1. Hot Tooth Endodontic Nontraumatic Emergencies
Svetlana Berman, DDS, MSD
Indiana University School of Dentistry
National Oral Health Care Conference
Dallas, TX
November, 2008

2. Dental Emergencies 30% of all dental emergencies are endodontic
In 90% of painful emergencies, pain is pulpal or periapical

3. 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

4. Endodontic Pain Management
Preoperative:
Diagnosis
Anxiety reduction
Intraoperative:
Effective local anesthetics
Operative techniques
Postoperative:
Pharmacologic agents

5. 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?

6. 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?

7. Interview 3. What drugs have you taken for the pain?
Drug addicts: last pill before the weekend

8. 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

9. Medical and Dental History
SBE prophylaxis
Referred pain
Patient motivation to retain dentition
Restorative treatment plan
Blood pressure and temperature

10. 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

11. 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

12. 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)

13. DIAGNOSIS
REPRODUCTION OF THE CHIEF COMPLAINT IS THE MAJOR FACTOR IN REDUCING THE MISDIAGNOSIS of
ODONTOGENIC VS.
NON-ODONTOGENIC PAIN

14. Odontogenic Diagnoses
Dentinal Hypersensitivity
Reversible Pulpitis
Irreversible Pulpitis
Necrotic pulp
Acute Apical Periodontitis
Acute Apical Abscess
Cellulitis

15. 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

16. 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

17. 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”

18. 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”

19. 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

20. 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

21. 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

22. 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)‏

23. 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

24. 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

25. 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

26. 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?

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. Intraosseous Anesthesia
Long-acting anesthetic are not long- acting 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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 % NaOCl
Calcium hydroxide intracanal dressing

46. 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

47. 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

48. Long-acting Anesthetics
Bupivacaine, ropivacaine: blocks up to 8-10h
Block the activation of unmyelinated C nociceptors (anesthesia)‏
Decrease potential for central sensitization

49. 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)‏

50. 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

51. 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 mg
Timing: Q6-8 h for the first few days

52. 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

53. 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

54. 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

55. 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

56. 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.)‏

57. Flexible Analgesic Plan Aspirin-like Drugs are Indicated
Mild pain: mg ibuprofen or 650 mg aspirin
Moderate: mg ibuprofen plus combo analgesic = 60 mg codeine
Severe: mg ibuprofen plus combo analgesic = 10 mg oxycodone

58. Aspirin-like Drugs are Contraindicated
Mild pain: mg acetaminophen
Moderate: mg acetaminophen and opiate = 60 mg codeine
Severe: 1000 mg acetaminophen and opiate = 1 mg oxycodone

59. 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

60. 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

61. 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

62. 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

63. 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 (Depo- Medrol 40 mg/ml): significantly less pain
Bramy et al.

64. 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

65. 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

66. 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

67. 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

68. Case #1
Sinusitis
No definitive treatment plan until the diagnosis is confirmed

69. Case #2 Irreversible Pulpitis with Acute Apical Periodontitis
Tooth #18

70. 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

71. Case #3 Necrotic Pulp with Acute Apical Abscess
Tooth #18

72. 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

73. 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

74. 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 mg q6h
Endodontically: conservative care, may or may not remove the fill

75. Summary Accurate diagnosis Successful anesthesia Timely and effective
treatment
QUESTIONS?
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