthetic (lidocaine)
Bupivacaine found to be more potent
Alternate and supplementary injection sites:
intraosseous, intraligamentory
Anatomic limitations: dense bone, accessory
innervation (mylohyoid nerve branch)
Local Anesthesia
IANB
Gow-Gates & Akinosi-Vasirani methods
Stabident:
- effective in 89%
Parente & Welte, 1998
- 2% lido with epi 1:100,000 increased heart
rate in 67% of patients to 97 bpm
Replogle & Reader, 1999
Mandibular Anesthesia
IANB: most failures; 25% of accurate blocks
fail; central core theory
EPT is predictable for pulpal anesthesia
Lip sign is not predictable, but lack of it (5%)
predicts failure; requires re-administration
Noncontinuous anesthesia 12-20% man
Slow onset 19-27% after 15min; 8% after
30min
Duration 2.5 h
Inferior Alveolar Nerve Block
Double volume (2 cartridges) of 2%
lidocaine with epinephrine does not
increase the incidence of pulpal
anesthesia
Increase epinephrine concentration to
1:50,000: no advantage
3% mepivacaine is as effective as 2%
lidocaine with 1:100,000 epinephrine
IANB
Articaine: as effective, but no advantage
Contraindications: Sulfa allergy
Mandibular buccal infiltration with 4%
articane is more effective that 2% lidocaine
with epinephrine
Kanaa et al. J Endod (32)4:296
4% Articaine with epinephrine 1:200,000
Paresthesias?
IANB
Long-acting anesthetics:
Bupivacaine (Marcaine): 4 hours of lip
numbness, ask patient
0.5% Ropivacaine with 1:200,000
epinephrine (Naropin): lower potential
for CNS and cardiovascular toxic
effects
Mandibular Teeth
Infiltration with 2% lidocaine and
epinephrine: no advantage
Gow-Gates: no advantage in
anesthesia, less possibility for the
intravascular injection
Akinosi-Vasirani technique: trismus
Incisive nerve block at mental foramen:
premolar teeth
Needle Deflection and STA
Bi-directional needle rotation technique
Computer-assisted Wand or STA
(Single Tooth Anesthesia):
no significant differences in success
for IANB
Pain perception: less painful with STA
Supplemental Injections
Intraligamentory Anesthesia
STA (CompuDent):
intraligamentory
single tooth anesthesia
2% lidocaine with
epinephrine 1:100,000 or
4% articaine
with epinephrine 1:200,000
Intraosseous Injection
Stabident
X-Tip
Key to success: deposition into the
cancellous space; 10% constricted spaces
In 0-48% transient moderate to severe pain
on perforation and deposition of anesthetic
Perforator breakage
Optimal site: DISTAL to the problematic tooth
Except second molars: MESIAL to the tooth
Immediate onset
Intraosseous Anesthesia
Irreversible pulpitis: IANB 44-81% failures
Mandibular intraosseous anesthesia of 1.8 ml
of 2% lidocaine with 1:100,000 epinephrine
gives 91% success (Nusstein et al.)
Transient increase in heart rate (4 min)
Supplemental 1.8 ml 3% mepivacaine
produces 80% success; repeated injection
increases success to 98%; no increase in
heart rate
Intraosseous Anesthesia
Long-acting anesthetic are not longacting with this technique and have
cardiotoxic effects: no advantage
Large volumes: overdose reactions
Should not be considered intravascular
Postoperative discomfort 2-15%
Less than 5% swelling/exudate on
perforation site; may take weeks to
heal; bone overheating
Intrapulpal Anesthesia
5-10% of irreversible pulpitis cases do
not respond to supplemental
anesthesia
Moderately to severe painful
Short (20 min)
Pulp must be exposed
Predictable under back-pressure
Clinical Management
of Endodontic Anesthesia
Irreversible pulpitis:
IANB for mandibular teeth, observe lip sign,
inform patient, intraosseous anesthesia 1.8
ml 3% mepivacaine; apply rubber dam; if
painful, administer intraosseously another
carpule of 3% mepivacaine
Use #2 sharp round bur to make a channel
into the pulp chamber. If pulp is entered and
painful, proceed with intrapulpal anesthesia
Irreversible Pulpitis
Maxillary Teeth
Double the initial anesthetic dose for
the buccal infiltration
PSA for molars
Small amount 0.5 ml palatally for the
clamp and palatal canals; avoid
1:50,000 epinephrine
Less failures, but can occur
Intraosseous anesthesia
Repeat infiltration during the treatment
Symptomatic Teeth with Pulpal Necrosis
and Periapical Radiolucencies
Mandible: inferior alveolar nerve block
Maxilla: infiltration or block
Swelling: injection on either side
SLOWLY access
DO NOT use intraosseous, periodontal
ligament, or intrapulpal injections:
painful and ineffective, introduce
bacteria periapically
Intraoperative Management
Combined Approach
Pharmacological (not drugs alone)
Non-pharmacological:
Pulpectomy
Pulpotomy: reduces pain in 90% of patients
Incision for drainage, trephination/apical
fenestration
Occlusal reduction
Informed Consent Form
Pulpotomy
Case of acute pain of pulpal origin, NO
periapical pathology, and not enough time for
pulpectomy
Goal: to remove coronal pulp; place rubber
dam, use slow speed round bur to the canal
orifice
Bleeding is managed with sterile cotton pellet
With or without dressing; cavity should be
sealed
High level of success: alteration of pulpal
hemodynamics, reduction of interstitial fluid
pressure and inflammatory mediator
concentrations
Pulpotomy vs. Partial
Pulpectomy
Pulpotomy is preferable when there is
lack of time for complete pulpectomy
with accurate canal length
measurements
Partial pulpectomy may result in a
profuse hemorrhage and more
postoperative pain; traumatizes already
inflammed tissue
Pulpectomy
Reduction of inflammatory mediators
levels and interstitial tissue pressure to
relieve peripheral terminals of
nociceptors
With/without I & D provides predictable
pain reduction in endodontic
emergencies
Pulpectomy
Intracanal medications
Calcium hydroxide (Ultracal): effective
antibacterial, not analgesic
Leave tooth open or closed? Closed!
Open tooth: additional bacterial
contamination, foreign body reaction,
blockage with food, and complications
Incision & Drainage Rationale
Decreases number of bacteria
Reduces tissue pressure, which alleviates
pain & trismus and improves circulation
Prevents spread of infection
Alters oxidation-reduction potential
Accelerates healing
Trephination: #3 spreader in patients with
pain, radiolucencies, and no swelling
Results in more pain, routinely not justified
Moss et al. 1996
Irreversible Pulpitis
with Periapical Inflammation
PULPECTOMY: anterior teeth; posterior
teeth on all roots
Occlusal reduction
Rubber dam
Instrumentation to a size #25 minimum
Irrigation with 2.6 % or 5.25% NaOCl
Necrotic Pulp, No Swelling
Complete debridement
Estimated working length (1 mm short
of anatomical length)
Instrument crown-down to a size #25
minimum or 3 sizes larger than the first
file that binds
Copious irrigation with 2.6-5.25%
NaOCl
Calcium hydroxide intracanal dressing
Necrotic Pulp, Localized
Swelling
Complete debridement: determine working
length for all canals, rotary Ni-Ti files
If drainage through the tooth is obtained,
I & D is optional; antibiotic is not indicated
Do NOT leave tooth open
Fluctuation: anesthesia around it and I & D
Warm saline rinses for 48 h
No fluctuation: I & D is contraindicated
Cellulitis
Diffuse extraoral or intraoral swelling
Rapid spread into spaces
Systemic signs of infection
Lymphadenopathy, fever
Difficulty swallowing, mouth opening
Sublingual and palatal aspects
Referral to an oral surgeon or ER
Long-acting Anesthetics
Bupivacaine, ropivacaine: blocks up to
8-10h
Block the activation of unmyelinated C
nociceptors (anesthesia)
Decrease potential for central
sensitization
Postoperative management
Non-narcotic analgesics
Pretreatment is effective for post
treatment pain:
Ibuprofen (800mg) (Advil Liquid Gel) or
Flurbiprofen (100mg)
Patients who cannot tolerate NSAIDs:
GI disorders, active asthma, hypertension
(renal effects of NSAIDs or interactions with
anti-HTN drugs):
Acetaminophen (1000mg) (also, COX-3
enzyme inhibition)
NSAIDs: Mechanism of Action
for Irreversible Pulpitis
Reduction of pulpal levels of the
inflammatory mediator PGE-2 causes:
- Decrease in pulpal nociceptor
sensitization
- Decrease of a prostanoid-induced
stimulation of TTX-resistant sodium
channel activity
- Decrease in resistance to local
anesthetics
Ibuprofen and
Acetaminophen
Combination may be more effective
than ibuprofen alone for the
management of postoperative
endodontic pain
Menhinick et al. 2004
Ibuprofen 400 mg and Acetaminophen
1000 mg
Timing: Q6-8 h for the first few days
Codeine
Patients taking 30 mg of codeine have
as much analgesia as with placebo
Troullis et al. 1986
60 mg of codeine (2 Tylenol-3) produce
significantly more analgesia than
placebo, but less that 650 mg of
aspirin, or 600 mg acetaminophen
The Most Effective Analgesics
Combination of flurbiprofen and
tramadol
Combination of preoperative and
postoperative flurbiprofen
Doroshak et al. J Endod 1999;25:660
Tramadol hydrochloride: an opioid
agonist and a reuptake inhibitor of
serotonin and norepinephrine
Analgesic Doses
Codeine 60 mg
Oxycodone 5-6 mg
Hydrocodone 10 mg
Dihydrocodone 60 mg
Propoxyphene HCl (Darvon) 102 mg
Meperidine (Demerol) 90 mg
Tramadol (Ultram) 50 mg
NSAIDs Drug Interactions
Anticoagulants: increased prothrombin time
or bleeding time
ACE inhibitors, Beta Blockers, Thiazide:
reduced antihypertensive effects
Cyclosporine: increased risk of
nephrotoxicity
Lithium: increased serum levels of lithium
Sympathomimetics: increased blood
pressure
Flexible Prescription Plan
Goal: to obtain maximal analgesic benefits
with minimal side effects
First, maximize the dose of non-narcotics
before prescribing narcotics
If patient still has pain:
1. NSAIDs with acetaminophen over a short
period of time
2. NSAIDs with opioid or with
acetaminophen/opioid
Flurbiprofen with Tramadol (Holstein et al.)
Flexible Analgesic Plan
Aspirin-like Drugs are Indicated
Mild pain: 200-400 mg ibuprofen or 650
mg aspirin
Moderate: 600-800 mg ibuprofen plus
combo analgesic = 60 mg codeine
Severe: 600-800 mg ibuprofen plus
combo analgesic = 10 mg oxycodone
Aspirin-like Drugs are
Contraindicated
Mild pain: 600-1000 mg acetaminophen
Moderate: 600-1000 mg acetaminophen
and opiate = 60 mg codeine
Severe: 1000 mg acetaminophen and
opiate = 1 mg oxycodone
Indications for Antibiotic
Therapy
Systemic involvement or fascial space
involvement
Compromised host resistance
Inadequate surgical drainage
Select antibiotic with anaerobic spectrum or
antibiotic-sensitivity charts (C & S available)
Contraindicated as a preventive measure
Use a larger dose for a shorter period of time
Pseudomembranous colitis
Penicillin V
When Gram stain and C & S results are
not available, PCN is antibiotic of
choice
Loading dose: 1-2 g, then 500 mg qid
for 7-10 days
Metronidazole: 250 mg qid 7-10 days
Used in conjunction with Penicillin V
Clindamycin
Loading dose: 300 mg
150-300 mg qid for 7-10 days
Cephalexin (Keflex)
Loading dose: 1 g
500 mg qid for 7-10 days
Steroids
Multiple sites of action
Reduce pulpal concentrations of PGE2
Reduction of bradikinin (proinflammatory)
Produce vasocortin (decreases edema)
Inhibit nitric oxide synthase (amplifier of
inflammatory response)
Single large dose or short course up to 1
week is harmless
Contraindications: systemic fungal
infections, renal insufficiency, ulcerative
colitis, diabetes, others
Steroids
Intracanal Ledermix (triamcinolone and
tetracycline derivative) or dexamethasone 0.1
ml per canal: significantly less pain
Liesenger et al. J Endod 1993:19:35
Symptomatic necrotic teeth; pulpectomy with
intraosseous methylprednisolone (DepoMedrol 40 mg/ml): significantly less pain
Bramy et al.
Steroids
Antibiotics are NOT routinely required
in conjuction to prevent infection
secondary to reduced inflammation in
healthy patient
Steroids are effective as an adjunct to
but not replacement for appropriate
endodontic treatment
Systemic steroids are highly effective
for patients with moderate/severe
preoperative pain and pulpal necrosis
with periapical radiolucency
Causes of Flare-Ups
Overinstrumentation, overmedication
Debris extruded into periapical tissue
Incomplete debridement or missed canal
Exacerbation of chronic apical periodontitis
Over-irrigation, NaOCl accident
Hyperocclusion: occlusal reduction benefit
symptomatic patients (vital pulp, no PARL)
Root fracture
Wrong tooth
Air emphysema: air syringe into root canal; Stropko
syringes
Pasteur effect (overgrowth of facultative anaerobes)
Seltzer & Naidrof J Endod 1985
Predictors of Post-Endo Pain
Preoperative pain or swelling
Walton and Fouad 1992
Preoperative pain and anxiety
Torabinejad 1994
Preoperative pain, necrotic, PARL,
females
Genet 1987
Treatment of Flare-Ups
Psychological (reassurance), localized
operative, and pharmacological
Necrotic pulp with swelling: open, re-debride,
I & D, adjust occlusion
Analgesics
Antibiotics: rapid increase S & S, anatomical
danger zone, disease/drug that compromises
immune status, systemic involvement (LAD,
fever, malaise)
Steroids: effective for lower levels of pain;
single dose dexamethasone 4-6 mg
Case #1
Sinusitis
No definitive treatment plan until the
diagnosis is confirmed
Case #2
Irreversible Pulpitis with Acute Apical
Periodontitis
Tooth #18
Case #2
Irreversible Pulpitis with Acute Apical
Periodontitis
Preoperative: NSAID (ibuprofen 800 mg or
flurbiprofen 100 mg) possibly with tramadol
(50mg) or acetaminophen (500mg)
augmentation for the next 2 days
IANB; intraosseous 3% mepivacaine distally
Occlusal reduction
Endo: #2 round bur access into the chamber;
intrapulpal anesthesia; complete pulpectomy
Case #3
Necrotic Pulp with Acute Apical
Abscess
Tooth #18
Case #3
Necrotic Pulp with Acute Apical
Abscess
Preoperative: NSAIDs or acetaminophen
IANB; avoid intraosseous in necrotic teeth
and PARLs or distal to the adjacent tooth
(Reader, Nusstein)
Complete pulpectomy; avoid intrapulpal
injections
Postoperative: flexible analgesic plan
Occlusal reduction?
Antibiotics are not required and do not
reduce postoperative pain
Case #4Postendodontic Flare-Up
Repeat vitality tests (missed canals)
Contributing risk factors: female, necrotic
pulp, acute apical periodontitis
Patient did not respond to NSAIDs: pain is
due to non-prostaglandin mediators
Case #4
Treatment
Reassurance in a favorable prognosis
Effective local anesthesia: infiltration or
block with bupivacaine
Steroid injection: dexamethasone 4-6mg
(immune-mediated hypersensitivity reaction
inhibition)
Daily contact
Postoperative analgesics: flurbiprofen 100
mg tid with tramadol 50-100 mg q6h
Endodontically: conservative care, may or
may not remove the fill
Summary
Accurate diagnosis
Successful anesthesia
Timely and effective
treatment
QUESTIONS?
THANK YOU!