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Management of Nontraumatic, Endodontic Emergencies

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Presentation on theme: "Management of Nontraumatic, Endodontic Emergencies"— Presentation transcript:

1 Management of Nontraumatic, Endodontic Emergencies
Dr. Langston D. Smith Chairman, Department of Endodontics Howard University College of Dentistry Washington, D.C.

2 Emergency Impacts Patient Staff Dentist

3 Patient Presentation Pain Pain and swelling Trauma (later lecture)

4 Successful Management
3 D’s of Successful Management Diagnosis Definitive dental treatment Drugs

5 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

6 Treatment Plan to REMOVE the ETIOLOGY

7 When do patients present for emergency endodontic care?
No prior RCT / initial infection After RCT initiated After obturation

8 Initial Presentation PAIN! Primary infection

9 After Initiation of Endodontic Therapy

10 After Initiation of Endodontic Treatment
Before obturation

11 After Obturation Recent obturation Non-healing endodontic therapy

12 Determine a Pulpal and Periradicular Diagnosis

13 Pulpal Diagnosis Normal pulp Reversible pulpitis Irreversible pulpitis
Necrotic pulp Pulpless/ previously treated

14 Periradicular Diagnosis
Normal periradicular tissues Acute periradicular periodontitis Acute periradicular abscess

15 Periradicular Diagnosis
Chronic periradicular periodontitis Symptomatic Asymptomatic Chronic periradicular abscess (suppurative periradicular periodontitis)

16 Periradicular Diagnosis
Focal sclerosing osteomyelitis (condensing osteitis): LEO

17 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?

18 Contents of the Root Canal
Pulp tissue Bacteria Bacterial by-products Endodontic therapy materials

19 Dentist Controlled Factors
Over-instrumentation Inadequate debridement Missed canal Hyper-occlusion* Debris extrusion Procedural complications*

20 Hyperocclusion Rosenberg PA, Babick PJ, Schertzer L, Leung A. The effect of occlusal reduction on pain after endodontic instrumentation. J Endodon 1998;24:492.

21 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

22 Procedural Complications
Perforation Separated instrument Zip Strip NaOCl accident Air emphysema Wrong tooth

23 Dentist Controlled Factors
Dentist’s personality

24 Host Factors Allergies Age Sex Emotional state

25 Host Factors Complex etiology Microbiologic Immunologic Inflammatory

26 Bacteria! Bacterial by-products/ endotoxin

27 Host Defense is Multi-factorial

28 Successful Management
Three D’s of Successful Management Diagnosis Definitive dental treatment Drugs

29 Emergency Treatment Non-surgical Surgical Combined

30 Non-surgical Emergency Treatment
Pulpotomy Partial pulpectomy Complete pulpectomy Debridement of the root canal system*

31 Surgical Emergency Treatment
Incision for drainage Trephination/apical fenestration

32 Rationale for I & D Decreases number of bacteria
Reduces tissue pressure Alleviates pain/trismus Improves circulation Prevents spread of infection Alters oxidation-reduction potential Accelerates healing

33 Management Inadequate debridement Debris extrusion
Over-instrumentation Missed canal Fluctuant swelling Severe pain, no swelling

34 Treatment For severe pain without visible swelling… Trephination!


36 “Should I leave the tooth OPEN or CLOSED?”

37 “Should I place an Interappointment Medicament?”

38 “Should I prescribe ANTIBIOTICS?”

39 Successful Management
Three D’s of Successful Management Diagnosis Definitive Dental Treatment Drugs

40 Remember, there is a Complex Etiology
Microbiologic Immunologic Inflammatory

41 And, not all can be easily treated...
Debris extrusion Over-instrumentation Over-filling Over-extension

42 Breaking the PAIN CHAIN

43 Use a Flexible Analgesic Strategy

44 Drugs Pre - op / loading dose Long acting anesthesia Prescription

45 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 :123.

46 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 :123.

47 Ibuprofen and Acetaminophen*
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:

48 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

49 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.”

50 Analgesic Doses

51 Flexible Analgesic Plan

52 Flexible Analgesic Plan

53 Selected NSAID Drug Interactions

54 Indications for Antibiotic Therapy Systemic involvement
Compromised host resistance Fascial space involvement Inadequate surgical drainage

55 Guidelines for Antibiotic Therapy
Select antibiotic with anaerobic spectrum Use a larger dose for a shorter period of time (“hard and fast” rule)

56 Appropriate Antibiotic
Selecting the Appropriate Antibiotic 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

57 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

58 Metronidozole (Flagyl)
Used in conjunction with Penicillin V 500 mg of Penicillin V with 250 mg Metronidozole, qid x 7-10 days

59 Clindamycin Loading dose: 300 mg mg qid x 10 days

60 Closely Follow All Infected Patients

61 Components of a Successful Management
Appropriate attitude of dentist Proper patient management Accurate diagnosis Profound anesthesia Prompt and effective treatment

62 Patient Instructions By the Clock NOT PRN

63 Questions ?

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