Dr Rosenberg Endodontic pain.pdf

Endodontic Pain: CLINICAL FACTORS Lecture 2 Paul A. Rosenberg, DDS Diplomate American Board of Endodonti cs Professor Department of Endodonti cs NYUCD [email protected] October 20,2023 Pizzo PA, et al. Alleviating Suffering: Pain Relief in the United States N Engl J Med 2012 Effectiveness of pain t...

Endodontic Pain: CLINICAL FACTORS Lecture 2 Paul A. Rosenberg, DDS Diplomate American Board of Endodonti cs Professor Department of Endodonti cs NYUCD [email protected] October 20,2023 Pizzo PA, et al. Alleviating Suffering: Pain Relief in the United States N Engl J Med 2012 Effectiveness of pain treatment depends greatly on the strength of the clinician-patient relationship. Pain treatment is never about the intervention alone, but about the clinician and patient working together. Local Anesthesia and Irreversible Pulpitis What is irreversible pulpitis? Irreversible pulpitis is characterized by : • Acute lingering pain following a cold stimuli • Heat may also cause pain • Sensitivity to percussion • Spontaneous pain • These symptoms indicate the pulp is beyond repair without an intervention EFFECT OF INFLAMMATION ON INF. ALVEOLAR NERVE BLOCK 1.8 CC OF LIDOCAINE WITH 1: 100,000 EPI. NORMAL PULP  75-90% EFFECTIVE IRREVERSIBLE PULPITIS  30-80% INEFFECTIVE !!!! HARGREAVES KM AND KEISER K. LOCAL ANESTHETIC FAILURES IN ENDODONTICS ENDODONTIC TOPICS 2002 ; 1: 26-39. …STUDIES INDICATE THAT ANESTHETIC BLOCKS GIVEN TO PATIENTS WITH IRREV. PULPITIS IN A MANDIBULAR TOOTH HAVE , ON AVERAGE……. ONLY A 55% INCIDENCE OF PULPAL ANESTHESIA, EVEN IN THE PRESENCE OF 100% LIP NUMBNESS. HARGREAVES KM AND KEISER K. LOCAL ANESTHETIC FAILURE IN ENDODONTICS ENDODONTIC TOPICS 2002 ;1: 26-39. Other studies… RESULTS OF CLINICAL STUDIES… “… PATIENTS WITH IRREVERSIBLE PULPITIS HAD AN 8 - FOLD HIGHER FAILURE OF LOCAL ANESTHETIC INJECTIONS IN COMPARISON TO NORMAL CONTROL PATIENTS.” Lip Numbness: Soft Tissue vs. Dental Anesthesia Check the Chief Complaint Before Starting! When is your patient ready to start an Endodontic procedure? • Numb lip? • Numb gingiva? • Tingling lip? None of the above !!!! Hsiao-Wu GW et al. Use of the Cold Test as a Measure of Pulpal Anesthesia During Endodontic Therapy JEndod 2007;33:406-410 • Soft tissue signs are inadequate to assess pulpal anesthesia during RCT • Subjects who received a negative response to a cold test were approximately 80% less likely to experience pain during RCT compared to those A numb lip is a poor way to assess profound local anesthesia!!! Use a cold test and/or the chief complaint to assess local anesthesia!!! Endo Ice • Is there a response to application of cotton soaked with Endo Ice spray? IF THE ANSWER IS “YES”, THE PATIENT DOES NO HAVE COMPLETE LOCAL ANESTHESIA!!! Important clinical strategy • If a patient does not have a numb lip… provide an additional mandibular block • If a patient has a profoundly numb lip but still has pain from provocation with the chief complaint , Endo Ice or percussion… provide a supplemental injection “THE HOT TOOTH” Consider the biologic process Wallace JA et al. Clinical Problem of Regionally Anesthetizing the Pulp of an Acutely Inflamed Mandibular Molar. Oral Surg Oral Med Oral Pathol. 1985; 123: 27-34. “ Nerves in inflamed tissue have altered thresholds, resting potentials and excitability.” Will this case pose a problem with anesthesia ? What is the probable biological process… “…A situation in which in spite of the local anesthetic agent, transmission of the impulse does Strategies: Local Anesthesia     Infiltration Nitrous Oxide Oral Sedation Additional Block     Ligamental Intraosseous Intrapulpal IV Sedation* Ligamental Intraosseous Intrapulpal X Birchfield J, and Rosenberg PA. Role of the Anesthetic Solution in Intrapulpal Anesthesia. J Endod 1975;1:26-27 • Intrapupal injections (saline or local anesthetic ) were given in a double blind manner… • Anesthesia produced by the intrapulpal technique was not the result of the anesthetic solution… Pressure seemed to be the key factor. Nitrous Oxide Patient with rubber Dam and nitrous mask Predisposing factors that affect a patient’s variable responses to endodontic procedures. Genetics STRESS Immune System Sex Age Environmenta l Factors Comorbidities de Sa AR, et al • Association of IL1B, IL6, IL10 and TNFA functional gene polymorphisms with symptomatic dental abscesses • Int Endo J. 2007;40: 563-572 Summary: • …the study suggests that genetic factors are associated with a susceptibility to develop symptomatic dental abscesses Menezes –Silva R et al • Genetic Susceptiblity to Periapical Disease: Conditional Contribution of MMP2 and MMP3 Genes to Development of Periapical Lesions and Healing Response JEndod 2012;38:604-607 Summary: • Findings suggest that markers in MMP3 and MMP2 genes could predict host susceptibility to developing periapical lesions and the healing response Conclusions • Genetic predisposition in certain genes can contribute to persistent apical periodontitis Karatas E, et al. Association Between Single-Nucleotide Polymorphisms in Candidate Genes and Success of Pulpal Anesthesia after Inferior Alveolar Nerve Block J. Endod 2023;49:18-25 In patients with symptomatic irreversible pulpitis, it may be concluded that variations in SCN10A gene affect the success rate of anesthesia after IANB Antunes LS et al. Association between genetic polymorphisms in the promoter region of the Defensin Beta 1 gene and persistent apical periodontitis Int Endo J. 2020; 53: 1167-1312 Compared genomic DNA from saliva of 73 patients with post-treatment PAP and 89 patients with healed PAP: 1 Year follow-up Polymorphisms in DEFB1 genes were associated with the development of post-treatment persistent apical periodontitis (P< 0.0001) Pharmacogenomics NIH December 2013 The study of how genes affect the way medicines work in your body is called pharmacogenomics. If doctors know your genes, they can predict drug responses and incorporate this information into their medical decisions. By screening to know who should not get certain drugs life-threatening side reactions can be prevented. Examples of Remarkable Specificity Genetic Variations and Opioids CYP2D6, a gene variant, is associated with enhanced responses to codeine, which can increase i toxicity by increasing the metabolism of codeine to morphine. Codeine and Tramadol are ineffective in patients with genetic variants that result in low or no CYP2D6 activity. Stamer IM et al. 2012 Summary: Genetic Research Potential Predict: patients susceptible to abscess formation Predict: Response to treatment of those with apical periodontitis Assist in pharmacologic management of post-op pain Identify those with increased susceptibility to PA pathosis Identify those with an increased susceptibility to persistent PA pathosis Genetic and non genetic variables influencing the response to an analgesic A Complex Mix Genetic background Sex, age, organ function Psychological variables, anxiety Severity and type of pain Social-environmental variables Comorbidities Placebo effect, patient compliance Pharmacodynamics Stamer UM et al, Phamacogenomics, Genetics The 600 pound gorilla in the room??? What is the importance of prior painful dental visits ? The mass of evidence suggests that women and men are not affected in the same way by pain disorders. Fillingim RB, et al. Sex, Gender, and Pain: A Review of Recent Clinical and Experimental findings. Pain 2009;10: 447-485 …evidence clearly demonstrates that women are at substantially greater risk for many clinical pain conditions …a growing body of evidence over the last 1015 years indicates that there are substantial sex differences in clinical and experimental pain responses and some evidence suggests that pain treatment responses may differ for women and men. Clinical studies of multiple pain disorders indicate that a patient’s sex is a common risk factor for pain. Filingim RB, et al Sex, Gender and Pain: A Review Pain, 2009 Gender and Pain Society for Neuroscience May 2007 Women are at a greater risk for developing Chronic pain disorders (ex. migraine and backache) A patient’s sex influences pain perception, how patients cope with it, the medications we use and the dosage Research may lead to sex-specific medications Medication by Sex Women are at increased risk of pain from: TMD Trigeminal neuralgia Migraine Arthritis Fibromyalgia Irritable bowel syndrome Pain after oral, perio. or knee surgery A government study found that 8 of 10 drugs removed from the market 1997-2000 posed greater health risks to women. ESTROGEN Analgesic Considerations Mogil,JS Qualitative sex differences in pain processing: emerging evidence of a biased literature Nature Reviews Neuroscience 2020;21:353-365 It is increasingly clear that male and female humans and rodents process pain in different ways … important differences in mechanisms involved at genetic, molecular, cellular and physiological levels Mogil JS 2020 (Continued) …most pain research remains overwhelmingly based on the study of male rodents, continuing to test hypotheses derived from earlier experiments on males “This is an important blind spot in pain research, particularly as it relates to new medications and most chronic pain sufferers are women” Mogil JS 2020 (Continued) Because of the bias in pain research we are increasingly learning about the biology of pain in MALES We are wrongly concluding from such research that it is relevant to the biology of “pain”. Actually, it is only relevant to the biology of pain in MALES Mogil JS. 2020 (Continued) Progress is being made More than 1,000 scholarly articles reviewed in Pain 2016-2019, more papers included females than male rodents Male only studies dropped from 80% of the total in 2015 to only 50% in 2019 Analgesic Premedication A pre-emptive pain preventive strategy Key Question: When should I take an analgesic? Start the analgesic at the time of trauma and then by the clock Do not wait for the onset of pain! ANALGESIC STRATEGIES FOR PAIN PREVENTION AND MANAGEMENT HYDROCODONE & IBUPROFEN / ACETAMINOPHEN (Vicodin) ACETAMINOPHEN / IBUPROFEN & CODEINE OTC ASPIRIN * ACETAMINOPHEN * IBUPROFEN NAPROXEN NSAID LONG ACTING LOCAL ANESTHETIC PREEMPTIVE MEASURES INTRAOPERATIVE MODERATE PAIN MILD PAIN NSAID PAIN ONSET Modified from R.Dionne SEVERE PAIN Validity of Specific Pain Predictors Could we identify patients likely to experience an exacerbation or treatment failure? Recent Research Arias A, de la Macorra JC, Et al. Predictive models of pain following root canal treatment: a prospective clinical study Int Endo J 2013;46:784-793 A total of 500 single-visit root canal treatments were completed by an endodontist. 500 questionnaires concerning pain were given to patients and 274 were returned. Results… Predictive models showed that the incidence of post-endodontic pain was lower when : • The treated tooth was not a molar (P=0.003) • Demonstrated periapical radiolucencies (P=0.003) • Had no history of previous pain (P=0.006) • No occlusal contact (P<0.0001) Results… Predictive models showed that the probability of experiencing moderate or severe pain was higher with: • Increasing age (P=0.09) • Mandibular teeth (P=0.045) Results…The probability of pain lasting more than 2 days was: • • • Increased with age (p=0.1) Decreased in males (p=0.0007) When a radiolucent lesion was present on radiographs (p=0.1) Moore PA, Dionne R, et al. Why do we prescribe Vicodin? JADA 2016;147:530-533 “ Surprisingly, we could find no references in the literature in which investigators found acetaminophen-hydrocodone combinations, to be more effective than non-steroidal anti-inflammatory drugs (NSAIDS).” Vicodin ?? ? Important Concept: Think Prevention • Start analgesics immediately before or after the Endo. procedure • Goal….block formation of inflammatory mediators rather than waiting for pain to occur JACKSON DL . JADA 1989 ; 119 : 641 - 47. PREOPERATIVE NON STEROIDAL ANTI INFLAMMATORY MEDICATION FOR THE PREVENTION OF POSTOPERATIVE DENTAL PAIN . RESULTS: IBUPROFEN PRETREATMENT DELAYS ONSET AND REDUCES SEVERITY OF PAIN AFTER LOCAL ANESTHESIA HAS WORN OFF. DIONNE RA. NEW APPROACHES TO PREVENTING AND TREATING POSTOPERATIVE PAIN. JADA 1992; 123: 27-34. • PREOPERATIVE …IBUPROFEN OR FLURBIPROFEN ( NSAID ) DELAYED ONSET AND DECREASED SEVERITY OF PAIN… • ADDITIVE WITH EFFECTS OF LONG LASTING LOCAL ANESTHETIC… COMBINATION PROVIDED BETTER PAIN RELIEF THAN EITHER ONE ALONE. FOR THOSE WHO CAN’T USE NSAID’s… MOORE PA. et al. ANALGESIC REGIMENS FOR THIRD MOLAR SURGERY JADA 1986; 113: 739-744 • WHEN ACETAMINOPHEN (1000 mg.) WAS ADMINISTERED 30 MINUTES BEFORE SURGERY, ONSET OF PEAK PAIN WAS DELAYED AND PATIENT DISCOMFORT WAS DECREASED 3, 4, 5 HOURS AFTER SURGERY. Acetaminophen Caution Is Acetaminophen safe? Acetaminophen overdoses are the no.1 cause of acute liver failure in the U.S. One key reason… many medications contain acetaminophen and patients take it without realizing it. Mayo Clinic Women’s Health Source. January 2010. Daily Dose of Acetaminophen, 2020 NYC Poison Control • DO NOT EXCEED 3 GRAMS PER DAY, ASSUMING A HEALTHY LIVER • BEWARE OF OTHER MEDICATIONS CONTAINING ACETAMINOPHEN J. Nature Reviews Endodontology Sept.23, 2021 Consensus statement signed by 91 scientists from Australia, Brazil, Canada, Brazil, Canada, UK, U.S. The health care community should “ carefully consider the use of acetaminophen during pregnancy until it is thoroughly investigated for its potential impact on fetal development.” J. Nature Reviews Endodontology Sept.23, 2021 Consensus statement signed by 91 scientists from Australia, Brazil, Canada, Brazil, Canada, UK, U.S. The health care community should “ carefully consider the use of acetaminophen during pregnancy until it is thoroughly investigated for its potential impact on fetal development.” ”…any medication taken during pregnancy should be used only as needed , in moderation, and after consultation with their doctor.” “…minimize exposure by using the lowest effective dose for the shortest period of time.” Ibuprofen Caution Caution : Ibuprofen and Pregnancy National Health Service, UK, 2016 Current Advice Do not take ibuprofen from 20 week of pregnancy onwards. At that stage of pregnancy an association with increased risk of complications including heart problems. It is best to avoid taking medication during pregnancy particularly during the first 3 months. When using any medication during pregnancy take the lowest effective dose for the shortest time. Ibuprofen Ibuprofen has been associated with birth defects and damage to the baby’s heart and blood vessels. “High dosages of aspirin have been linked to bleeding in the brain and congenital defects.” What will you advise pregnant mothers to do? Analgesic Efficacy Current Research A randomised,five-parallel-groupplacebo controlled trial comparing efficacy and tolerability of analgesic combination including a novel single – tablet combination of ibuprofen/paracetamol for post operative dental pain Daniels SE, Goulder MA, Aspley S, Reader S Pain 152 (2011) 632-642 Placebo Analgesics Evaluated Paracetamol 500 mg/codeine 15 mg Ibuprofen 200mg/codeine 12.8 mg Ibuprofen 200mg/paracetamol 500mg Ibuprofen 400mg/paracetamol 1000 mg Outcomes Ranking of the 5 treatments (best to worst)  2 tablets of ibuprofen 200mg / paracetamol 500mg  1 tablet of ibuprofen 200mg / paracetamol 500mg 2 tablets of ibuprofen 200mg / codeine 12.8 mg 2 tablets of paracetamol 500mg / codeine 15 mg Placebo    Adverse Effects  The proportion of subjects reporting adverse effects was statistically significantly less with either 1 or 2 tablets of the single tablet combination of ibuprofen/paracetamol than the codeine combinations  Codeine is associated with a number of side effects, including nausea and vomiting. Statistics  This study showed that 1 or 2 tablets of the single-tablet combination of ibuprofen 200mg/paracetamol 500mg was statistically significantly more efficacious than 2 tablets of paracetamol/codeine.  The peak pain relief was both higher and sustained longer with 2 tablets of the single- tablet combination of ibuprofen/paracetamol compared with all other treatments.