Emergency Impacts

Patient Staff Dentist

Patient Presentation

Pain Pain and swelling Trauma (later lecture)

3 D’s ofSuccessful Management

Diagnosis Definitive dental treatment Drugs

Diagnosis

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 Planto

REMOVEthe

ETIOLOGY

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

Initial Presentation

PAIN!

Primary infection

After Initiation ofEndodontic Therapy

After Initiation ofEndodontic Therapy FLARE-UP!

After InitiationofEndodontic Treatment Before obturation

After Obturation

Recent obturation

Non-healing endodontic therapy

Determine aPulpal

andPeriradicular

Diagnosis

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

Periradicular Diagnosis Normal periradicular tissues Acute periradicular periodontitis Acute periradicular abscess

Periradicular Diagnosis Chronic periradicular periodontitis

Symptomatic Asymptomatic

Chronic periradicular abscess (suppurative periradicular periodontitis)

Periradicular DiagnosisFocal sclerosing

osteomyelitis(condensing osteitis):

LEO

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

DentistControlled Factors Over-instrumentation Inadequate debridement Missed canal Hyper-occlusion* Debris extrusion Procedural complications*

HyperocclusionRosenberg PA, Babick PJ, Schertzer L,

Leung A. The effect of occlusalreduction on pain after endodontic

instrumentation. J Endodon1998;24:492.

Hyperocclusion Researchers have

foundthat patients most likelyto benefit from occlusalreduction are thosewhose teeth initiallypresent with symptoms. Indiscriminant

reductionof the occlusal surface isnot 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

DentistControlled Factors Dentist’s

personality

Host Factors Allergies Age Sex Emotional state

Host Factors

Complex etiology

Microbiologic Immunologic Inflammatory

Bacteria! Bacterial

byproducts/ endotoxin

Host Defense is Multi-factorial

Three D’sofSuccessful Management

Diagnosis Definitive dental treatment Drugs

EmergencyTreatment

Non-surgical Surgical Combined

Non-surgicalEmergency Treatment

Pulpotomy Partial pulpectomy Complete pulpectomy Debridement of the root canal

system*

SurgicalEmergency Treatment

Incision for drainage

Trephination/apical fenestration

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

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 anInter-appointment

Medicament?”Ca(OH)2

“Should I prescribeANTIBIOTICS?”

Three D’sofSuccessful Management

Diagnosis Definitive Dental Treatment Drugs

Remember, there is aComplex Etiology

Microbiologic Immunologic Inflammatory

And, not all can be easilytreated...

Debris extrusion Over-instrumentation Over-filling Over-extension

Breakingthe

Use a Flexible AnalgesicStrategy

Drugs Pre - op / loading dose Long acting anesthesia Prescription

Codeine Prototype opioid for orally available

combination drugs Studies found that 60 mg of codeine

(2T-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 indentistry. Anesth Prog 1986 33:123.

Ibuprofen andAcetaminophen* 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 andAcetaminophen* 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 andAcetaminophen*

“The results demonstrate thatthe combination of ibuprofenand acetaminophen may be

more effective than ibuprofenalone for the management of

postoperative endodonticpain.”

Analgesic Doses Codeine 60mg Oxycodone 5-6 Hydrocodone 10 Dihydrocodone 60 Propoxyphene HCl (Darvon) 102 Meperidine (Demerol) 90 Tramadol (Ultram) 50

Flexible Analgesic Plan

Flexible Analgesic Plan

Selected NSAID DrugInteractions 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

Indications forAntibiotic Therapy Systemic involvement Compromised host

resistance Fascial space involvement Inadequate surgical

drainage

Guidelines forAntibiotic Therapy

Select antibiotic with anaerobicspectrum

Use a larger dose for a shorterperiod of time (“hard and fast”

rule)

Selecting theAppropriate 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

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 InfectedPatients

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

E Evaluate the case M Make diagnosis E Evacuate swelling R Rubber dam and local anasthetic G Gain access and remove caries E Eliminate pulpal content and irrigate N No canal instrumentation if time

limited C Canal dressing and coronal seal. Y You have to give post-op instructions:

AnalgesicsAntibiotics