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Patient Presentation  Pain  Pain and swelling  Trauma (later lecture)

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Page 1: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)
Page 2: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Emergency Impacts

Patient Staff Dentist

Page 3: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Patient Presentation

Pain Pain and swelling Trauma (later lecture)

Page 4: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

3 D’s ofSuccessful Management

Diagnosis Definitive dental treatment Drugs

Page 5: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Diagnosis

Page 6: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

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

Page 7: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Treatment Planto

REMOVEthe

ETIOLOGY

Page 8: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

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

Page 9: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Initial Presentation

PAIN!

Primary infection

Page 10: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

After Initiation ofEndodontic Therapy

Page 11: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

After Initiation ofEndodontic Therapy FLARE-UP!

Page 12: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

After InitiationofEndodontic Treatment Before obturation

Page 13: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

After Obturation

Recent obturation

Non-healing endodontic therapy

Page 14: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Determine aPulpal

andPeriradicular

Diagnosis

Page 15: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

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

Page 16: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Periradicular Diagnosis Normal periradicular tissues Acute periradicular periodontitis Acute periradicular abscess

Page 17: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Periradicular Diagnosis Chronic periradicular periodontitis

Symptomatic Asymptomatic

Chronic periradicular abscess (suppurative periradicular periodontitis)

Page 18: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Periradicular DiagnosisFocal sclerosing

osteomyelitis(condensing osteitis):

LEO

Page 19: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

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?

Page 20: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Contents of theRoot Canal Pulp tissue Bacteria Bacterial by-

products Endodontic therapy

materials

Page 21: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

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

Page 22: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

HyperocclusionRosenberg PA, Babick PJ, Schertzer L,

Leung A. The effect of occlusalreduction on pain after endodontic

instrumentation. J Endodon1998;24:492.

Page 23: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

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

Page 24: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

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

Page 25: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

DentistControlled Factors Dentist’s

personality

Page 26: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Host Factors Allergies Age Sex Emotional state

Page 27: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Host Factors

Complex etiology

Microbiologic Immunologic Inflammatory

Page 28: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Bacteria! Bacterial

byproducts/ endotoxin

Page 29: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Host Defense is Multi-factorial

Page 30: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Three D’sofSuccessful Management

Diagnosis Definitive dental treatment Drugs

Page 31: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

EmergencyTreatment

Non-surgical Surgical Combined

Page 32: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Non-surgicalEmergency Treatment

Pulpotomy Partial pulpectomy Complete pulpectomy Debridement of the root canal

system*

Page 33: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

SurgicalEmergency Treatment

Incision for drainage

Trephination/apical fenestration

Page 34: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

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

Page 35: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

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

Page 36: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Treatment For severe pain without visible

swelling… Trephination!

Page 37: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

QUESTIONS

Page 38: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

“Should I leave the tooth OPEN or CLOSED?”

Page 39: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

“Should I place anInter-appointment

Medicament?”Ca(OH)2

Page 40: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

“Should I prescribeANTIBIOTICS?”

Page 41: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Three D’sofSuccessful Management

Diagnosis Definitive Dental Treatment Drugs

Page 42: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Remember, there is aComplex Etiology

Microbiologic Immunologic Inflammatory

Page 43: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

And, not all can be easilytreated...

Debris extrusion Over-instrumentation Over-filling Over-extension

Page 44: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Breakingthe

Page 45: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Use a Flexible AnalgesicStrategy

Page 46: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Drugs Pre - op / loading dose Long acting anesthesia Prescription

Page 47: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

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.

Page 48: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

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.

Page 49: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

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.

Page 50: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

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

Page 51: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Ibuprofen andAcetaminophen*

“The results demonstrate thatthe combination of ibuprofenand acetaminophen may be

more effective than ibuprofenalone for the management of

postoperative endodonticpain.”

Page 52: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

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

Page 53: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Flexible Analgesic Plan

Page 54: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Flexible Analgesic Plan

Page 55: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

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

Page 56: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Indications forAntibiotic Therapy Systemic involvement Compromised host

resistance Fascial space involvement Inadequate surgical

drainage

Page 57: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Guidelines forAntibiotic Therapy

Select antibiotic with anaerobicspectrum

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

rule)

Page 58: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

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

Page 59: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

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

Page 60: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Metronidozole(Flagyl) Used in conjunction with

Penicillin V 500 mg of Penicillin V with

250 mg Metronidozole, qid x 7-10 days

Page 61: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

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

Page 62: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Closely Follow All InfectedPatients

Page 63: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Components of aSuccessful Management Appropriate attitude of dentist Proper patient management Accurate diagnosis Profound anesthesia Prompt and effective

treatment

Page 64: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

Patient Instructions By the Clock NOT PRN

Page 65: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

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

Page 66: Emergency Impacts Patient Staff Dentist Patient Presentation Pain Pain and swelling Trauma (later lecture)

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