Endodontic Emergencies – Principles of Management W/Prof. Paul V. Abbott AO Emergency Treatment & Pain Control **Winthrop Prof. Paul V. Abbott AO** BDSc, MDS, FRACDS(Endo), FPFA, FADI, FICD, FACD, FIADT Specialist Endodontist Winthrop Professor of Clinical Dentistry The University of Western Australia 1 **Dental and Oral Pain** $\times$ Most oral pain problems are related to: Caries Bacteria within teeth $\square$ **Restorations breaking down, cracks, etc.** Pulp Pathosis Periapical Conditions Periodontal Diseases 2 2nd Year DMD - 2020 Page 1 ## **The Problem of Dental and Oral Pain** - Most oral pain problems are related to: - Caries - Bacteria within teeth - **Restorations breaking down, cracks, etc.** - Pulp Pathosis - Periapical Conditions - Periodontal Diseases Endodontic Emergencies – Principles of Management W/Prof. Paul V. Abbott AO **Dental Practice in Australia** ARCPOH – Uni Adel Aust J Dent 2007 Figure 5: Reason for visit by main diagnosis or condition **** 3 **Endodontic Emergencies** x **Before treatment** x **During treatment** x **After treatment** 4 2nd Year DMD - 2020 Page 2 ### **Dental Practice in Australia** ARCPOH – Uni Adel Aust J Dent 2007 Figure 5: Reason for visit by main diagnosis or condition **** ## **Endodontic Emergencies & Associated Pain** ### **Types of Endodontic Emergencies** - **Before treatment** - **During treatment** - **After treatment** Endodontic Emergencies - Principles of Management W/Prof. Paul V. Abbott AO **Pain – Before and During Treatment** % **“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 5 **Pain After Endodontic Treatment** 6 2nd Year DMD - 2020 Page 3 ### **Public Perception and Patient Anxiety** - **“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 Endodontic Emergencies – Principles of Management W/Prof. Paul V. Abbott AO **Pain After Endodontic Treatment** * 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) 7 **Pain After Endodontic Treatment** * 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) 8 $2^{nd}$ Year DMD - 2020 Page 4 ### **Pain After Endodontic Treatment: Key Studies** - 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) Endodontic Emergencies - Principles of Management W/Prof. Paul V. Abbott AO **Emergencies and Pain Control** * Complicated by: * Distressed patient 9 **Emergencies and Pain Control** * Complicated by: * Distressed patient * **In pain:** * **Unexpected** * **Often severe** 10 2$^{\text{nd}}$ Year DMD - 2020 Page 5 ## **Challenges in Emergency Management** - Complicated by: - Distressed patient - **In pain:** - **Unexpected** - **Often severe** Endodontic Emergencies – Principles of Management W/Prof. Paul V. Abbott AO **Emergencies and Pain Control** * Complicated by: * Distressed patient * **In pain**: * **Unexpected** * **Often severe** * **Lack of sleep** * **May be a new patient** * **May be a new dentist** 11 **Emergencies and Pain Control** * Very important to: * Allow adequate **TIME** for emergencies 12 2nd Year DMD - 2020 Page 6 - **Lack of sleep** - **May be a new patient** - **May be a new dentist** ### **Key Considerations for Practice** - Very important to: - Allow adequate **TIME** for emergencies Endodontic Emergencies – Principles of Management W/Prof. Paul V. Abbott AO **Emergencies and Pain Control** * Very important to: * Allow adequate **TIME** for emergencies * Treat: * the **PATIENT** * the **TOOTH**, and * the **PULP / CANAL** 13 **Emergencies and Pain Control** **The 3-D’s** - Principles for Managing Dental Pain * **Diagnosis** * **Dental treatment** * **Drugs** 14 2nd Year DMD - 2020 Page 7 - 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** Endodontic Emergencies – Principles of Management W/Prof. Paul V. Abbott AO **Emergencies and Pain Control** **Principles to follow:** * Take a thorough history 15 **Emergencies and Pain Control** **Principles to follow:** * Take a thorough history * **PROVISIONAL diagnosis of problem(s)** * **Pulp / root canal status** * **Periapical status** 16 2nd Year DMD - 2020 Page 8 ### **1. Diagnosis** #### **Principles to Follow** - Take a thorough history - **PROVISIONAL diagnosis of problem(s)** - **Pulp / root canal status** - **Periapical status** Clinical examination of teeth for emergency and pain control involving intraoral inspections and pulp sensibility tests using CO₂ Endodontic Emergencies - Principles of Management W/Prof. Paul V. Abbott AO **Emergencies and Pain Control** **Principles to follow:** * Thorough clinical examination * Pulp sensibility tests: **Heat** 19 **Emergencies and Pain Control** **Principles to follow:** * Thorough clinical examination * Pulp sensibility tests: **Electric** 20 2nd Year DMD - 2020 Page 10 A device used for pulp sensibility testing with heat. Two images; one showing an electric pulp tester device and the other showing the probe being used clinically on a tooth. - Thorough clinical examination - Pulp sensibility tests: - **Heat** - **Electric** Endodontic Emergencies - Principles of Management W/Prof. Paul V. Abbott AO **Emergencies and Pain Control** **Principles to follow:** - Thorough clinical examination - **Radiographs: PA’s, BW’s, Panoramic** 21 **Emergencies and Pain Control** **Principles to follow:** - Examination, tests, radiographs, etc - **CONFIRM** the **DIAGNOSES** - Confirm which **TOOTH**, **and** - **Help decide the CAUSE** (e.g. caries, cracks, restoration breakdown, etc) 22 2$^{\text{nd}}$ Year DMD - 2020 Page 11 Three example radiographs: a periapical radiograph, a panoramic radiograph, and a bitewing radiograph. - **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) Endodontic Emergencies – Principles of Management W/Prof. Paul V. Abbott AO **Emergencies and Pain Control!** G The history Exam findings, tests, radiographs, etc The DIAGNOSES Which TOOTH, and The CAUSE = Determine the MANAGEMENT OPTIONS & help to assess the PROGNOSIS 23 **Emergencies and Pain Control** **The 3-D's** - Principles for Managing Dental Pain <div style="background-color: darkblue; border: 2px solid white; padding: 10px;"> <div style="color: white; font-size: 1.2em;"> <span style="color: lightgreen; font-size: 1.5em; font-weight: bold;">✓ </span><span style="color: white; font-weight: bold; text-decoration: underline;">Diagnosis</span> </div> <div style="color: lightgreen; font-weight: bold; margin-top: 10px;"> <span style="color: orange; font-weight: bold;">￮ </span><span style="text-decoration: underline;">Dental treatment</span> </div > <div style="color: orange; font-weight: bold; margin-top: 10px;"> <span style="color: orange; font-weight: bold;">￮ </span><span style="text-decoration: underline;">Drugs</span> </div> </div> 24 2nd Year DMD - 2020 Page 12 #### **Synthesizing Information for a Management Plan** - The history - Exam findings, tests, radiographs, etc - The DIAGNOSES - Which TOOTH, and - The CAUSE - = Determine the MANAGEMENT OPTIONS & help to assess the PROGNOSIS <div style="background-color: darkblue; border: 2px solid white; padding: 10px;"> <div style="color: white; font-size: 1.2em;"> <span style="color: lightgreen; font-size: 1.5em; font-weight: bold;">✓ </span><span style="color: white; font-weight: bold; text-decoration: underline;">Diagnosis</span> </div> <div style="color: lightgreen; font-weight: bold; margin-top: 10px;"> <span style="color: orange; font-weight: bold;">￮ </span><span style="text-decoration: underline;">Dental treatment</span> </div > <div style="color: orange; font-weight: bold; margin-top: 10px;"> <span style="color: orange; font-weight: bold;">￮ </span><span style="text-decoration: underline;">Drugs</span> </div> </div> Endodontic Emergencies – Principles of Management W/Prof. Paul V. Abbott AO **Page 13** **Dental and Oral Pain** - Most oral pain problems are related to: - Caries - Bacteria within teeth - **Restorations breaking down, cracks, etc.** - Pulp Pathosis - Periapical Conditions - Periodontal Diseases **Management Options:** > Restoration > Endodontic treatment > Periodontal treatment > Extraction 25 **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 26 2$^{nd}$ Year DMD - 2020 Page 13 ### **2. Dental Treatment** #### **Management Options** - Restoration - Endodontic treatment - Periodontal treatment - Extraction #### **Evidence for Treatment Efficacy** - **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 Endodontic Emergencies - Principles of Management W/Prof. Paul V. Abbott AO **Management of Acute Dental Pain** **Matthews, Peak & Scully - Brit Dent J 1994** | 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 | 27 **Pain Relief after Dental Treatment** **Hargreaves & Baumgartner - 2006** **No “active” pain medication given - Placebo only** A graph showing pain (VAS) over time (hours) after dental treatment categorized by preoperative pain levels (Severe, Moderate, Mild, No preoperative pain). 28 $2^{nd}$ Year DMD - 2020 Page 14 | 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** Endodontic Emergencies - Principles of Management W/Prof. Paul V. Abbott AO **Pain Relief after Dental Treatment** **Hargreaves & Baumgartner - 2006** 29 **Principles of Management - I** * 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) 30 2nd Year DMD - 2020 Page 15 - 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) Endodontic Emergencies - Principles of Management W/Prof. Paul V. Abbott AO **Principles of Management - I** - 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)** 31 **Principles of Management - I** - Remove the pulp / debris from canals - **Barbed broach** - **If possible** - **With care** 32 2nd Year DMD - 2020 Page 16 Three images showing the progression of caries removal and access opening. Image of a barbed broach with debris collected. - Remove the pulp / debris from canals - **Barbed broach** - **If possible** - **With care** Endodontic Emergencies – Principles of Management W/Prof. Paul V. Abbott AO **Principles of Management - I** Provide drainage - ONLY if required - Via canal, **or** - Via soft tissue incision 33 ??? Drainage <img src="endodontic_emergencies_drainage_images.jpg" alt="Images showing clinical relevance of drainage in endodontic emergencies, with numbers 9 and 7 overlaid on different photos."> 34 2nd Year DMD - 2020 Page 17 - Provide drainage - ONLY if required - Via canal, **or** - Via soft tissue incision ??? Drainage Endodontic Emergencies - Principles of Management W/Prof. Paul V. Abbott AO **Principles of Management - I** ™ Medication - Intracanal (see later) 35 **Principles of Management - I** ™ Medication - Intracanal (see later) š Interim restoration G Close the pulp chamber and the tooth 36 2nd Year DMD - 2020 Page 18 A sequence of three images showing teeth before and after restoration. The first image shows two separate teeth. The second image shows the two teeth together being prepared or partially restored. The third image shows the completed restoration. Arrows indicate the progression. - Medication - Intracanal (see later) - Interim restoration - Close the pulp chamber and the tooth Endodontic Emergencies – Principles of Management W/Prof. Paul V. Abbott AO **Principles of Management - I** o 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 **Investigation and Stabilisation** 37 **Emergencies and Pain Control** **The 3-D's** - Principles for Managing Dental Pain <img alt="The 3-D's for Managing Dental Pain: Diagnosis, Dental Treatment, and Drugs." />  **Diagnosis**  **Dental treatment** > Drugs 38 2nd Year DMD - 2020 Page 19 - **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 Endodontic Emergencies – Principles of Management W/Prof. Paul V. Abbott AO # **Principles of Management - II** ⊗ Medication ○ Local (i.e. tooth) ² Local anaesthetic - Long acting ² Pulp medicaments - Anti-inflammatory - Anti-bacterial ○ Systemic ² Anti-bacterial ² Anti-inflammatory ² Analgesic **Depends on the DIAGNOSIS !!!** 39 # **Principles of Management - III** ⊗ Prescribe REST ○ Tooth ( + interim restoration) ² **Relieve from occlusion** 40 2$^{\text{nd}}$ Year DMD - 2020 Page 20 A small description of two types of articulating paper packaging. ### **3. Drugs (Medication)** - 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** <html> <table border="1"> <tr> <th colspan="4">The effect of occlusal reduction on pain after endodontic instrumentation<br>Rosenberg et al, J Endod 1998; 24: 492-6</th> </tr> <tr> <th>Occlusal Reduction</th> <th>No Pain (%)</th> <th>Moderate Pain (%)</th> <th>Severe Pain (%)</th> </tr> <tr> <td>Complete Reduction</td> <td>75</td> <td>25</td> <td>0</td> </tr> <tr> <td>Simulated Reduction</td> <td>0</td> <td>80</td> <td>20</td> </tr> </table> </html> #### **Evidence for Occlusal Reduction** - **The effect of occlusal reduction on pain after endodontic instrumentation (Rosenberg et al, J Endod 1998; 24: 492-6)** <html> <table border="1"> <tr> <th colspan="4">The effect of occlusal reduction on pain after endodontic instrumentation<br>Rosenberg et al, J Endod 1998; 24: 492-6</th> </tr> <tr> <th>Occlusal Reduction</th> <th>No Pain (%)</th> <th>Moderate Pain (%)</th> <th>Severe Pain (%)</th> </tr> <tr> <td>Complete Reduction</td> <td>75</td> <td>25</td> <td>0</td> </tr> <tr> <td>Simulated Reduction</td> <td>0</td> <td>80</td> <td>20</td> </tr> </table> </html> Endodontic Emergencies - Principles of Management W/Prof. Paul V. Abbott AO The effect of occlusal reduction on pain after endodontic instrumentation Rosenberg et al J Endod 1998; 24: 492-6 A bar graph showing the effect of occlusal reduction on pain. **Occlusal Reduction** | | No Pain | Moderate Pain | Severe Pain | |---|---|---|---| | Complete Reduction | 75 | 80 | 0 | | Simulated Reduction | 0 | 25 | 20 | | No Reduction | 0 | 80 | 20 | 43 **Principles of Management - III** * Prescribe REST $\text{o}$ Tooth (+ interim restn) $\text{o}$ Relieve occlusion $\text{o}$ General rest $\text{o}$ Sleep $\text{o}$ No work, etc 44 2nd Year DMD - 2020 Page 22 - **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 Rest** - Prescribe REST - Tooth (+ interim restn) - Relieve occlusion - General rest - Sleep - No work, etc # **General rest** - Sleep - No work, etc [[L18 Emergencies.pdf#page=1|L18 Emergencies, p.1]] [[L18 Emergencies.pdf#page=2|L18 Emergencies, p.2]] [[L18 Emergencies.pdf#page=3|L18 Emergencies, p.3]] [[L18 Emergencies.pdf#page=4|L18 Emergencies, p.4]] [[L18 Emergencies.pdf#page=5|L18 Emergencies, p.5]] [[L18 Emergencies.pdf#page=6|L18 Emergencies, p.6]] [[L18 Emergencies.pdf#page=7|L18 Emergencies, p.7]] [[L18 Emergencies.pdf#page=8|L18 Emergencies, p.8]] [[L18 Emergencies.pdf#page=9|L18 Emergencies, p.9]] [[L18 Emergencies.pdf#page=10|L18 Emergencies, p.10]] [[L18 Emergencies.pdf#page=11|L18 Emergencies, p.11]] [[L18 Emergencies.pdf#page=12|L18 Emergencies, p.12]] [[L18 Emergencies.pdf#page=13|L18 Emergencies, p.13]] [[L18 Emergencies.pdf#page=14|L18 Emergencies, p.14]] [[L18 Emergencies.pdf#page=15|L18 Emergencies, p.15]] [[L18 Emergencies.pdf#page=16|L18 Emergencies, p.16]] [[L18 Emergencies.pdf#page=17|L18 Emergencies, p.17]] [[L18 Emergencies.pdf#page=18|L18 Emergencies, p.18]] [[L18 Emergencies.pdf#page=19|L18 Emergencies, p.19]] [[L18 Emergencies.pdf#page=20|L18 Emergencies, p.20]] [[L18 Emergencies.pdf#page=21|L18 Emergencies, p.21]] [[L18 Emergencies.pdf#page=22|L18 Emergencies, p.22]]