**Pain Control During Endodontic Treatment**
**W/Prof. Paul V. Abbott AO**
---
**Pain Control During Endodontic Treatment**
**Prof. Paul V. Abbott AO**
BDSc, MDS, FRACDS(Endo), FPFA, FADI, FICD, FACD, FIADT
Specialist Endodontist
Winthrop Professor of Clinical Dentistry
UWA Dental School
The University of Western Australia
---
**Strategies for Managing Pain During Endodontic Treatment**
Abbott PV, Parirokh M.
*Aust Endo J 2018; 44: 99-113.*
---
2nd Year DMD - 2020
Page 1
# **Pain Control During Endodontic Treatment**
**W/Prof. Paul V. Abbott AO**
BDSc, MDS, FRACDS(Endo), FPFA, FADI, FICD, FACD, FIADT
Specialist Endodontist
Winthrop Professor of Clinical Dentistry
UWA Dental School
The University of Western Australia
**Strategies for Managing Pain During Endodontic Treatment**
Abbott PV, Parirokh M.
*Aust Endo J 2018; 44: 99-113.*
**Pain Control During Endodontic Treatment**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 2
---
**Importance of Pain Control During Treatment**
- Pain during treatment significantly impacts on the amount of post-op. pain
- **Hence, adequate pain control is essential**
---
**Local Anaesthesia**
*Hargreaves & Khan Endod Topics 2005*
- Three goals of local anaesthesia:
- Anaesthesia during treatment
- Haemostasis during treatment
- Prolonged post-operative pain control
## **Importance of Pain Control During Treatment**
- Pain during treatment significantly impacts on the amount of post-op. pain
> [!info]
> ==The more pain a patient feels *during* treatment, the more pain they will experience *after* treatment.==
- **Hence, adequate pain control is essential**
## **Local Anaesthesia**
*Hargreaves & Khan Endod Topics 2005*
- Three goals of local anaesthesia:
- Anaesthesia during treatment
- Haemostasis during treatment
- Prolonged post-operative pain control
**Pain Control During Endodontic Treatment**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 3
---
**Local Anaesthesia**
*Hargreaves & Khan Endod Topics 2005*
- Pain control from local anaesthetics - two mechanisms:
1. **Direct**: Block discharges from peripheral nerves
- *Duration: Minutes → Hours*
2. **Indirect**: Prolonged blocking of peripheral input reduces central sensitization
- *Duration: Hours → Days*
---
**Local Anaesthesia**
*Hargreaves & Khan Endod Topics 2005*
- Inadequate local anaesthesia
1. **Pain during treatment**
2. **More post-operative pain**
- Since prolonged exposure to sensory input increases allodynia and hyperalgesia
![]()
Diagram showing two labeled boxes: "Pain from non-injurious stimuli" and "Exaggerated sense of pain"
## **Local Anaesthesia**
*Hargreaves & Khan Endod Topics 2005*
### **Mechanisms of Pain Control**
- Pain control from local anaesthetics - two mechanisms:
1. **Direct**: Block discharges from peripheral nerves
- *Duration: Minutes → Hours*
2. **Indirect**: Prolonged blocking of peripheral input reduces central sensitization
- *Duration: Hours → Days*
### **Inadequate Local Anaesthesia**
1. **Pain during treatment**
2. **More post-operative pain**
- Since prolonged exposure to sensory input increases allodynia and hyperalgesia
- ==**Allodynia:** Pain resulting from a stimulus that would not normally be painful.==
- ==**Hyperalgesia:** An exaggerated pain response to a stimulus.==
**Pain Control During Endodontic Treatment**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 4
**Anaesthetic efficacy of the supplemental intraosseous injection of 2% lidocaine with 1:100,000 epinephrine in irreversible pulpitis**
Nusstein J, Reader A, Nist R, Beck M and Meyers WJ.
*J Endod* 1998; 24: 487 - 91
**25 Maxillary Teeth**
Nusstein et al *JoE* 1998
```mermaid
graph TD
A[Bu Infiltration Injection<br>Lignocaine + 1:100,000 Adr] --> B[No Response to PT's 92 %]
A --> C[Responded to PT's 8 %]
B --> D[No Pain 68 %]
B --> E[Pain in Dentine 4 %]
B --> F[Pain in Pulp 20 %]
C --> G[Need supplementary LA techniques]
F --> G
```
## **Anaesthetic efficacy of the supplemental intraosseous injection of 2% lidocaine with 1:100,000 epinephrine in irreversible pulpitis**
Nusstein J, Reader A, Nist R, Beck M and Meyers WJ.
*J Endod* 1998; 24: 487 - 91
### **25 Maxillary Teeth**
*Nusstein et al JoE 1998*
```mermaid
graph TD
A[Bu Infiltration Injection<br>Lignocaine + 1:100,000 Adr] --> B[No Response to PT's 92 %]
A --> C[Responded to PT's 8 %]
B --> D[No Pain 68 %]
B --> E[Pain in Dentine 4 %]
B --> F[Pain in Pulp 20 %]
C --> G[Need supplementary LA techniques]
F --> G
```
> [!success] Conclusion
> ==Even with a successful buccal infiltration in the maxilla, a significant portion of patients (24%) still experience pain during treatment for irreversible pulpitis.==
**Pain Control During Endodontic Treatment**
**W/Prof. Paul V. Abbott AO**
**2nd Year DMD - 2020**
**Page 5**
---
### **26 Mandibular Teeth**
**IAN Block Injection**
*Lignocaine + 1:100,000 Adr*
- **No Response to PT’s** — 38 %
- **Responded to PT’s** — 62 %
- **No Pain** — 7 %
- **Pain in Dentine** — 12 %
- **Pain in Pulp** — 19 %
- **Need supplementary LA techniques**
---
### **Why Does Local Anaesthesia Not Work with Acute Irreversible Pulpitis?**
- Various theories proposed — none proven
- Most commonly discussed:
- Inflammation activates nociceptors (pain receptors) and associated central pain mechanisms
- Inflammatory mediators reduce threshold of nociceptor activation
→ So minor stimuli fire the neurons
- Mediated by prostaglandins
→ Produced by arachidonic acid metabolism
- Prostaglandins sensitize nerve endings
→ Enhances pain and inflammation
- Inflamed pulps have high levels of both prostaglandins and arachidonic acid
---
*Nusstein et al JoE 1998*
### **26 Mandibular Teeth**
**IAN Block Injection**
*Lignocaine + 1:100,000 Adr*
- **No Response to PT’s** — 38 %
- **Responded to PT’s** — 62 %
- **No Pain** — 7 %
- **Pain in Dentine** — 12 %
- **Pain in Pulp** — 19 %
- **Need supplementary LA techniques**
> [!failure] Conclusion
> ==The IAN block has a very high failure rate for mandibular molars with irreversible pulpitis.==
*Nusstein et al JoE 1998*
## **Why Does Local Anaesthesia Not Work with Acute Irreversible Pulpitis?**
- Various theories proposed — none proven
- Most commonly discussed:
- Inflammation activates nociceptors (pain receptors) and associated central pain mechanisms
- Inflammatory mediators reduce threshold of nociceptor activation
→ So minor stimuli fire the neurons
- Mediated by prostaglandins
→ Produced by arachidonic acid metabolism
- Prostaglandins sensitize nerve endings
→ Enhances pain and inflammation
- Inflamed pulps have high levels of both prostaglandins and arachidonic acid
> [!warning]
> ==However, most of these theories focus on local factors around the tooth and fail to adequately explain why a **block injection**, administered several centimetres away from the site of inflammation, would fail.==
**Pain Control During Endodontic Treatment**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 6
---
### **Why Does Local Anaesthesia Not Work with Acute Irreversible Pulpitis?**
- Various theories proposed - none proven
- LA unable to block conduction of all nerve impulses
→ When pain present - have more impulses than normal
- pH is more acidic in the presence of inflammation so LA is less effective
- Spread of inflammation along myelin sheaths may restrict absorption of the LA solution
- Increased vascularity increases blood flow and removes the LA more rapidly
- Periapically, there may be stasis - reduced blood flow
- Pain can neutralise the effects of LA in the CNS
> But most of these theories do not make total sense and they do not explain why a block injection does not work!
---
### **Why Does Local Anaesthesia Not Work with Acute Pulpitis?**
- Other possible causes:
- Insufficient dose
- Incorrect injection site
- Incorrect technique
- Intravascular injection
- Individual variation - anatomy, dosage, etc.
- Variation in pain threshold and perceptions
- Inadequate time for LA to work
## **Why Does Local Anaesthesia Not Work with Acute Irreversible Pulpitis? (Continued)**
- Various theories proposed - none proven
- LA unable to block conduction of all nerve impulses
→ When pain present - have more impulses than normal
- pH is more acidic in the presence of inflammation so LA is less effective
- Spread of inflammation along myelin sheaths may restrict absorption of the LA solution
- Increased vascularity increases blood flow and removes the LA more rapidly
- Periapically, there may be stasis - reduced blood flow
- Pain can neutralise the effects of LA in the CNS
> But most of these theories do not make total sense and they do not explain why a block injection does not work!
### **Other Possible Causes**
- Insufficient dose
- Incorrect injection site
- Incorrect technique
- Intravascular injection
- Individual variation - anatomy, dosage, etc.
- Variation in pain threshold and perceptions
- Inadequate time for LA to work
- ==This is a major factor. Dentists often wait only 3-5 minutes, but a block injection for a “hot” tooth may require **up to 15 minutes** to become fully effective.==
**Pain Control During Endodontic Treatment**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 7
---
**Continued Pain After LA Injection**
- **Three stages when pain may be felt:**
1. Pre-operative
2. Dentine
3. Pulp
---
**Strategies to Manage Acute Irreversible Pulpitis in a Lower Molar**
1. Pre-empt the difficult situation - i.e. Diagnosis !!
2. Consider pre-medication with ibuprofen
→ Assuming no contra-indication
## **Continued Pain After LA Injection**
- **Three stages when pain may be felt:**
1. Pre-operative
2. Dentine
3. Pulp
## **Strategies to Manage Acute Irreversible Pulpitis in a Lower Molar**
1. Pre-empt the difficult situation - i.e. Diagnosis !!
2. Consider pre-medication with ibuprofen
→ Assuming no contra-indication
**Pain Control During Endodontic Treatment**
**W/Prof. Paul V. Abbott AO**
**2nd Year DMD - 2020**
**Page 8**
---
**J Endod 2010;36:1450–1454**
**The Effect of Premedication with Ibuprofen and Indomethacin on the Success of Inferior Alveolar Nerve Block for Teeth with Irreversible Pulpitis**
---
### **Materials and Method:**
- **Randomized double-blinded clinical trial**
- **Mandibular molars - acute irreversible pulpitis**
→ Confirmed by moderate-severe pain and lingering pain to cold pulp sensibility tests
→ **BUT** no spontaneous pain
→ **AND** no radiographic periapical changes
○ i.e. without acute apical periodontitis
---
**J Endod 2010;36:1450–1454**
## **The Effect of Premedication with Ibuprofen and Indomethacin on the Success of Inferior Alveolar Nerve Block for Teeth with Irreversible Pulpitis**
*J Endod 2010;36:1450–1454*
### **Materials and Method:**
- **Randomized double-blinded clinical trial**
- **Mandibular molars - acute irreversible pulpitis**
→ Confirmed by moderate-severe pain and lingering pain to cold pulp sensibility tests
→ **BUT** no spontaneous pain
→ **AND** no radiographic periapical changes
- i.e. without acute apical periodontitis
- ==This targeted an *earlier stage* of irreversible pulpitis.==
**Pain Control During Endodontic Treatment**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 9
---
**The Effect of Premedication with Ibuprofen and Indomethacin on the Success of Inferior Alveolar Nerve Block for Teeth with Irreversible Pulpitis**
**Materials and Method:**
- 150 patients (50 per group) - given:
- Placebo
- Ibuprofen - 600 mg, or
- Indomethacin - 75 mg
→ Taken 1 hour before local anaesthesia
- 2% lignocaine + 1:80,000 adrenaline used
→ 1.8 ml given as an IAN block
*J Endod 2010;36:1450–1454*
---
**The Effect of Premedication with Ibuprofen and Indomethacin on the Success of Inferior Alveolar Nerve Block for Teeth with Irreversible Pulpitis**
**Materials and Method:**
- Pain scored on a visual analogue scale
→ Before taking the medication
→ 15 minutes after LA injection
→ In response to a cold pulp test
→ During access cavity preparation, and
→ During root canal instrumentation
*J Endod 2010;36:1450–1454*
### **Materials and Method (Continued):**
- 150 patients (50 per group) - given:
- Placebo
- Ibuprofen - 600 mg, or
- Indomethacin - 75 mg
→ Taken 1 hour before local anaesthesia
- 2% lignocaine + 1:80,000 adrenaline used
→ 1.8 ml given as an IAN block
- Pain scored on a visual analogue scale
→ Before taking the medication
→ 15 minutes after LA injection
→ In response to a cold pulp test
→ During access cavity preparation, and
→ During root canal instrumentation
*J Endod 2010;36:1450–1454*
**Pain Control During Endodontic Treatment**
*W/Prof. Paul V. Abbott AO*
**2nd Year DMD - 2020**
**Page 10**
---
**The Effect of Premedication with Ibuprofen and Indomethacin on the Success of Inferior Alveolar Nerve Block for Teeth with Irreversible Pulpitis**
**Results:**
- **No sig. diff. in pre-treatment pain scores**
- **120 pt’s did not respond to the cold pulp sensibility tests 15 minutes after LA injn**
→ **But 34 (28%) had pain during treatment**
- **Overall 64 had ineffective LA**
→ **30 of these had pain to cold testing**
*J Endod 2010;36:1450–1454*
---
**The Effect of Premedication with Ibuprofen and Indomethacin on the Success of Inferior Alveolar Nerve Block for Teeth with Irreversible Pulpitis**
**Results:**
- **Overall success**
→ **Placebo - 32%**
→ **Ibuprofen - 78%**
→ **Indomethacin - 62%**
- **Ibuprofen + Indomethacin**
→ **Sig. diff. to Placebo**
→ **But not sig. diff. to each other**
*J Endod 2010;36:1450–1454*
### **Results:**
- **No sig. diff. in pre-treatment pain scores**
- **120 pt’s did not respond to the cold pulp sensibility tests 15 minutes after LA injn**
→ **But 34 (28%) had pain during treatment**
- ==This confirms that sensibility testing is not a perfect predictor of profound anaesthesia.==
- **Overall 64 had ineffective LA**
→ **30 of these had pain to cold testing**
- **Overall success**
→ **Placebo - 32%**
→ **Ibuprofen - 78%**
→ **Indomethacin - 62%**
- **Ibuprofen + Indomethacin**
→ **Sig. diff. to Placebo**
→ **But not sig. diff. to each other**
*J Endod 2010;36:1450–1454*
**Pain Control During Endodontic Treatment**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 11
---
**The Effect of Premedication with Ibuprofen and Indomethacin on the Success of Inferior Alveolar Nerve Block for Teeth with Irreversible Pulpitis**
*J Endod 2010;36:1450–1454*
---
**Discussion:**
- Pre-medication with a NSAID helped with pain control during treatment for acute irreversible pulpitis in mandibular molars
→ **Ibuprofen more effective**
→ **And has less side effects than Indomethacin**
○ Esp. higher risk of heart attack, stroke, GIT problems, ulcers, etc.
*J Endod 2010;36:1450–1454*
![]()
Bar chart comparing pain vs. no pain outcomes across placebo, ibuprofen, and indomethacin groups for inferior alveolar nerve block success in teeth with irreversible pulpitis.
### **Discussion:**
- Pre-medication with a NSAID helped with pain control during treatment for acute irreversible pulpitis in mandibular molars
→ **Ibuprofen more effective**
→ **And has less side effects than Indomethacin
- ==Esp. higher risk of heart attack, stroke, GIT problems, ulcers, etc.==
**
- Esp. higher risk of heart attack, stroke, GIT problems, ulcers, etc.
*J Endod 2010;36:1450–1454*
**Pain Control During Endodontic Treatment**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 12
---
**The Effect of Premedication with Ibuprofen and Indomethacin on the Success of Inferior Alveolar Nerve Block for Teeth with Irreversible Pulpitis**
**Discussion:**
- **Previous studies - mixed results**
→ **Pre-medication with NSAID is beneficial**
- e.g. Seymour and Ward (1996)
- Ianiro et al (2010)
→ **Others: Pre-medication NOT beneficial**
- e.g. Aggarwal et al (2010), Oleson et al (2010)
- Their main criterion for acute irreversible pulpitis was “spontaneous pain”
- More advanced pulp inflammation
- NSAID and LA less effective
*J Endod 2010;36:1450–1454*
### **Discussion (Continued):**
- **Previous studies - mixed results**
→ **Pre-medication with NSAID is beneficial**
- e.g. Seymour and Ward (1996)
- Ianiro et al (2010)
→ **Others: Pre-medication NOT beneficial**
- e.g. Aggarwal et al (2010), Oleson et al (2010)
- Their main criterion for acute irreversible pulpitis was “spontaneous pain”
- ==This represents a more advanced and inflamed state where premedication may be less effective.==
- More advanced pulp inflammation
- NSAID and LA less effective
*J Endod 2010;36:1450–1454*
**Pain Control During Endodontic Treatment**
**W/Prof. Paul V. Abbott AO**
**2nd Year DMD - 2020**
**Page 13**
---
### **Acute Irreversible Pulpitis**
```mermaid
graph TD
A[May or may not have pain to bite and percussion] --> B[?]
B --> C[± Pain is spontaneous]
B --> D[± Pain lying down]
B --> E[± Pain wakes patient]
B --> F[± Primary acute apical periodontitis]
C --> G[Intense throbbing / aching pain; continuous or may come and go]
D --> G
E --> G
F --> H[Pain to bite & tender to percussion]
I[Pain with cold stimuli] --> J[Short, very sharp pain then lingering ache / throb]
K[± Pain with heat] --> J
```
---
### **The Effect of Premedication with Ibuprofen and Indomethacin on the Success of Inferior Alveolar Nerve Block for Teeth with Irreversible Pulpitis**
- **Conclusion:**
- Pre-medication with a single dose of Ibuprofen can help with pain control during treatment of acute irreversible pulpitis in mandibular molars
→ If there is no spontaneous pain
- Highlights the need for a thorough history and diagnosis of the presenting complaint
*J Endod. 2010;36:1450–1454*
## **Acute Irreversible Pulpitis**
```mermaid
graph TD
A[May or may not have pain to bite and percussion] --> B[?]
B --> C[± Pain is spontaneous]
B --> D[± Pain lying down]
B --> E[± Pain wakes patient]
B --> F[± Primary acute apical periodontitis]
C --> G[Intense throbbing / aching pain; continuous or may come and go]
D --> G
E --> G
F --> H[Pain to bite & tender to percussion]
I[Pain with cold stimuli] --> J[Short, very sharp pain then lingering ache / throb]
K[± Pain with heat] --> J
```
### **Conclusion of Premedication Study**
- Pre-medication with a single dose of Ibuprofen can help with pain control during treatment of acute irreversible pulpitis in mandibular molars
→ If there is no spontaneous pain
- Highlights the need for a thorough history and diagnosis of the presenting complaint
> [!tip] Practical Challenge
> ==The main practical challenge is scheduling the one-hour wait time for the premedication to take effect in a busy practice.==
*J Endod. 2010;36:1450–1454*
**Pain Control During Endodontic Treatment**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 14
---
### **Strategies to Manage Acute Irreversible Pulpitis in a Lower Molar**
1. **Pre-empt the difficult situation** - *i.e. Diagnosis !!*
2. **Consider pre-medication with ibuprofen**
3. **Test tooth: triplex air + percussion during exam**<sup>n</sup>
4. **Give Gow-Gates Block**
---
### **The Gow-Gates Mandibular Block**
- **Developed by Dr. George Gow-Gates**
- **Sydney, Australia**
- **First used in 1947**
- **First published in OS:OM:OP in 1973**
- *After 26 years of daily use and testing*
- **Many publications and practical courses since then** - with:
- **Dr John Watson – Anatomist & Orthodontist**
- **A/Prof. Michael Kafalias – Prosthodontist**
- **University of Sydney**
---
2nd Year DMD - 2020
Page 14
## **Strategies to Manage Acute Irreversible Pulpitis in a Lower Molar**
1. **Pre-empt the difficult situation** - *i.e. Diagnosis !!*
2. **Consider pre-medication with ibuprofen**
3. **Test tooth: triplex air + percussion during exam**n
4. **Give Gow-Gates Block**
## **The Gow-Gates Mandibular Block**
- **Developed by Dr. George Gow-Gates**
- **Sydney, Australia**
- **First used in 1947**
- **First published in OS:OM:OP in 1973**
- *After 26 years of daily use and testing*
- **Many publications and practical courses since then** - with:
- **Dr John Watson – Anatomist & Orthodontist**
- **A/Prof. Michael Kafalias – Prosthodontist**
- **University of Sydney**
**Pain Control During Endodontic Treatment**
**W/Prof. Paul V. Abbott AO**
**2nd Year DMD - 2020**
**Page 15**
---
**The Gow-Gates Mandibular Block**
*Target site: Lateral region of the neck of the condyle, just below the insertion point of the lateral pterygoid muscle*
---
**The Gow-Gates Mandibular Block**
![]()
Diagram showing needle placement for Gow-Gates Mandibular Block with green arrow indicating target site.
![]()
Diagram of mandible with multiple arrows indicating anatomical landmarks or injection points.
### **Technique and Landmarks**
*Target site: Lateral region of the neck of the condyle, just below the insertion point of the lateral pterygoid muscle*
> [!info] Goal
> ==To anaesthetise the *entire mandibular nerve trunk* after it exits the foramen ovale. This includes accessory branches that are often missed by a standard IAN block, which is why it is more effective.==
**Pain Control During Endodontic Treatment**
**W/Prof. Paul V. Abbott AO**
---
**The Gow-Gates Mandibular Block**
*Entry point: Medial to the deep tendon of the temporalis muscle and slightly below the Palatal cusp of the UPPER 2nd molar*
**The Gow-Gates Mandibular Block**
*External landmarks: Apex of the intertragic notch and the lower border of the tragus through to opposite corner of the mouth*
---
**2nd Year DMD - 2020**
**Page 16**
*Entry point: Medial to the deep tendon of the temporalis muscle and slightly below the Palatal cusp of the UPPER 2nd molar*
*External landmarks: Apex of the intertragic notch and the lower border of the tragus through to opposite corner of the mouth*
**Pain Control During Endodontic Treatment**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 17
---
### **The Gow-Gates Mandibular Block**
**Advantages**
- **High success rate**
- GG: 92 - 99 %
- IAN: 65 - 85 %
- **Complete Mandibular Nerve (V₃) block**
- **No supplementary injections needed**
- i.e. Do not need Long Buccal or Lingual nerve injections
---
### **The Gow-Gates Mandibular Block**
**Advantages**
- **Less muscle involved**
- **Less painful**
- **Even though larger needle used!**
- 25 Gauge long needle
### **Advantages of the Gow-Gates Block**
- **High success rate**
- GG: 92 - 99 %
- IAN: 65 - 85 %
- **Complete Mandibular Nerve (V₃) block**
- **No supplementary injections needed**
- i.e. Do not need Long Buccal or Lingual nerve injections
- **Less muscle involved**
- **Less painful**
- **Even though larger needle used!**
- 25 Gauge long needle
- ==Requires about **15 minutes** to take full effect==
- ==This waiting time can be productively used for patient consultation.==
**Pain Control During Endodontic Treatment**
**W/Prof. Paul V. Abbott AO**
**2nd Year DMD - 2020**
**Page 18**
---
### **The Gow-Gates Mandibular Block**
**Advantages**
- A safer technique
- Less blood vessels at injection site
- *Positive aspiration rate - negligible*
- *G-G injection site*
- *IAN injection site*
---
### **The Gow-Gates Mandibular Block**
**Advantages**
- A safer technique
- Less blood vessels at injection site
- *Positive aspiration rate - negligible*
- No vaso-constrictor required
- *Use plain Prilocaine (e.g. Citanest 4%)*
- *Only 1 carpule required (i.e. 2.2 ml)*
- A safer technique
- Less blood vessels at injection site
- *Positive aspiration rate - negligible*
- *G-G injection site*
- *IAN injection site*
- No vaso-constrictor required
- *Use plain Prilocaine (e.g. Citanest 4%)*
- *Only 1 carpule required (i.e. 2.2 ml)*
**Pain Control During Endodontic Treatment**
**W/Prof. Paul V. Abbott AO**
---
### **The Gow-Gates Mandibular Block**
**Incidence of Grade “A” anaesthesia**
<table>
<thead>
<tr>
<th></th>
<th>IAN</th>
<th>G-G</th>
</tr>
</thead>
<tbody>
<tr>
<td>3% Prilocaine + Adrenaline</td>
<td>83.9 %</td>
<td>98.25 %</td>
</tr>
<tr>
<td>3% Prilocaine + Felypressin</td>
<td>85.4 %</td>
<td>98.4 %</td>
</tr>
<tr>
<td>4% Prilocaine Plain</td>
<td>-</td>
<td>100 %</td>
</tr>
</tbody>
</table>
---
### **Strategies to Manage Acute Irreversible Pulpitis in a Lower Molar**
1. **Pre-empt the difficult situation** - i.e. Diagnosis !!
2. Consider pre-medication with ibuprofen
3. Test tooth: triplex air + percussion during exam
4. **Gow-Gates Block**
→ First injection
→ Then discuss findings, treatment, etc.
---
**2nd Year DMD - 2020**
**Page 19**
### **Incidence of Grade “A” anaesthesia**
| | **IAN** | **G-G** |
| :--- | :--- | :--- |
| **3% Prilocaine + Adrenaline** | 83.9 % | 98.25 % |
| **3% Prilocaine + Felypressin** | 85.4 % | 98.4 % |
| **4% Prilocaine Plain** | - | 100 % |
## **Strategies to Manage Acute Irreversible Pulpitis in a Lower Molar (Continued)**
1. **Pre-empt the difficult situation** - i.e. Diagnosis !!
2. Consider pre-medication with ibuprofen
3. Test tooth: triplex air + percussion during exam
4. **Gow-Gates Block**
→ First injection
→ Then discuss findings, treatment, etc.
**Pain Control During Endodontic Treatment**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 20
---
**Strategies to Manage Acute Irreversible Pulpitis in a Lower Molar**
1. **Pre-empt the difficult situation** - i.e. Diagnosis !!
2. Consider pre-medication with ibuprofen
3. Test tooth: triplex air + percussion during exam
4. **Gow-Gates Block**
→ First injection
→ Then discuss findings, treatment, etc.
5. **Re-test with triplex air and percussion**
→ If no pain: place rubber dam and re-test !!
→ If still pain: Give IAN Block + Buccal Infiltration
---
**Inferior Alveolar Nerve Block**
*Hints*
![]()
Diagram showing needle placement for Inferior Alveolar Nerve Block with blue arrow indicating trajectory into mandibular foramen.
5. **Re-test with triplex air and percussion**
→ If no pain: place rubber dam and re-test !!
→ If still pain: Give IAN Block + Buccal Infiltration
## **Inferior Alveolar Nerve Block Hints**
> [!tip] Technique Tip
> ==The most frequent mistake is placing the needle too far distally. Using a **short needle** with a **slight bend** can improve control and help target the correct area. The historical fear of needle breakage at the hub is obsolete with modern, single-piece needle manufacturing.==
Pain Control During Endodontic Treatment
W/Prof. Paul V. Abbott AO
**Inferior Alveolar Nerve Block**
*Hints*
**"Short" needle**
**Inferior Alveolar Nerve Block**
*Hints*
X
2nd Year DMD - 2020
Page 21
**"Short" needle**
X
**Pain Control During Endodontic Treatment**
*W/Prof. Paul V. Abbott AO*
**2nd Year DMD - 2020**
Page 22
**Efficacy of combining a buccal infiltration with an inferior alveolar nerve block for mandibular molars with irreversible pulpitis**
**Materials and Method:**
- 84 patients with acute irreversible pulpitis in a lower first molar tooth
- Randomly assigned to three groups of 28 patients each:
→ **Group I** - IAN block with 1.8 ml of LA soln*
→ **Group II** - IAN block with 3.6 ml of LA soln*
→ **Group III** - 1.8 ml as an IAN block PLUS 1.8 ml as a buccal infiltration
*OS:OM:OP:OR:Endo 2010;109:468–473*
## **Efficacy of combining a buccal infiltration with an inferior alveolar nerve block for mandibular molars with irreversible pulpitis**
*OS:OM:OP:OR:Endo 2010;109:468–473*
### **Materials and Method:**
- 84 patients with acute irreversible pulpitis in a lower first molar tooth
- Randomly assigned to three groups of 28 patients each:
→ **Group I** - IAN block with 1.8 ml of LA soln*
→ **Group II** - IAN block with 3.6 ml of LA soln*
→ **Group III** - 1.8 ml as an IAN block PLUS 1.8 ml as a buccal infiltration
**Pain Control During Endodontic Treatment**
**W/Prof. Paul V. Abbott AO**
**2nd Year DMD - 2020**
**Page 23**
---
**Efficacy of combining a buccal infiltration with an inferior alveolar nerve block for mandibular molars with irreversible pulpitis**
**Materials and Method:**
- Used Lignocaine 2% + 1:80,000 adrenaline
- Visual analogue scale to rate pain:
➜ Pre-operative - before LA
➜ At 15 minutes after LA injection
➜ During access cavity preparation
➜ During instrumentation of root canals
*OS:OM:OP:OR:Endo 2010;109:468–473*
---
**Efficacy of combining a buccal infiltration with an inferior alveolar nerve block for mandibular molars with irreversible pulpitis**
**Materials and Method:**
- Cold pulp sensibility test 15 mins after injn
- Data analyzed by chi-square, ANOVA, Kruskal-Wallis, and Mann-Whitney tests
*OS:OM:OP:OR:Endo 2010;109:468–473*
### **Materials and Method (Continued):**
- Used Lignocaine 2% + 1:80,000 adrenaline
- Visual analogue scale to rate pain:
→ Pre-operative - before LA
→ At 15 minutes after LA injection
→ During access cavity preparation
→ During instrumentation of root canals
- Cold pulp sensibility test 15 mins after injn
- Data analyzed by chi-square, ANOVA, Kruskal-Wallis, and Mann-Whitney tests
*OS:OM:OP:OR:Endo 2010;109:468–473*
**Pain Control During Endodontic Treatment**
*W/Prof. Paul V. Abbott AO*
**2nd Year DMD - 2020**
Page 24
---
**Efficacy of combining a buccal infiltration with an inferior alveolar nerve block for mandibular molars with irreversible pulpitis**
**Results:**
- Pre-op pain scores - no sig. diff.
→ Group I - 117.2 ± 29.9
→ Group II - 119.2 ± 22.8
→ Group III - 112.8 ± 30.4
**OS:OM:OP:OR:Endo 2010;109:468–473**
---
**Efficacy of combining a buccal infiltration with an inferior alveolar nerve block for mandibular molars with irreversible pulpitis**
**Results - overall success**
<table>
<thead>
<tr>
<th>Group</th>
<th>Technique</th>
<th>No Pain</th>
</tr>
</thead>
<tbody>
<tr>
<td>I</td>
<td>1.8 ml IAN Block</td>
<td>14.8%</td>
</tr>
<tr>
<td>II</td>
<td>3.6 ml IAN Block</td>
<td>39.3%</td>
</tr>
<tr>
<td>III</td>
<td>1.8 ml IAN Block + 1.8 ml Bu Infiltration</td>
<td>65.4%</td>
</tr>
</tbody>
</table>
**Sig. Diff**
*OS:OM:OP:OR:Endo 2010;109:468–473*
### **Results:**
- Pre-op pain scores - no sig. diff.
→ Group I - 117.2 ± 29.9
→ Group II - 119.2 ± 22.8
→ Group III - 112.8 ± 30.4
#### **Overall Success**
| **Group** | **Technique** | **No Pain** |
| :--- | :--- | :--- |
| I | 1.8 ml IAN Block | 14.8% |
| II | 3.6 ml IAN Block | 39.3% |
| III | 1.8 ml IAN Block + 1.8 ml Bu Infiltration | 65.4% |
*Sig. Diff*
> [!info]
> ==This indicates that adding a buccal infiltration is more effective than simply increasing the volume at the IAN block site. However, a 35% failure rate still exists.==
*OS:OM:OP:OR:Endo 2010;109:468–473*
**Pain Control During Endodontic Treatment**
**W/Prof. Paul V. Abbott AO**
**2nd Year DMD - 2020**
**Page 25**
---
**Efficacy of combining a buccal infiltration with an inferior alveolar nerve block for mandibular molars with irreversible pulpitis**
**No. of patients with pain at each stage and overall success**
**OS:OM:OP:OR:Endo 2010;109:468–473**
---
**Efficacy of combining a buccal infiltration with an inferior alveolar nerve block for mandibular molars with irreversible pulpitis**
- **Overall 49 (60.5%) pt’s had inadequate anaesthesia**
- **Only 17 responded to a cold pulp sensibility test 15 minutes after injection**
- ➔ More in Group I
- **32 pt’s had pain when access cavity prepared**
- ➔ Despite no response to a cold pulp test
- ➔ Group II - more when the pulp chamber was entered
**OS:OM:OP:OR:Endo 2010;109:468–473**
![]()
Bar chart showing pain/no pain at different stages for Group I and Group II, with annotations: "Pain", "No Pain", arrows indicating trends.
#### **No. of patients with pain at each stage and overall success**
- **Overall 49 (60.5%) pt’s had inadequate anaesthesia**
- **Only 17 responded to a cold pulp sensibility test 15 minutes after injection**
- → More in Group I
- **32 pt’s had pain when access cavity prepared**
- → Despite no response to a cold pulp test
- → Group II - more when the pulp chamber was entered
*OS:OM:OP:OR:Endo 2010;109:468–473*
**Pain Control During Endodontic Treatment**
*W/Prof. Paul V. Abbott AO*
**2nd Year DMD - 2020**
**Page 26**
---
**Efficacy of combining a buccal infiltration with an inferior alveolar nerve block for mandibular molars with irreversible pulpitis**
**Discussion:**
- Combining an IAN block with a Buccal infiltration provided more effective LA for acute irreversible pulpitis in lower molars
- Pulp testing after LA is not necessarily an indication of adequate pain control
→ Dentists need to be aware of the possible need for extra pain control strategies
*OS:OM:OP:OR:Endo 2010;109:468–473*
---
**Efficacy of combining a buccal infiltration with an inferior alveolar nerve block for mandibular molars with irreversible pulpitis**
**Discussion:**
- Group II better than Group I - but not sig. diff.
→ Greater volume of LA solution helps a little
→ But an alternative injection site was more effective
○ Targets different nerves which may be involved in the pain sensation process
*OS:OM:OP:OR:Endo 2010;109:468–473*
### **Discussion:**
- Combining an IAN block with a Buccal infiltration provided more effective LA for acute irreversible pulpitis in lower molars
- Pulp testing after LA is not necessarily an indication of adequate pain control
→ Dentists need to be aware of the possible need for extra pain control strategies
- Group II better than Group I - but not sig. diff.
→ Greater volume of LA solution helps a little
→ But an alternative injection site was more effective
- Targets different nerves which may be involved in the pain sensation process
*OS:OM:OP:OR:Endo 2010;109:468–473*
**Pain Control During Endodontic Treatment**
**W/Prof. Paul V. Abbott AO**
**2nd Year DMD - 2020**
**Page 27**
---
**Efficacy of combining a buccal infiltration with an inferior alveolar nerve block for mandibular molars with irreversible pulpitis**
**Discussion:**
- Two Articaine studies with both IAN and Bu
- Two Articaine studies with both IAN and Bu
> [!warning] Articaine vs. Lidocaine
> ==A review of the literature shows **no significant advantage** in using 4% articaine over 2% lidocaine for block anaesthesia in these situations. While some studies show a benefit for infiltration, its use for IAN blocks is discouraged due to its higher concentration (4% vs 2%) and the associated, albeit debated, increased risk of lingual nerve paraesthesia.==
**Pain Control During Endodontic Treatment**
**W/Prof. Paul V. Abbott AO**
**2nd Year DMD - 2020**
**Page 28**
---
**Efficacy of combining a buccal infiltration with an inferior alveolar nerve block for mandibular molars with irreversible pulpitis**
**Discussion:**
→ **Hence, no advantage in using Articaine**
→ **Beware potential side effects with IAN blocks**
→ **Esp. lingual nerve paraesthesia**
*OS:OM:OP:OR:Endo 2010;109:468–473*
---
**Efficacy of combining a buccal infiltration with an inferior alveolar nerve block for mandibular molars with irreversible pulpitis**
**Conclusions:**
- **More effective LA for acute irreversible pulpitis in lower molars when an IAN block is combined with a Bu infiltration**
- **However, some patients will still have pain !!**
*OS:OM:OP:OR:Endo 2010;109:468–473*
→ **Hence, no advantage in using Articaine**
→ **Beware potential side effects with IAN blocks**
→ **Esp. lingual nerve paraesthesia**
### **Conclusions:**
- **More effective LA for acute irreversible pulpitis in lower molars when an IAN block is combined with a Bu infiltration**
- **However, some patients will still have pain !!**
*OS:OM:OP:OR:Endo 2010;109:468–473*
**Pain Control During Endodontic Treatment**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 29
---
**Supplementary Injections - Other Teeth**
- Labial infiltration for lower anterior teeth
- Palatal infiltration for upper molars
- Palatal for upper premolars and anterior teeth
- Anterior middle superior alveolar (AMSA) nerve block
---
**Strategies to Manage Acute Irreversible Pulpitis in a Lower Molar**
1. Pre-empt the difficult situation - i.e. Diagnosis !!
2. Consider pre-medication with ibuprofen
3. Test tooth: triplex air + percussion during exam
4. Gow-Gates Block
→ First injection - then discuss findings, treatment, etc.
5. Re-test with triplex air and percussion
→ If no pain: place rubber dam and re-test !!
→ If still pain: Give IAN Block + Buccal Infiltration
6. Allow more time for LA to work
7. Place rubber dam - use cuff technique
## **Supplementary Injections - Other Teeth**
- Labial infiltration for lower anterior teeth
- Palatal infiltration for upper molars
- ==This is a highly effective supplement to a buccal infiltration because it directly anaesthetises the palatal root, which is often missed by buccal-only approaches.==
- Palatal for upper premolars and anterior teeth
- Anterior middle superior alveolar (AMSA) nerve block
## **Strategies to Manage Acute Irreversible Pulpitis in a Lower Molar (Continued)**
1. Pre-empt the difficult situation - i.e. Diagnosis !!
2. Consider pre-medication with ibuprofen
3. Test tooth: triplex air + percussion during exam
4. Gow-Gates Block
→ First injection - then discuss findings, treatment, etc.
5. Re-test with triplex air and percussion
→ If no pain: place rubber dam and re-test !!
→ If still pain: Give IAN Block + Buccal Infiltration
6. Allow more time for LA to work
7. Place rubber dam - use cuff technique
**Pain Control During Endodontic Treatment**
**W/Prof. Paul V. Abbott AO**
**2nd Year DMD - 2020**
**Page 30**
---
### **Rubber Dam Cuff Technique**
**Advantages:**
- Enables PDL injections if required
- Full access to the entire tooth
- Better vision
---
### **Strategies to Manage Acute Irreversible Pulpitis in a Lower Molar**
**8. Re-test again with triplex air and percussion**
→ **If no pain:** proceed with treatment
● **Turn the H/S handpiece water off !!**
→ **If pain:** give PDL injection and test again
● Can then normally cut enamel or restoration
## **Rubber Dam Cuff Technique**
==This technique involves isolating only the tooth being treated, without using a clamp.==
### **Advantages:**
- Enables PDL injections if required
- Full access to the entire tooth
- Better vision
## **Strategies to Manage Acute Irreversible Pulpitis in a Lower Molar (Continued)**
**8. Re-test again with triplex air and percussion**
→ **If no pain:** proceed with treatment
- **Turn the H/S handpiece water off !!**
→ **If pain:** give PDL injection and test again
- Can then normally cut enamel or restoration
**Pain Control During Endodontic Treatment**
**W/Prof. Paul V. Abbott AO**
**2nd Year DMD - 2020**
**Page 31**
**Periodontal Ligament Injection**
**Periodontal Ligament Injection**
![]()
Radiograph showing needle placement for periodontal ligament injection
![]()
Radiograph with magnified inset showing needle placement and bone detail
## **Periodontal Ligament Injection**
> [!info] Mechanism
> ==The PDL injection is effectively an **intraosseous injection** that works very quickly (20-30 seconds). The anaesthetic is not intended to track down the ligament space. Instead, high pressure forces the solution through the porous cancellous bone of the socket wall to reach the apex.==
### **Technique**
- ==Place the needle into the gingival sulcus, angled into the PDL space.==
- ==The **bevel of the needle must face the bone**, not the tooth root.==
- ==Inject with firm, steady pressure at 4-6 points around the tooth (e.g., mesiobuccal, distobuccal, mesiolingual, distolingual corners).==
- ==Only a very small amount of solution can be injected at each site.==
**Pain Control During Endodontic Treatment**
W/Prof. Paul V. Abbott AO
**Periodontal Ligament Injection**
**Periodontal Ligament Injection**
2nd Year DMD - 2020
Page 32
![]()
Diagram illustrating Periodontal Ligament Injection with radiographic and anatomical views.
![]()
Clinical image showing injection sites in the periodontal ligament, marked with purple arrows.
**Pain Control During Endodontic Treatment**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 33
---
**Periodontal Ligament Injection**
---
**Periodontal Ligament Injection**
| Device | Label |
|--------------------|-------------------|
|  | **Ligaject** |
| | **Citoject** |
|  | **Standard LA syringe** |
---
**2nd Year DMD - 2020**
**Page 33**
![]()
Periodontal Ligament Injection diagram with labeled arrows pointing to injection sites on teeth.
<table>
<tr>
<td></td>
<td><strong>Ligaject</strong></td>
</tr>
<tr>
<td></td>
<td><strong>Citoject</strong></td>
</tr>
<tr>
<td></td>
<td><strong>Standard LA syringe</strong></td>
</tr>
</table>
**Pain Control During Endodontic Treatment**
**W/Prof. Paul V. Abbott AO**
**Periodontal Ligament Injection**
Extra short - 12 mm
Short - 22 mm
Long - 35 mm
**Intra-osseous Injections**
Stabident
2nd Year DMD - 2020
Page 34
### **Needle Lengths**
- Extra short - 12 mm
- Short - 22 mm
- Long - 35 mm
## **Intra-osseous Injections**
- Stabident
**Pain Control During Endodontic Treatment**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 35
---
**Intra-osseous Injections**
*X-Tip*
---
**Strategies to Manage Acute Irreversible Pulpitis in a Lower Molar**
8. Re-test again with triplex air and percussion
→ If no pain: proceed with treatment
• Turn the H/S handpiece water off !!
→ If pain: give PDL injection and test again
• Can then normally cut enamel or restoration
9. If pain felt on reaching the dentine
→ PDL injection
10. If pain felt on reaching the pulp
→ Intra-pulp injection
- *X-Tip*
> [!warning]
> ==While dedicated systems exist for direct intraosseous injection, they are less practical. They are difficult to use, cannot be administered with a rubber dam in place, and carry a risk of iatrogenic damage to the tooth root. The PDL injection is a simpler and safer alternative.==
## **Strategies to Manage Acute Irreversible Pulpitis in a Lower Molar (Continued)**
8. Re-test again with triplex air and percussion
→ If no pain: proceed with treatment
- Turn the H/S handpiece water off !!
→ If pain: give PDL injection and test again
- Can then normally cut enamel or restoration
9. If pain felt on reaching the dentine
→ PDL injection
10. If pain felt on reaching the pulp
→ Intra-pulp injection
**Pain Control During Endodontic Treatment**
*W/Prof. Paul V. Abbott AO*
**2nd Year DMD - 2020**
Page 36
---
### **Intra-Pulp Injection**
---
### **Strategies to Manage Acute Irreversible Pulpitis in a Lower Molar**
8. **Re-test again with triplex air and percussion**
→ If no pain: proceed with treatment
→ If pain: give PDL injection and test again
• Can then normally cut enamel or restoration
• **Remember - turn the H/S handpiece water off !!**
9. **If pain felt on reaching the dentine**
→ PDL injection
10. **If pain felt on reaching the pulp**
→ Intra-pulp injection
11. **If still pain**
→ Pulpotomy only - CS-AB dressing
→ Re-appoint - 3-4 weeks later
![]()
Illustration showing three tooth diagrams: first with green checkmark indicating correct needle placement, second with red X indicating incorrect placement, third with green checkmark indicating correct placement with pulp access.
## **Intra-Pulp Injection**
> [!tip] Technique
> ==This injection is most effective when administered through a **very small pulp exposure**. The small opening allows for the creation of back-pressure, which forces the anaesthetic solution into the pulp tissue, achieving profound anaesthesia. It is recommended to give an intra-pulp injection proactively as soon as a pinpoint exposure is made. If the pulp chamber is widely opened, the lack of back-pressure renders the technique ineffective.==
## **Strategies to Manage Acute Irreversible Pulpitis in a Lower Molar (Final)**
8. **Re-test again with triplex air and percussion**
→ If no pain: proceed with treatment
→ If pain: give PDL injection and test again
- Can then normally cut enamel or restoration
- **Remember - turn the H/S handpiece water off !!**
9. **If pain felt on reaching the dentine**
→ PDL injection
10. **If pain felt on reaching the pulp**
→ Intra-pulp injection
11. **If still pain**
→ Pulpotomy only - CS-AB dressing
- ==The goal should shift from complete instrumentation to pain relief. Place a corticosteroid-antibiotic paste (e.g., **Leder mix paste**) over the canal orifices to control inflammation.==
→ Re-appoint - 3-4 weeks later
**Pain Control During Endodontic Treatment**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 37
---
**Pain Relief after Pulpotomy**
*Hargreaves & Baumgartner - 2006*
---
**Acute Irreversible Pulpitis - Lower Molar Tooth**
```mermaid
flowchart TD
A[Discuss Diagnosis, Treatment Plan, etc] --> B[TEST - Cold, Percussion]
B --> C[Gow-Gates Mandibular Block]
C --> D[TEST - Cold, Percussion]
D --> E[Inferior Alveolar Nerve Block + Buccal Infiltration]
E --> F[TEST - Cold, Percussion]
F --> G[Periodontal Ligament Injection]
G --> H[TEST - Cold, Percussion]
H --> I[Intra-Pulp Injection]
I --> J[Pulpotomy + CS-AB Dressing]
```
![]()
Bar chart showing pain relief percentages after various interventions for acute irreversible pulpitis in lower molar teeth. Includes labels: "Pain relative to pre-operative pain (100%)", "Weighted average 18%", and categories: Gow-Gates, Mandibular Block, Inferior Alveolar Nerve Block + Buccal Infiltration, Periodontal Ligament Injection, Intra-Pulp Injection, Pulpotomy + CS-AB Dressing.
## **Pain Relief after Pulpotomy**
*Hargreaves & Baumgartner - 2006*
> [!success]
> ==A pulpotomy is highly effective for pain relief. One study found that it can reduce pre-operative pain by an average of 82% (from 100% down to 18%).==
## **Acute Irreversible Pulpitis - Lower Molar Tooth (Flowchart)**
```mermaid
flowchart TD
A[Discuss Diagnosis, Treatment Plan, etc] --> B[TEST - Cold, Percussion]
B --> C[Gow-Gates Mandibular Block]
C --> D[TEST - Cold, Percussion]
D --> E[Inferior Alveolar Nerve Block + Buccal Infiltration]
E --> F[TEST - Cold, Percussion]
F --> G[Periodontal Ligament Injection]
G --> H[TEST - Cold, Percussion]
H --> I[Intra-Pulp Injection]
I --> J[Pulpotomy + CS-AB Dressing]
```
**Pain Control During Endodontic Treatment**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 38
---
**And ...**
❌ **Do NOT prescribe antibiotics !!!**
- AB’s are unnecessary and contra-indicated
- AB’s are not pain relieving medications
- AB’s do not help treat inflammation
- Pulpitis is an **INFLAMMATORY** condition
- Even though it is caused by the presence of bacteria in the tooth
- And a systemically-administered AB will not reach the bacteria in in the caries, crack, restoration/tooth interface, etc.
---
**Root Canal Memoirs**
- By a patient - a theatre OMFS nurse
- Classic description
- 37 - Acute irreversible pulpitis
- Endodontic treatment started
- But with local anaesthesia problems
- **+ a prescription for Antibiotics!!!**
## **And ...**
❌ **Do NOT prescribe antibiotics !!!**
- AB’s are unnecessary and contra-indicated
- AB’s are not pain relieving medications
- AB’s do not help treat inflammation
- Pulpitis is an **INFLAMMATORY** condition
- Even though it is caused by the presence of bacteria in the tooth
- And a systemically-administered AB will not reach the bacteria in in the caries, crack, restoration/tooth interface, etc.
> [!danger]
> ==Prescribing antibiotics in this situation is inappropriate, ineffective (acting only as a placebo), and contributes to antibiotic resistance. Pain should be managed with **analgesics and NSAIDs**, not antibiotics.==
## **Root Canal Memoirs**
- By a patient - a theatre OMFS nurse
- Classic description
- 37 - Acute irreversible pulpitis
- Endodontic treatment started
- But with local anaesthesia problems
- **+ a prescription for Antibiotics!!!**
**Pain Control During Endodontic Treatment**
W/Prof. Paul V. Abbott AO
---
**Strategies for Managing Pain During Endodontic Treatment**
Abbott PV, Parirokh M.
*Aust Endo J 2018; 44: 99-113.*
---
**Summary**
- Achieving adequate pain control is difficult, and unpredictable, when treating acute irreversible pulpitis
- Dentists need various strategies to ensure good pain control for their patients
- Before treatment
- During treatment
- After treatment
---
2nd Year DMD - 2020
Page 39
**Strategies for Managing Pain During Endodontic Treatment**
Abbott PV, Parirokh M.
*Aust Endo J 2018; 44: 99-113.*
## **Summary**
- Achieving adequate pain control is difficult, and unpredictable, when treating acute irreversible pulpitis
- Dentists need various strategies to ensure good pain control for their patients
- Before treatment
- During treatment
- After treatment
**Pain Control During Endodontic Treatment**
**W/Prof. Paul V. Abbott AO**
**Summary**
1. **Pre-empt the difficult situation**
2. **Consider pre-medication**
3. **Test tooth pre-op:**
➜ Triplex air + percussion
4. **Gow-Gates Block**
➜ Discuss treatment, etc.
5. **Re-test: triplex air + percussion**
➜ If no pain: proceed with treatm
➜ Turn water off H/S handpiece
➜ If still pain: Give IAN Block + Buccal Infiltration
6. **Allow more time for LA to work**
7. **Place rubber dam - cuff tech.**
8. **Re-test again: air + percussion**
➜ If no pain: proceed with treatm
➜ Turn water off H/S handpiece
➜ If pain: give PDL injection
9. **If pain felt on reaching dentine**
➜ PDL injection
10. **If pain felt on reaching the pulp**
➜ Intra-pulp injection
11. **If still pain**
➜ Pulpotomy - CS-AB dressing
➜ Re-appoint - 3-4 weeks later
*2nd Year DMD - 2020*
*Page 40*
## **Summary of Management Strategy**
1. **Pre-empt the difficult situation**
2. **Consider pre-medication**
3. **Test tooth pre-op:**
→ Triplex air + percussion
4. **Gow-Gates Block**
→ Discuss treatment, etc.
5. **Re-test: triplex air + percussion**
→ If no pain: proceed with treatm
→ Turn water off H/S handpiece
→ If still pain: Give IAN Block + Buccal Infiltration
6. **Allow more time for LA to work**
7. **Place rubber dam - cuff tech.**
8. **Re-test again: air + percussion**
→ If no pain: proceed with treatm
→ Turn water off H/S handpiece
→ If pain: give PDL injection
9. **If pain felt on reaching dentine**
→ PDL injection
10. **If pain felt on reaching the pulp**
→ Intra-pulp injection
11. **If still pain**
→ Pulpotomy - CS-AB dressing
→ Re-appoint - 3-4 weeks later
# **Post-Operative Follow-up**
## **Timeline**
- 3-4 weeks later
## **Additional Instructions**
- ==Patients should be prescribed appropriate **analgesics or anti-inflammatory agents** (e.g., ibuprofen) for post-operative pain management.==
- ==Patients should be explicitly told that **antibiotics are not necessary or helpful** for this condition.==
This lecture contains lots of graphical figures and study results. For grahpical figures omit any mention unless it can be used to add context to the exsiting text. For academic studies, their results should be summarized into 1 or 2 key points maximum (as they often contain unneccessary informat).
[[O1A Pain control During retreatment.pdf#page=1|O1A Pain control During retreatment, p.1]]
[[O1A Pain control During retreatment.pdf#page=2|O1A Pain control During retreatment, p.2]]
[[O1A Pain control During retreatment.pdf#page=3|O1A Pain control During retreatment, p.3]]
[[O1A Pain control During retreatment.pdf#page=4|O1A Pain control During retreatment, p.4]]
[[O1A Pain control During retreatment.pdf#page=5|O1A Pain control During retreatment, p.5]]
[[O1A Pain control During retreatment.pdf#page=6|O1A Pain control During retreatment, p.6]]
[[O1A Pain control During retreatment.pdf#page=7|O1A Pain control During retreatment, p.7]]
[[O1A Pain control During retreatment.pdf#page=8|O1A Pain control During retreatment, p.8]]
[[O1A Pain control During retreatment.pdf#page=9|O1A Pain control During retreatment, p.9]]
[[O1A Pain control During retreatment.pdf#page=10|O1A Pain control During retreatment, p.10]]
[[O1A Pain control During retreatment.pdf#page=11|O1A Pain control During retreatment, p.11]]
[[O1A Pain control During retreatment.pdf#page=12|O1A Pain control During retreatment, p.12]]
[[O1A Pain control During retreatment.pdf#page=13|O1A Pain control During retreatment, p.13]]
[[O1A Pain control During retreatment.pdf#page=14|O1A Pain control During retreatment, p.14]]
[[O1A Pain control During retreatment.pdf#page=15|O1A Pain control During retreatment, p.15]]
[[O1A Pain control During retreatment.pdf#page=16|O1A Pain control During retreatment, p.16]]
[[O1A Pain control During retreatment.pdf#page=17|O1A Pain control During retreatment, p.17]]
[[O1A Pain control During retreatment.pdf#page=18|O1A Pain control During retreatment, p.18]]
[[O1A Pain control During retreatment.pdf#page=19|O1A Pain control During retreatment, p.19]]
[[O1A Pain control During retreatment.pdf#page=20|O1A Pain control During retreatment, p.20]]
[[O1A Pain control During retreatment.pdf#page=21|O1A Pain control During retreatment, p.21]]
[[O1A Pain control During retreatment.pdf#page=22|O1A Pain control During retreatment, p.22]]
[[O1A Pain control During retreatment.pdf#page=23|O1A Pain control During retreatment, p.23]]
[[O1A Pain control During retreatment.pdf#page=24|O1A Pain control During retreatment, p.24]]
[[O1A Pain control During retreatment.pdf#page=25|O1A Pain control During retreatment, p.25]]
[[O1A Pain control During retreatment.pdf#page=26|O1A Pain control During retreatment, p.26]]
[[O1A Pain control During retreatment.pdf#page=27|O1A Pain control During retreatment, p.27]]
[[O1A Pain control During retreatment.pdf#page=28|O1A Pain control During retreatment, p.28]]
[[O1A Pain control During retreatment.pdf#page=29|O1A Pain control During retreatment, p.29]]
[[O1A Pain control During retreatment.pdf#page=30|O1A Pain control During retreatment, p.30]]
[[O1A Pain control During retreatment.pdf#page=31|O1A Pain control During retreatment, p.31]]
[[O1A Pain control During retreatment.pdf#page=32|O1A Pain control During retreatment, p.32]]
[[O1A Pain control During retreatment.pdf#page=33|O1A Pain control During retreatment, p.33]]
[[O1A Pain control During retreatment.pdf#page=34|O1A Pain control During retreatment, p.34]]
[[O1A Pain control During retreatment.pdf#page=35|O1A Pain control During retreatment, p.35]]
[[O1A Pain control During retreatment.pdf#page=36|O1A Pain control During retreatment, p.36]]
[[O1A Pain control During retreatment.pdf#page=37|O1A Pain control During retreatment, p.37]]
[[O1A Pain control During retreatment.pdf#page=38|O1A Pain control During retreatment, p.38]]
[[O1A Pain control During retreatment.pdf#page=39|O1A Pain control During retreatment, p.39]]
[[O1A Pain control During retreatment.pdf#page=40|O1A Pain control During retreatment, p.40]]