1. Management of Nontraumatic,
Endodontic Emergencies

2. • Patient
• Staff
• Dentist
Emergency Impacts

3. • Pain
• Pain and swelling
• Trauma (later
lecture)
Patient Presentation

4. • Diagnosis
• Definitive dental treatment
• Drugs
3 D’s of
Successful Management

5. 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

6. Treatment Plan
to
REMOVE
the
ETIOLOGY

7. When do patients present for
emergency endodontic care?
• No prior RCT / initial infection
• After RCT initiated
• After obturation

8. Initial Presentation
• PAIN!
• Primary
infection

9. After Initiation of
Endodontic Therapy
FLARE-UP!

10. After Initiation
of
Endodontic Treatment
Before obturation

11. After Obturation
• Recent
obturation
• Non-healing
endodontic
therapy

12. Determine a
Pulpal
and
Periradicular
Diagnosis

13. • Normal pulp
• Reversible pulpitis
• Irreversible pulpitis
• Necrotic pulp
• Pulpless/
previously treated
Pulpal DiagnosisPulpal Diagnosis

14. • Normal periradicular
tissues
• Acute periradicular
periodontitis
• Acute periradicular
abscess
Periradicular DiagnosisPeriradicular Diagnosis

15. • Chronic periradicular
periodontitis
• Symptomatic
• Asymptomatic
• Chronic periradicular
abscess (suppurative
periradicular
periodontitis)
Periradicular DiagnosisPeriradicular Diagnosis

16. • Focal sclerosing
osteomyelitis
(condensing osteitis):
LEO
Periradicular DiagnosisPeriradicular Diagnosis

17. 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?

18. Contents of the
Root Canal
• Pulp tissue
• Bacteria
• Bacterial by-products
• Endodontic therapy materials

19. Dentist
Controlled Factors
• Over-instrumentation
• Inadequate debridement
• Missed canal
• Hyper-occlusion*
• Debris extrusion
• Procedural complications*

20. Hyperocclusion
• Rosenberg PA, Babick PJ,
Schertzer L, Leung A. The effect
of occlusal reduction on pain after
endodontic instrumentation. J
Endodon 1998;24:492.

21. Hyperocclusion
• Researchers have
found that patients
most likely to benefit
from occlusal
reduction are those
whose teeth initially
present with
symptoms.
• Indiscriminant
reduction of the
occlusal surface is
not indicated
• PRE-OP PAIN
• PULP VITALITY
• PERCUSSION
SENSITIVITY
• ABSENCE OF A
PERIRADICULAR
RADIOLUCENCY
• COMBINATION OF
THESE SYMPTOMS

22. Procedural
Complications
• Perforation
• Separated instrument
• Zip
• Strip
• NaOCl accident
• Air emphysema
• Wrong tooth

23. Dentist
Controlled Factors
Dentist’s personalityDentist’s personality

24. Host Factors
• Allergies
• Age
• Sex
• Emotional state

25. Host Factors
• Complex
etiology
• Microbiologic
• Immunologic
• Inflammatory

26. Bacteria!
• Bacterial by-
products/
endotoxin

27. Host Defense is Multi-
factorial
C E L L S
n e u tro p h ils , lym p h o c yte s ,
p la s m a c e lls , m a c ro p h a g e s ,
o s te o c la s ts , e p ith e lia l c e lls , d e n d ritic c e lls
M O L E C U L A R M E D IA T O R S
c yto k in e s (IL , IF N , C S F , T G F )
e ic o s a n o id s (P G , L T )
e n z ym a tic e ffe c to r m o le c u le s
A N T IB O D IE S
im m u n o g lo b u lin s (Ig G , e tc .)
p ro d u c e d b y p la s m a c e lls
M ixe d M ic ro flo ra

28. • Diagnosis
• Definitive dental treatment
• Drugs
Three D’s
of
Successful Management

29. Emergency
Treatment
• Non-surgical
• Surgical
• Combined

30. • Pulpotomy
• Partial pulpectomy
• Complete pulpectomy
• Debridement of the
root canal system*
Non-surgical
Emergency Treatment

31. Surgical
Emergency Treatment
Incision for drainage
Trephination/apical fenestration

32. • Decreases number of bacteria
• Reduces tissue pressure
• Alleviates pain/trismus
• Improves circulation
• Prevents spread of infection
• Alters oxidation-reduction potential
• Accelerates healing
Rationale for I & D

33. Management
• Inadequate
debridement
• Debris extrusion
• Over-instrumentation
• Missed canal
• Fluctuant swelling
• Severe pain, no
swelling

34. Treatment
• For severe pain without visible
swelling…
• Trephination!

35. QUESTIONS

36. “Should I leave the tooth
OPEN or CLOSED?”

37. “Should I place an
Interappointment
Medicament?”
Ca(OH)2

38. “Should I prescribe
ANTIBIOTICS?”

39. • Diagnosis
• Definitive Dental Treatment
• Drugs
Three D’s
of
Successful Management

40. Remember, there is a
Complex Etiology
• Microbiologic
• Immunologic
• Inflammatory

41. And, not all can be
easily treated...
• Debris extrusion
• Over-instrumentation
• Over-filling
• Over-extension

42. Breaking
the

43. Use a Flexible
Analgesic
Strategy

44. • Pre - op / loading dose
• Long acting anesthesia
• Prescription
Drugs

45. Codeine
• Prototype opioid for orally available
combination drugs
• Studies found that 60 mg of codeine
(2 T-3) produces significantly more
analgesia than placebo but less
analgesia than 650 mg aspirin, or
600 mg acetaminophen

46. Codeine
Patients taking 30 mg of codeine
report only as much analgesia as
placebo

47. • 57 patients
• Local anesthesia,
pulpectomy, post- op
analgesic
• Placebo
• 600 mg ibuprofen
• 600 mg ibuprofen & 1000 mg
acetaminophen
Ibuprofen and
Acetaminophen

48. • 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 and
Acetaminophen*

49. “The results demonstrate
that the combination of
ibuprofen and
acetaminophen may be
more effective than
ibuprofen alone for the
management of
postoperative endodontic
pain.”
Ibuprofen and
Acetaminophen*

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

51. Flexible Analgesic Plan
M I L D
2 0 0 - 4 0 0 m g ib u p r o fe n
o r 6 5 0 m g a s p ir in
M O D E R A T E
6 0 0 - 8 0 0 m g ib u p r o fe n
p lu s c o m b o a n a lg e s ic =
6 0 m g c o d e in e
S E V E R E
6 0 0 - 8 0 0 m g ib u p r o fe n
p lu s c o m b o a n a lg e s ic =
1 0 m g o x y c o d o n e
A s p ir in - lik e D r u g s a r e I n d ic a t e d

52. Flexible Analgesic Plan
M IL D
6 0 0 -1 0 0 0 a c e ta m in o p h e n
M O D E R A T E
6 0 0 -1 0 0 0 m g a c e ta m in o p h e n
a n d o p ia te =
6 0 m g c o d e in e
S E V E R E
1 0 0 0 m g a c e ta m in o p h e n
a n d o p ia te =
1 0 m g o x y c o d o n e
A s p irin -lik e D ru g s a re C o n tra in d ic a te d

53. Selected NSAID Drug
Interactions
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

54. • Systemic involvement
• Compromised host
resistance
• Fascial space involvement
• Inadequate surgical
drainage
Indications for
Antibiotic Therapy

55. Select antibiotic with
anaerobic spectrum
Use a larger dose for a
shorter period of time (“hard
and fast” rule)
Guidelines for
Antibiotic Therapy

56. • 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
Selecting the
Appropriate Antibiotic

57. 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

58. Metronidozole
(Flagyl)
• Used in conjunction with Penicillin
V
• 500 mg of Penicillin V with 250 mg
Metronidozole, qid x 7-10 days

59. Clindamycin
• Loading dose: 300 mg
• 150-300 mg qid x 10 days

60. Closely Follow All Infected Patients

61. Components of a
Successful Management
• Appropriate attitude of
dentist
• Proper patient management
• Accurate diagnosis
• Profound anesthesia
• Prompt and effective
treatment

62. Patient Instructions
• By the Clock
• NOT
• PRN

63. Questions ?