L18 Emergencies_formatted_text

Endodontic Emergencies – Principles of Management

Emergency Treatment & Pain Control

The Problem of Dental and Oral Pain¹

• Most oral pain problems are related to:
  • Caries
  • Bacteria within teeth
    • Restorations breaking down, cracks, etc.
  • Pulp Pathosis
  • Periapical Conditions
  • Periodontal Diseases

Dental Practice in Australia²

ARCPOH – Uni Adel Aust J Dent 2007

Figure 5: Reason for visit by main diagnosis or condition

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Endodontic Emergencies & Associated Pain

Types of Endodontic Emergencies

• Before treatment
• During treatment
• After treatment

Public Perception and Patient Anxiety³

• “Public perception of endodontic treatment is often associated with pain”
• “Expectations of pain can increase the patient’s anxiety level and make the treatment more difficult”
  • Rogers et al JoE 1999

Pain After Endodontic Treatment: Key Studies⁴

• 40% of patients experience some pain after endodontics (Seltzer et al 1961)
• 25% had moderate to severe pain after instrumentation appointment (Clem 1970)
• 16% moderate to severe pain during or after treatment visits (O’Keefe 1976)
• 75% had “at least some pain” after initial treatment of asymptomatic chronic apical periodontitis (Orstavik et al 1998)
• Strong relationship between pre-operative and post-operative pain
  • If moderate to severe pre-operative pain -
    • FIVE times more likely to have moderate to severe post-operative pain (O’Keefe 1976)
• Patient’s psychological profiles for coping with pain modulate their perception of post-operative pain (Orstavik et al 1998)

Challenges in Emergency Management⁵

• Complicated by:
  • Distressed patient
    • In pain:

      • Unexpected

      • Often severe

      • Lack of sleep

    • May be a new patient
    • May be a new dentist

Key Considerations for Practice⁶⁷

• Very important to:

  • Allow adequate TIME for emergencies

  • Treat:

    • the PATIENT
    • the TOOTH, and
    • the PULP / CANAL

Core Principles of Management: The 3-D’s

• Principles for Managing Dental Pain
  • Diagnosis
  • Dental treatment
  • Drugs

1. Diagnosis⁸

Principles to Follow⁹¹⁰¹¹

• Take a thorough history

• PROVISIONAL diagnosis of problem(s)

  • Pulp / root canal status
  • Periapical status

• Thorough clinical examination

• Pulp sensibility tests:

  • Heat
  • Electric

• Radiographs: PA’s, BW’s, Panoramic

• Examination, tests, radiographs, etc

  • CONFIRM the DIAGNOSES
  • Confirm which TOOTH, and
  • Help decide the CAUSE (e.g. caries, cracks, restoration breakdown, etc)

Synthesizing Information for a Management Plan¹²

• The history
• Exam findings, tests, radiographs, etc
• The DIAGNOSES
• Which TOOTH, and
• The CAUSE
• = Determine the MANAGEMENT OPTIONS & help to assess the PROGNOSIS

✓ Diagnosis

￮ Dental treatment

￮ Drugs

2. Dental Treatment¹³

Management Options

• Restoration
• Endodontic treatment
• Periodontal treatment
• Extraction

Evidence for Treatment Efficacy¹⁴

• Management of Acute Dental Pain (Matthews, Peak & Scully - Brit Dent J 1994)
  • Studied 172 patients with acute dental pain
    • Managed by various means – treatment, drugs, etc
    • Surveyed 24 hours later re: pain relief
    • Rated their pain on a scale of 1 to 5
  • Overall 87% of patients had marked or total pain relief within 24 hours following dental treatment
    • Depended on “decompression of inflamed tissue”
  • Antimicrobials alone were poor at controlling pain

Condition	Most Effective Management
Acute irreversible pulpitis	Pulp removal + Cs-Ab dressing
Acute reversible pulpitis	Cavity dressing - ${\text{Ca(OH)}}_2$
Acute pericoronitis	Opposing tooth/cusp removal
TMD pain	Occlusal adjustment
ANUG	Debridement + Metronidazole
Soft tissue lesion	Removal of trauma + mouthwash

• Pain Relief after Dental Treatment (Hargreaves & Baumgartner - 2006)
  • No “active” pain medication given - Placebo only

Key Treatment Steps (“Investigation and Stabilisation”)^1515161718

• Remove the cause(s):

  • Must remove ALL restorations to assess tooth for future restoration and its L-T prognosis
    • Access to caries, cracks, b’down margin(s)

• Remove the pulp / debris from canals

  • Barbed broach
    • If possible
    • With care

• Provide drainage

  • ONLY if required
  • Via canal, or
  • Via soft tissue incision

??? Drainage

• Medication - Intracanal (see later)

• Interim restoration

  • Close the pulp chamber and the tooth

• Summary of Steps:

  • Remove the cause(s)
    • Caries, cracks, b’down restorations, etc
  • Remove the pulp / debris from canals
  • Provide drainage - only if required
  • Medication - intracanal
  • Interim restoration - pulp chamber + tooth

 Diagnosis  Dental treatment

Drugs

3. Drugs (Medication)¹⁹²⁰

• Medication choice Depends on the DIAGNOSIS !!!
• Local (i.e. tooth)
  • Local anaesthetic - Long acting
  • Pulp medicaments - Anti-inflammatory, Anti-bacterial
• Systemic
  • Anti-bacterial
  • Anti-inflammatory
  • Analgesic

Prescribe REST

• Prescribe REST
  • Tooth ( + interim restoration)
    • Relieve from occlusion

Evidence for Occlusal Reduction²¹

• The effect of occlusal reduction on pain after endodontic instrumentation (Rosenberg et al, J Endod 1998; 24: 492-6)

The effect of occlusal reduction on pain after endodontic instrumentation Rosenberg et al, J Endod 1998; 24: 492-6
Occlusal Reduction	No Pain (%)	Moderate Pain (%)	Severe Pain (%)
Complete Reduction	75	25	0
Simulated Reduction	0	80	20

• The effect of occlusal reduction on pain after endodontic instrumentation (Rosenberg et al J Endod 1998; 24: 492-6)

Occlusal Reduction	No Pain	Moderate Pain	Severe Pain
Complete Reduction	75	80	0
Simulated Reduction	0	25	20
No Reduction	0	80	20

General Rest²²

• Prescribe REST
  • Tooth (+ interim restn)
    • Relieve occlusion
  • General rest
    • Sleep
    • No work, etc

General rest

• Sleep
• No work, etc

Footnotes

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