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

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Presentation on theme: "Management of Nontraumatic, Endodontic Emergencies Dr. Langston D. Smith Chairman, Department of Endodontics Howard University College of Dentistry Washington,"— 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 Patient Patient Staff Staff Dentist Dentist Emergency Impacts

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

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

5 Diagnosis Determine the CC Determine the CC Take an accurate medical history Take an accurate medical history Complete a thorough exam, with all necessary tests Complete a thorough exam, with all necessary tests Perform a radiographic exam Perform a radiographic exam Analyze and synthesize results Analyze and synthesize results Establish a treatment plan 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 No prior RCT / initial infection After RCT initiated After RCT initiated After obturation After obturation

8 Initial Presentation PAIN! PAIN! Primary infection Primary infection

9 After Initiation of Endodontic Therapy FLARE-UP!

10 After Initiation of Endodontic Treatment Before obturation

11 After Obturation Recent obturation Recent obturation Non-healing endodontic therapy Non-healing endodontic therapy

12 Determine a Pulpal and Periradicular Diagnosis

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

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

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

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

17 Etiology After listening to the patient, begin to determine the etiology of the chief complaint: 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 Pulp tissue Bacteria Bacteria Bacterial by-products Bacterial by-products Endodontic therapy materials Endodontic therapy materials

19 Dentist Controlled Factors Over-instrumentation Over-instrumentation Inadequate debridement Inadequate debridement Missed canal Missed canal Hyper-occlusion* Hyper-occlusion* Debris extrusion Debris extrusion Procedural complications* 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. 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. 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 Indiscriminant reduction of the occlusal surface is not indicated PRE-OP PAIN PRE-OP PAIN PULP VITALITY PULP VITALITY PERCUSSION SENSITIVITY PERCUSSION SENSITIVITY ABSENCE OF A PERIRADICULAR RADIOLUCENCY ABSENCE OF A PERIRADICULAR RADIOLUCENCY COMBINATION OF THESE SYMPTOMS COMBINATION OF THESE SYMPTOMS

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

23 Dentist Controlled Factors Dentist’s personality

24 Host Factors Allergies Allergies Age Age Sex Sex Emotional state Emotional state

25 Host Factors Complex etiology Complex etiology – Microbiologic – Immunologic – Inflammatory

26 Bacteria! Bacterial by- products/ endotoxin Bacterial by- products/ endotoxin

27 Host Defense is Multi-factorial

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

29 Emergency Treatment Non-surgical Non-surgical Surgical Surgical Combined Combined

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

31 Surgical Emergency Treatment Incision for drainage Trephination/apical fenestration

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

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

34 Treatment – For severe pain without visible swelling… Trephination! Trephination!

35 QUESTIONS

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

37 “Should I place an Interappointment Medicament?” Ca(OH) 2

38 “ Should I prescribe ANTIBIOTICS?”

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

40 Remember, there is a Complex Etiology Microbiologic Microbiologic Immunologic Immunologic Inflammatory Inflammatory

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

42 Breaking the

43 Use a Flexible Analgesic Strategy

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

45 Codeine Prototype opioid for orally available combination drugs 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 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 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 57 patients 57 patients Local anesthesia, pulpectomy, post- op analgesic 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: Ibuprofen and Acetaminophen*

48 Visual analogue scale & baseline 4-point category pain scale Visual analogue scale & baseline 4-point category pain scale 1 hr, 4 hr, 6 hr, 8 hr 1 hr, 4 hr, 6 hr, 8 hr General linear model analyses General linear model analyses Significant differences Significant differences – Placebo and combination – Ibuprofen and combination No significant difference No significant difference – Placebo and ibuprofen Ibuprofen and Acetaminophen*

49 “ The results demonstrate that the combination of ibuprofen and acetaminophen may be more effective than ibuprofen alone for the management of postoperative endodontic pain.” “ 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*

50 Analgesic Doses

51 Flexible Analgesic Plan

52

53 Selected NSAID Drug Interactions

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

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

56 Gram stain results available: antibiotic-sensitivity charts Gram stain results available: antibiotic-sensitivity charts C & S results available: antibiotic-sensitivity charts C & S results available: antibiotic-sensitivity charts No gram stain or C & S results: No gram stain or C & S results: PCN is antibiotic of choice PCN is antibiotic of choice Selecting the Appropriate Antibiotic

57 Penicillin V Still, the drug of choice for infections of endodontic origin Still, the drug of choice for infections of endodontic origin Loading dose: 1-2 g then 500 mg qid x days Loading dose: 1-2 g then 500 mg qid x days

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

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

60 Closely Follow All Infected Patients

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

62 Patient Instructions By the Clock By the Clock NOT NOT PRN PRN

63 Questions ?


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